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Ralph Tufano, M.B.A., M.D.

• Professor of Otolaryngology - Head and Neck Surgery

https://www.hopkinsmedicine.org/profiles/results/directory/profile/0015647/ralph-tufano

His parents report that approximately two weeks ago he had a fever and diarrhea that resolved treatment yellow jacket sting purchase antabuse with a mastercard. On further questioning medications causing dry mouth discount antabuse 500mg overnight delivery, his parents state that he is home-schooled and that he has never received vaccinations symptoms 11 dpo order 500 mg antabuse with mastercard. On physical examination he is unable to dorsifex (A) Corticosteroid use or evert at the ankle symptoms bladder cancer purchase antabuse in united states online. In addition, the patient (B) Intravenous drug use reports pain and numbness in the lateral leg (C) Miliary tuberculosis and dorsum of the foot. When asked to walk, (D) Multiple sexual partners he raises his affected leg high off the ground (E) Sickle cell anemia and his foot slaps the ground when walking. A 22-year-old woman who is a professional tenfollowing structures is most likely to be comnis player presents to her physician because of promised by this fracturefi A 50-year-old man who recently returned from (A) Lengthening of A band; no change in H visiting family in northern New Mexico comes band; shortening of I band to the physician with exquisitely tender and (B) No change in A band; lengthening of H enlarged lymph nodes. He also complains of band; lengthening of I band fever, chills, and general weakness. On physi(C) No change in A band; shortening of H cal examination, the physician notes a painful band; shortening of I band ulcer surrounded by dark, hemorrhagic pur(D) Shortening of A band; no change in H pura on the right arm in the area where, acband; shortening of I band cording to the patient, a fea had bitten him (E) Shortening of A band; shortening of H fve days ago. After being admitted to the hosband; no change in I band pital, the patient soon develops abnormal coagulation times and is quickly started on a regi37. A 38-year-old man comes to the clinic with a men of streptomycin and tetracycline. The patient also has scaly plaques with well-defned bor(A) Babesia microti ders along the skin just distal to both elbows. A 63-year-old man and known alcoholic has (B) Elevated erythrocyte sedimentation rate been unable to afford alcohol. He now pre(C) Negatively birefringent crystals in joint sents with hypertension and profuse sweating, fuid and is agitated because he believes that insects (D) Positive rheumatoid factor are crawling all over his skin. During the ex(E) Weakly positively birefringent crystals in amination, he loses consciousness and begins joint fuid to seize on the stretcher. A 20-year-old man presents to the physician lowing changes in length within each sarcowith a nontender indurated mass over his manmerefi He has had this mass for four months after undergoing oral surgery and decided to come to the physician because the mass Sarcomere started to ooze a thick yellow exudate. Yellow granules are seen on microscopic examinaI A tion of the discharge and an antibiotic is preM line band band Z line scribed. Which of the following best describes the mechanism of action of the antibiotic most H band likely prescribedfi He is diagnosed ver, malaise, muscle pain, hypertension, abwith an inguinal hernia on his left side, and dominal pain, bloody stool, and prerenal failundergoes surgery two days later to repair the ure six months after recovering from an acute hernia. Which of the following plains of numbness and tingling of his scrodisease processes is most likely responsible for tum. She also reports stiffness which of the following labeled layers in this in both hands that is worse in the morning imagefi The patient was diagnosed with bilateral sacroiliitis E four months ago because of his tenderness to percussion of the sacroiliac joints and pain on springing the pelvis up. A 38-year-old woman presents to the emerto the emergency