Men's Health.....Part II.

We'll continue with health issues specifically affecting men, that you are very likely to
encounter on your board examination and in the clinical setting.


Q: Why is TESTICULAR TORSION an urologic emergency?


A: As in any condition with arterial circulatory compromise...time is golden.
Testicular salvage is 80-100% at within 8 hours and ZERO percent at 12 HOURS.




Q: What is the BEST immediate procedure of choice for treatment of torsion?



A: MANUAL DETORSION... by rotating the testis outward offers a 30-70% chance of
restoring arterial blood flow,,, with immediate PAIN RELIEF being the best guide.




Q: What is the MOST COMMON AGE GROUP for occurence of torsion?


A: The AGES of 12-18 YEARS. It is uncommon after age 30.




Q: What is ORCHITIS?



A: It is an INFECTION of the testes....usually under the age of 10. The MOST COMMON
cause is VIRAL....typically MUMPS.




Q: What is PRIAPISM?



A: It is a painful, continued ERECTION lasting greater then 4 hours.



Q: What is the MOST COMMON CAUSE?



A: Today....DRUG THERAPY for erectile dysfunction is the primary cause. In the past
ischemic (venoocclusive) was the most common cause...due to decrease or absence
of cavernous blood flow. E.g. Sickle Cell Crisis or pelvic vascular thrombosis.




Q: What is the BEST MEDICAL THERAPY?



A: Immediate application of ICE PACKS....then ORAL TERBUTALINE 5mg.
If this fails....an alpha AGONIST like PHENYLEPHRINE is injected.




Q: What is EPIDIDIMYTIS?



A: It is an infectious process (usually bacterial) involving the epididymis.
It is IMPORTANT to REMEMBER that on the boards...AGE is the main CLUE
as to the cause.
Thus, UNDER AGE 35...the likely causative agents are STD's...primarily
Chlamydia Trachomatis and Nisseria Gonorrheae

OVER AGE 35...Gram Negative bacteria, such as E.COLI is the likely cause.




Thanks again for your time...we'll continue soon.

Men's Health....TESTICULAR TUMORS.

It has been a while since the last posting...but we'll make up for it in the months ahead.

Today's topic is a suggestion of a students rotating through the ED. She has lamented, that on prepation for the boards, the subject of men's health specifically, is lacking. With this in mind we'll cover some important disorders...with due credit to Shara.


TESTICULAR CANCERS:


Q: What is the MOST COMMON cell type...causing testicular cancer?


A: GERM CELL tumors cause approximately 95%.



Q: What classification are they divided into?


A: SEMINOMAS....account for about 60% and NON-SEMINOMAS...@ 40%.





Q: What cell type causes the remaining 5% of testicular cancer?


A: STROMAL CELL tumors....namely LEYDIG CELL CA or SERTOLI CELL CA.



Q: How to definitely DIAGNOSE testicular cancer?


A: NEVER BIOSPY!!!!....an INGUINAL ORCHIECTOMY is the procedure of choice.



Q: What are the RISK FACTORS for development of testicular cancer?


A: 1. Undescended Testicle (Abdominal Cryptorchidism).
2. Prior History of Testicular Cancer
3. Kleinfelter's Syndrome
4. Positive Family History
5. Testicular Feminization Syndromes



Q: What are the GENERAL CURE RATES?


A: They are HIGHLY CURABLE!!!

NON-METASTATIC DISEASE....100% cure rate.
METASTATIC DISEASE................70% cure rate.



Q: What are the common AGE GROUPS affected by testicular cancer?



A: It tends to be BIMODAL. Most common in young men, ages 15-35....and another peak
occuring in at age > 60.




Q: What is the HALF LIFE of serum B-HCG and AFP.. and why are they important?


A: The half life of B-HCG is ONE DAY.......and that of AFP is ONE WEEK!

They are important post surgically....because if either one is elevated beyond the
expected half life.....RESIDUAL DISEASE EXISTS.




We'll continue with more of Men's Health soon....

RARE INFECTIOUS DISORDERS...

These disorders may be rare in clinical practice...but are frequently the topic of board
exams...so, it's worth remembering.


