– Transient tachypnea of the newborn (TTN) is a common cause of respiratory distress in newborns.- It is characterized by tachypnea with the respiratory rate being above 60 breaths per minute, cyanosis and increased work of breathing.- It usually resolves within 24 hours but may persist up to 72 hours.- Treatment is supportive with nutrition, good temperature control and supplemental oxygen if needed.- Intubation is not necessary unless a different disease process is underlying.- Diuretics have not been proven effective when treating TTN.- Fluid restriction may be considered in severe cases of TTN where respiratory support was needed for longer than 48 hours.- IV fluid hydration may be considered with high respiratory rates or when increased work of breathing prohibits oral feeding.

– Paget disease of bone is a bone remodelling disorder with excessive bone resorption followed by an increase in bone formation- It is the second most common metabolic bone disorder after osteoporosis- Symptoms include bone and/or joint pain, bone deformity, hearing loss, nerve root compression, spinal stenosis, pathologic fractures, secondary osteoarthritis, osteosarcoma, and high-output heart failure- Radiographs are usually diagnostic, showing the characteristic deformity of bone, with cortical thickening marked by tunnelling, and coarsened trabeculae

This patient has a history of prednisolone intake (steroid). The most likely diagnosis is steroid-induced acne. It has a sudden onset and patients will give a history of use of steroid medications. The lesions will appear monomorphic (at the same stage of development). The usual areas of involvement are the upper trunk. Pityriasis rosea is an acute self-limiting disorder affecting young adults and teens. Lesions have a characteristic pattern and shape, described as thin oval plaques, often with a central scale, and a characteristic herald patch. This is not what is seen on this patient’s physical examination. Acne vulgaris – while the patient does have findings that are suggestive of acne vulgaris on her face, these lesions include comedones and are described as being in various stages of healing. However, the new symptoms of rash are of sudden onset and the question asks the most likely diagnosis of the new symptoms. Varicella – this rash is characterized by 2-3 successive crops of diffuse, pruritic vesicles or papules over several days. These lesions evolve into pustules and crusted erosions so that various stages of development are present together. Acne rosacea – a chronic skin disease that usually affects persons aged 30-50 years. The course is chronic with remissions and relapses. It most commonly affects the face and is characterized by flushing and telangiectasias. This does not describe the findings here. Note: Steroid-induced acne has an explosive onset and tends to involve the upper trunk. Patients present with acneiform lesions that are all at the same stage of development and history of topical or oral steroid use.

One of the criteria for use of supplemental oxygen is hypoxia, which this patient with moderate COPD and moderate non pulmonary arterial hypertension pulmonary hypertension has. Sildenafil and nifedipine are utilized in pulmonary arterial hypertension. However there is little evidence to support their use in pulmonary hypertension associated with chronic lung disease and/or hypoxemia.Low-dose prednisone may be a possible option in the future.

In type 2 (hypercapnic) respiratory failure, the PaCO2 is greater than 50 mmHg, and PaO2 may be normal or, in the event of respiratory pump failure, low.Symptoms and signs of hypercapnia:- Headache- Change of behavior- Coma- Asterixis- Papilloedema- Warm extremitiesCarbon dioxide (CO2) narcosis is a condition that develops when excessive CO2 is present in the bloodstream, leading to a depressed level of consciousness. This condition largely results from lung disease, hypoventilation, or environmental exposure. Hypercapnia, a state of elevated serum carbon dioxide (CO2), can manifest as a broad spectrum of disease, the most severe of which is CO2 narcosis. The delineating feature of CO2 narcosis is a depressed level of consciousness. It is essential to recognize impending or current CO2 narcosis.Adults with COPD have extensive collateral ventilation secondary to airway destruction and thus are less likely to develop resorption atelectasis in the presence of an obstructing lesion (i.e., intrathoracic tumor). The use of high inspiratory oxygen concentration (high FiO2) during induction and maintenance of general anesthesia also contributes to atelectasis via absorption atelectasis. Room air is 79% nitrogen| nitrogen is slowly absorbed into the blood and therefore helps maintain alveolar patency. In contrast, oxygen is rapidly absorbed into the blood.