department because he gency department complaining of increaspunched a wall and now has pain in his hand. She frst nothe physician tells the patient that he has broticed the muscle weakness approximately one ken his hand. On physical (C) Metacarpals examination, deltoid and quadriceps strength (D) Phalanges are 2/5 bilaterally. Creatine kinase, lactate de(E) Scaphoid hydrogenase, and aldolase levels are elevated. Chondrosarcomas are strates osteoblastic lesions of the pelvis secmalignant cartilaginous tumors that occur ondary to metastatic cancer. Prostate cancer, most commonly in men 30-60 years old, usuthe most common cause of cancer in men, is ally in the pelvis, spine, scapula, humerus, notorious for producing osteoblastic lesions tibia, or femur. Enchondromas are bedetected on physical examination through the nign cartilaginous tumors found in intrameduse of a digital rectal examination. Digital recullary bone, and are most often found in the tal examination can also be useful in detecting distal extremities. Ewmen may assist in the detection of leukemia or ing sarcoma most commonly occurs in the dilymphoma, as splenomegaly is a common preaphyses of long bones, pelvis, scapula, and ribs. These cancers occur much less frequently than prostate cancer, and more Answer D is incorrect. Renias protrude directly through the abdominal nal metastases are more commonly osteolytic. Palpation of the neck dered by the inguinal ligament (inferiorly), may be helpful in detecting thyroid cancer. Direct versus indirect distinguishes where the hernia enters Answer E is incorrect. A thorough skin exthe inguinal canal, either through the interamination would be vital in detecting a melanal ring (indirect) or straight through the abnoma. However, melanoma is much less comdominal wall (for direct hernias, think directly mon than prostate cancer, and most often through the wall). In this case the abdominal produces osteolytic lesions when it metastacontents pierced through the abdominal wall sizes to bone. Osteosarcoma is the as a result of pressure and tension exerted over most common primary malignant bony tumor. Direct hernias are less common <20 years old and occur at the metaphyseal reand have less risk of strangulation than indirect gion of long bones. Diaphragmatic hernias associated with both osteosarcoma and retinoare serious birth defects that are lethal unless blastoma, which was likely present in this parepaired soon after birth. Femoral hernias procending paralysis and muscle weakness that trude inferior to the inguinal ligament and occur as a consequence are secondary to the do not go through the external inguinal ring. They protrude below and lateral to the pubic tubercle and are more common in women. While Campylobacter jejuni does produce an enterotoxin, the Answer D is incorrect. Hiatal hernias are mechanism described in this answer choice hernias of the stomach protruding superiorly is not the major hypothesized pathogenesis of through the diaphragm. Molluscum contagionias occur when abdominal contents enter the sum is a member of the poxvirus family that internal inguinal ring through a patent procescauses a localized infection consisting of nonsus vaginalis, exit the inguinal canal through erythematous, pearly, dome-shaped papules the external ring, and usually descend into the on the skin of an infected individual. These hernias are the most common and immunosuppressed patients are often intype found both in men and in women, but fected with this virus. They self-limited and spontaneously resolves after a are found often in young individuals. Adenovirus is a comto avoid the complications of strangulation and mon cause of upper respiratory infections. This patient has hepatitis B with jaundice being a possible derGuillain-Barre as a result of his gastroenteritis. Thus, it makes sense that an excessive zoster virus causes chickenpox, which can reimmune response to an infection (such as activate and result in shingles. The lesions are from a pathogen like Campylobacter jejuni) painful vesicles with an erythematous base.

