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This patient is currently asymptomatic, which is why treatment for her should be IFN-β (or glatiramer or natalizumab).
If she still had symptoms of an acute MS exacerbation, treatment would consist of corticosteroids (i.e., dexamethasone/methylprednisolone). If symptoms persist in spite of steroids, she should undergo plasmapheresis.
I would make a different argument. Because the infant is covered by Penicillin the pneumonia is likely gram negative. We don't have imaging to see the lung parenchyma but I would like to cover pseudomonas (ceftriaxone has partial coverage). Lastly, Ciprofloxacin given orally isn't likely to be done for inaptient (it would need to be an IV medication here). Also Cipro isn't a respiratory floroquinolone unlike moxifloxacin, gemifloxacin and levofloxacin.
Also, fluoroquinolones are contraindicated in children (tendinopathy)
THe question said initial step. I thought this was a clinical dx that required elevated ESR, CRP. In reality we would order these and have him get an x-ray. I'm not sure if we can reliably dx Ankylosing Spondylitis unless we have the ESR unless the x-ray clearly shows that bones are fusing. THis is a younger guy too.
There was a uworld question that mirrors this if you use the search function you can probably find it. The reasoning they had there said that acute phase markers are usually elevated in AS but they have low specificity for establishing the dx.
BONE SCAN - not good for AS, but it is good for osteomyelitis, suspected fractures, and neoplasms > MRI indicated for neurological s/sx
Just found that UWorld question – it asked which would be most likely to establish a diagnosis in the patient. In that case, X-ray of SI joints is the right answer. However, the NBME question asked for initial step. My first step would probably be to order an ESR. It's nonspecific, but ESR is pretty much always nonspecific, so why would you ever order it?
Reason for pH >4.5 is that Gardnerella outcompete Lactobacilli fauna, which (as their name implies) pump out acid
1) petechial hemorrhages
2) will see respiratory alkalosis in fat embolism, and metabolic acidosis in ARDS
i was also torn on this one because their PaO2/FiO2 is low (267), which I think technically qualifies as ARDS, especially with the fluffy infiltrates. I think the petechiae is the main thing that points to fat embolism over ARDS
Also worth keeping in mind that, according to UWorld, the petechial rash doesn't necessarily always present in fat embolism syndrome. However, if it does present along with the rest of the clinical picture, it's a dead ringer for FES.