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the composite kaplan and usmleworld notes
i am posting it here so that others can also benifit.
1. Decreasing LDL is more imp to prevent CAD than stopping smoking, DM control, HTN control or exercise. DM is the second most important.
2. Pt with CHF on amiodarone comes with desaturation and basal crackles- probably chronic interstitial pneumonitis, or organizing pneumonia due to amiodarone. It’s a cumulative dose effect, and not dependent on blood levels. Other adrs are liver, lungs, thyroid, BM toxicity and skin changes including Photosensitivity. Steroids can be used for severe pul disease.
3. Young patient with sec HTN, most common finding is abdominal bruit( 50%). Tachycardia if pheochromocytoma, but is less common.
4. In a patient with HTN, in absence of any known CAD, baby aspirin is useless.
5. All pts with stable angina should undergo stress EKG for risk stratification. High risk patients, ie those with failure to inc BP with exercise, inability to complete stage I of Bruce protocol,, or appearance of downsloping or horizontal ST segment during exercise >1mm, should undergo cor angiography, and thallium scan to see viable salvageable myocardium before PTCA or CABG.
6. Pt on warfarin is started on amiodarone- dec the warfarin dose by 25%
7. In a pt with h/o angioedema with ACEI, ARB are not the choice drugs- B blockers are, because ARB still have low risk of causing angioedema. Especially if the pt has no compelling indication to use ACEI, like Diabetic Nephropathy.
8. Stress Echo is always more sensitive than stress ECG, and can show wall motion abnormalities, but stress ECG is still the first choice for risk stratification in pts with stable angina. In patients who cannot exercise, eg due to OA, use dopamine stress EKG or Echo. Probably can use adenosine and dipyridamole stress EKG/Echo too.
9. Adenosine thallium/sestamibi scan, Dipyridamole thallium perfusion/viability scan both are c/I if the pt has COPD or asthma. These are used to see hypoperfused myocardium during stress.
10. Pharmacological stress testing (and probably radionuclide scan) are done in those who cant exercise eg due to OA or MI or unstable angina, and in those with abnormal baseline ECGs like LBBB, LVH, baseline ST changes, WPW, externally paced heart, etc.
11. Aortic sclerosis and ESM are normal finding in old patients.
12. Pt with CHF is given ACEI even in asymptomatic stage, ie if Echo shows low EF; B blockers and diuretics are added only if symptomatic. Isosorbide Dinitrate if evidence of pul edema. Low sodium diet and diuretics if pt has some fluid retention.
13. Orthostatic hypotension means fall of 20 mm in systolic and 10 mm in diastolic
14. Verapamil, quinidine, amiodarone and spironolactone can cause digoxin toxicity, so for eg a pt on digoxin comes with nausea, vomiting, confusion after starting verapamil.
15. In a pt with high LDL and TG, the first step is always targeting LDL with statin, then add fibrates if statin doesn’t decrease the TG. Cholestyramine can increase TG so is contraindicated.
16. Post CABG angina, with permanent ECG changes- do radionuclide perfusion imaging and not stress EKG or even stress Echo, as we cant interpret the Echo with previous wall motion abnormality due to previous MI or ischemic cardiomyopathy.
17. Inc fibrinogen >2.7 7 puts patient at high risk of MI; and lovastatin and atorva both increase fibrinogen. So if the patient has elevated levels of fibrinogen, change to either prava or simvastatin, as they have no effect on fibrinogen.
18. Wt loss is the single most imp measure to dec BP, more than stopping smoking, or dec salt or alcohol consumption or exercise
19. Preop cardiovascular risk assessment; age above 70 yrs 5 points, MI6 mo 5 points; angina on walking 1-2 blocks 10 points, angina at rest 20 points, and critical aortic stenosis 20 points
20. Drug lupus with hydralazine, mdopa, CPZ, IFN a, diltiazem, minocycline, penicillamine, procainamide, INH- starts with flu like symptoms, fever, malaise, arthralgia and facial rash.
21. Asymptomatic hypoNa in CHF patients- water restriction is the TOC, even if NA 1mm in 2 contiguous leads, after nitroglycerine is given to rule out coronary spasm. Also in pts with new LBBB. No benefit in NSTEMI. C/I with BP>180, recent surgery or ischemic stroke. ST depression occurs with ischemia, strain, digitalis, hypokalemia and hypomagnesemia, so is not an indication, unless it is due to posterior MI.
40. Poor R wave progression- if the R remains same through V1 to V4. Seen in COPD, RVH, LVH, ant infarction, blocks and cardiomyopathy.
41. Prolonged QT means more than half of RR, seen in antiarrythmic drugs, TCA, hypokalemia, seizure and stroke.
42. Metformin should be stopped before coronary angio or other dye related procedures that can harm kidney and cause lactic acidosis. Also in renal or hepatic failure, CCf, sepsis and alcoholics.
43. Aspirin should be stopped 7 d before most procedures, but needn’t be stopped for coronary angio or cath.
44. TCA overdose is treated with sod bicarb. Lidocaine is the DOC for any vent arythmia that occurs. Procainamide, disopyramide and quinidine are membrane stabilizer, hence increase TCA toxicity re. Also ppnl is contraindicated, as it dec conduction and inc arythmogenic potential of TCA re.
45. Pt can resume sexual activity 6 weeks after uncomplicated MI- ie if he recovers without any post MI chest pain, CCF or arythmia.
