UW12 Flashcards
(169 cards)
1
Q
If you have made a dx of osteosarcoma, what is the next imaging study to be done?
A
CT chest to rule out pulmonary mets (it loves the lungs) DO NOT do CXR
1
Q
What is a serious and fatal issue assoc with Natalizumab? MOA?
A
Reactivation of JC polyomavirus; binds integrins on leukocyte cell walls and prevents them from getting into the tissue where the MS is occuring
1
Q
What platelet count is an indication for a pt who is actively bleeding?
A
50,000
1
Q
T/F: Chewing Tobacco can cause Buerger’s dz
A
True; any kind can
1
Q
What named nerve innervates the dorsum of the foot?
A
Common peroneal
1
Q
If a pt has bleeding secondary to uterine atony and is acutely hypertensive without a hx of HTN what should you give?
A
Oxytocin; do not give methylergonavine to pts with high BP
1
Q
What is a big difference in the presentation of EBV mononucleosis and CMV mononucleosis? What if a pregnant pt gets CMV mononucleosis?
A
CMV typically has much less LAD and ABSENCE of pharyngitis; baby may have calcified ventricles (CMV = Calcify My Ventricles)
1
Q
How many times a day should type I DM check their blood sugar?
A
MULTIPLE times per day i.e. > 2
1
Q
MC weak muscle in patellofemoral syndrome?
A
Vastus medialis obliquus
1
Q
What is the major difference in labs between alcoholic ketoacidosis and DKA?
A
Both have anion gap acidosis with ketones but alcoholic ketoacidosis will have normal to low glucose
1
Q
What is DOC for migraines in pregnancy? DOC in kids?
A
Acetaminophen; Ibuprofen
2
Q
Describe the appearance of a pt with Beckwith-Weideman syndrome? Tests?
A
Hemihypertrophy with OMPHALOCELE; do renal US q 3-6 months to rule out Wilms tumor (WT1 gene on chromosome 11)
2
Q
How do you tx unilateral aldosteronomas vs. bilateral?
A
Unilateral = adrenalectomy; bilateral = medical therapy with spironolactone or eplerenone
3
Q
What are the 4 grades of internal hemorrhoids?
A
I = no prolapse II = prolapse with defecation but spontaneous reduction III = prolapse with defectation and manual reduction IV = prolapse and cannot be reduced
3
Q
What precautions are taken in pts with Influenza, group A strep throat, epiglottiis, and mumps
A
Droplet precautions
3
Q
What is the treatment of choice for grades II-III internal hemorrhoids?
A
Rubber band ligation
4
Q
What are 3 important meds to give in thyroid storm?
A
Propanolol is most important then give PTU (not methimazole bc does not block peripheral conversion T4 to T3) then iodine 1 hour after administration of thionoamide
5
Q
What named nerve innervates the medial foot?
A
Saphenous nerve
5
Q
What is the next best step if a pt has LBP with a positive step-off sign? If neurologic sx?
A
Plain film with oblique view looking for pars interarticularis fx i.e. spondylolisthesis; MRI for cord compression
5
Q
What is the first line tx of postherpetic neuralgia? What if they fail that?
A
TCA (i.e. nortryptiline) then try pregabalin (Lyrica)
5
Q
What is the MOA of probenicid?
A
Blocks tubular reabsorption of uric acid
6
Q
What ventilator setting allows the pt to take a breath on their own and then the vent gives preset tidal volume, if no spontaneous breathing occurs then it will give that breath at a backup rate?
A
Assist control
6
Q
When is IV labetalol indicated prior to tPA in stroke?
A
If BP is greater than 185/110 as this is associated with increased risk of conversion to hemorrhagic stroke
7
Q
If a pt is volume overloaded and isnt quite having the response you’d like to furosemide, what can you do?
A
Add a thiazide diuretic since they operate at different sites (TALH NKCC vs. DCT Na/Cl) they can have a synergistic effect; ultimately if you are medically refractory to volume overload that is an indication for hemodialysis
7
What are some risk factors for MRSA i.e. in an outpatient case of cellulitis?
Recent hospitalization, IVDA, recent incarceration or current; Tx is then TMP-SMX, clindamycin, or doxycycline; if pt is toxic then admit with IV vancomycin
7
What is the most specific CLINICAL test for ACL injury
Lachman test
7
What named nerve innervates the lateral foot?