Syndromes

• Abnormal prothrombin time (PT)
• Anxiety
• Need for surgery to repair damage
• Living near an area with a lot of ticks
• Amount swallowed
• Hiatal hernia
• Blood tests
• Molindone (Moban)

Maintain and disseminate information neglect and to improve the well-being of on best practices related to differential victims of child abuse or neglect symptoms brain tumor purchase 500mg antabuse otc, with at least a response portion of such research being field initiated medications without doctors prescription generic 500 mg antabuse overnight delivery. Maintain and disseminate information about best practices used for achieving Conduct research on the national incidence improvements in child protective systems of child abuse and neglect and produce a 5 treatment ulcer buy discount antabuse. Enhancing the general child protective public and private agencies and communitysystem by developing medicine you can overdose on purchase cheap antabuse, improving, and based organizations to assist such agencies implementing risk and safety assessment in planning, improving, developing, and tools and protocols, including the use of carrying out programs and activities, including differential response replicating successful program models relating 5. Developing and updating systems of to the prevention, assessment, identification, technology that support the program and and treatment of child abuse and neglect. Developing, strengthening, and facilitating environments for visitation; education, training identification, prevention, and treatment; risk 7. Improving the skills, qualifications, and and safety assessment tools; and training. Developing, facilitating the use of, and implementing research-based strategies 3. Developing, implementing or operating developmental disabilities, and domestic programs to assist in obtaining or violence service agencies coordinating necessary services for families 6. The intake, assessment, screening, and differential response investigation of reports of child abuse or 11. Developing and enhancing the capacity of neglect community-based programs to integrate 2. Creating and improving the use of shared leadership strategies between multidisciplinary teams and improving legal parents and professionals to prevent preparation and representation and treat child abuse and neglect at the 3. Case management, including ongoing case neighborhood level monitoring, and delivery of services and treatment provided to children and their families 210 Child Protective Services: A Guide for Caseworkers 12. Supporting and enhancing interagency Provide for community-based grants for collaboration between the child protection the prevention of child abuse and neglect system and the juvenile justice system to support community-based efforts to for improved delivery of services and develop, operate, expand, enhance, and treatment, including methods for continuity coordinate initiatives, programs, and activities of treatment plan and services as children to prevent child abuse and neglect and transition between systems to support the coordination of resources 13. Supporting and enhancing interagency and activities to better strengthen and collaboration among public health support families to reduce the likelihood of agencies, agencies in the child protective child abuse and neglect; and to foster an service system, and agencies carrying out understanding, appreciation, and knowledge private community-based programs of diverse populations in order to be effective in preventing and treating child abuse and 14. Award grants to states for programs relating to investigation and prosecution of child abuse and neglect cases designed to assist states in developing, establish, and operating programs designed to improve assessment and investigation of suspected child abuse and neglect cases. Mandate the coordination of child abuse and neglect programs, including providing periodic reports to Congress. Child Protective Services: A Guide for Caseworkers 211 Appendix F: Content of an Intake Report Specific requirements may vary slightly, 0 Description of emotional and physical depending on state, tribal, or jurisdictional symptoms laws. If it will, the maltreatment has increased in severity or intake worker may ask questions to be able to frequency prioritize the response time indicated by the 0 Description of specific events and alleged circumstances. There will be a check of whether objects or weapons were used agency records and state