Counseling on tobacco use and other substance abuse is recommended as part of all routine preventive care.- Mammograms are not recommended until age 50.- Lead screening is recommended for at-risk individuals between 6 months and 6 years of age.- Colorectal cancer screening for average-risk individuals is recommended at age 50.- The Preventive Services Task Force recommends a routine physical examination every 3-5 years for young adults until the age of 40.

Hypoxia can be caused by disorders of the respiratory and/or cardiovascular system or blood and there are different types. 1. Hypoxic hypoxia – there is a reduction in PaO2 and as a result, there is consequent reduction in % saturation and oxygen concentration in blood. Cyanosis is a known sign of this form of hypoxia. 2. Anemic hypoxia – PaO2and % saturation are normal, but the blood oxygen concentration is low as a result of the low oxygen carrying capacity of blood. Because the % saturation of hemoglobin is normal in anemic hypoxia, there is no cyanosis.3. Stagnant hypoxia – all oxygen parameters in arterial blood are normal, but there is low tissue perfusion which impairs the delivery of oxygen to tissues. Sluggish circulation might lead to peripheral cyanosis. 4. Histotoxic hypoxia – oxygen parameters and tissue perfusion are normal, but the tissue cannot extract oxygen from the blood, and cyanosis is not a feature.Blood volume and cardiac output drops with dehydration, and so, severe dehydration is the correct answer. There is low cardiac output and pulmonary blood flow is reduced. Carbon dioxide elimination is sometimes impaired. In this situation, a high discrepancy between PaO2 and end-tidal PCO2(from capnography) may develop.In hypoventilation, whatever air ventilates the lung eliminates CO2and the discrepancy between PaO2 and end-tidal PCO2(from capnography) is not usually high.In anemia, carbon dioxide elimination is unaffected. Most CO2in blood is transported as bicarbonate and is not bound to hemoglobin.High cardiac output leads to increased pulmonary blood flow and improves CO2 elimination. Discrepancy between PaO2 and end-tidal PCO2(from capnography) would be reduced.Increases in dead space lead to decreases in end-tidal PCO2 as the air coming from over ventilated alveoli would have low PCO2 as this air did not equilibrate with blood.

– Ipratropium bromide is an anticholinergic agent- Nebulized ipratropium can cause inadvertent ocular effects such as blurred vision and pupil inequality- Ipratropium has been shown to decrease the rate of hospital admissions in severe asthmatic attacks- Corticosteroids may elevate glucose levels in diabetic patients, but the onset would be more gradual- Adrenergic agents used for acute asthma do not commonly produce adverse ocular effects (level of evidence 3)

Eosinophilia generally represents an allergic reaction or parasitic infection. Since in this case, the person has eaten BBQ, he might have suffered from a parasitic infection. Diagnosis of this condition involves stool study for ova and parasites.

Ascites is the abnormal buildup of fluid in the abdomen. Technically, it is more than 25 ml of fluid in the peritoneal cavity, although volumes greater than one liter may occur. Symptoms may include increased abdominal size, increased weight, abdominal discomfort, and shortness of breath. Complications can include spontaneous bacterial peritonitis.The serum to ascites albumin gradient (SAAG) < 1.1 seen in this patient indicates non portal hypertension and suggests a peritoneal cause of ascites. Examples include tuberculosis, pancreatitis, nephrotic syndrome and various types of peritoneal cancer.- The ascites is most likely caused by cirrhosis due to chronic hepatitis is incorrect. We do not know how long the patient has had Hepatitis B. Also cirrhosis is most likely to cause an ascites with SAAG > 1.1, which is not the case in this patient.- This patient’s ascites is most likely due to alcoholic liver disease is incorrect. While excessive alcohol intake is the most common cause of liver cirrhosis in North America, the ascites that results is usually a transudate or SAAG > 1.1. This is not the likely cause of this patient’s condition given the SAAG value.

