LYMPHADENOPATHY
VIT B12 DEFICIENCY
ASD
BOARD STYLE QUESTIONS
MISCELLANEOUS
100
the preferred initial test for lymphadenopathy and why
What is core needle biopsy
it is less prone to sampling errors and retains tissue architecture
Core needle biopsy is a better initial test than fine-needle aspiration, especially for lymphomas, because it is less prone to sampling errors and retains tissue architecture, which aids in diagnosis. Traditionally, patients with cervical lymphadenopathy undergo fine-needle aspiration sampling, followed by excisional lymph node biopsy for definite diagnosis, because intact tissue is required. A core needle biopsy combined with immunohistochemical and molecular investigative techniques is an alternative to traditional fine-needle aspiration and excisional biopsy.
100
BEST TREATMENT FOR VITAMIN B 12 DEFICIENCY,,,,ORAL OR INTRAMUSCULAR VITAMIN B12?
several studies have shown no statistically significant difference in the rates of vitamin B12 normalization between oral and intramuscular supplementation
Treating patients with 1,000 mcg daily of oral vitamin B12 is efficacious and cost-effective.
Traditionally, intramuscular vitamin B12 supplementation was thought to be the best treatment for pernicious anemia or deficiency due to autoimmune gastritis. However, several studies have shown no statistically significant difference in the rates of vitamin B12 normalization between oral and intramuscular supplementation.
A 2018 Cochrane review showed no difference in disease-oriented outcomes in those treated with oral vs intramuscular formulations, with oral administration being more affordable. Even in those with pernicious anemia or Roux-en-Y gastric bypass, 1,000 mcg daily of oral vitamin B12 is noninferior to intramuscular vitamin B12. There is also no difference in posttreatment hemoglobin level, mean corpuscular volume, or homocysteine level among those treated with oral, intramuscular, and sublingual vitamin B12.
Once-daily sublingual or once-weekly nasal vitamin B12 may be preferred in some patients because of ease of use; however, these formulations have lower bioavailability.Subcutaneous vitamin B12 may be considered as an alternative in those requiring intramuscular vitamin B12 who are receiving anticoagulation. Intramuscular vitamin B12 can lead to a faster rate of normalization and a higher total vitamin B12 level, making it a reasonable initial choice for those who have severe vitamin B12 deficiency, autoimmune gastritis, or neurologic manifestations, or who have undergone gastrectomy.
100
AAP recommendation for screening for autism
The most commonly used screening tool is
18 to 24 months
The AAP recommends screening for autism using a validated tool at 18 and 24 months of age in addition to regular developmental surveillance at well-child visits
The US Preventive Services Task Force found insufficient evidence to assess the balance of benefits and harms of universal screening in children ages 18 to 30 months without developmental concerns
the Modified Checklist for Autism in Toddlers, Revised With Follow-Up (M-CHAT-R/F).
The M-CHAT-R/F is widely available, accessible, and translated into several languages. It has been assessed and validated in the primary care setting, including studies supporting its use in Black and White children as identified by parental self-report
100
A 55-year-old female presents with a 2-month history of right lateral hip pain. Her symptoms began shortly after she started jogging. The pain worsened a week ago after a long car trip. She reports that the pain has been interfering with her sleep quality, particularly when she rests on her right side. You note a right-sided Trendelenburg gait.
Which one of the following is the most likely diagnosis?
A. Femoroacetabular Impingement
B. Greater trochanteric pain syndrome
C. A hamstring strain
D. A labral tear
E. Sacroiliac joint dysfunction
B
This patient presents with lateral hip pain and symptoms of greater trochanteric pain syndrome, which can include bursitis as well as gluteus medius tendinopathy or tears. She exhibits a Trendelenburg gait, which indicates gluteus muscle weakness. Both femoroacetabular impingement and labral tears generally cause anterior hip pain. Femoroacetabular impingement is one of the most common causes of hip pain in young adults. Labral tears and hamstring injuries are usually associated with a history of trauma or sports-related injury. Hamstring injuries and sacroiliac joint dysfunction generally cause posterior hip pain.
