Permission for the release of patient information should always be in writing. Although the actual medical record is the property of the physician, the information in the chart is the property of the patient. Ethically and legally, patients have a right to the information in their medical records, and it cannot be withheld from the patient or a third party (at the request of the patient), even if medical bills are unpaid or the physician is concerned about the patient.

Aspirin is know as a salicylate and a nonsteroidal anti-inflammatory drug, working by blocking a certain natural substance in the body to reduce pain and swelling.It is a self-treatment that could be used without a prescription of the doctor. Although its several benefits, Aspirin has many side effects including the most common one which is tinnitus, or ringing in the ears, described as a perception of sound in one or both ears in the absence of an external source.This sensation tends to increase with dosage and could start disappearing after stopping Aspirin intake.

This patient has developed signs and symptoms suggestive of anaphylaxis, a serious allergic or hypersensitivity reaction that is rapid in onset and may cause death. The diagnosis of anaphylaxis is based primarily upon clinical symptoms and signs, as well as a detailed description of the acute episode, including antecedent activities and events occurring within the preceding minutes to hours.There are three diagnostic criteria for anaphylaxis:Criterion 1—Acute onset of an illness (minutes to several hours) involving the skin, mucosal tissue, or both (e.g., generalized hives, pruritus or flushing, swollen lips-tongue-uvula)and at least one of the following:- Respiratory compromise (e.g., dyspnoea, wheeze/bronchospasm, stridor, reduced peak expiratory flow, hypoxemia)OR- Reduced blood pressure (BP) or associated symptoms and signs of end-organ malperfusion (e.g., hypotonia [collapse], syncope, incontinence)Note that skin symptoms and signs are present in up to 90 percent of anaphylactic episodes. This criterion will therefore frequently be helpful in making the diagnosis.Criterion 2—Two or more of the following that occur rapidly after exposure to a likely allergen for that patient(minutes to several hours):- Involvement of the skin-mucosal tissue (e.g., generalized hives, itch-flush, swollen lips-tongue-uvula).- Respiratory compromise (e.g., dyspnoea, wheeze/bronchospasm, stridor, reduced peak expiratory flow, hypoxemia).- Reduced BP or associated symptoms and signs of end-organ malperfusion (e.g., hypotonia [collapse], syncope, incontinence).- Persistent gastrointestinal symptoms and signs (e.g., crampy abdominal pain, vomiting).Criterion 2 incorporates gastrointestinal symptoms in addition to skin symptoms, respiratory symptoms, and reduced BP. It is applied to patients with exposure to a substance that is a likely allergen for them.Criterion 3—Reduced BP after exposure to a known allergen for that patient(minutes to several hours):- Reduced BP in adults is defined as a systolic BP of less than 90 mmHg or greater than 30 percent decrease from that person’s baseline.- In infants and children, reduced BP is defined as low systolic BP (age-specific)* or greater than 30 percent decrease in systolic BP.* Low systolic BP for children is defined as:•Less than 70 mmHg from 1 month up to 1 year•Less than (70 mmHg + [2 x age]) from 1 to 10 years•Less than 90 mmHg from 11 to 17 yearsCriterion 3 is intended to detect anaphylactic episodes in which only one organ system is involved and is applied to patients who have been exposed to a substance to which they are known to be allergic (for example, hypotension or shock after an insect sting).There will be patients who do not fulfil any of these criteria but for whom the administration of epinephrine is appropriate as in a patient with a history of severe anaphylaxis to peanut who presents with urticaria and flushing that developed within minutes of a known or suspected ingestion of peanut.Although, ACE inhibitor-induced angioedema may presented with similar feature, this patient has other anaphylaxis reactions as such difficulty in breathing & urticaria.

Uterine rupture is often first indicated by abnormal fetal heart rate patterns, such as prolonged, variable, or late decelerations and bradycardia (fetal distress). Studies have found that this was the case in 87% of patients. In some cases, vaginal bleeding was also present, occurring in 11-67% of cases and always accompanied by pain.