Q: What is CREUTZFELD-JACOB DISEASE?


A: It is a rapidly progressive encephalopathy caused by a PRION. It is similar to Mad Cow
Disease....causing ataxia, dementia and myoclonic jerking movements along with visual
defects. CT/MRI Images of the Brain are normal. EEG shows Triphasic Waveforms.
Almost always FATAL.


Q: What is PML (Progressive Multifocal Leukoencephalopathy)?


A: It is...as the name implies a form of encephalopathy....caused by JC-VIRUS ( a papovavirus),
which causes LYSIS of the Oligodentrocytes....leading to a WHITE MATTER disease.
There is no effective therapy.



Q: What is HAM (HTLV-1 Associated Myelopathy)?


A: It is a RETROVIRUS borne disorder, that MIMICS Multiple Sclerosis. In USA can occur
in Southeast Florida. Pathophysiology: It is due to an autoimmune attack by CD8 T Cells
on HTLV-1 infected GLIAL cells. Serologies will confirm diagnosis.



Q: What type of meningitis is associated with GENITAL HERPES HSV-2 ?


A: MOLLARET'S MENINGITIS. It is a cause of BENIGN recurrent lymphocytic meningitis.
An astute practitioner will identify clinical findings in the genitalia (ulcers/lesions).
TX: Self Limited illness....No Acyclovir needed. DX: Confirmed by PCR.



Q: What Infections Disorders are most common and important to consider in TRAVELERS?


A: 1. MALARIA
2. TYPHOID FEVER
3. HEPATITIS (HAV/HBV/HEV/HCV)
4. DENGUE FEVER
5. AMEBIC LIVER ABSCESS



Thanks for your time....be back soon.

CLINICAL ALLERGY-IMMUNOLOGY

This is the perfect season for this topic to be covered....
Pollen, bee stings and lots of outdoor activities.
Of course, as you well know by know...the boards want to know....how much you know.


Q: What is an ANAPHYLACTIC REACTION?


A: It is an immune response... IgE mediated Type I...hypersensitivity reaction.
HINT: Best way to remember...Ig"E" = "E"mergency. This is important on the
boards.



Q: Which laboratory test can be useful in definitely establishing the diagnosis of
Anaphylaxis?


A: SERUM B-TRYPTASE, if drawn within 30 minutes of onset. It will help differentiate
from other similar, but NON-anaphylactic reactions.




Q: Does anaphylaxis have a LATE PHASE?


A: Yes, it tends to be BIPHASIC....thus, it is best to admit the patient to ICU for 24 hours.
As, despite the treatment given in the ER...the patient can experience another bout
of clinical symptoms.




Q: What is the BEST medication to use in patients with anaphylaxis, who are on B-Blockers?


A: GLUCAGON...1 mg...this medication is also useful in REFRACTORY anaphylaxis.




Q: What is an ANAPHYLACTOID REACTION?


A: It is a NON-IgE mediated!!! ...MAST CELL or COMPLEMENT induced reaction.
Clinically indistinquishable from anaphylaxis.




Q: What are most common causes of an ANAPHYLACTOID REACTION?


A: IV CONTRAST or NSAID, ASA administration.




Q: Can a patient who is ASPIRIN sensitive be given NSAIDS?


A: NO....there is a strong degree of CROSS REACTIVITY.




Thanks for your time...we'll continue soon

SUCCESS TIPS.....

It has been a bit of a time lapse from the last posting...so thanks for your patience. Now I
have some very good news to share with you.........

I've had great feedback from people taking the PA exam. All have achieved good
results. One emergency medicine PA -C in particular scored outstanding...on the re-certifying
examination....in the top 5%!!!! Congratulations to her and all of you on your hard work.


Today, riding on the wave of recent successes I"d like to expand on the subject of itself.

The ideas are not mine...but universal for ages past. Nonetheless, they become very helpful
if practiced daily. These simple "recipes" will aid you on achieving positive results, whether
at home, the work environment, in preparation for your exam.....or just with life itself.

So, here are tips for YOUR success, as I see them:


1. Demand the BEST of yourself. Don't settle for average. You didn't get to where you
are in your present life and profession, by being just so....!!!