Sural nerve
7
What should be suspected in any pt with conjunctival injection after sugery? Tx?
Corneal abrasion (the MC ophthalmoscopic complication of surgery) confirm dx with slit lamp; ppx broad spec abx recommended i.e. TMP and polymixin B
7
What is a Mallet finger
Injury to the DIP leading to inability to extend the distal phalanx
7
What is the dx for new HTN in a pregnat woman with 260 mg proteinuria in 24 H
Gestational HTN would need \> 300 mg proteinuria to be pre-eclampsia
8
What is the best initial test in renal artery stenosis?
US doppler of renals
9
What is a strong predictor of getting diabetic retinopathy?
Presence of renal dz
9
What is osteonecrosis of the navicular bone?
Kohler's dz
9
What is the only way to make a definitive dx of adenomyosis?
Histologic exam of a HYSTERECTOMY SPECIMEN not an endometrial bx; you need to see endometrial tissue within the myometrium at least one low power field from the endomyometrial jxn
10
What two dimorphic fungi often have erythema nodosum? Which has granuolmatous nodules that may be verrucous in nature?
Coccidiodes immitis and Histoplasma capsulatum; Blastomyces dermatidis
11
What is the tx of lead poisoning? What two populations can be seen on peripheral smear?
PO succimer or IV dimercaprol or EDTA; a normochromic and hypochromic population both microcytic
11
What is the name of the femoral bruit heard in pts with AR?
Duroziez's sign
12
What are the two most common AE of injectable contraception with medroxyprogesterone acetate (DepoProvera)?
Irregular menstrual bleeding and breast tenderness
13
What is Rett syndrome? Mutation involved?
A disease only seen in girls associated with disintegration of previoulsy acquired milestones and HAND WRINGING; MECP2
14
What are the 4 diagnostic criteria for DM?
HbA1C \> 6.5%, Fasting glucose \> 126, Random glucose \> 200 IF WITH Sx, 2 HR glucose tolerance test \> 200 after a 75 gram load
16
What is the best way to CONFIRM DM neuropathy?
EMG, if just suspect in a pt without prior hx DM you should do one of the 4 tests to dx DM
16
What is the general mgmt for asystole and PEA?
CPR and epinephrine (pressors i.e. vasopressin is an alternative)
16
What is the mainstay of Tx of PNH? What is the only cure? When do you do this?
Ecluzimab (anticompliment Ab that targets CD5 compliment pathway) and prednisone; Allogeneic hematopoietic stem cell transplant but only if develop acute leukemia or aplastic anemia
17
What is the BP criterion for severe preeclampsia? Proteinuria?
greater than 160/110 on 2 occasions 6 hours apart, 24 hour urinary protein greater than 5 g
18
What is Becks syndrome
bilateral loss of pain and temp with spastic paresis below the lesion and flaccid paralysis at the lesion; more commonly known as anterior spinal artery syndrome
18
Where is the MC location for ureteral injury during a hysterectomy?
At the cardinal ligament where it courses below the uterine arery (i.e. you ligate the uterine artery/cardinal ligament and accidentally bag the ureter)
19
What is salvage therapy for failed induction tx of cryptococcal meningitis?
Intrathecal amphotericin B; i.e. if failed IV amphotericin B and flucytosine
20
What is renal osteodystrophy?
Essentially a form of osteoporosis that occurs in CKD due to secondary hyperparathyroidism (low to normal Ca and high PTH)
20
What is Kohler's dz? What is Kahler's dz?
Osteonecrosis of the navicular bone; Eponym for multiple myeloma
21
How do you tx polymyositis/dermatomyositis?
Steroids
22
Loss of the stapedial reflex is commonly seen in what inherited disorder?
Otosclerosis (AD genetics) presents in young ppl 20-30
23
Why is dicloxacillin a good drug for impetigo?
Because it covers strep and staph (MSSA) which are the 2 mc causes of impetigo? you can also do mupirocin cream
23
What is assoc with Anti-scl-70
Diffuse scleroderma (systemic fibrosis)
25
What precautions are taken with TB and SARS?
Airborne isolation precautions
27
What is the MC cause of an infected shunt in hydrocephalus?
CoNS
28
What is Frieberg's infarction?
Osteonecrosis of the second metatarsal head
28
What is a fx of the neck of the 5th metacarpal? Tx?
