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Consequently, typical antipsychotics, such as haloperidol, that block dopamine D2 receptors, have been used. Unfortunately, dopamine antagonism has adverse effects, such as interfering with the normal feedback inhibition of dopamine in the hypothalamicpituitary axis. Since dopamine inhibits prolactin secretion from the anterior pituitary, the blockade of dopamine receptors may cause hyperprolactinemia and galactorrhea. Antipsychotics may cause an imbalance in dopamine and muscarinic receptor antagonism, which results in extrapyramidal adverse effects, such as dystonia, akinesia, akathisia, and tardive dyskinesia. Dystonia is characterized by sustained and prolonged contraction of agonist and antagonist muscles producing abnormal postures. Akinesia is the absence of movement, while akathisia refers to the feeling of restlessness that is relieved by movement. Tardive dyskinesia commonly presents as involuntary choreiform movements of the lower face, characterized by rhythmic protrusion of the tongue, lip smack- ing, and chewing. Ataxia, or poor coordination, is a known adverse effect of lithium but not neuroleptics. Typical antipsychotics have an antimuscarinic effect that can cause constipation, not diarrhea. Typical antipsychotics have anti-a-receptor effects that can cause hypotension, not hypertension. Typical antipsychotics have an antihistamine effect that causes sedation, not insomnia. This patient has Hashimoto thyroiditis, an autoimmune disorder in which patients have antibodies attacking thyroglobulin, thyroid peroxidase, or another part of the thyroid gland or thyroid hormone synthesis pathway. Addison disease does have a high prevalence in patients with Hashimoto thyroiditis. Conn syndrome, which is also known as primary hyperaldosteronism, usually results from a solitary aldosterone-secreting adenoma of the adrenal cortex. Signs of this condition include hypotension, skin hyperpigmentation, hyponatremia, and hyperkalemia. Glitazones such as rosiglitazone and pioglitazone are thiazolidinediones used to increase sensitivity to insulin. They stimulate peroxisome proliferator-activated receptor-gamma, leading to increased glucose uptake in muscle and adipose tissue. Sulfonylureas such as glyburide and glipizide stimulate the release of endogenous insulin stores. They close potassium channels in b cells, leading to an influx of calcium, cell depolarization, and insulin release. The pituitary sits immediately behind the optic chiasm, and increases in its size may lead to impingement on the nasal tracts that cross in the midline of the chiasm, causing bi-temporal hemianopia. Loss of vision only in the right eye is caused by lesions of the right eye or right optic nerve that are distal to the optic chiasm. Left homonymous hemianopia is caused by a lesion of the right optic tract that is just proximal to the optic chiasm. Left-upper-quadrant anopia is caused by a lesion in Meyer loop in the temporal lobe on the right. Left-lower-quadrant anopia is caused by a lesion in the dorsal optic radiation that goes through the parietal lobe. The clinical picture is marked by hypertension, weight gain, moon facies, truncal obesity, hyperglycemia, striae, and osteoporosis. Depression, constipation, and fractures are symptoms that are associated with hyperparathyroidism. Other commonly associated symptoms include kidney stones, chronic renal insufficiency, gallstones, pancreatitis, weakness, fatigue, and valvular calcifications. Pheochromocytoma usually results from neoplasms of the adrenal medulla that secrete catecholamines. Classic symptoms of Pheochromocytoma include the "5 Ps": elevated blood Pressure, Pain (headache), Perspiration, Palpitations, and Pallor with diaphoresis. Though its mechanism of action is poorly understood, metformin, a biguanide, is thought to decrease serum glucose levels by stimulating glycolysis in peripheral tissues and decreasing hepatic gluconeogenesis. Insulin and insulin analogs bind the insulin receptor on cell membranes, subsequently activating a tyrosine kinase that leads to the absorption of glucose into the cell.