The best next step is referral for colonoscopy as the patient is presenting with several red flags, including:1) Age > 502) Change in stool calibre3) Obstructive symptomsOther red flag symptoms which are indicative of a colonoscopy referral are:4) Heme – positive stools5) Iron deficiency anemia6) Rectal bleeding.It is vital to exclude malignancy prior to commencing treatment.Lifestyle modifications, Phosphosoda enemas, and Trial of lactulose are management strategies indicated after the elimination of the possibility of malignancy.Biofeedback training is used to manage pelvic floor dysfunction caused by loss of coordination of pelvic floor muscles whilst attempting an evacuation. It usually presents as prolonged or excessive straining, soft stools that are difficult to pass, and rectal discomfort.Key point: Red flags for colonoscopy referral (to exclude malignancy) include age >50, a change in stool calibre, obstructive symptoms, heme-positive stools, iron deficiency anemia, and rectal bleeding.

In a diabetic patient with well-controlled blood glucose levels, the most common cause of sudden onset hypoglycemia is diabetic renal disease, provided that diet and insulin regimen changes have been ruled out. Since the kidneys metabolize exogenous insulin, any impairment in kidney function would cause an increased half-life of insulin as it is not being cleared out of the bloodstream. Spontaneous improvement of beta-cell function: After chronic diabetes mellitus, 15 years, in this case, spontaneous improvement of beta-cell function would be highly unlikely.A reduction in physical activity: Any reduction in physical activity would cause impaired glucose uptake, leading to hyperglycemia rather than hypoglycemia.Insulin antibodies: Insulin antibodies would appear earlier in the disease course and not after 15 years of therapy. Additionally, the presence of antibodies would increase insulin requirements and cause hyperglycemia.Islet cell adenoma: While an islet cell adenoma can cause fasting hypoglycemia, it is uncommon, and it is more important to rule out more common causes first, such as renal disease.

– Spontaneous abortion is defined as expulsion of an embryo or fetus weighing 500g or less, typically corresponding to a gestational age of 20-22 weeks or less- Risk factors include advanced maternal age, previous spontaneous abortions, smoking, cocaine use, NSAIDs use, high caffeine consumption, prolonged ovulation to implantation interval, prolonged time to achieving pregnancy, maternal weight (BMI less than 18.5 kg/m² or above 25 kg/m²), untreated celiac disease- Management depends on type of spontaneous abortion| watch and wait for threatened abortions, ectopic pregnancy should be ruled out with any vaginal bleeding in early pregnancy- DIC, molar pregnancies, placental abruption and thrombocytopenia are unlikely in this case

Seizures are sudden, abnormal electrical activity in the brain that can cause convulsions or go unnoticed. Between 5-10% of the population will experience at least one seizure, with the highest incidence occurring in early childhood and late adulthood. Causes of seizures can include sleep deprivation, metabolic abnormalities, infections, trauma, and drug or alcohol withdrawal. Epilepsy is not the same as a seizure, and requires two unprovoked seizures to be diagnosed. When a new drug is prescribed or its dose is changed, it takes at least five half-lives of the drug for its blood levels to reach a steady state.

• Six-month regimen is used for patients with culture-positive TB, consisting of Isoniazid, Rifampin, Pyrazinamide, and Ethambutol. • All four agents are used for the initial 2 months, followed by Isoniazid and Rifampin for the continuation phase of 4 months. • Mechanism of action, possible adverse effects, and properties of the four drugs: Isoniazid (inhibits synthesis of the Mycobacterial cell wall, hepatotoxicity in fast acetylators, neuropathy in slow acetylators), Rifampin (inhibits DNA-dependent RNA polymerase, inhibits RNA synthesis, minor: nausea, jaundice), Pyrazinamide (inhibits mycolic acid synthesis, inactive at pH:7.4, active at acidic pH in phagosomes, hepatotoxicity, urate underexcretion), Ethambutol (inhibits arabinosyl transferase, visual disturbances from retrobulbar neuritis, urate underexcretion).