Boxer's fx. Ulnar gutter splint
30
When you calculate fluid replacement via the Parkland formula what is the timeline for giving fluids?
Occurs over 24 hours; first half of the calculated amount is in first 8 hours, second half over the ensuing 16 hours
30
What is the best screening test for acute cholecystitis? Confirmatory?
Abdominal US; HIDA scan
31
What is the most common neurological deficit after meningitis?
Deafness
33
Where, anatomically, does breast CA MC occur?
Upper outer quadrant of breast
34
How can you treat refractory depression in a pregnant pt? AE?
ECT is SAFE IN PREGNANCY; Amnesia
36
How do you tx scabies? Who else should be tx?
5% permethrin cream neck down or PO ivermectin; contacts
37
What should the initial tx be for infantile GERD? How would you technically CONFIRM the dx?
Positional changes and thickening of the formula; 24 hour esophageal pH monitoring (I mean think about how ridiculous this is)
38
What is the most common cause of death in kids 1-4
Unintentional injuries of which DROWNING is MC
39
What is an alternative to steroids in asthma in ppl who don?t want them?
Montelukast
40
What can be used for shock-refractory ventricular fibrillation and ventricular tachycardia?
Amiodarone
42
What are the CURB-65 criteria for inpatient CAP? What are your outpatient option for CAP?
Confusion, Uremia with BUN greater than 20, RR greater than 30, BP less than 90/60 or age over 65? If 2 or more then admit; outpatient can be macrolide, quinolone, or doxycycline
43
What is osteochondrosis of the calcaneal tuberosity in skeletally immature pts
Severs dz
46
What are ulnar gutter splints used for?
Boxer's fracture i.e. fx of neck of 5th metacarpal
46
T/F: aspirin mediated respiratory dz is a true allergy
False it is NOT IgE mediated it is related to leukotrienes and can be tx with montelukast
48
What is the gram stain of P. multiocida? Tx?
Gram negative rod; Tx of cat bite, dog bite, or human bite is all Amoxicillin-Clavulanate
50
How do you treat ANY type of staphylococcal endocarditis (S. aureus or S. epidermidis)
IV Vancomycin
51
If you are exposed to a person with ACTIVE TB what is a positive PPD?
\> 5 mm induration in ANYONE exposed to ACTIVE TB
52
What must you give in a pt with bronchiectasis and an acute infection i.e. superimposed PNA?
Must cover for P. aeruginosa (i.e. piperacillin-tazobactam, cefepime, etc)
53
What are the 2 indications for steroids in PCP pna?
Either a PaO2 of less than 70 or an Aa gradient of more than 35
53
End tidal CO2 volumes are MC seen in what?
Malignant hyperthermia
54
What are some things that qualify as "autonomic instability"
Fluctuating blood pressure, tachycardia, sweating
55
Vaginismus has strong associations with what?
Sexual abuse
56
What is removed in the Whipple procedure? (5)
Head of pancreas, Duodenum, proximal jejunum, distal stomach, and gallbladder
57
How would you confirm dx of a central lung mass? Peripheral lung mass?
Bronchoscopy; CT-Guided Bx
58
Say you are treating a pt for febrile neutropenia with a solid combo of gram positive and antipseudomonal gram negative coverage but they arent improving, what should you do next?
Check a fungal blood Cx and add IV amphotericin B
59
What CLASS of drug is used for Hairy Cell leukemia? What are 2 markers that are fairly specific for it? 2 reasons it causes dry tap
Nucleoside analogs (Cladribine); CD11c and TRAP positivity; it induces secondary myelofibrosis and its hairy extensions make it hard to aspirate
60
What is the cause of a beefy red rash in the skin folds of the diaper region? Tx?
Candidal dermatitis; Topical antifungal i.e. miconazole
61
What are the 2 C's of riboflavin deficiency?
Cheiliosis and Corneal vascularization
63
What antibody is elevated in mixed connective tissue dz?
Anti-U1-ribonucleoprotein
64
What are 3 drugs you can use to tx CMV retinitis? Classic presentation? CD4 count?
Ganciclovir, Cidofovir, Foscarnet; Painless vision loss in AIDS with CD4 less than 50 (if painful think VZV or HSV retinal necrosis)
65
What is the deal for tx of benzo OD with flumazenil?