Upon questioning, the patient denies coronary or lipid abnormalities but admits to having multiple sinus infections and a chronic productive cough. An anxious young woman presents to the emergency department because of acute-onset severe abdominal pain. A 65-year-old woman with a history of anxiety presents to her doctor with renewed anxiety. She had been prescribed barbiturates in the past, but has heard that benzodiazepines are now more commonly prescribed. Which of the following statements accurately contrasts the features of benzodiazepines with barbiturates A 3-week-old girl is brought to the emergency department by her mother, who says her daughter has suddenly developed a large, tense bulge on the top of her head and a fever. The mother also notes that the patient has become more irritable and has not been feeding well. The patient undergoes lumbar puncture, and a Gram stain of cerebrospinal fluid is shown in the image. Which of the following best characterizes the disease-causing agent in this patient Which of the following would, if present, predispose a patient to the condition causing symptoms in this woman A 42-year-old man with no medical history visits a doctor after he develops sudden, unilateral left-arm weakness after an argument with his wife. He states that he packed up a few of his things and walked out, but when he got to the garage, he could not open the car door. Physical examination findings are normal except for 0/5 strength in his left arm and 2+ deeptendon reflexes. Ultrasonography reveals a blockage in the hepatic venous connection to the inferior vena cava and absence of any waveform in the hepatic veins. A 4-year-old boy with a history of mental retardation and seizures is brought to the physician with a three-month history of worsening shortness of breath. When at rest, his left eye is deviated downwards and laterally, as pictured in the image. Also, the left lid droops, and the left pupil is dilated and unresponsive to light. Which of the following culture conditions would aid in identifying the most likely single causative organism The system will measure radiolabeled glucose levels in cell culture media both before and at intervals after the addition of insulin. Which of the following cell types is the best choice for use in this experimental system A 61-year-old man with a medical history of cancer presents with a two-week history of constant and severe headaches that are most severe when he wakes up in the morning. Physical examination shows a healing ecchymotic lesion on the right forearm, papilledema in the left eye, a right-sided pronator drift, and weakness of the right arm. A 24-year-old man is brought to the emergency department by his mother because of a change in mental status. Physical examination reveals a febrile, dysarthric patient with retinal hemorrhages and numerous crusted puncture marks on his left forearm. Myasthenia gravis is an autoimmune disorder that affects approximately 3 in 100,000 people. Individuals with mysasthenia gravis classically present with complaints of muscle weakness and fatigue secondary to the formation of autoantibodies directed against the acetylcholine receptors at neuromuscular junctions. The most accurate method of diagnosis involves the detection of these autoantibodies. If an individual has a positive test for autoantibodies against the acetylcholine receptor, what is the approximate posttest probability of having this disease, assuming a pretest probability of 50% A 55-year-old alcoholic woman presents to the emergency department because of bloody emesis.

Liver biopsy may be required in affected individuals to evaluate possible cirrhosis or to quantify tissue iron. Death in untreated pts results from cardiac failure (30%), cirrhosis (25%), and hepatocellular carcinoma (30%); the latter may develop despite adequate Fe removal. Less frequent phlebotomy is then used to maintain serum Fe at 27 mol/L (150 g/dL). However, a definite diagnosis requires demonstration of the specific enzyme deficiency or gene defect. Acute Intermittent Porphyria this is an autosomal dominant disorder with variable expressivity. Porphyria Cutanea Tarda this is the most common porphyria and is characterized by cutaneous photosensitivity and, usually, hepatic disease. It is due to deficiency (inherited or acquired) of hepatic uroporphyrinogen decarboxylase. Erythropoietic Porphyria In erythropoietic porphyria, porphyrins from bone marrow erythrocytes and plasma are deposited in the skin and lead to cutaneous photosensitivity. Chronic skin changes may include lichenification, leathery pseudovesicles, labial grooving, and nail changes. Protophorphyrin levels are increased in bone marrow, circulating erythrocytes, plasma, bile, and feces. Cholestyramine or activated charcoal may promote fecal excretion of protoporphyrin. For initial neurologic therapy, trientine and zinc are recommended for 8 weeks, followed by therapy with zinc alone. Trientine may induce bone marrow suppression and proteinuria, and free serum copper levels (adjusting total serum copper for ceruloplasmin copper) must be followed for a therapeutic response. Memory can be tested by asking the pt to immediately recall a sequence of numbers and by testing recall of a series of objects after defined times (e. Recall of major historic events or dates of major current events can be used to assess knowledge. Evaluation of language function should include assessment of spontaneous speech, naming, repetition, reading, writing, and comprehension. Additional tests such as ability to draw and copy, perform calculations, interTable 183-1 the Mini-Mental Status Examination Points Orientation Name: season/date/day/month/year Name: hospital/floor/town/state/country Registration Identify three objects by name and ask patient to repeat Attention and calculation Serial 7s; subtract from 100 (e. Thigh Iliopsoas Glutei Quadriceps Adductors Hamstrings Foot Gastrocnemius Tibialis ant. Check for failure to move fully in particular directions and for presence of regular, rhythmic, involuntary oscillations of eyes (nystagmus). Examine sensation over entire face as well as response to touching each cornea lightly with a small wisp of cotton. Test taste for sweet (sugar), salt, sour (lemon), and bitter (quinine) using a cotton-tipped applicator moistened in appropriate solution and placed on lateral margin of protruded tongue halfway back from tip. Sensation in region of tonsils, posterior pharynx, and tongue may also require testing. Look for atrophy, deviation from midline with protrusion, tremor, and small flickering or twitching movements (fibrillations, fasciculations). Assess upper limb strength by checking for pronator drift and strength of wrist or finger reflexes. Power should be systematically tested for major movements at each joint (Table 183-2). The speed of movement, the ability to relax contractions promptly, and fatigue with repetition should all be noted. Any involuntary movements should be noted at rest, during maintained posture, and with voluntary action. A common grading scale is 0 absent, 1 present but diminished, 2 normal, 3 hyperactive, and 4 hyperactive with clonus (repetitive rhythmic contractions with maintained stretch). The plantar reflex should be tested by using a blunt-ended object such as the point of a key to stroke the outer border of the sole of the foot from the heel toward the base of the great toe.