46. Severe symptomatic AS (area 10.
3. Immobility is a common cause of hypercalcemia, esp in adolescent and those with paget’s disease, who have high bone turnover, due to uncoupling of bone turnover, ie more resorption and less formation. Subsequent hypercalcemia will suppress PTH, and low PTH in turn suppresses D3 levels. Biphosphonates can be used in these patients to prevent this.
4. For every 1 g/dl decrease below 4 of serum albumin, add 0.8 mg to the total calcium level.
5. Paraproteinemia can increase the bound calcium, hence the total calcium in the serum.
6. Hypoglycemia with high C peptide can be both due to insulinoma and sulfonylurea overdose. History and context is imp. To differentiate, measure serum proinsulin levels. Also checking for sulfonylurea level in urine and plasma can be helpful.
7. Autoimmune hypoglycemia due to insulin antibodies which bind to insulin receptors, or release excess insulin into circulation
8. Diabetic for planned CS section- don’t stop regular dose of insulin night before, to prevent ketoacidosis, even if she is npo. Then start insulin infusion during the surgery, with D5,1/2NS and KCL. Insulin requirement will drop following delivery of the placenta. Switch to scheduled sc dosage as soon as the patient starts tolerating food.
9. DKA management- continue NS and insulin till blood glucose is 250, then change to DNS with KCL, and decrease the insulin infusion dose. Dextrose infusion is very imp to decrease ketone levels. Start KCL regardless of serum level. Switch to oral feed and sc insulin only after the anion gap has corrected, HCO3>10m and precipitating factor like infection is corrected. But always start sc insulin 1 hr before discontinuing iv insulin, as sc insulin needs time to act, so otherwise it might precipitate DKA again if we don’t overlap the insulin.
10. Pt with hyperthyroidism with chief complaints of palpitation- treatment is ppnl and not PTU
11. Preop patient for emergency surgery like CABG for unstable angina is found to have hypothyroidism- its not a contraindication for surgery, tho there is higher risk of ileus, hyponatremia and oversedation with narcotic. Only after the surgery, start with low dose T4 as the patient has CAD.
12. DM pt on metformin develops anion gap acidosis, and there is no leukocytosis or hyperamylasemia- implies its probably lactic acidosis and not DKA- so do ABG and blood lactate level, instead of ketone level and urinalysis, or instead of starting DKA treatment.
13. In patients with thyroid cancer in remission, T4 supplementation should be used to suppress TSH below normal range (ie between 0.1-0.3). If distant mets, even lower, to undetectable levels, tho that increases the risk of AF and bone loss. T3 is only used short term and never used for long term management of hypothyroidism. Hormone supplement should be taken on empty stomach.
14. Mental state change in elderly- always do TFT for diagnosing apathetic hyperthyroidism.
15. A pt on prednisone for RA develops infection and then hypotension- acute adrenal insufficiency. Administer fluid and dexamet, as it is long acting and doesn’t interfere with measurement of serum cortisols. Then do cosyntropin test. Mineralocorticoids aren’t used, because, one- they are not deficient, two- they take a longer time then just simply infusing saline.
16. Amiodarone- monitor patient’s TFT 6mthly; if it causes hypothyroid, no need to stop amiodarone. Just give larger dose of T4, as amiodarone prevents peripheral conversion of T4 into T3. But check TSH first. If hyperthyroid, it can be either due to induction of Graves disease, which is treated with PTU or methimazole, or it is due to induction of destructive thryoiditis, in which case the treatment is steroids.
17. Female on HRT for hot flashes develops DVT- should stop HRT, then give warfarin for 3 mo as this DVT has a precipitating cause and is the first episode. DVT without precipitating cause, or subsequent episode should get warfarin for 6 months. Increasing anticoagulation for continuing HRT is not justified, neither does tamoxifen help with postmenopausal symptoms.
18. Urinary metanephrines and catecholamines are better test then VMA for pheochromocytoma. Alpha blockade should be started only after the test, as it can falsely increase the level of the CA. Only after biochemical confirmation we do CT/MRI to confirm location. Both have equal sensitivity, but MRI is useful for extraadrenal foci, and also to differentiate benign from malignant ones. MIBG scan can be used if either of the above three tests are equivocal and we still suspect pheo, or one test shows pheo but the other doesn’t. Treatment is with alpha blockade, only then start beta blockade. Long acting phenoxybenzamine is used before surgery, along with liberal salt and fluid intake to increase the intravascular volume. The common complication after surgery is hypotension- use normal saline bolus and infusion. Dopamine doesn’t help as the alpha blockade will blunt the response to vasoconstrictors.
19. Pt with Hashimoto develops rapidly enlarging thyroid and SVCO- probably thyroid lymphoma. Treatment is RT.
20. Long acting sulfonylurea induced hypoglycemia- treat with D50 bolus, then D5 infusion is required to prevent rebound hypo due to the D50 induced insulin release. If refractory to this treatment, start octreotide sc. Somatostatin is iv and is short lived so not used. Giving D10 or D50 infusion for long time is not recommended as they can cause thrombophlebitis. Glucagon is also not recommended as it is short acting, plus increases insulin release causing reboud hypo. Glucagon is hence only used in acute mgmt of hypo with mental obtundation, and the patient is given readily absorbed carbo after gaining consciousness.
21. Pt on amiodarone can have inc T4 and low T3 due to decrease in conversion from T4 to T3. Ppnl also does that, but not atenolol. Aspirin displaces T4 from albumin, so don’t use it as an antipyretic in the treatment of thryotoxic storm.