central registries to 0 Description of any injuries observed (if determine if the family is currently involved in applicable), including size, shape, color, an open case or has a history of involvement in etc. If the state has a differential response system, meaning it diverts some referrals to community agencies for assessment (prevention) instead of investigation, there could be questions about whether the family is aware that the reporter is making a referral. Child Protective Services: A Guide for Caseworkers 213 Appendix G: Assessment Instruments Selected examples of instruments that could be useful to inform comprehensive family assessments with children and families referred due to child maltreatment are summarized in the table below. Instruments are categorized by the targeted domains they purport to assess and classified by type of instrument. The worker who conducted the comprehensive family assessment usually completes observational assessments based on a series of interviews and other collected data. Spatial instruments, like genograms or ecomaps, are usually completed collaboratively between the worker and family members. Substance Abuse, Criminal org/tools/the-child-and-adolescentand Delinquent Behavior, needs-and-strengths-cans/ Care Management, Caregiver Needs and Reference: Lyons, J. Family the first six categories may assessment form: A practice based be used at multiple points approach to assessing family in time to assess change functioning. There also is an optional check list that identifies behaviors concerns regarding children via 31 scales organized into five factors: Acting Out Behaviors, Inner-Directed Behaviors, School Behavior Problems, Health and Development Problems, and Temperament. The first demographic section Reference: Institute for Educational is to be completed by Research & Public Service, University program staff and program of Kansas. The development participants complete the and validation of the protective second section. The Brief compulsive, interpersonal Symptom Inventory: An introductory sensitivity, depression, report. One clinical-practice/screening-tools#drugs or more affirmative answers should be considered a Reference: Brown, R. Conjoint screening questionnaire the need for a more for alcohol and other drug abuse: comprehensive assessment Criterion validity in a primary care of use, abuse, or addiction. Burlington: University syndrome scales and a of Vermont, Department of Psychiatry. There are seven html categories of adverse childhood experiences: Reference: Felitti, V. Relationship of childhood with household members abuse and household dysfunction to who were substance many of the leading cause of death abusers, mentally ill or in adults. The family and relocation, legal status, use of culturagrams to assess and worker time in community, empower culturally diverse families. Family Genogram Assessment Numerous text books that provide Spatial History is a generational family details about how to construct a assessment map that allows a person genogram and there are numerous developed to see a family system sites online with toolkits for depicting collaboratively historically. For each event the Psychometric properties of the life person is asked to note events checklist. Social them as a measure of supports, everyday stressors, and chronic daily stressors. University of covering five problem North Carolina at Chapel Hill; Hall, areas: role overload, L. Supports, stressors, and parenting worries, depressive symptoms in mothers of employment problems, young children. Measuring the abusive parents, responses potential for child maltreatment: the to the inventory provide an reliability and validity of the Adult index of risk for practicing Adolescent Parenting Inventory-2. Poster presentation at the Florida Conference on Child Health Psychology, Gainesville, Florida. A Reference for a version of this instrument for women with substance abuse problems who were involved in child welfare is: Mullins, S. The impact of motivational interviewing on substance abuse treatment retention: A randomized control trial of women involved with child welfare. A combined motivation and and the belief that change parent-child interaction therapy package is possible. Measuring the adequacy of as the needs of individual resources in households with young family members. Support; Necessities and Health; Physical Necessities and Shelter; Intra-family Support; Child Care; and Personal Resources.

