A 4 month old male is brought to your office by his parents for a wellness check. They are concerned about his repeated bouts of eczema and recurrent infections. He has a complicated medical history significant for bloody diarrhea and hard to control epistaxis during the second month of his life. Your physical examination found a feeble baby with eczema, dry blood in the perinatal region and splenomegaly. You ordered some routine labs for this patient. Later that evening a technician from the laboratory called you to inform you of some ‘red flag’ lab results, which are a platelet count of 60000/ platelets/µL with reduced sized platelets in clumps. Concerned about the possibility of an immunodeficiency disorder you ordered a genetic test, which revealed a genetic defect on the short arm of the X-chromosome. You called the parents to explain the lab results in the light of your clinical findings. How do you explain the pathogenesis of this disease to his parents?

A 45 year-old male presents with pain in the abdomen, nausea, constipation, bloating, loose,greasy, bulky, and bad-smelling stools and chronic diarrhea. After examining him and ordering some labs, you discover that this patient has celiac disease.  Laboratory results show undetectable IgA levels and normal IgG and IgM levels. As you discussed this diagnosis with the patient, the patient revealed that he was previously diagnosed with selective IgA deficiency. He requests you to administer intravenous immunoglobulin to treat his selective IgA deficiency. He states that this course of action is especially important in the light of his newly discovered celiac disease.The physician started IgG-RT infusion at the rate of 5 ml/kg/hr. After 20 minutes, patient developed swelling of his throat and tongue, noisy and difficulty breathing, confusion, and faintness. Which of the following statements is true? 

A 70-year-old African-American male came to your office for refills on his current medications. He works as a economics professor emeritus at the local university. He takes sertraline 100 mg daily for depression, trazodone 50 mg daily for insomnia, alprazolam 1 mg for anxiety, hydrochlorothiazide 25 mg and metoprolol 100 mg for hypertension, and gabapentin 100 mg for neuropathy. As you assess his risk of falls, which of the following is the most dangerous risk factor for falls in this individual? 

A 62 year-old male was about to be discharged from the hospital. He was diagnosed with a stroke and was started on medications. He regained some of his strength in both upper and lower extremities but still has a visual field defect with loss of vision on the same side of both eyes. He has an outpatient appointment with a neurologist in two weeks. He is a commercial truck driver and the primary breadwinner for his family. You advised him not to drive until he regains full strength and complete vision. However, the patient reports that he cannot afford not to work and expresses strong desire to drive from tomorrow. What is the most appropriate step in the management of this patient regarding his driving?

A 76 year-old female is brought to your office by her caregiver for an annual physical examination. She reports ‘feeling very down’, not sleeping much, not eating much, not taking her medications properly, not asking for refills on time and having difficulty remembering things. She talks more openly when she is alone with you in the room and becomes reticent when her caregiver enters the room. In the physical examination, she has distinct bruises with pale central areas lined on either side by linear ecchymosis on both upper extremities. She also has some bruising around her eyes and ears. You asked the caregiver to leave the room briefly and asked the patient about the bruises. The patient replies that they happened three weeks ago. You asked the patient, ‘has anyone threatened you or harmed you?’ Patient replied, ‘It happened only once. I am praying for him. It will be alright’. What is the most appropriate next step in the management of this patient?

Mrs. Ruth is a mother of three boys of ages 7, 5 and 3. She brings all three kids to your practice for sick visits. You have been educating her on the importance of immunizations to her and her three children. She refused all immunizations because she heard that vaccines can cause genetic defects. You’ve spent considerable time in clearing the misconceptions about immunizations. You’ve explained where the disinformation about vaccines comes from, and emphasized the collective benefits of vaccinations. You showed her clinical trials which showed how vaccinations work and prevent their targeted diseases. Then, one day she brought her 5 year-old unimmunized boy to your office for an illness visit. The boy has a 3 day history of fever, cough, rhinorrhea, rash and watery eyes. On examination, his temperature is 101.5 F. The boy appears ill but is in no acute distress. He has a red raised rash on his face. His conjunctivae are injected. There are small white papules with bluish-white centers on the buccal mucosa. You noticed a blanching, erythematous, palpable rash over his chest, abdomen and back. You diagnosed him with measles. The mother informs you that her other two boys,who are at home with their dad, are also having similar signs and symptoms, though mild. What would be the best approach to this mother who still refuses immunizations?