2. Take PRIDE in your work.....it's the only one you have. You can "shine" anywhere you
work, by making it a choice...so, take charge of your perspective, today.


3. Be INQUISITIVE....attempt to carve out 15 minutes a day...to read about a topic, which
you "never have the time" to learn about.


4. Be CARING....do something every day, for someone other then yourself. Do it with genuine
want....and it will become part of you, before you know it.


5. Be HONEST.....first and foremost with yourself, your immediate loved ones and your
co-workers......the rewards are self explanatory.


6. Set HIGH STANDARDS....in all aspects of your life. Being mediocre will lead to, just
that.....mediocre. So, take an honest inventory of yourself to see where you stand.


7. Be of GOOD SPIRITS....it always helps being on the lighter side.


8. Be THANKFUL....appreciate everything you have, as you could just as well have been
on the other side of the fence, in life...."looking in thru the outdoor" !!!


9. Have COMPASSION....with patients and people....life for any of us, could change in a single
instant......So, be happy to be giving care, instead of receiving one.


10. ......lastly PRAY DAILY, to being the fortunate one, to practice all the above!!!!



Thanks for your time...be back real soon.

PEDIATRICS.....PART TWO....RARE FEVERS

Today, we'll cover some of the rarer disorders...causing fever in the pediatric/adolescent
populations....which can be encountered in practice...and are often covered on the Boards.


Q: Which are the "common" HEREDITARY PERIODIC FEVER SYNDROMES?


A: There are three disorder, which one should consider "outside" of the common
causes of fever...when seeing a patient for recurrent fever, without a secondary
cause and explanation.

1. FAMILIAL MEDITERRANEAN FEVER
2. HYPER- IgD SYNDROME
3. FAMILIAL HIBERNIAN FEVER a.k.a TNF Receptor-Associated Periodic Syndrome.



Q: What is FAMILIAL MEDITERRANEAN FEVER (FMF)?


A: It is an inherited illness, causing recurrent fevers and "ITIS"-es. Eg. peritonitis,
pleuritis, arthritis and rarely pericarditis. Occurs predominantly Mediterranean
descendants....Italians/Greeks/Cypriots/Turks/Armenians/Jews.
TREATMENT: COLCHICINE....will also prevent potential Amyloidosis.



Q: What is the HYPER-IgD SYNDROME?


A: It is rare illness, producing recurrent fever in children in, the first year of life.
These can be triggered by vaccination/stress. Occurs mainly in Northern European,
Dutch, French children. Besides the fever, common symptoms are vomiting/diarrhea
arthralgias, maculopapular rash and cervical adenopathy.
DIAGNOSIS: is established by: Serum IgD level > 100 IU/ml. TX: is empiric.



Q: What is FAMILIAL HIBERNIAN FEVER, a.k.a TNF Receptor-Associated Periodic
Syndrome?


A: It is also a hereditary condition, casuing recurrent fevers, arthralgias, and rash occuring
in Scottish, Irish descendants...but is not limited to this ethnic group. This is more common
in adolescents...before age 20. SYMPTOMS: Fever, with myalgias and extremity swelling.
Diagnosis: Low levels of type 1 TNF receptor ( < 1 ng/ml)....between attacks.
TREATMENT: PREDNISONE and ETERNACEPT.


Of note...both Familial Mediterranean Fever and Familial Hibernian Fever can be
complicated by AMYLOIDOSIS!


Thank you for your time...we'll be back shortly.

PEDIATRIC DISORDERS.....

Common causes of Dyspareunia are: Atrophic Vaginitis, Endometriosis, Vulvar Vestibulitis.



Today, we are moving on the Pediatric topics...that are always covered on the exams.



Q: What CRITERIA are required to make the diagnosis first episode of RHEUMATIC
FEVER?


A: The revised JONES CRITERIA is divided into Major and Minor subtypes.
One is required to have either TWO MAJOR or ONE MAJOR and TWO MINOR
components....to establish the diagnosis.



Q: What are the revised MAJOR and MINOR JONES CRITERIA?