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The bone marrow is dominant site of hematopoiesis between fetal the predominant site of hematopoiesis beginweeks three and eight treatment for ringworm purchase 250mg antabuse with visa. A 30-year-old sexually active woman presents (A) Blastomyces dermatitidis with a painful vesicle on her external genita(B) Coccidioides immitis lia and bilateral inguinal lymphadenopathy pure keratin treatment purchase antabuse no prescription. A (C) Cryptococcus neoformans Tzanck smear from the vesicle is negative counterfeit medications 60 minutes buy antabuse 250 mg cheap, and (D) Histoplasma capsulatum a Venereal Disease Research Laboratory assay (E) Paracoccidioides brasiliensis is also negative the treatment 2014 online generic antabuse 250mg free shipping. He went on a summer (A) Acyclovir hiking trip in eastern Massachusetts about six (B) Ceftriaxone months ago but does not recall getting a tick (C) Foscarnet bite and notes no rashes. Louis, Mis(A) Brugada syndrome souri presents to his primary care physician (B) Chagas disease with recent-onset productive cough, pleuritic (C) Hypertrophic cardiomyopathy chest pain, and a fever of 39. The paductive cough that has developed over the past thologist is able to identify several dividing 10 days. X-ray of the chest staining (see image) is notable for large, broaddemonstrates patchy bilateral interstitial inflbased budding from mother cells. A lumbar puncture shows a normal opening pressure, and cerebrospinal fuid analysis shows a mildly elevated protein level and the presence of myelin basic protein, with a mild mononuclear pleocytosis. Which of the following entities is most likely Courtesy of the Centers for Disease Control and Prevention. A family who recently emigrated from Romania brings their 7-year-old child to the pedia8. A 38-year-old man comes to the emergency trician with complaints of conjunctivitis and department complaining of cyclic fevers and periorbital swelling. The fevers began about one week ing with a runny nose and high fever for three ago; two weeks ago the patient returned from days. A 5-year-old girl is brought to her pediatrician because of an eight-day history of a painful rash confned to her fank. Which of the following describes the mechanism of action of the treatment for this lesionfi Infuenza virus type A usually produces a mild, with a two-day history of fever and headache. He also asks that occurred at different times in history due to the lights in the room be turned down. In the meantime, (B) Antigenic shift bacterial and fungal culture results are nega(C) Hemagglutinin develops the ability to detive. A 66-year-old woman who recently emigrated D from Mexico comes to the physician beE cause she has begun to have seizures. Which of the following organs or tissues is most likely to have (A) A similar lesionsfi Some introduce oncogenes directly into host cells, while others force cells to repeatedly undergo cycles of proliferation that eventually become unregulated. Still others introduce oncogenic potential by manipulating chromosomal structure through deletions or translocations. Which of the following viruses causes neoplasia by inactivating tumor suppressor genes such as p53 and Rbfi Per-Lennart Westesson, University of Roches(C) Human immunodefciency virus ter Medical Center. A 27-year-old woman presents to her physi(B) Bone cian complaining of fever, chills, and fu-like (C) Kidney cortex symptoms. Which of the following is (E) Small bowel most likely to be elicited on further questioningfi A young girl living in rural New Mexico is brought to her pediatrician with complaints of fever, cough, and fatigue for the past two weeks. The physician notices that the patient is having intermittent bouts of many coughs in a single breath, followed by a deep inspiration. The parents report that this pattern of coughing had started in the past two days. The physician informs them that their daughter will most likely recover with only supportive care. Hardin, Centers for Disease Control and (B) Charcoal yeast extract with iron and cystePrevention. A worried mother brings her infant to the (D) Recent hiking in wooded areas emergency department because he appears to (E) Recent work in her large rose garden be unable to swallow and continues to choke on his formula. At birth, a newborn is noted to be unresponphysician notes generalized muscle weakness. A 45-year-old man presents to the clinic com(C) Erythromycin plaining of several weeks of vague abdominal (D) Prompt replacement of water and electrodiscomfort and early satiety. A 65-year-old man with a history of viral hepaanalysis of the biopsy specimen shows sheets of titis presents to his primary care physician with atypical lymphocytes. The patient says he has lived in Rochester, New York (upstate) for his entire life, has not traveled Choice Urease Catalase Oxidase outside of the country, and received two blood A negative negative transfusions in the early 1970s following an aunegative tomobile accident. Work-up reveals extensive B negative negative positive macronodular cirrhosis with a 2-fi2-cm mass C in his liver. A neonate with purulent umbilical discharge for one day presents with fever, irritability, and (A) A diffuse fushing. One day later she is covered (B) B in large, fuid-flled blisters that rupture easily, (C) C leaving raw red areas beneath. Blood cultures (D) D are taken, which within 24 hours grow an or(E) E ganism that is subsequently Gram stained with (F) F the results shown below. The skin symptoms (G) G observed in this case are due to the involvement of which of the following intercellular 18. She reports havday, his mother notices that he seems lethargic ing severe headaches associated with some and brings him to the urgent care center. Laboratory Her urine has been exceptionally dark for the tests show a hemoglobin level of 9 g/dL, platepast few days. The patient is mildly jaundiced let count of 40,000/mm3, and creatinine level with scleral icterus. If the patient had unprotected intercourse (A) Campylobacter during this infection, the presence of which of (B) Escherichia coli the following would be most concerning for (C) Rotavirus her partnerfi A 32-year-old man presents to his doctor with (C) Hepatitis B surface antibody painful urination and a purulent urethral dis(D) IgG hepatitis B core antibody charge. The discharge material is cultured, (E) IgM hepatitis B core antibody and a sample from the culture is stained with Giemsa and is shown in the image. A 1-year-old girl presents to the emergency (C) Hageman factor room because of a three-day history of cough(D) C5a ing attacks that are occasionally followed by (E) Interleukin-1 episodes of vomiting. Her parents are espe(F) Nitric oxide cially concerned because sometimes she becomes blue after an episode. She is afephysician because of a two-day history of a febrile and has no other symptoms. A bacterial infection is the patient is found to have cervical adenopadiagnosed.

Diseases

• Carnosinase deficiency
• Congenital deafness
• Hemangiomatosis, familial pulmonary capillary
• Fish poisoning
• Malignant mesenchymal tumor
• Kawasaki syndrome
• Gastroesophageal reflux
• Ti?che Jadassohn nevus