– Maternal serum triple marker screening: 15-18 weeks- Post partum visit: 6 weeks after delivery- CVS: 10-12 weeks- Oral glucose challenge test: 24-28 weeks- Rhogam: 28 weeks for RH negative women

Paradoxical respiration (chest wall moves in with inspiration) can occur when a segment of the chest wall moves independently of the rest of the chest wall resulting in a flail chest. This can cause disturbances in respiratory function and impairment of gas exchange. The immediate priority is to stabilise the patient’s condition. This can be done by commencing positive-pressure ventilation assistance through an endotracheal tube (correct answer). After commencing positive pressure ventilation, it is essential to carefully monitor the patient’s physical signs, effectiveness of the gas exchange, and oxygen saturation. Positive-pressure ventilation could exacerbate the small right pneumothorax present, especially if positive end-expiratory pressure (PEEP) ventilation is used. When a large flail segment is present (in this case the patient has six rib fractures) chest strapping will not be effective. The cause of his laboured breathing is the ineffective ventilation resulting from his flail chest. Therefore, aspiration of the small pneumothorax will not a have an immediate effect.Immediate management is to ensure that endotracheal intubation and ventilation are safely and effectively commenced. Subsequently, a right-sided pleural underwater seal drain tube can be inserted as a precautionary measure. Intercostal nerve anaesthetic blockade may also be useful during further management at a later stage, however, it is not the most important step for initial management of this patient.

Cluster A personality disorders are characterized by odd or eccentric behavior. These include paranoid personality disorder, schizoid personality disorder, and schizotypal personality disorder.Cluster B personality disorders are characterized by dramatic, erratic, or unpredictable behavior. These include antisocial personality disorder, borderline personality disorder, histrionic personality disorder, and narcissistic personality disorder.Cluster C personality disorders are characterized by anxious or fearful behavior. These include avoidant personality disorder, dependent personality disorder, and obsessive-compulsive personality disorder.

The nephritic syndrome is a clinical syndrome that presents as hematuria, elevated blood pressure, decreased urine output, and edema. The major underlying pathology is inflammation of the glomerulus that results in nephritic syndrome. It causes a sudden onset of the appearance of red blood cell (RBC) casts and blood cells, a variable amount of proteinuria, and white blood cells in the urine. The primary pathology can be in the kidney, or it can be a consequence of systemic disorders.The treatment in nephritic syndrome is mainly supportive. The treatment consists of:Antihypertensives: Antihypertensives are administered in patients with elevated blood pressure despite dietary salt, fluid restriction, and loop diuretics. In severe cases, hypertension is treated with ACE inhibitors, ARBs, and calcium channel blockers.Diuretics: Loop diuretics may be administered to excrete excess sodium and water retained in the body. It helps to decrease fluid retention in the body. The reduced fluid load on kidneys helps speed up the healing process.Immunomodulators: Immunosuppressive drugs reduce and block the antigenic effects of the inciting agents. It is most useful for rapidly progressive glomerulonephritis. The use of corticosteroids and immunomodulators is controversial in certain causes of the nephritic syndrome, including staphylococcal endocarditis. It can aggravate the sepsis and result in increased mortality.Antibiotics: Post streptococcal GN patients with evidence of streptococcal infection are administered penicillin. Erythromycin is preferred for patients allergic to penicillin. Early treatment of streptococcal infection with antibiotics reduces the severity and incidence of glomerulonephritis.Dialysis: In some cases, the disease has a fulminating course leading to renal failure. In such cases, renal replacement therapy with dialysis is performed.Glucocorticoids, although rarely used in some nephritic cases, are not generally indicated for the management of acute nephritic syndrome. It may be considered in severe cases such as rapidly progressive glomerulonephritis.

Based on the history this is the case of epididymitis/orchitis. The two most likely etiologies of sudden onset, constant, testicular pain with radiation and scrotal swelling are epididymitis/orchitis or testicular torsion. Since the patient has fever and discharge epididymitis is more common. For men < 35 years of age, gonorrhea or chlamydia are the most common infectious organisms leading to epididymitis. So the best choice for this question is Gonorrhea.

Alpha-fetoprotein (AFP) is a plasma protein produced by the embryonic yolk sac and the fetal liver. AFP levels in serum, amniotic fluid, and urine functions as a screening test for congenital disabilities, chromosomal abnormalities, as well as some other adult occurring tumors and pathologies. This tumor marker is a glycoprotein encoded by the AFP gene on chromosome 4q25. Prenatal levels in developing human embryo rise from the end of the first trimester and begin to fall after 32 weeks of gestation. Maternal serum AFP forms part of the triple or quadruple screening tests for fetal anomaly.Moreover, amniotic fluid from neural tube defect-affected pregnancies contains three forms of acetylcholinesterase (AChE), the major species of which is present only in trace amounts in normal pregnancies or those associated with a non-NTD fetal malformation. The activity of this ‘specific’ AChE is increased 62-fold in the presence of NTD and its measurement provides a sensitive and specific test for the biochemical detection of this disorder.Although maternal serum AFP is a sensitive test for NTDs, it could also be elevated due to dating error and thus is not sufficiently specific for NTDs.