22. AF due to Grave disease is treated like any other AF- with b blockers and anticoagulation. So antithyroid drug or RI ablation is not the answer.
23. Effect of tight glycemic control on microvascular complications is proved, but not macrovascular. It reduces the incidence of neuropathy, but there are conflicting evidence for reversing previous neuropathy.
24. Fahr syndrome: pseudohypoparathyroidism, with Albright hereditary osteodystrophy (short stature, round facies, short metacarpals and short neck); they have hypocalcemia with hyperphosphatemia, latter causing basal ganglia calcification and cataract. Their PTH is also elevated. Patients with hypopara will have low ca, high phosphorus and also low PTH. Vit D deficiency causes low ca and phosphorus both, and inc PTH. Acute hyperphosphatemia like with rhabdomyolysis, seizures, ARF can cause decrease in calcium, but no basal ganglia calcification and cataract like in chronic hyperphosphatemia.
25. Hypercalcemia due to sarcoidosis- , due to 1a hydroxylase enzyme, vit D increases, PTH is suppressed, hence urinary calcium is increased. Treatment is glucocorticoid and not pamidronate.
26. Exercise increases non insulin mediated glucose uptake by muscles, so can cause hypoglycemia in a patient on insulin. Avoid insulin injection to the exercising limb, and lower the dose of insulin.
27. Medullary Ca thyroid, post surgery rise in calcitonin level indicates residual metastatic disease- first step is HRCT of neck and chest with HRUSG of neck, with surgical resection if possible. If these don’t show any lesion, HRCT abdomen and bone scan, or iodine 111-octreotide scan and PET may be required. Total body iodine scan is for follicular and not medullary cancer, as the parafollicular cells don’t take iodine. Thallium scintiscan is also nonspecific.
28. Don’t take thyroxin with calcium or iron over the counter supplements.
29. Pt with amenorrhea, low FSH and LH with high alpha subunit, high prolactin and a pituitary mass- probably has gonadotroph adenoma, with lack of functioning beta subunit. Increase in prolactin is probably due to compression effect. Treatment is surgery as bromocriptine works only with GH or prolactin secreting tumor. RT is never the first choice due to delayed risk of hypopituitarism. Octreotide is also not much effective.
30. Pituitary incidentaloma with no symptoms shouldn’t be treated, only followed up with regular MRI.
31. To diagnose spurious hyperthryroidism due to external intake and to differentiate it from primary thyrotoxicosis, do the thyroglobulin level. It is decreased in external thyrotoxicosis. RAIU study doesn’t help, as the intake is decreased also in different thyroiditis, iodine or amiodarone induced thyrotoxicosis.
32. Subclinical hypothyroidism- treat if TPO AB present, as they have high rate of conversion to overt hypothyroidism. Also treat if symptomatic subclinical (ie inc TSH but normal T4).
33. HTN with hypokalemia- do aldosterone to renin ratio to differentiate hypo and hyperreninemic hyperaldosteronism. In Conn’s syndrome, the ratio is >30, with high aldosterone level also needed for diagnosis, as essential HTN can also suppress renin. Patients present with polyuria and polydipsia due to hypokalemia induced DI. If hyperreninemic, then do MR angio of renal arteries, with fibromuscular dysplasia giving a beaded appearance, and is the most common cause of RAS in young patients. Suppression of both renin and aldosterone in a pt with hypokal and HTN is probably due to apparent mineralocorticoid excess (AME), so obtain a serum cortisol level.
34. Pt with DM, NASH due to hyperTG, and obesity- TOC is metformin, as it causes wt loss,, and helpful in hyper TG and NASH. Glitazones are contraindicated as they cause wt gain, partly due to fluid retention, as well as they are hepatotoxic.
35. Subacute thyroiditis- thyrotoxicosis with painful thyroid enlargement. Tt is NSAID and beta blocker, and steroid rarely if severe. Since preformed thyroid hormones are the cause of the problem, antithyroid drugs and RI are not effective. Its not difficult to differentiate from bacterial suppurative thryoiditis, as in the latter case, people aren’t usually thyrotoxic as it involves the center of the gland, as well as USG will show multiple abscesses.
36. Hyperthyroidism in pregnancy- PTU is the TOC, as methimazole is teratogenic. If PTU doesn’t work, or cause neutropenia, surgery is indicated, else she can have thyroid storm during the stress of childbirth.
37. Asymptomatic thyroid nodules: first step is to, do TSH- if normal, and if 1cm need FNAC. If TSH is decreased, then RAIU study- if hot nodule, only observation. If symptomatic, then antithyroid drugs….. RAIU is seldom used in management of thyroid nodule, as most of cold nodules are benign, though most of malignant nodules are also cold. Since most of the nodules are benign, all nodules don’t need surgery, only FNAC is enough. Still, if we have done RAIU, then all cold nodules must be biopsied. IF the nodule is toxic or if there is carcinoma on FNAC, then the patient needs surgery.
38. CT of neck is less sensitive than USG for nodular thyroid diseases.
39. If pt has papillary cancer on FNAC, then he needs NTT- near total thyroidectomy, and then RI ablation therapy for residual tissue and mets, then RAIU study to see for remaining mets, then lifelong Thyroxine to suppress TSH. Also thyroglobulin can be followed up as a tumor marker. TSH should be suppressed below the normal range, tho this can risk AF and bone loss. Doing only subtotal thyroidectomy is ineffective, as it is difficult to ablate the remaining gland with RI, and we cant also use thyroglobulin as a marker when lot of thyroid tissue is still left in the body.