A: MAJOR CRITERIA are: Carditis/Chorea/Erythema Marginatum/Polyarthritis
and Subcutaneous Nodules

MINOR CRITERIA are: Arthralgia/Elevated ESR or CRP/Fever/PR Prolongation.



Q: What does PROGNOSIS depend on in patiens affected by Rheumatic Fever?


A: The SEVERITY of initial CARDITIS. (So, of all the criteria...this is the most important).




Q: What is the MOST COMMON organism causing Rheumatic Fever?


A: GROUP A STREPTOCOCCUS (GAS).....Usually occurs 2-4 weeks after a bout of
pharyngitis.




Q: What is the most common AGE GROUP affected by Rheumatic Fever?


A: Ages 5 to 15.....It is rare under 3 and over age 21.



Q: What is the BEST diagnostic tool to establish NEUROFIBROMATOSIS?


A: CLINICAL OBSERVATION....tumors and Cafe au Lait spots will be most evident
to the naked eye....in adolescence...the most common age group affected.



Q: How many TYPES of NEUROFIBROMATOSIS are known?


A: TWO.....Type I is most common (90%) of cases.
Type II....about (10%).... is associated with ACOUSTIC NEUROMAS.



Q: What is LEGG-CALVE-PERTHES DISEASE?


A: ASEPTIC NECROSIS OF THE FEMORAL CAPITAL EPIPHYSIS...which occurs
spontaneously....causing hip pain and limping. Most common age groups affected
are 5-10 years old. MRI is the BEST diagnostic tool.



Q: Which CONGENITAL CONNECTIVE TISSUE DISORDERS can cause AORTIC
DISSECTION....in a younger patient presenting with chest and back pain to the ER?


A: MARFAN'S SYNDROME
EHLER'S-DANLOS SYNDROME




Thanks for your time....it was good to depart from adult subjects to the field of Pediatrics.

WOMEN'S HEALTH....PART TWO

The answer: "What is the Hallmark of Osteoporosis"?......is LOSS OF BONE MASS.
This condition occurs due to an imbalance between bone resorption and formation, as
diagnosed by DEXA imaging.



Q: What are the major risk factors for OSTEOPOROSIS?


A: Menopause...Glucocorticoid use...White/Asian race...Low Ca intake
Tobacco/Alcohol use....Family History...Frequent Falls




Q: What is FITZ-HUGH-CURTIS SYNDROME?


A: Acute PERIHEPATITIS occuring only in sexually active women. Symptoms
resemble cholecystitis (fever/RUQ pain/) along with clinical findings of salpingitis.
The majority are due the Chlamydiae Trachomatis. The LFT's and RUQ Sonogram
are normal. Treatment: is of the underlying infection.



Q: In which conditions is pregnancy CONTRAINDICATED?


A: Eisenmenger's Syndrome...Marfan's Syndrome...Primary Pulmonary Hypertension
Severe Mitral Stenosis.



Q: Which physical condition is associated with ENDOMETRIAL CANCER?


A: OBESITY



Q: Which laboratory test is HIGHLY suggestive of PREECLEMPSIA in a hypertensive
pregnant woman, with proteinuria, edema.


A: Plasma URIC ACID level >4.5 md/dl.



Q: Which type of breast examination is better BSE (Breast self examination) or
CBE (Clinical breast examination) in SCREENING for breast cancer.


A: CBE...Though not standardized, CBE has about a 50% sensitivity, whereas
BSE has not been shown to have real benefit.




To ponder until next time: What gynecologic conditions can cause DYSPAREUNIA?



Thanks again for your time, we'll be back shortly.

WOMEN'S HEALTH .....

The answer to what is the most life threatening complication
of Hypothyroidism......is MYXEDEMA COMA.


Today we'll cover a topic encountered in practice and on board exam questions,
that is somewhat of a departure for me....but important, nonetheless.



Q: What is the use of Rho-Gam?


A: Rho-Gam is given to the Rh Negative mother to PREVENT a secondary immune
response by the fetal Rh Positive RBC's.



Q: What is the time definition of infertility?


A: By definition, infertility exists after failure to conceive for ONE YEAR of
unprotected intercourse.




Q: Which type of virus is mainly associated with CERVICAL CANCER?