The patient presents with the classic symptoms of Rocky Mountain Spotted Fever (RMSF). A toxin from Rocky Mountain wood ticks can cause paralysis in the legs and spread to other muscles during the period the tick is feeding. Paralysis can extend to muscles responsible for respiration and result in death if not treated in time. Incidence of RMSF is rare in Canada but Rocky Mountain wood ticks are found from central Saskatchewan to British Columbia. In US, it is found mostly in North Carolina, Tennessee, Arkansas, Oklahoma, and Missouri.- Anaplasmosis is rare in Canada and most frequently reported from the upper Midwest and northeastern US similar to geographic distribution of Lyme disease. In lab tests, visualization of morulae in the cytoplasm of granulocytes is highly suggestive of a diagnosis. Also, look for antibodies to A. phagocytophilum 7 to 10 days after onset. The gold-standard serologic test looks for a four-fold change in antibody titers.- Babesiosis is most frequently reported from the northeastern and upper Midwestern US in areas where Babesia microti is endemic. In immunocompetent individuals, infection is either subclinical or mild with fever and headache. However, severe outcomes may occur in older patients, infants, and asplenic or immunocompromised patients.- Ehrlichioses is mostly reported in southern US and incidence in Canada is largely unknown. There are two major types of Ehrlichioses and they are: human monocytic ehrlichiosis (HME) caused by Ehrlichia chaffeensis and human granulocytic ehrlichiosis (HE) caused by E. phagocytophila. Symptoms include fever, headache, myalgia and rash. Complications such as respiratory distress syndrome and renal failure occur in 10 – 20% of patients.- Lyme disease often presents with low-grade fever, fatigue, headache, arthralgia, and a painless, erythematous skin lesion known as erythema migrans (EM). If left untreated, the disease may progress to disseminated disease and involve CNS, heart and joints. Currently, Lyme disease is most often seen in Southeastern Canada near the US border.Key point: Rocky Mountain Spotted Fever is a tick-borne disease caused by Rickettsia rickettsii, an obligate intracellular gram-negative bacteria. Along with flu-like symptoms, look for leg paralysis and a rash on palms and soles that spread proximally.

Croup or laryngotracheobronchitis is an acute inflammation of the upper and lower respiratory tract. It is commonly caused by infection with parainfluenza virus type 1. It is characterized by a barking cough and inspiratory stridor. Antipyretics, hydration, nebulized racemic epinephrine, and corticosteroids are used in management. Humidified O2 is administered if O2 saturation falls to < 92%.

With the child’s facial symptoms (Bell’s palsy), his recent trip to Vermont and the rash described (erythema migrans) the most likely diagnosis is Lyme disease. Borrelia burgdorferi is one of the causative agents of Lyme disease in humans. There is usually a recent outdoor activity in the endemic areas like Southern and eastern Ontario, Southeastern Quebec, parts of New Brunswick and Nova Scotia.While prednisone is effective for treating idiopathic Bell’s palsy, it is not appropriate for treating the underlying Lyme disease.Use of doxycycline in children under 8 years of age is associated with teeth discoloration.Clarithromycin is not the best treatment option for Lyme disease.Ice packs on face is not effective for treating Lyme disease.Lyme disease is treated with doxycycline in adults and children over the age of eight, and amoxicillin in children under the age of eight.

Hemochromatosis is a disorder associated with deposits of excess iron that causes multiple organ dysfunction. Normally, iron absorption is tightly regulated because the body is incapable of excreting excess iron. Hemochromatosis occurs when there are high pathologic levels of iron accumulation in the body. Hemochromatosis has been called “bronze diabetes” due to the discoloration of the skin and associated disease of the pancreas. Hereditary hemochromatosis is the most common autosomal recessive disorder in whites. Secondary hemochromatosis occurs because of erythropoiesis disorders and treatment of the diseases with blood transfusions. After the damage of transfused red blood cells by macrophages, iron freed from heme is accumulated in the body.Clinical signs of the condition depend on the organ system that is affected the most. Patients usually are asymptomatic until adulthood, and often a diagnosis will not be made until multiple systems are affected. Symptoms are related to the organ affected, but almost all patients complain of severe fatigue. Patients are typically symptomatic for up to ten years before diagnosis. A high index of suspicion, combined with a thorough family history, is required to diagnose this condition.Women with hemochromatosis become symptomatic later in life than men due to the blood loss and consequent iron excretion associated with regular menstruation.