40. If medullary cancer, first test for RET to see for MENII syndrome, or do urine metanephrine/CA or abdominal CT to diagnose any concomitant pheochromo. Then start the pt on alpha blockade for a few weeks before surgery then beta blockade only after alpha blockade (else there will be vasomotor crisis), then do surgery- total thyroidectomy with central neck dissection.
41. DM with autonomic dysfunction, gastroparesis- its difficult to adjust insulin because due to delayed gastric emptying, pt will be hypoglycemic just after meal. Plus problems of postprandial bloating and constipation. Treatment is metoclopramide, or cisapride or erythromycin, and small frequent, low fat meals. Cisapride is especially shown to be beneficial, tho it is not freely available due to incidence of QT prolongation and Torsades. Last resort is feeding jejunostomy. Metoclopramide cant be used for long due to side effects and tachyphylaxis, so cisapride is the TOC re. High fiber diet will increase the constipation.
42. Octreotide can be given in intractable diarrhea in DM gastroparesis patient.
43. DM neuropathy- amitryptiline is the DOC, but since most patients have heart disease also, beware- use gabapentin instead.
44. Erectile dysfunction with normal morning erection- its psychological impotence. Erectile dysfunction is never a normal part of aging, so don’t tick that.
45. Pt of hypoparathyroidism- Tt is high dose of vit D( calciferol) and calcium; high dose because conversion to calcipotriol is defective. We don’t use calcipotriol as it is expensive. Calcipotriol has a rapid OOA, and can be used in hypercalcemic crisis, or if pt is refractory to calciferol. Pts thus treated with vit D and Ca for hypoPTH usually develop high urinary excretion of Ca, due to lack of PTH, which can lead to nephrocalcinosis. So adding THIAZIDE not only helps reduce urinary calcium, but also increases the serum calcium effectively.
46. Hypercalcemia with high PTH- can be either primary hyperPTH, lithium toxicity or familial hypocalciuric hypocalcemia. If hyperPTH, surgery is indicated if Bone mineral density is less than 2.5 SD (ie T score below -2.5), overt bone disease or fracture, kidney stone, reduced creatinine clearance, Ca level more than normal by 1, urinary calcium >400 mg/d, or if young than 50 years. For eg a postmenopausal woman with T score of -3 comes with hypercalcemia and high PTH, then she probably needs surgery. Alendronate is not as effective as surgery in preserving the BMD.
47. Those with hyperPTH who don’t need surgery are managed with periodic msmt of ca, Cr, and BMD. Pt can continue their vit D and Ca supplement, as research hasn’t shown any aggravation on calcium level with those.
48. Acromegaly: COD is cardiac- LV dysfunction, asymmetric septal hypertrophy, CAD, HTN and myocardial fibrosis; these changes may be reversible with treatment. Also increased risk of colon cancer.
49. Offspring of mother with DM I has 3% risk, if father then 6% risk of having DM I.
50. A patient with unknown goiter undergoes cardiac cath, then develops thyrotoxicosis- its iodine induced thyrotoxicosis. Treatment is b blocker, or Antithyroid drugs or KCLO4, but RAIU doesn’t help, as the iodine uptake is reduced in the gland.
51. Pt with inc TSH following say, pneumonia, with normal T4 but dec T3, its not subclinical hypothyroidism, its EUTHYROID SICK SYNDROME (low T3 syndrome). Just followup with TFT in a few weeks. No treatment needed, and no investigations for antibodies too.
52. T score in DEXA is calculated in comparison to healthy adult of age 25, while Z score is calculated in comparison with similar aged adults. WHO classifies T between -1 to -2.5 as osteopenia, and below that as osteoporosis. In a pt with osteoporosis, do CBC/Ca and PO4 levels for secondary causes; can do urinary calcium, SPEP, PTH, TSH, N telopeptide for bone resorption and AlP for bone formation. Pts with T score< -2, with low wt, smoking patient, or with fragility factures irrespective of T score, need antiresorptive therapy with alendronate or risedronate, in addition to vit D and Ca. Etidronate is old and not used, Pamidronate iv is used if pt cannot tolerate oral alendronate due to esophagitis. Calcitonin is not very effective, teriparatide (PTH) is very effective but needs daily injection and is expensive. HRT has fallen out of favor since 2002 due to report of inc MI, DVT, Stroke, and breast cancer. Pt who doesn’t respond with biphosphonates, has constitutional symptoms and pallor should be strongly suspected to have myeloma. Myeloma cells release OAF( osteoclast activating factor).
53. Medical therapy is the TOC in prolactinoma even if large and has effect on vision.
54. Pt with Addison’s disease develops diabetes I- its autoimmune polyglandular failure type II (Schmidt’s syndrome), which also has Graves, pernicious anemia, premature ovarian failure, vitiligo and celiac disease.
55. Postpartum patient on heparin for DVT comes with osteoporosis – discontinuing breastfeeding can help re, increasing dose of vit D and Ca isnot as much helpful.
56. Old male comes with hip pain- XR shows thick outer cortex with sclerosis, and Tm scan shows increased uptake- its Paget’s disease. Biphosphonates are indicated if intolerable pain, involve wt bearing bones, hypercalcemia, or CCF. Calcitonin and steroids are not useful.