100
_________ lowers blood sugar and helps patients with obesity and prediabetes to lose weight and reduce the likelihood that they will develop type 2 diabetes.
Tirzepatide
Tirzepatide is an effective drug for weight loss, and the authors also found that it can prevent a diagnosis of type 2 diabetes in patients with obesity and prediabetes.
Tirzepatide is a good drug for the treatment of obesity and type 2 diabetes, but it should not be recommended to prevent type 2 diabetes as the sole rationale. (Level of Evidence = 1b)
200
In chronic localized or generalized lymphadenopathy, the recommended imaging is ?
Why?
What is chest radiograph
What is mediastinal widening seen with lymphoma and sarcoidosis.
In chronic localized or generalized lymphadenopathy, chest radiography is recommended to evaluate for mediastinal widening seen with lymphoma and sarcoidosis. Chest radiography can also identify mediastinal lymph node enlargements compressing the airway, hilar lymphadenopathy, and calcification due to tuberculosis if CT is not performed.
200
WHAT IS THE CLINICAL SIGNIFICANCE OF ELEVATED VITAMIN B12 LEVELS?
higher risk of cardiovascular mortality
increased risk of hematologic disorders such as chronic myeloid leukemia, polycythemia vera, and myeloproliferative syndromes
In the National Health and Nutrition Examination Survey, patients with elevated vitamin B12 levels had a higher risk of cardiovascular mortality (hazard ratio = 1.45). Patients with elevated levels are also at increased risk of hematologic disorders such as chronic myeloid leukemia, polycythemia vera, and myeloproliferative syndromes. Liver and kidney disease can lead to elevated vitamin B12 levels due to decreased clearance.In one study of patients with persistently elevated levels, 22% had liver disease, 21% had solid cancers, and 17% had hematologic malignancies. Transient vitamin B12 elevation can occur with acute inflammation and is not associated with these risks.
There is no clear consensus on how to approach vitamin B12 elevation. If vitamin B12 is elevated on initial testing, a repeat test should be performed to confirm persistent elevation. Some experts recommend obtaining a complete blood cell count, comprehensive metabolic panel, and liver ultrasonography. There is no consensus on further testing for solid cancer but, at minimum, recommended routine cancer screening should be up to date. Use of the vitamin B12 level as a screening test for solid cancer is not recommended given the invasiveness and cost of testing at the population level.
200
The most common cause of death in autistic children younger than 15 years
In autistic people without intellectual disability
The most common cause of death in autistic children younger than 15 years is unintentional injury, with the leading causes being drowning, suffocation, and asphyxiation. Among individuals with co-occurring intellectual disability, complications from epilepsy tend to be the most common cause of death.
In autistic people without intellectual disability, suicide is the most common cause of premature mortality. The autistic population has an increased risk of dying by suicide that is 2 to 10 times greater compared with the general population,and autistic individuals who are women, transgender, or gender-nonconforming are at an increased risk of suicide compared with autistic men.
Autistic individuals are at significantly higher risk of being bullied, mistreated, and sexually abused, with 9 out of 10 autistic women experiencing sexual violence.Autistic children are at higher risk of experiencing physical abuse compared with their neurotypical peers.
Disability and under- and unemployment have repeatedly been linked to reduced life expectancy. Up to one-half of autistic adults are underemployed, and 38% are unemployed.
200
A 50-year-old male presents with a 3-month history of persistent burning and numbness in his anterolateral left thigh. He has not had any injury, back pain, radiation of pain, or weakness. He has not noticed any exacerbating or remitting factors. He has type 2 diabetes and a BMI of 37 kg/m2, and his job is sedentary.
An examination reveals normal deep tendon reflexes in the patella and ankle, and the straight leg–raising test is negative bilaterally. His strength is preserved throughout his lower extremities. His pinprick sensation is slightly reduced along the anterolateral thigh. Burning discomfort is reproduced with tapping over the lateral aspect of the inguinal ligament.