Infection from the varicella-zoster virus (VZV) most commonly occurs in childhood and is spread by airborne, droplet, and contact transmission. Herpes zoster results from reactivation of the latent VZV within a sensory nerve ganglion, often presenting decades after the initial infection. The disease typically presents as a unilateral maculopapular or vesicular rash in a single dermatomal distribution. Herpes zoster ophthalmicus (HZO) is defined as the viral involvement of the ophthalmic division (V1) of the trigeminal cranial nerve (V).While the diagnosis of HZO does not necessarily imply eye involvement, ocular disease occurs in about 50% of HZO cases. Ocular manifestations can include conjunctivitis, uveitis, episcleritis, keratitis, and retinitis. The condition is considered an ophthalmologic emergency due to the risk of vision loss if not quickly identified and treated early in the disease course, thus a consultation with an ophthalmologist is necessary.

Idiopathic thrombocytopenic purpura is also called immune thrombocytopenia. It is defined as isolated thrombocytopenia (low platelet count, less than 100,000) in the presence of:- petechial rash- bruising or- bleedingThe child or adult is healthy otherwise. The treatment of ITP includes:1. restriction of activities posing a bleeding risk when platelet count < 30,000/microL2. avoid antiplatelet medications3. steroids such as prednisone are the first-line treatment for:-children with non-life-threatening mucosal bleeding and/or decreased health-related quality of life- adults with a platelet count of less than 30 x 10/L who are asymptomatic and have minor mucosal bleedingOther treatments used in ITP are:- splenectomy- IV immune globulin- thrombopoietin receptor agonist – Rituximab

This patient is suffering from acute kidney injury. According to his history, the cause of it is most likely to be the intravenous contrast material which was used for his CT scan recently.He is at risk of developing acute kidney injury as he had a long-standing history of diabetes mellitus and hypertension which could have already resulted in renal impairment. This is supported by the decrease need for insulin as kidney is the organ that metabolizes and excrete insulin. With kidney impairment, there will be increase insulin in the circulation, thus increasing the risk of hypoglycaemia. Contrast media causes acute kidney injury via multiple mechanisms. Firstly, they have a direct cytotoxic effect on the renal proximal tubular cells. They produces reactive oxygen species that induce cellular damage. Lastly, contrast media increases renal vasoconstriction leading to reduced renal blood flow. These effects are more prominent in those with underlying kidney disease. – Although it is likely that he is having hyperkalemia-related arrhythmia, but it is not the cause of his acute renal failure.- Diabetic ketoacidosis is seen in patients with diabetes mellitus type 1 with poor insulin compliance. Features that go against the diagnosis of diabetic ketoacidosis include no altered level of consciousness, and normal breath smell. It also does not explain the cause of his acute kidney injury. – Acute kidney injury could be cause by prerenal, intrinsic and post-renal cause. This patient does not have risk factor for prerenal or postrenal cause of AKI as he is a previously healthy man in the middle-age group, with no history of heart diseases. Hence, acutely decompensated chronic heart failure and benign prostatic hyperplasia induced oliguria are unlikely.

In this case, the patient has atrial fibrillation which is most likely as a result of her congestive heart failure. The management strategies for such patients includes antiarrhythmic treatment (such as digoxin and beta-blockers) and anticoagulants (such as heparin and warfarin) to reduce the risk of thrombosis and strokes. Warfarin use can have adverse side effects, including warfarin-induced skin necrosis, as described in this case, which usually occurs between the 3rd and 6th day of warfarin therapy. This often presents as localized paresthesias with an erythematous flush, which tend progresses to petechiae and hemorrhagic bullae, possibly leading to full-thickness necrosis, with pain usually experienced in affected areas. Warfarin-induced skin necrosis is an uncommon but known side effect of warfarin therapy. The cause is unknown, but it is hypothesised that it can be a result of direct toxic effect (toxic vasculitis) at the intersection of the precapillary and arterial capillary of the dermovascular loop. It can also be a result of thrombosis, a hypersensitivity and deficiencies in factor VII, protein C and protein S which cause the formation of paradoxical blood clots which block blood vessels and interrupt blood supply to the area supplied by the vessel in question. It is predominant in women, often affecting breasts, buttocks and thighs. Risk factors for developing warfarin-induced skin necrosis include protein C deficiency, lupus, protein S, factor V leiden and antithrombin III deficiency.The patient’s history notes that the patient had a child who died of purpura fulminans, which is a fatal condition associated with a genetic protein C deficiency, which is a contraindication for warfarin therapy, and the most likely cause of warfarin-induced skin necrosis as protein C acts as an innate anticoagulant, and warfarin works to decrease its normal concentration. Heparin should be the anticoagulant agent of choice for this patient. Heparin therapy also has adverse side effects related to long-term use. These include decreased aldosterone secretion, osteoporosis and alopecia.Triple receptor-negative, E-cadherin overexpression is often found in relation to inflammatory breast cancer.Antithrombin III deficiency can cause warfarin-induced skin necrosis, but given this patient’s family history includes the death of a child from purpura fulminans, making her diagnosis more likely to be genetic protein C deficiency.Clostridium perfringens is a common infectious agents related to the occurence of an acute necrotizing fasciitis.Hyperhomocysteinemia occurs in relation to a hypercoagulable state and an increased risk of thrombotic events. It is not a known cause of warfarin-induced skin necrosis.