Only indicated if the pt is not a chronic benzo user i.e. a 16 yo that takes his moms benzos can get it but if the mom OD's then she cant because it will essentially cause DTs you must treat her supportively
66
What is the best beta blocker for acute aortic dissection?
Esmolol is better than metoprolol because faster acting, labetalol is good too; NEVER give hydralazine first
68
What are Wright's and Adson's tests used for? What is the difference?
Wright's = passively and progressively abduct and externally rotate the arm. Adson's = abduct to 90 degrees and turn and face the ipsilateral hand? Both are tests for thoracic outlet syndrome
69
What are the anterior Chapman points for 1) Bladder 2) Kidney 3) Adrenals
1) Periumbilical 2) 1 inch superior and 1 inch lateral to umbilicus 3) 1 inch lateral and 2 inches superior to umbilicus
71
Which acute gout meds should be used with caution in pts with CKD?
NSAIDs and Colchicine as they can worsen CKD (don?t pick probenicid just because it acts in the kidney)
73
A pt with what kind of dementia will have a paucity of speech and be less likely to name 12 animals in minute?
Picks Frontotemporal dementia
74
What is one risk associated with medical induction of ovulation with clomiphene?
Multiple gestations
75
What are the 2 tendons involved in DeQuervain's tenosynovitis? Provacative test? Tx?
Extensor pollicus longus and abductor pollicus longus (there is not named tendon for abductor pollicus brevis), Finkelstein test; First rest, ice and NSAIDs, then steroid injxn then surigical release
76
What is the Biker's palsy?
An ulnar nerve palsy due to entrapment in Guyon's canal from having the wrists on the handlebar (will have positive Froment sign which is inability to pinch first and second fingers)
78
If you suspect that a pt with seizure had it due to hyperkalemia what is the next best step?
EKG takes precidence to noncontrast CT; i.e. you can get non con CT to rule out bleeding but if likely from hyperK the heart is more important!
79
What should you give in a bleeding pt who is deficient in fibrinogen?
Cryoprecipitate
79
What should you suspect as a cause for syncope in a pt with longstanding DM?
Autononomic neuropathy
82
What is the most likely cause of chemotherapy induced pulmonary fibrosis in pt being tx for SCC? CML?
Bleomycin for SCC; Busulfan for CML but no one really uses busulfan
83
What should you suspect in a pt with PMHx of thyroid CA or Grave's that now has a dry mouth?
Possible radiation sialadenitis from the radioactive iodine
85
What precautions are taken in pts with diarrhea, PNA, C. diff, and presumed meningitis?
Contact precautions
87
How do you prophylax for dental procedures in a pt with hx of endocarditis?
2 g amoxicillin 30 min prior to procedure
89
What is the confirmatory test for a ruptured biceps tendon?
MRI
90
What is the safest initial step in tx of NPH? Then what do ya do?
CT scan to rule out bleeding or other pathology; Then do a large volume CSF removal to look for improvement in sx if there is improvement then do a VP shunt
92
What is assist control on the ventilator?
Pt takes their own breath and vent gives present tidal volume, if no spontaneous breathing then it will give that tidal volume at a backup rate
93
What are 2 syndromes assoc with Sertoli cell tumors?
Peutz Jehgers (AD genetics) and Carney syndrome (atrial myxoma, blue nevi, lentigines)
95
When would Rh immunoglobulin TECHNICALLY be unneccessary?
If mom is Rh positive or If both mom and dad were Rh negative but you know what, ppl cheat so you give them the Rh immunoglobulin if Rh negative at 28 weeks and at 72 hours after birth
96
What is osteonecrosis of the second metatarsal head?
Frieberg's infarction
98
What is the MOA of Ecluzimab?
Anticompliment Ab against CD5 compliment pathway
100
What is Keinbocks dz
AVN and collapse of the lunate
102
What often precedes erysipelas? What layers are involved?
Commonly preceded by streptococcal pharyngitis; involves upper layer of dermis which is responsible for making it the raised and demarcated lesion
104
What is the best step by step way to handle nicotine addiction?
Starts with nicotine patch then you can try bupropion (assuming not epileptic or bulimic)
105
What hormone is repsonsible for gestational DM?
Human placental lactogen
107
What is Paget-Schroetter syndrome?