1. Pt of NHL comes with epidural spinal cord compression( radicular pain)- give high dose steroid, obtain an MRI to confirm diagnosis, then start RT. If only back pain due to vertebral mets, only RT. If saddle anesthesia or bowel bladder involvement, immediate decompressive surgery.
2. Patient comes with metastatic ER/PR + cancer with occult primary in breast- no need for multiple core biopsy of breast or RM- only do chemo and hormonal therapy. Tamoxifen is preferred, with fulvestrant in those not responding to tamoxifen. Trastuzumab (HERceptin) in Her + ones.
3. Pt with AML gets multiple platelet transfusion, still the platelet count doesn’t increase- its called platelet refractoriness, due to alloimmunisation (formation of anti-platelet antibodies). If initial increase in platelet and then decrease within 24 hrs, think DIC or sepsis or active bleeding or antiplatelet drugs.
4. Pt with lung tumor with FEV1 and contribution of each lung given- the best next thing to do is still to do CT staging. PET/ bone scan can be used too. CT is best as it gives mediastinal and chest wall invasion, mets to adrenal and liver, and can also help in CT guided biopsy.
5. SVCO: dyspnea, persistent cough, hoarseness, dysphagia, syncope, chest and neck pain, cyanosis, collateral veins in thorax, ocular proptosis, lingual edema- best thing is CT with contrast. MRI only if dye cant be used.
6. If imatinib is not in the choices, then BMT is the TOC for CML, aka HCT( hematopoietic cell transplantation.) IFNa will lead to cytogenetic and not molecular remission. CPS is used to prepare for BMT to prevent GVHD.
7. HIT usually presents as thrombosis- very tricky- type I is less severe and occurs early, type II more severe and occurs after 4-10 days, due to heparin-platelet factor 4 complex antibody, decreases platelet upto 30,000, can lead to limb gangrene, mesenteric ischemia, cerebral sinus thrombosis. Prevention of HIT is by using LMWH or danaparoid, or using heparin for less than 5 days; while treatment is using DTI like lepirudin or argatroban. LMWH are not the treatment of HIT, as they can also rarely cross react with the antibodies and increase the problem.
8. Prostate cancer post treatment- f/u with PSA. If rising PSA or if skeletal complaints, do bone scan.
9. Pts on tamoxifen should be screened for endometrial hyperplasia with annual Pap and detailed history. TVS has a lot of false +ve leading to unnecessary endom biopsy, so not recommended.
10. Plt transfusion are useless in ITP, as they will also be rapidly destroyed. Only use in life threatening emergencies as intracerebral and massive GI hemorrhage. Steroid are the TOC in most cases, with IVIG in severe cases ( IVIG is not the first answer). Plasmapheresis is for HUS and TTP.
11. Alcohol and colon cancer are strongly linked than remote smoking history, so beware if the pt is smoking currently. NSAID and hormone replacement are protective. Alcohol probably causes the risk by interfering with folate absorption.
12. Among inherited thrombophilia, factor V leiden is the most common, don’t tick antiphospholipid syndrome, that is not inherited. Methyl tetrahydrofolate reductase gene mutation is related to homocystinemia, and is another risk factor. Any patient with inherited thrombophilia and spontaneous thrombosis should be on lifelong warfarin. Also those with life threatening VTE like massive PE, or unusual site like mesenteric or cerebral venous thrombosis should also be on lifelong warfarin.
13. Primary vs secondary polycythemia- WBC and platelet count will also increase in the former. If secondary cause is suspected, eg in a pt with COPD, first test is pulse oximetry after minimal exertion, and sleep study to determine nocturnal desaturation.
14. Pt with RA has pneumonia and found to have anemia- ferritin is high ( can be due to both infection or due to ACD), transferring and TIBC are low (can be due to both IDA and ACD). In these patients, do BM biopsy to differentiate ACD and IDA.
15. Pts requiring frequent transfusion might develop antibodies to RH, Kelly and other antigens, causing acute transfusion reaction. Rx is hydration, stopping transfusion. Dopamine and osmotic diuresis can be used.
16. Of all the features of Pancoast syndrome, chest movement asymmetry with asymmetric lower leg DTR is the most dangerous, as it signifies phrenic nv involvement with possible iv foramina invasion and imminent cord compression.
17. Pt of CRF comes with esophagitis and massive bleeding- Desmopressin is the TOC as it releases VIII/VWF from the endothelium, after that dialysis. Cryoppt can be used but associated with infections. Estrogen can be used too.
18. Pt with prostate cancer comes with back pain due to mets- TOC is hormonal therapy- LHRH analogue with flutamide to counter the initial flare, if back pain is unresponsive to this, then EBRT followed by chemotherapy. Radionuclide bone scan is the most effective diagnostic modality. DES reduces LHRH release from the hypothalamus too, but increases MI, PE and stroke.
19. SCC skin- surgery first line, RT if pt refuses surgery, and 5FU is the third line treatment.
20. Pancoast: RT with surgical resection is the TOC, but if there is evidence of distant mets, or brachial plexus involvement, or positive bone scan, then RT alone.
21. AIDS with PCNSL- best therapy is HAART itself, tho RT and corticosteroid help, they don’t increase life expectancy. The most important prognostic factor is the increase in CD4 count.