Combination therapy with 5-fluorouracil and cisplatin is currently the mainstay of treatment in esophageal squamous cell carcinoma. This malignancy often presents with jaundice, epigastric pain radiating to the back, and weight loss. The red, swollen, tender lower extremity indicates a possible deep vein thrombosis. Patients with pancreatic adenocarcinoma may present with migratory thrombophlebitis, which is called Trousseau sign. Laboratory studies show increased amylase, lipase, and alkaline phosphatase levels. These markers are generally not sensitive or specific enough to be used for diagnosis, but they do have use in monitoring the course of the disease and response to therapy. Treatment for pancreatic adenocarcinoma is surgical removal, yet for most patients this is impossible, as the cancer has already metastasized prior to its discovery. If possible, pancreaticoduodenectomy or distal pancreatectomy is preferred to a total pancreatectomy in order to preserve some of the pancreatic function. However, an a-fetoprotein level is not found in pancreatic malignancies; rather, it is elevated in hepatocellular carcinomas and nonseminomatous germ cell tumors of the testis. While hepatocellular carcinomas can occasionally present with jaundice and derangements in liver function tests, they are unlikely to cause elevations in amylase and lipase levels. Furthermore, the characteristic signs of migratory thrombophlebitis (Trousseau sign) should lead you to think of pancreatic adenocarcinoma as the most likely diagnosis. However, the a-fetoprotein level is elevated in hepatocellular carcinomas and nonseminomatous germ cell tumors of the testis. It is also elevated in the setting of several types of testicular germ cell tumors, such as seminomas and choriocarcinomas. Given the clinical presentation, none of these is the best diagnosis for this patient, so this is not the best answer. The image shows a section of biopsied tissue from a skin lesion on the forehead of a 60-yearold farmer. A 43-year-old man comes to the physician complaining of heartburn and black, tarry stools. He states that he has been eating much less than usual, although he still manages to drink at least one beer per day, which he reports having done for the past 20 years. On physical examination the patient exhibits diffuse tenderness and guarding over the entire epigastric area. Serum levels of which of the following substances are likely to be elevated in this patient A 65-year-old man presents with a two-month history of cough, severe left-sided shoulder pain, and hoarseness. Most concerning to him, however, is the droop of his left eyelid, which developed over the previous few weeks. The patient worked as a technician in a nuclear power plant before retiring last year and has a 40-year history of smoking. Physical examination reveals that his left pupil is smaller than his right, and the skin on the left side of his face is extremely dry. Hematology-Oncology (A) 5- to 10-mm oval, tan-brown patches that do not darken with sunlight (B) Raised, pearly borders surrounded by fine telangiectasias (C) Sharply defined red, scaling plaques (D) Tan-brown, rough lesion <1 cm in diameter (E) Thickened, hyperpigmented skin with velvet-like texture 2. A 55-year-old man comes to his physician for a routine health maintenance examination. Toward the end of the visit, he tells his physician that he has worked in the textiles industry for 30 years. He knows that he has been exposed to aniline dyes and is concerned about how this may affect his health. A 58-year-old man presents to his primary care physician complaining of years of heartburn that has not resolved with over-the-counter drugs. A 4-year-old girl is brought to the emergency department with an eight-hour history of projectile vomiting and headache. Her parents say that the patient was well until two months ago, when they noted that she was becoming increasingly clumsy. Physical examination shows nystagmus in all directions of gaze, as well as truncal ataxia.