Which one of the following is the most likely diagnosis?
A. Cauda equina syndrome
B. Diabetic neuropathy
C. Femoral neuropathy
D. Left S1 radiculopathy
E. Meralgia paresthetica
E
Meralgia paresthetica is a common cause of anterolateral hip pain and dysesthesia. It is caused by compression of the lateral femoral cutaneous nerve as it courses under the inguinal ligament into the subcutaneous tissue of the thigh. Tapping over this area during the examination can reproduce symptoms. In patients with obesity, compression of the nerve from overlying pannus can cause characteristic symptoms. Diabetes mellitus is associated with a 7-fold higher incidence over the general population. Cauda equina syndrome presents with saddle anesthesia and other neurologic symptoms including lower extremity weakness and urinary retention and incontinence. Diabetic neuropathy is a peripheral neuropathy initially affecting distal nerves of the toes and feet. Femoral neuropathy would affect sensation in the anteromedial thigh and medial lower leg with weakness in the quadriceps muscle group. The anterolateral thigh would represent the L3-L4 dermatome, not S1, and the normal straight leg–raising test and absence of back pain are evidence against a left S1 radiculopathy.
200
____________ is more effective than placebo for treatment of vasomotor symptoms of menopause in individuals who cannot or will not take hormones.
Fezolinetant (Veozah)
In people with moderate to severe vasomotor symptoms of menopause who will not or cannot receive hormone therapy, fezolinetant decreases the frequency and severity of symptoms and improves sleep. More people are likely to receive benefit from fezolinetant than placebo, but placebo is effective in some users. (Level of Evidence = 1b)
300
Mention 3 medications and 3 vaccines associated with lymphadenopathy
What is
300
CLINICAL FEATURES OF VITAMIN B12 DEFICIENCY
1 COGNITIVE
1 NEUROLOGICAL
1 SKIN
300
Mention 3 Interventions for Autism Spectrum Disorder
Behavior, Developmental,Educational
300
A 36-year-old male presents to the urgent care clinic 2 days after he fell on his outstretched arm while snow skiing. He reports pain located in the deltoid region that is exacerbated when lifting the arms overhead. The pain is so severe that it awakens him at night. Examination of the shoulder demonstrates weakness with external rotation, internal rotation, and abduction. The empty can and drop arm tests are positive. Shoulder radiographs are negative.
Based on the presentation and examination, which one of the following would be the most appropriate next step in management?
A. Rest, Ice, Compression, Elevation and Home exercise
B. NSAIDS and Physical Therapy
C. Corticosteroid Injection
D. MRI
D
Weakness and pain are common symptoms of rotator cuff tears. When a tear is highly suspected, as in this case, they are best diagnosed by MRI, which allows evaluation of the location, size, and degree of tear. The empty can test has a sensitivity of 70% and a specificity of 81% for supraspinatus muscle tear. The drop arm test has a low sensitivity of 21% for supraspinatus muscle tear, but a very high specificity of 96%. In large or full thickness acute rotator cuff tears, expeditious surgical repair is recommended in otherwise young, healthy individuals. Delayed repair of such tears can result in tendon degeneration, retraction, and compromised surgical results. Surgical repair should be performed within 6 weeks of the injury. Rest, ice, compression, elevation, and home exercises; NSAIDs and physical therapy; and corticosteroid injection would not be the most appropriate options for the next step in the management of this patient's injury.
300
___________ is effective in treating patients with Alzheimer disease and mild cognitive impairment.
Galantamine
In people with mild to moderate Alzheimer disease, treatment with galantamine, 8 to 12 mg twice daily, slows the decline in cognitive function, behavioral function, and functional disability at 6 months compared with placebo.1 Galantamine also slows the decline in global function at 6 months. However, it leads to more all-cause discontinuation of pharmacotherapy and more nausea.