22. CholangioCa, even if Klatskin- if with mets, is inoperable, so the treatment is ERCP and stenting for the pruritus and jaundice. PTC only if ERCP fails. Ursodeoxycholic acid doesn’t help as it doesn’t relieve the obstruction.
23. Pt comes with diarrhea, sclerotic bone lesions, eosinophilia and peptic ulcer- Systemic mastocytosis.
24. Lobular CIS of breast- it is multicentric and bilateral, so the best treatment is close observation, annual mammogram and tamoxifen which has shown dec risk of progression to overt carcinoma. Surgery, If at all, has to be bilateral prophylactic mastectomy. Local excision is useless.
25. Pt with ACD- low iron, high ferritin, normal or low transferring and transferrin saturation. BM is diagnostic, and shows normal or increased iron in macrophages, and decreased no of sideroblasts. Do EPO level, if it is low, EPO is the treatment. If EPO is already high, then periodic blood transfusion is the treatment. Plus treatment of the underlying disease with close f/u might be the right answer.
26. Pt with ESRD and ACD, doesn’t respond to EPO- first thing is to do iron study to rule out iron deficiency. Then see for folate deficiency, systemic inflammation and Al toxicity. Avoid BT in them, as that can risk causing allogenic graft rejection after kidney transplant.
27. Advanced gallbladder Ca with neuropathic pain in right thigh- for sharp pain, DOC is carbamazepine, second line being valproate or gabapentin. For dull pain, desipramine is the DOC. Not narcotics.
28. Pt treated for SCLC comes with features of acoustic neuroma, its probably not neuroma but mets. Contrast MRI showing the multiple well circumscribed mass with local edema is the investigation of choice.
29. A pt with normocytic anemia- first thing to do is retic count- if high, its hemolysis, if low its hypoproliferative Electrophoresis and Coombs for earlier, BM for the latter.
30. Myaesthenic syndrome means Lambert Eaton- treatment is plasmapheresis and immunosuppressive therapy. Electrophysiological studies confirm incremental response with repetitive stimulation. DTR are lost unlike in myasthenia gravis or polymyositis re.
31. Breast cancer metastasis to brain- stereotactic surgery if single, EBRT if multiple. Chemo don’t penetrate, steroid help, and prophylactic anticonvulsant are not indicated.
32. Sickling crisis- during mens, alcohol, nocturnal hypoxemia- mainstay of treatment is hydration. Morphine or iv ketorolac for pain.
33. Sickling crisis with splenomegaly- beware of splenic sequestration- dramatic fall in hemoglobin causing hypovolemic shock. So CBC should be monitored in these pts. CXR, blood and urine culture are followed by iv antibiotics esp if the pt wasn’t on prophylactic penicillin. Avoid contact sports.
1. If polyps are found in sigmoidoscopy, next thing to do is colonoscopy to see for synchronous lesions and remove them. Double contrast enema is inferior, plus doesn’t allow intervention also.
2. TPN: average need is 30Kcal/d and protein 1g.kg.d, but in malnourished or critically ill patients, its 35-40 and 1.5 respectively. Overfeeding leads to hyperglycemia, hyperinsulinemia, inc TNF. PEG (percut gastrostomy) should be considered if pts need TPN for a long time.
3. LGIB: urgent colonoscopy is the procedure of choice due to diagnostic and therapeutic advantage. IF there is poor visualization due to bleeding, then do Tm tagged RBC scan, which is better than angio to localize the site. Vasopressin is inferior as bleeding recurs after stopping, and it can cause ischemic damage to organs and arythmia. Octreotide works only in variceal bleeding. Urgent colectomy might be needed, but only after localization of the site of bleeding.
4. Chronic pancreatitis: low fat diet is the most effective method to stop steatorrhea, while enzyme supplement is inferior.
5. Mallory Weiss tear that has stopped bleeding needs no intervention. Hiatal hernia is a very frequent predisposing factor for the tear, and can occur during blunt abd trauma, CPR and endoscopy too.
6. Mesentric angina- duplex USG is the screening test done first, as it has a high negative predictive value. Angiography is the gold standard, but is done only after duplex.
7. Mild pancreatitis- manage with pain control and iv fluid, npo, ng aspiration to prevent further pancreatic stimulation. Hypoechoic mass in pancreas doesn’t mean abscess unless there are systemic signs. Antibiotics have been shown to be useful prophylactically only in severe pancreatitis (Ranson criteria), or necrotizing pancreatitis or large peripancreatic fluid collection. Imipenem or cefuroxime penetrate pancreas well. No indication of daily CT scan or CT aspiration unless features suggestive of infected necrosis. Surgical debridement if severe necrosis, biliary pancreatitis, lack of response to therapy or complications. ERCP if concurrent dilatation of biliary system or elevated LFT.
8. If the patient with pancreatitis develops fever, then take blood culture and start imipenem, piperacillin, quinolones. IF pt fails to improve after 1 week of antibiotic therapy, a CT guided aspiration of the tissue for C/s is done.
9. Acute HepB needs only supportive treatment, as most resolve on their own. Only chronic active hepatitis needs lamivudine and adefovir. Conversion to chronic stage depends on age- 90% if perinatal, 20-50% if below 5 and 7, ie class B or C in child pugh classification. Class A is
|* Re:Can Someone Share Kaplan Step 3 Q bank Notes?
||this is the mksap synopsis
My MKSAP 14 neurology notes:
1. A spinal cord disorder should be considered in any patient with bilateral motor and sensory dysfunction in the extremities in the absence of signs or symptoms of brain or brainstem dysfunction.