A: HPV(Human Papillomavirus), especially HPV16 and 18 subtypes.

Other risk factors are: multiple partners/early age sexual activity/smoking
co-existing STD's/low socioeconomic status and HIV.



Q: What are the recommended SCREENING INTERVALS for cervical cancer?


A: Sexually active person WITHOUT risk factors....it is EVERY 3 YEARS.
Sexually active person WITH risk factors........... it is ANNUALLY.




Q: What is AMNIOTIC FLUID EMBOLISM SYNDROME?


A: It is a CATASTROPHIC event at time of LABOR/DELIVERY...like a massive PE.
Leading to sudden onset HYPOXIA/DYSPNEA/CYANOSIS/HYPOTENSION
and occasionally DIC/COMA...due to uterine manipulation. MORTALITY 50%!!!
TREATMENT: Supportive....Intubation/rapid delivery/IV Fluids.




Q: What is Beta-TOCOLYTIC INDUCED PULMONARY EDEMA?


A: Occurs about 12 HOURS POST DELIVERY. It is UNIQUE to PREGNANT WOMEN.
Sudden onset of PULMONARY EDEMA...due to either TERBUTALINE,
SALBUTEROL, ISOXSUPRINE or RITODRINE......fortunately rare!
TREATMENT: Supportive and diuretics.




Until next time.....What is the HALLMARK feature of OSTEOPOROSIS?



Thanks again for your time....be back soon.

THYROID TRIVIA......

Apathy....surprisingly, is the major symptom of APATHETIC HYPERTHYROIDISM.
The disorder occurs in elderly/debilitated patients in whom progressive apathy is the presenting
chief complaint. Mistakenly depression or dementia is often diagnosed.


Today, we'll continue with common thyroid related issues, encountered in practice
and for certain, on your boards.



Q: What is the drug of choice for the treatment of THYROID STORM?


A: PTU...(Propylthyouracil) is the preferred drug, as it has additional benefit over
Methimazole(MMI), by decreasing the peripheral converion of T4 to T3.



Q: Which THYROID NODULES are usually MALIGNANT...Cold or Hot?


A: COLD NODULES....(HINT: Cold=Cancerous). About 15-20% of Cold nodules
are malignant, while only about 1% of the Hot nodules are....good to know!!!



Q: Which type of PRIMARY thyroid cancer is the MOST COMMON?


A: PAPILLARY type...has an excellent prognosis with >95% 10 year survival
for early stage disease.



Q: Which type of PRIMARY thyroid cancer has WORST PROGNOSIS?


A: ANAPLASTIC type...it usually affects older men and women....since cell
types are undifferentiated...survival is dismal.



Q: Which type of THYROIDITIS causes CONSTITUTIONAL SYMPTOMS...fever/chills
with a tender-enlarged thyroid gland and an elevated ESR?


A: SUBACUTE (DeQUERVAIN'S) THYROIDITIS...a self limited, probable viral
disorder, usually treated with NSAID's and steroids.




To ponder until the next posting:....What is the major LIFE THREATENING complication
of HYPOTHYROIDISM, requering emergency diagnosis and treatment?



Again, thanks for your time.

THYROID STUDIES.......Made Simple

The answer to the question in the previous posting is MAGNESIUM.



Today we'll review the common labs tests in interpreting of thyroid function studies,
that you are likely to be asked on your boards....or encounter in daily pratice.


Q: What is the single BEST screening test to determine thyroid function status?


A: TSH level....It will tell you whether patient is hyper/hypothyroid or neither.
Low levels=Hyperthyroidism. High levels=Hypothyroidism. HINT: This is
first test to obtain, regardless of which thyroid disorder you are looking for.
.


Q: What is the BEST test to determine if person is surreptitiously abusing thyroid hormone?
(For weight loss/ psychiatric reasons...resulting in EXOGENOUS HYPERTHYROIDISM).


A: Serum THYROGLOBULIN level...(on the boards). This test is also elevated in thyroiditis.



Q: What test is the BEST indicator of EUTHYROID SICK SYNDROME?
(This is generally an asymtomatic disorder seen in hospitalized/terminally ill patients.
Therapy consist of treating the underlying cause without thyroid medications).