– Leukocyte scans are sensitive for diagnosing foot ulcers- MRI is now the imaging study of choice when osteomyelitis is suspected- MRI has a sensitivity and specificity of 90% or greater in diabetic patients

In schizophrenia patients treated with antipsychotics, especially the second generation/ atypical antipsychotics such as clozapine and olanzapine are at an increased risk of type 2 diabetes. Potential metabolic consequences of using antipsychotics include weight gain, hyperglycemia and dyslipidemia. Due to these metabolic disturbances, the risk of comorbid hypertension and heart disease are increased.

The correct answer is acute bronchiolitis, which is a viral illness that is most frequently caused by the respiratory syncytial virus (RSV). The peak incidence occurs at 6 months of age. The illness causes a few days of mild upper respiratory symptoms, then increased coughing and wheezing. Examination usually reveals tachypnea and often there is intercostal retractions, seem by the use of the accessory muscles of respiration. Acute asthma is uncommon in the first year of life, and is difficult to diagnose without recurrent episodes or prior respiratory problems. With croup, the presenting complaint is usually stridor. Pertussis and pneumonia do not usually present with wheezing.

MRI is the best way to evaluate SB, but it may also show distention of the fluid-filled sac which is not specific for SB. An impingement test may be positive with SB and/or rotator cuff pathology. In cases where clinicians find it difficult to differentiate between the differential diagnoses of shoulder pain based on history and clinical examination alone, further diagnostic testing should be considered.

A Colles’ fracture refers to a complete extra-articular fracture of the distal portion of the radius bone in the forearm, resulting in the dorsal and radial displacement of the fragment of the distal radius. It is a common fracture that most commonly occurs as a result of a fall on an outstretched hand (FOOSH) while the forearm is pronated in dorsiflexion.The appropriate management of a Colles’ fracture includes orthopedic intervention and a rehabilitation program to preserve hand, wrist and elbow functions.The appropriate reduction technique for this case is a closed reduction with a cast applied below the dorsal elbow to immobilize the wrist in 20° palmar flexion and in 20° ulnar deviation for 6 weeks.A closed reduction is performed by producing traction with extension to exaggerate the injury, then traction using ulnar deviation, pronation and flexion of distal fragment.Slight extension, full pronation, and full ulnar deviation is wrong as ulnar deviation should be performed after the initial extension, and then the pronation and flexion of distal fragment.Slight flexion, full supination, and full radial deviation is wrong as the first step should be an extension, and the final step an ulnar deviation.Slight extension, full supination, and full ulnar deviation is wrong as supination is not included of the closed reduction of a Colles’ fracture injury.Slight extension, full pronation, and full radial deviation is wrong as it should be an ulnar deviation.

Research has shown that pregnancy does not worsen ulcerative colitis and that the medications sulfasalazine and corticosteroids do not have any negative effects on the mother or fetus. Additionally, the risk of miscarriage, stillbirth, and congenital abnormality for women with ulcerative colitis in remission is the same as that for healthy women.