Many difficulties can occur with the percutaneous installation of central venous lines. The most significant consequences differ according to the placement site. Injury to the adjacent artery, however, is a severe danger with all line placements. The occurrence of a cold foot without pulses on the side ipsilateral to the line placement clearly suggests that the femoral artery has been damaged in this case.

• Patient is likely suffering from a pulmonary embolism (PE).• Acute onset chest pain and shortness of breath, risk factors include smoking, cancer, and recent long flight.• Treatment of PE in hemodynamic instability includes systemic administration of recombinant tissue plasminogen activator or catheter directed thrombolysis.• Treatment of PE in hemodynamically stable patients includes anticoagulation.• Thrombolysis may also be appropriate in hemodynamically stable patients with signs of acute right ventricular failure.• Warfarin is not the best choice for this patient acutely.

Cauda equina syndrome (CES) is caused by compression or irritation of the roots of the lumbosacral nerve below the conus medullaris (below the L2 level) and by narrowing the space in the vertebral artery below L2. It is usually caused by a herniated disc with or without spinal stenosis, a vertebral fracture, and a tumor. Symptoms are usually intense and affect all three types of neurons (human, sensory, and autonomic). Symptoms of lower extremities include weakness/ paraparesis and decreased deep tendon reflexes (patellar and/or ankle). Nerve involvement includes low back pain that radiates to the legs, loss of consciousness or pain, and sedative (S2-S5). Patients may also have urinary retention and/or fecal insufficiency due to loss of anal sphincter tone.CES is a disease that commonly mimics disc herniation / spinal stenosis, but saddle anesthesia and vesicular or rectal dysfunction are warning signs that distinguish CES from less serious causes of back pain. Prompt examination and decompression of the affected area are necessary to preserve the intestines, bladder, and sexual function and to prevent the possible progression of paraplegia. This is a medical emergency so we need immediate treatment.MRI is currently the preferred course in screening patients with suspected CES. However, it is contraindicated in patients with pacemakers, aneurysm clips, and pieces of metal near vital organs. CT with myelography can be used as an alternative. MRI findings in patients with CES often indicate compression and/or narrowing of the vertebral spine in the lower lumbar and sacral (option D), which may confuse disc herniation or spinal stenosis. Therefore, patient history plays an important role in distinguishing CES from common causes of back pain.→ Spinal cord injury causes Brown-Sequard syndrome, not CES.→ Herniation of the cerebellar tonsils below the foramen magnum level (option B) is associated with type 1 Chiari impairment in about 70% of cases of syringomyelia, but not CES.→ Thoracic spine insertion is seen in disc herniation, but CES affects the lumbar and sacral spine, not the thoracic.→ Ventricular growth near cerebrospinal fluid (CSF) of the brain is present in patients with normal hydrocephalus pressure and not CES. Common side effects of NPH include triad – ataxia/apraxia, urinary incontinence, and dementia.Key point:MRI findings in patients with cauda equina syndrome often show compression and/or narrowing of the vertebral spine in the lower lumbar and sacral areas, which may confuse disc herniation or spinal stenosis.

Anorexia nervosa mainly affects teenage girls and young women. People with anorexia typically weigh 15% or more below the expected weight for their age, sex and height and often have BMI below 17.5. Concerning this patient, and since her BMI is under 18, then this most likely reflects her anorexic state and confirm her diagnosis with anorexia nervosa in addition to the other parameters, namely the potassium level.

Anticholinergics (e.g. tricyclic antidepressants, antihistamines, and benztropine), when overdosed, manifests as agitated delirium, tachycardia, visual hallucinations, hyperthermia, dilated pupils, dry flushed skin, urinary retention, and constipation. Opiates (e.g. morphine, codeine, oxycodone, fentanyl and buprenorphine) overdose manifest as respiratory depression, constricted pupils, bradycardia, and decreased the level of consciousness.

This patient is hemodynamically unstable and has severe abdominal pain. The most likely diagnosis in this patient is placental abruption. 20% of patients with placental abruption bleed into the retroplacental space (concealed abruptio placentae) and may not have overt vaginal bleeding. A high degree of suspicion may be required to diagnose these patients. Abdominal pain is almost always present and should raise the suspicion of abruptio placenta. Chorioamnionitis is less likely in the absence of fever, spontaneous rupture of membranes, dysuria, and burning micturition. Placenta previa is incorrect because these patients present with vaginal bleeding. Preeclampsia is unlikely in the absence of hypertension and edema. This patient has hypotension and is hemodynamically unstable. Thromboembolism is incorrect because it presents with unilateral leg swelling, dyspnea, and hemoptysis.