For people with mild cognitive impairment, galantamine is responsible for more all-cause discontinuation of pharmacotherapy, nausea, and death compared with placebo.1 (Strength of Recommendation: A, consistent, good quality, patient-oriented evidence.)
400
the first-line imaging modality for the evaluation of peripheral lymphadenopathy in children < 14 years
in >14 yrs
in adults
What is Ultrasound
What is CT
What is CT or MRI of the neck with contrast
Ultrasonography is the first-line imaging modality for the evaluation of peripheral lymphadenopathy in children 14 years and younger. In addition to being more accessible and less expensive than other options, noninvasive, and radiation free, ultrasonography can assess the location, size, and character of a lymph node. Ultrasonography was shown to have a high sensitivity (98%) and negative predicative value (97%) to differentiate lymphadenopathy as benign or malignant in adults at a tertiary referral center.
Computed tomography (CT) can be used as the imaging modality of choice in patients older than 14 years and may be more useful in the evaluation of the thorax, abdomen, and pelvis.
CT or magnetic resonance imaging of the neck with contrast is preferred in adults, especially in those with high risk of malignancy
400
3 MEDICATION RISK FACTORS OF VIT B12 DEFICIENCY
Metformin, PPI, H2 blocker, nitrous oxide
400
Name any 4 Conditions Associated With Autism Spectrum Disorder
Autoimmune disorders: IBS, T1DM
Eating disorder: Pica, food selectivity and nutrient deficiencies
Seizure disorder
GI disorders
400
A 72-year-old previously healthy male presents with a 3-week history of mild, intermittent chest pressure that occurs when he walks up a steep hill.
Which one of the following EKG abnormalities would dictate the use of a pharmacologic stress test as opposed to an exercise stress test? (check one)
A. First degree atrioventricular block
B. Left bundle branch block
C. Poor R-wave progression in leads V1 through V3
D. Q-waves in the inferior leads
E. Ventricular trigeminy
B
Left bundle branch block makes the EKG uninterpretable during an exercise stress test, and can also interfere with nuclear imaging performed during the test. It is associated with transient positive defects in the anteroseptal and septal regions in the absence of a lesion within the left anterior descending coronary artery. This leads to a high rate of false-positive tests and low specificity. Pharmacologic stress tests using vasodilators such as adenosine with nuclear imaging have a much higher specificity and positive predictive value for LAD lesions, and the same is true for dobutamine stress echocardiography, which is why these are the preferred methods for evaluating patients with left bundle branch block. Pharmacologic stress testing would not be preferred for evaluating the other EKG abnormalities listed.
400
using the clinical risk score, which patients with acute abdominal pain and elevated lipase levels have acute pancreatitis?
mention 2 of the predictors
patients with a risk score of 8 or greater have a 93% likelihood of acute pancreatitis and can be treated empirically.
In clinical practice, patients with a risk score of 8 or greater have a 93% likelihood of acute pancreatitis and can be treated empirically. Patients with a score of less than 5 have only a 13% likelihood of acute pancreatitis, and evaluation for other diagnoses should be prioritized. Those with a score between 5 and 7 points should receive prompt imaging (ultrasonography or computed tomography) for ruling acute pancreatitis in or out.
500
Name 5 miscellaneous conditions that can cause lymphadenopathy
What is
Angiofollicular lymph node hyperplasia (castleman disease), histiocytosis, Kawasaki disease, multsystem inflammatory syndrome in children, Kikuchi lymhadenitis, Kimura disease, sarcoidosis, Marshall syndrome/PFAPA (periodic fever, apthous stomatitis, pharyngitis and adenopathy), immunoglobulin G4- related disease , Rosai Dorfman Disease.
500
HOW IS ATROPHIC GASTRITIS DIAGNOSED?
Anti–intrinsic factor antibody is specific and anti–parietal cell antibody is sensitive for autoimmune gastritis, but definitive testing requires endoscopic biopsy.