Effort thrombosis of the UE i.e. a UE DVT from exercise still gonna tx with heparin to warfarin bridge because can still embolize to lung
109
How do you tx localized dz in Bullous pemphigoid? Disseminated?
Corticosteroids; Rituximab (knocks out the anti-hemidesmosome producing B cells)
110
What is the 1st line tx for CP in cocaine OD
Benzodiazepines as BB will lead to unopposed alpha and cause HTN emergency
111
When do you tx hairy cell leukemia?
You wait for cytopenias or sx i.e. anemia, painful splenomegaly, anemia etc. Tx = Nucleoside analog, Cladribine
112
What are your basic treatment options for Croup? (3)
Racemic epinephrine, dexamethasone, or cool mist tx
114
What is the DOC for acute interstitial nephritis?
DC drug and give steroids
116
What is the the BEST initial tx for meningitis? Normal age group
Ceftriaxone, vancomycin AND STEROIDS? Add ampicillin in elderly or other risk factors for Listeria
117
At what K level do you see peaked T waves on EKG? Sine waves? What causes a sine wave?
Peaked T waves at K of 5.5 to 6.5 and Sine waves with K greater than 8? To have a sine wave you get the peaked T wave then a bundle branch block due to widening of QRS that merges into the peaked T wave giving the sine wave appearance this is very severe
118
How do you tx DeQuervain's tenosynovitis? What tendons involved?
First RICE with PO NSAIDs, then corticosteroids, then release of tendon sheath; Abductor pollicus longus and extensor pollicus longus
120
T/F: a painful ulcer in DM is a neuropathic ulcer?
False they are not painful
121
What is the blowing diastolic murmur with a mid-diastolic rumble of AR called?
Austin-Flint murmur
122
What is Frey's syndrome?
This is aka "Auriculotemporal syndrome" it is due to damage of the auriculotemporal nerve (branch of trigeminal) after parotid surgery in which the autonomics get messed up and the pt sweats when seeing food rather than salivating
123
What is the MC cause of sigmoid volvulus? How does tx differ for sigmoid vs. cecal volvulus?
Chronic constipation because leads to lengthening and stretching of the sigmoid; Sigmoid can be reduced with colonoscopy and cecal is a surgical emergency
124
What is the difference between assist control and IMV?
Assist control allows pt to breath on their own but gives a preset tidal volume when they initiate the breath; IMV allows them to breath but DOES NOT give a preset tidal volume; BOTH will give breaths at a backup rate if there is no spontaneous breathing
126
What lab test can be used to rule out preterm labor?
Fetal fibronectin, if negative there is less than 1% chance of going into labor in the next 2 weeks
127
What antibody is elevated in polymyositis and dermatomyositis? What 2 labs are elevated? What is the confirmatory test for both? How can you differentiate??
Anti-Jo-1 ab, Aldolase and CK, Muscle Bx is confirmatory for both; differentiate by sx i.e. just muscle for polymyositis and skin manifestations in dermatomyositis
128
How does intrahepatic cholestasis of pregnancy present? Confirm the dx? Tx?
Pruritis and jaundice in 3rd trimester; confirm dx with increased bile salts; tx is ursodeoxycholic acid
130
What ventilator setting allows the pt to breath on their own without giving a present tidal volume but if there is no spontaneous breathing will give breaths at a backup rate?
Intermittent mandatory ventilation (IMV)
132
How should the baby be delivered in a pt with HELLP who is stable?
You can induce labor and deliver vaginally assuming mom and baby are both stable
133
What is a "Tillaux fracture"
Another name for a Salter-Harris III fx
134
What is the SAAG in Pseudomyxoma peritonei? What CA is assoc?
135
What is the preferred type of NPPV for AECOPD not responding to O2 via NC?
BPAP (reduces respiratory load by taking pressure of the diaphragm and increasing the tidal volume)
137
What presents as a bulging blue-domed translucent membrane at the vaginal introitus? What is the study of choice to evaluate?
Imperforate hymen; pelvic US
138
What are Dutcher bodies?
PAS staining perinuclear IgM deposits in plasma cells of Waldenstroms macroglobulinemia
139
How would you tx epididymitis in a young person?
Ceftriaxone + Azithromycin or Doxy to cover N. gonorrhea and C. trachomatis
140
Where do you commonly see U waves and flattened T waves? What electrophysiologic event underlies the U wave?