2. Spinal cord compression due to epidural metastasis is a neurologic emergency for which urgent MRI of the entire spine is appropriate.
3. Vertebral artery dissection typically presents with neck or head pain, Horner's syndrome, dysarthria, dysphagia, decreased pain and temperature sensation, dysmetria, ataxia, and vertigo.
4. Magnetic resonance angiography( MRA) is a sensitive diagnostic test for vertebral artery dissection as a cause of stroke.
5. Juvenile myoclonic epilepsy is a primary, genetic, generalized epilepsy that typically manifests with myoclonic jerks followed by a generalized tonic–clonic seizure
6. Guillain–Barré syndrome is characterized by proximal and distal weakness, autonomic symptoms, cranial nerve involvement, and respiratory failure.
7. Treatment of Guillain–Barré syndrome with either intravenous immunoglobulin or plasmapheresis is indicated in patients who cannot walk independently or who have impaired respiratory function or rapidly progressive weakness.
8. Small, stable, asymptomatic meningiomas can be followed with serial neuroimaging.
9. In large, symptomatic, or progressive meningiomas, surgical resection offers an 80% chance of cure.
10. Personality change, lost initiative, and slowing of thought, with relative preservation of recent memory, suggest frontotemporal dementia.
11. Frontotemporal dementia is usually associated with disproportionate atrophy of the anterior frontal and temporal lobes, a finding that is usually clearly demonstrated on MRI.
12. Elevation of the cerebrospinal fluid 14-3-3 protein in a patient with rapidly progressive dementia and normal structural imaging suggests Creutzfeldt–Jakob disease.
13. Treatment with interferon-beta decreases the incidence of additional attacks in patients with monosymptomatic demyelination, including optic neuritis and myelopathy.
14. Propranolol and primidone are first-line drugs in the treatment of essential tremor (postural and action tremor).
15. The diagnosis of Parkinson's disease requires the presence of at least two of the following: tremor at rest, bradykinesia, rigidity, and postural reflex abnormality.
16. The characteristics of migraine headache without aura include worsening of the headache with movement, limitation of activities, and photo- and phonophobia
17. Transverse myelitis is an acute or subacute demyelinative or inflammatory disorder of the spinal cord that causes motor, sensory, and autonomic dysfunction below a spinal cord level.
18. High-dose intravenous corticosteroids are indicated for initial treatment of acute transverse myelitis.
19. Secondary prevention of cardioembolic stroke consists of warfarin with a target INR of 2.0 to 3.0.
20. Heparin has no established role in the acute treatment of stroke.
21. The manifestations of partial seizures depend on their neuroanatomic location.
22. Frontal seizures are brief and are usually not associated with aura or postictal confusion.
23. Hereditary sensorimotor neuropathy (HSMN) is an autosomal dominant disorder that usually presents with clumsiness or difficulty running in the first decade of life.
24. Hereditary sensorimotor neuropathy is characterized by distal muscle atrophy, weakness, and sensory loss associated with high arches (pes cavus) and hammertoes
25. Cell type and tumor grade are the most important determinants of survival in glioma.
26. Higher-grade gliomas are more aggressive than lower grade.
27. Alzheimer's disease is characterized by primary dementia with prominent amnesia.
28. Dementia with Lewy bodies, characterized by fluctuating cognition, parkinsonism, and/or visual hallucinations, often coexists with Alzheimer's disease.
29. All patients with relapsing multiple sclerosis should be considered for immunomodulatory therapy with either a form of interferon-beta or glatiramer acetate.
30. Adult-onset idiopathic dystonia is usually focal or segmental and does not generalize to other parts of the body.
31. Botulinum toxin injections can correct the abnormal posture and alleviate the pain associated with cervical dystonia.
32. Approximately 20% of patients with migraine have headache with aura, that is, neurologic problems such as visual hallucinations or numbness or tingling before or during headache.
33. Lhermitte's sign, an “electric shock”–like sensation down the neck, back, or extremities occurring with neck flexion, is a helpful historical clue to a cervical spinal cord disorder.
34. Cervical spondylosis is a chronic disorder of degenerative and hypertrophic changes of the vertebrae, ligaments, and disks that may narrow the spinal canal and cause cervical spinal cord compression.
35. In patients with stroke not eligible for thrombolytic therapy, aspirin modestly reduces both the short-term risk of recurrent stroke and the long-term risk of stroke-related death and disability.
36. In patients with acute stroke, thrombolytic therapy must be started within 3 hours of the onset of symptoms or of the time the patient was last known to be well.
37. Elderly patients may be particularly sensitive to the cognitive, motor, and coordination side effects of phenytoin, even if the serum phenytoin level is in the therapeutic range.
38. Gabapentin, lamotrigine, and carbamazepine are equally effective at controlling partial onset seizures in the elderly, but gabapentin and lamotrigine are better tolerated.
39. Peripheral nervous system vasculitis usually presents with asymmetric weakness and sensory loss in specific nerve distributions.
40. In an elderly patient with recurrent glioblastoma and poor performance status, referral for hospice care is preferable to additional antitumor treatment.
41. The three specific criteria for dementia with Lewy bodies are fluctuating encephalopathy, parkinsonism, and visual hallucinations.
42. A centrally acting anticholinesterase agent may alleviate the inattention, hallucinations, and fluctuating encephalopathy of dementia with Lewy bodies.