Atrophic gastritis encompasses conditions that cause loss of gastric glandular cells such as Helicobacter pylori infection and autoimmune gastritis. Symptoms of atrophic gastritis include dyspepsia, early satiety, bloating, and features of vitamin B12 deficiency. Pernicious anemia is a late manifestation of autoimmune gastritis; the prevalence is 0.1% in the general population overall and 2% to 3% in those older than 65 years. Autoimmune gastritis should be suspected in patients who have vitamin B12 deficiency without a clear cause, megaloblastic anemia, or atrophic gastritis not caused by H pylori infection.
Initial evaluation for atrophic gastritis includes testing for H pylori and autoimmune gastritis autoantibodies. Anti– intrinsic factor antibodies are specific, whereas anti–parietal cell antibodies are sensitive for autoimmune gastritis.Given that approximately 20% of patients with biopsy-proven autoimmune gastritis are seronegative, endoscopy and biopsy to diagnose autoimmune gastritis should be performed if testing is positive for autoantibodies or clinical suspicion is high for pernicious anemia. Recognition of atrophic gastritis is important because it is associated with gastric neoplasms and micronutrient deficiencies (iron, calcium, ascorbic acid, vitamin D, and vitamin B12). Patients with atrophic gastritis should undergo routine surveillance endoscopy evaluations to detect these complications.
500
Any 3 Diagnostic Criteria for ASD
Persistent deficits in social communication and social interactions across multiple contexts as manifested by the following, currently or by history,
Restricted repetitive patterns of behavior, interest or activities as manifested by at least two of the following, currently or by history,
Symptoms must be present in the early development period.
Symptoms cause clinically significant impairment in social, occupational or other important areas of current functioning.
These disturbances are not better explained by intellectual developmental disorder or global developmental delay.
500
A 36-year-old male who participates in his neighborhood basketball league visits your office with a 3-week history of heel pain. On examination he has pain over the medial plantar region of the right heel and the pain is aggravated by passive ankle dorsiflexion.
Which one of the following should you order to confirm the diagnosis? (check one)
Plain films of the foot
Ultrasonography of the foot
CT of the foot
MRI of the foot
No diagnostic imaging
Correct
E
The diagnosis of plantar fasciitis is based primarily on the history and physical examination. Patients may present with heel pain, and palpation of the medial plantar calcaneal region may elicit a sharp pain. Discomfort in the proximal plantar fascia can be elicited by passive ankle/first toe dorsiflexion. Diagnostic imaging is rarely needed for the initial diagnosis of plantar fasciitis. In recalcitrant plantar fasciitis plain films may be helpful for detecting bony lesions of the foot. Ultrasonography is inexpensive and may be useful for ruling out soft-tissue pathology of the heel in some patients. While MRI is expensive, it is a valuable tool for assessing causes of recalcitrant heel pain.
500
Any 3 recommendations to prevent skin atrophy and other adverse effects with long-term topical steroid treatment
(1) consider steroid-sparing alternatives, such as topical calcineurin inhibitors, when appropriate;
(2) if topical steroids are necessary, use the lowest effective potency and limit application to 2 to 4 weeks for most conditions;
(3) for chronic conditions requiring longer treatment, implement a weekend-only regimen;
(4) if the condition does not improve with appropriate steroid use, consider biopsy and referral to a dermatologist;
(5) educate patients on proper use and potential adverse effects of topical steroids;
(6) schedule regular follow-up appointments to assess effectiveness and adverse effects.
Skin atrophy, one of the most prevalent and consequential adverse effects of long-term topical steroid treatment, begins 3 to 14 days after initiation of use.1 Due to vasoconstriction, steroid application temporarily relieves the burning sensation caused by skin atrophy.2 Due to rebound vasodilation, the sensation is further exacerbated with steroid withdrawal.2 The risk of steroid-induced atrophy increases with higher-potency topical steroids, use on body sites with thinner skin (eg, intertriginous areas), prolonged use, and occlusion.2