United States Medical Licensing Step 2

If the patient continues to suffer panic attacks for a substantial period, he is said to be suffering from panic disorder. SSRIs, such as paroxetine, are frequently effective and generally safe drugs for the treatment of panic disorder. Despite its usefulness in treating generalized anxiety disorder, buspirone seems to be ineffective in treating panic. Beta-blockers such as propranolol may block symptoms of palpitations or tremor, but are generally not as effective against panic attacks as are SSRIs. Antipsychotic medications such as ziprasidone and haloperidol are not appropriate medications for the first-line treatment of uncomplicated panic disorder.

Late posttraumatic epilepsy is diagnosed when a seizure occurs for the first time more than 1 week after a head injury. Factors that correlate with an increased risk of developing posttraumatic epilepsy include presence of a depressed skull fracture, acute intracranial hemorrhage, cerebral contusion, or unconsciousness lasting more than 24 hours. Because the risk of a subsequent seizure is approximately 75%, acute and chronic treatment with anticonvulsants is indicated. Loss of consciousness, retrograde amnesia, and vomiting are relatively common immediate consequences of head trauma. They are usually transient and are not highly correlated with a risk of subsequent posttraumatic seizures.

Although 515% of patients with lung cancer are identified while they are asymptomatic, most patients present with signs and symptoms including cough, hemoptysis, wheeze, stridor, shortness of breath, and postobstructive pneumonia.
Paraneoplastic syndromes are common among patients with lung cancer. Endocrine paraneoplastic syndromes are seen in 12% of patients. Hypercalcemia may result from ectopic production of PTH or PTH-related peptides by squamous cell carcinomas. Small cell cancers may secrete ACTH or excessive amounts of ADH leading to hyponatremia and SIADH. Other nonendocrine paraneoplastic manifestations may include anorexia, cachexia, weight loss, fever, suppressed immunity. peripheral neuropathy, and the myasthenic Eaton-Lambert syndrome.

Pyloric stenosis presents with nonbilious vomiting and gastric distention. An annular pancreas does not result in obstruction, except when it is associated with an underlying duodenal abnormality. Duodenal atresia is associated with Down syndrome. It results in early onset of bilious vomiting from complete duodenal obstruction distal to the ampulla. There is a "double bubble" sign on plain abdominal radiographs from air in the stomach and proximal duodenum. Midgut volvulus is a life-threatening complication of malrotation. It presents with acute onset of bilious vomiting, usually in infants in the first year of life. There is a paucity of gas on plain radiographs, with evidence of duodenal obstruction. UGI contrast study will confirm the abnormal position of the duodenaljejunal junction and may demonstrate a corkscrew of the duodenum from volvulus. Intussusception is uncommon in newborns. Bilious vomiting is unusual at the outset, but may develop if the intussusception has been present for a significant time. Imperforate anus can be excluded by clinical examination.

If unrecognized, the infant will develop a clinical picture of a distal bowel obstruction, with dilated small and large bowel. Meckel's diverticulum can present with obstruction secondary to volvulus around a Meckel's band, with a distal small-bowel obstruction. Contrast enema will demonstrate a normal-caliber decompressed colon, with proximal dilated small bowel. Meconium ileus is associated with cystic fibrosis. Obstruction occurs from inspissated meconium in the terminal ileum. Plain radiographs may demonstrate a "soap bubble" pattern in the right lower quadrant, with a decompressed colon on contrast enema. Hirsch-sprung's disease presents with a distal bowel obstruction and delayed passage of meconium. A contrast enema may demonstrate a transition zone, with a narrow distal aganglionic segment, and proximal colonic dilatation. Jejunal atresia is a result of an intrauterine vascular accident. Infants present with bile-stained vomiting and abdominal distention early after birth. The colon is unused, and characteristically, on contrast enema, it is abnormally small in caliber

This patient presents with a rapidly progressive, necrotizing soft-tissue infection. The skin edema, purple hue, bullae, water drainage, and crepitus are classic findings in clostridial infections. Although culture of the wound drainage may be confirmatory, the diagnosis should be suspected on a clinical basis. Antibiotics alone are insufficient therapy. The mainstay of therapy is radical surgical debridement of devitalized tissues, in conjunction with high-dose IV antibiotics.
Hyperbaric oxygen therapy may facilitate recovery.

The current treatment guideline from the Centers for Disease Control and Prevention for uncomplicated gonococcal infections is ceftriaxone 125 mg IM one time. Cefixime 400 mg orally is an alternative. Each is given as a single dose.
Importantly, the quinolone class, for example, ciprofloxacin is no longer considered appropriate treatment for gonococcal infections due to drug resistance. To the chosen drug is added azithromycin, 1 g orally, or doxycycline, 100 mg orally twice daily for 7 days. The second drug is added to treat C. trachomatis, which is present in almost 50% of women with gonorrhea. Sexual partners should be treated at the same time

Given that this is a classic case of constitutional growth delay, no diagnostic studies are indicated. Close monitoring of growth would be indicated. A bone age, if performed, would be less than chronologic age, demonstrating the growth potential for the patient. Cranial imaging would be indicated if the patient had evidence for onset of secondary hypopituitarism

Fluoxetine has the longest half-life of the current SSRIs (escitalopram's half-life is shorter--less than 24 hours), phenelzine is an MAOI and foods rich in tyramine can induce a hypertensive crisis. Venlafaxine can induce hypertension, especially at higher doses. Trazodone can rarely induce priapism (a painful sustained erection). Nortriptyline is a tricyclic antidepressant, and at high doses, it can cause arrhythmias.

Hypercalcemia is a common complication of malignancy. Mechanisms include bone metastases, humoral secretion (e.g., osteoclast-activating factor), prostaglandin, or ectopic parathormone production and immobilization. Hypercalcemia is often manifested by confusion and lethargy. The other metabolic abnormalities usually are not associated with confusion. Therapy is directed at increasing renal calcium clearance and inhibiting further bone resorption. Saline infusion raises the glomerular filtration rate and decreases calcium reabsorption in the proximal tubule. Under life-threatening circumstances, the infusion may need to be aggressive, as much as 6 L of saline daily plus furosemide. Radiotherapy will do nothing for the calcium. Tamoxifen is an antiestrogen used in the treatment of breast carcinoma and other malignancies. When used in the presence of bone metastases, it may contribute to hypercalcemia. Chemotherapy will not decrease the calcium levels. Glucocorticoids have an antitumor effect and reduce tumor production of humoral mediators, but act slowly.

Most cases of idiopathic thrombocytopenic purpura (ITP) in children are preceded by viral infections and, in contrast to adults, the great majority of children recover spontaneously. Although not all patients require therapy, most authorities suggest treating when the platelet count is less than 20,000. Standard treatment has been oral prednisone. Recently, IV gamma globulin has been shown to be effective. However, this agent is expensive and less convenient than oral prednisone. The child described in the question might reasonably be treated with either agent. Because the child's Hb is 13.3 g/100 mL, there is no indication for transfusion of RBCs. Although the platelet count is very low, platelet transfusions are short lived and generally are indicated only in the presence of serious bleeding, as, for example, from the GI tract. Thus, platelet transfusions are not indicated in this patient. Splenectomy is reserved for the very rare child who does not respond to conservative therapy or who develops chronic ITP.