A: LOW T3 level.



Q: What test are commonly seen elevated in HASHIMOTO'S THYROIDITIS?


A: Being an AUTOIMMUNE disorder...besides the expected elevated TSH/low FT4
combination...ANTIBODY tests will be positive... TPO (anti-thyroid peroxidase antibody)
and TG (anti-thyroglobulin antibody) will both be increased in this disorder.



Q: What is the BEST test to determine NEONATAL THYROTOXICOSIS in a pregnant
patient with GRAVES' Disease?



A: SERUM TSI (Thyroid Stimulating Immunoglobulin)....since this hormone crosses the
placenta.






To think about until next time........Which thyroid condition causes APATHY?....The answer
may surprise you!


Thanks for your time.

MORE CLINICAL WORD TIPS....

The answer to the previous posting suggests a person with Obsessive Compulsive Disorder(OCD). The correct response for the treatment is : CLOMIPRAMINE..(on the boards)
So, who wants to be a super PA Student or Medical Resident????

Let's continue with more clinical word tips.....and recall... answer what the "boards" are
looking for.



Q: Which drug is used for prophylactic treatment of a patient with ESOPHAGEAL VARICES?


A: NADOLOL or Propanolol (non-selective B-blocker) has been shown to reduce bleeding.



Q: What is the BEST serum test to order for diagnosis of VITAMIN D Deficiency?


A: 25-OH Vitamin VITAMIN-D. (NEVER!!! order 125-Vitamin-D on the boards)



Q: What is the BEST treatment for an adult (or pediatric) patient with acute ITP?


A; High dose PREDNISONE and platelet transfusion.



Q: What is the ONLY intervention known to increase LIFE EXPECTANCY in a hypoxemic
COPD patient?


A: OXYGEN therapy.



Q: Which drug has been shown to increase survival in a patient with PRIMARY PULMONARY
HYPERTENSION (PPH)?


A: WARFARIN




Q: What is the BEST test to diagnose PULMONARY EMBOLISM in a pregnant patient?


A: VENTILATION-PERFUSION SCAN (Can augment dx. with bilateral venous Dopplers)




......To ponder until next time....What is the BEST treatment of an ALCOHOLIC patient
with recurrent VENTRICULAR TACHYCARDIA?


Thanks for your time....we'll be back soon

CLINICAL WORD TIPS.....

We are well into the New Year, so it's time to pick up the books and continue on....

Short TIPS to memorize will add to your score and will help you in clinical practice,

so, when you read these WORDS on the exam....just ANSWER the question.



Q: What condition causes a BIRD BEAK appearance of the esophagus on barium swallow.


A: ACHALASIA.....an aperistaltic denervation of the esophageal smooth muscles.



Q: What vitamin deficiency will a strict VEGETERIAN/VEGAN develop?


A: VITAMIN B 12 (cyanocobalamin) deficiency.



Q: What condition causes ENAMEL LOSS of frontal teeth?


A: BULEMIA.....the repeated emesis of acidic contents will erode the enamel.
(This can also lead to premature dental caries)


Q: What organism can cause soft tissue cellulitis after swimming/contact with
SEAWATER?


A: VIBRIO VULNIFICUS infection.



Q: What bacteria is commonly involved in acute inflammatory neuropathy...
GUILLAIN-BARRE SYNDROME?


A: CAMPOLYBACTER JEJUNI....causing an acute diarrheal illness.




Q: What causes a grossly BLOODY NIPPLE DISCHARGE?


A: INTRADUCTAL Breast Cancer.



Q: What condition causes progressive PAIN, between the 2nd-3rd toes of the FEET?


A: MORTON'S NEUROMA.



Q: What condition causes CYANOSIS and COOLNESS of FEET, but perfectly
normal pulses in an otherwise healthy adult?


A: REFLEX SYMPATHETIC DYSTROPHY.





...........AND finally....What is the treatment of a PHYSICIAN ASSISTANT STUDENT
or for that matter a PGY-3 MEDICAL RESIDENT....who wants to be a SUPER?

A: ....BE PATIENT....we'll tell you in the next posting!




Thank for your time....see you soon.