Hypokalemia; Purkinje repolarization
141
What should be given in any pt with an indication for FFP but is volume overloaded?
Cryoprecipitate (Factor VII, XIII, vWF, and fibrinogen)
142
What are 6 risks associated with untreated UTI in pregnancy?
Pyelonephritis, preterm labor, 2nd trimester abortions, pre-ecclampsia, maternal anemia, chorioamnionitis
143
What are the Ottowa Ankle rules
Indications for imaging an ankle joint that comes into the office and they are 1) Inability to ambulate initially OR in the office or urgicare and 2) Tenderness or pain at the tip of or distal 6 cm of EITHER the medial OR lateral malleolus
144
An injury to the DIP leading to inability to extend the distal phalanx is a \_\_\_\_
Mallet finger
145
What is AVN and collapse of the lunate
Keinbock's dz
146
What is a positive Froment sign
Inability to pinch between the thumb and index (first and second digits); tests for ulnar nerve palsy specifically by testing the action of the adductor pollicus
147
What is the best intial test for a Baker's cyst? Confirmatory?
US; MRI
148
What is the best initial test for Budd-Chiari syndrome?
Abdominal US; hypercoagulability being MC cause
149
What is the most COMMON pathogen to get from blood transfusions?
BACTERIA then HBV and HCV and lastly HIV
150
What should you assume if a pt with IBD suddenly has severe watery stools?
Likely to be C. diff as this is an emerging cause of diarrhea in pts with IBD even without tx with broad spec Abx; check stool toxin
151
What is incidence?
new cases in a year/ total population
152
What should you call it if a pt has sx of bulimia and/or anorexia but does not really meet criteria for either?
Eating disorder NOS
153
What is the difference between CRPS I and II? What effect can they have on bone?
Essentially the same except that CRPS II has a defined peripheral neuropathy as well (not actual paralysis though); both can have "patchy bone demineralization"
154
What is the best screening test for ZE syndrome? Confirmatory? What if solitary gastrinoma? Metastatic to liver?
Fasting gastrin \> 1000, Secretin stimulation test, Surgical resection, no surgery can give octreotide for sx
155
Where are the deposits of lupus nephritis located?
SubENDOTHELIAL
156
What are the most important abx to give to a pt with febrile neutropenia
Pseudomonal coverage so Cefepime, meropenem or imipenem, ceftazidime, or piperacillin tazobactam
157
What is the first step when a pt has statin myositis? What if the CK is \> 10x upper limit of normal?
DC the statin and try a different statin; if CK is \> 10x upper limit of normal you DC statin altogether
158
Fully explain the tx for active TB
6 months total tx with 2 months of RIPE followed by 4 months of rifampin and INH
159
Where will you see lacunar cells with collagen banding? Tx?
Nodular sclerosing Hodgkin's lymphoma; ABVD (Doxorubicin, Bleomycin, Vincristine, and Dacarbazine)
160
How do you treat vulvar lichen sclerosis? What is the major concern with not treating?
Corticosteroids; SCC
161
What is the first line tx for endometriosus? Definitive?
OCPs; surgery
162
Should you reduce blood pressure in a pt with epistaxis?
No there is no evidence that that is a good move as the BP may be secondary to anxiety from the bleed, mgmt should include manual pressure first then anterior packing
163
What if a pt twisted his ankle and has been able to walk on it but has pain at the tip of the lateral malleolus to palpation?
Image; the Ottowa ankle rules say image if either they couldn?t walk after the injury OR at the office and if they have tenderness in the distal 6 cm of the medial OR lateral malleolus
164
What does the 4th generation cephalosporin, cefepime, cover?
Pseudomonas, Gram negs, and anaerobes
165
What named nerve innervates the first webspace of the foot?
Deep peroneal nerve
166
What does radon increase the risk for?
Lung CA
167
What is the MC bone CA in kiddos? What is the 2nd MC?
Osteosarcoma; Ewing sarcoma t(11;22)? Neuronal differentiation is the main diff
168
What named nerve innervates the sole of the foot?
Tibial nerve
169
What is the most likely cause of megaloblastic anemia if both folate and B12 are at lower limits of normal and homocysteine is elevated and MMA is not?
i.e. the folate and B12 levels are "equivocal" however the pt has megaloblastic anemia most likely from folate given the elevated homocysteine and normal MMA