Case-control studies begin with the outcomes and do not follow people over time. Researchers choose people with a particular result (the cases) and interview the groups or check their records to ascertain what different experiences they had. They compare the odds of having an experience with the outcome to the odds of having an experience without the outcome. That is, a case-control study compares two groups of people: those with the disease or condition under study (cases) and a very similar group of people who do not have the disease or condition (controls). This best depicts the described scenario. Here, the children with the ear infections are the cases and the other group of children are the control group.

The patient is suffering from HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome. If the cervix is favorable, labor induction with oxytocin is the appropriate management. However, in case of unfavorable cervix, cesarean delivery should be considered.HELLP syndrome has historically been classified as a complication or progression of severe preeclampsia. This progression, however, has been challenged with recent publications that suggest these pathologies have their own etiologies. Although there is still an overlap between preeclamptic pregnant women who develop HELLP syndrome, their association is not as straightforward as once thought to be. Genetic analysis of the heritability of predisposition for preeclampsia and/or HELLP syndrome in pregnancy has also been explored. Results show both genetic and immunological factors that play a role in pathogenesis.Given the lack of clinical trials for the management of HELLP syndrome based on the gestational age of presentation, many treatments are experimental in nature, and there has been a little significance in the improvement of perinatal outcomes between expectant management versus delivery before 34 weeks. That being said, the course of true HELLP syndrome has the potential to quickly turn life-threatening for both mother and fetus. Therefore the recommendation is always to hospitalize patients for strict monitoring of laboratory values. During hospitalization, patients should be treated as severely pre-eclamptic and should receive magnesium sulfate for seizure prophylaxis along with blood pressure control with hydralazine, labetalol, or nifedipine in usual recommended fashion.

The patient’s clinical picture is consistent with a small bowel obstruction. The distended bowel is unable to absorb fluid and electrolytes at a normal rate. thus, fluid resuscitation is important.Fluid loses can lead to hypovolemia and shock, compounded with vomiting. Nasogastric suction provides enteral decompression by removing accumulated gas and fluid proximal to the obstruction. A surgical consult is necessary as the patient might need to be sent to the OR to relieve the obstruction. An old surgical adage states “Never let the sun set or rise on a bowel obstruction.” Broad-spectrum antibiotics are appropriate when surgery is planned or when there is suspicion for vascular compromise or bowel perforation. Stool softener and enemas have no role in acute intestinal obstructions caused by mechanical causes. Adult SBO are diagnosed with an abdominal plain film, or CT scan, not by ultrasound.

This patient’s most likely diagnosis is orbital cellulitis, a pediatric disease with a median age of 7 years. Symptoms include proptosis, pain on eye movement, decreased vision, conjunctival chemosis, and elevated intraocular pressure. Common causes are Staphylococcus aureus, Streptococcus pneumonia, Streptococcus pyogenes, Haemophilus influenzae, anaerobic infections, and fungal infections. Orbital cellulitis is an ocular emergency and is usually caused by an extension of an infection from the periorbital structures, with over two thirds of cases being a complication of ethmoid sinusitis.

The clinical presentation of this patient suggests lead poisoning. While symptoms of lead poisoning are often non-specific, her symptoms, physical examination findings, and exposure to lead at her battery manufacturing factory all point to this diagnosis.Peripheral blood smear in lead poisoning shows basophilic stippling and ringed sideroblasts.Rouleaux formation is usually seen in patients with paraproteins or marked hypergammaglobulinemia. It is a pseudo-agglutination of red blood cells that produces regularly spaced clusters adhering side to side resembling coin stacks.Howell-Jolly bodies are seen in patients with functional hyposplenia or who had splenectomy. They are small, dense, perfectly round basophilic red cell inclusions, representing nuclear material from nuclear fragmentation.Target cells are seen in liver cirrhosis, thalassemia, HbC disease, and asplenia.Helmet cells or schistocytes are usually associated with ny type of hemolysis like disseminated intravascular coagulation, thrombotic thrombocytopenia purpura, autoimmune hemolytic anemia, and traumatic hemolysis.