43. Women taking immunomodulatory treatment for multiple sclerosis should use effective contraception, or if they want to become pregnant, stop therapy several months before attempting to conceive.
44. Involuntary brief, irregular, unpredictable movements fleeting from one body part to another are hallmarks of chorea.
45. Chorea can occur as a hereditary and degenerative disease or secondary to drugs, metabolic disorders, infections, immune-mediated diseases, and vascular lesions.
46. Tension-type headache is distinguished from migraine by the fact that patients with tension headache are not disabled and can carry out activities of daily living in a normal, expedient manner.
47. Vitamin B12 deficiency can cause dysfunction of the posterior columns and corticospinal tracts of the spinal cord, causing paresthesias, loss of vibration and position sense, sensory ataxia, weakness, and upper motor neuron signs.
48. Neurologic signs of vitamin B12 deficiency may manifest in the absence of hematologic signs of vitamin B12 deficiency.
49. In a patient with a transient ischemic attack, carotid artery ultrasonography showing a >50% stenosis of the internal carotid artery may be an indication for carotid endarterectomy.
50. A single antiepileptic drug should be used in pregnant women with epilepsy; multiple drug therapy increases the risk for birth defects.
51. Chronic inflammatory demyelinating polyneuropathy, the chronic form of Guillain–Barré syndrome, is characterized by proximal and distal weakness, areflexia, and distal sensory loss.
52. Chronic inflammatory demyelinating polyneuropathy progresses in a stepwise or relapsing course for at least 8 weeks and can occur early in the course of HIV infection.
53. In a young patient with totally resected low-grade glioma, postsurgical management consists of observation with serial neuroimaging.
54. Vascular dementia is suggested by a history of vascular risk factors, abrupt onset with subsequent improvement, periventricular white matter ischemia on imaging, and focal neurologic findings.
55. Intravenous methylprednisolone therapy followed by an oral prednisone taper speeds recovery of visual acuity in optic neuritis
56. The restless legs syndrome consists of abnormal sensations in the legs and restlessness relieved by movement.
57. Patients are at risk for developing analgesic overuse headache if they use prescription or over-the-counter medication for headache more than 2 days a week.
58. Pseudotumor cerebri is characterized by papilledema, postural change with headache, visual changes, recent report of rapid weight gain, or introduction of oral contraceptives or tetracycline.
59. Infarction of the spinal cord typically presents as sudden spinal cord dysfunction.
60. Spinal cord infarction usually affects the territory of the anterior spinal artery, causing weakness and pinprick loss of sensation with sparing of vibration and position sense.
61. CT scan may miss subarachnoid hemorrhage, especially when there is a delay in presentation after the initial hemorrhage.
62. Focal neurologic symptoms 3 to 7 days after a subarachnoid hemorrhage may be due to vasospasm with cerebral ischemia.
63. Patients with epilepsy who are most likely to remain seizure free after medication withdrawal are those with no structural brain lesion, no epileptiform or focal abnormalities on electroencephalogram, a sustained seizure-free period, and no abnormalities on neurologic examination.
64. Patients with epilepsy who discontinue antiepileptic medication should stop driving for at least 3 months and preferably 6 months from the start of the taper.
65. Critical illness polyneuropathy is a common cause of failure to wean from a ventilator in a patient with associated multiorgan failure and sepsis.
66. Critical illness polyneuropathy is characterized by generalized or distal flaccid paralysis, depressed or absent reflexes, and distal sensory loss with sparing of cranial nerve function.
67. Patients with primary central nervous system lymphoma should be evaluated for vitreal or uveal involvement before therapy is begun.
68. Aggressive resection is not recommended in primary central nervous system lymphoma; methotrexate chemotherapy is primary therapy.
69. Donepezil, an acetylcholinesterase inhibitor, may cause mild peripheral cholinergic side effects, including increased vagal tone, with bradycardia, and occasionally atrioventricular block.
70. In at least 50% of patients with relapsing–remitting multiple sclerosis, disease will evolve to a secondary progressive course.
71. Metoclopramide, which blocks dopamine receptors both in the periphery and inside the central nervous system, can induce parkinsonism.
73. Prednisone is the most appropriate treatment for episodic cluster headache.
74. Acute cervical spinal cord compression due to hyperextension injury is common in elderly patients.
75. Emergent MRI of the cervical spinal cord is indicated in any patient with quadriparesis after a fall.
76. The classic symptoms of cerebellar stroke are headache, vertigo, and ataxia.
77. Patients with epilepsy who fail to respond to three trials of antiepileptic drugs are unlikely to ever become seizure free with drug therapy.
78. Treatment-resistant patients with epilepsy should be evaluated for a surgically remediable epilepsy syndrome.
79. Myasthenia gravis is an autoimmune disease caused by antibodies against the acetylcholine receptor, which results in impaired neuromuscular transmission.
80. Myasthenia gravis is characterized by fatigable weakness with a predilection for ocular, bulbar, proximal-extremity, neck, and respiratory muscles.
81. Leptomeningeal spread of systemic carcinoma manifests as a cranial neuropathy or spinal polyradiculopathy, or as encephalopathy, diffuse brain infiltration, or communicating hydrocephalus.
82. Creutzfeldt–Jakob disease is suggested by subacute progression of dementia with myoclonus and other motor signs and a normal brain MRI.
83. In the setting of subacutely progressive dementia, the presence of 14-3-3 protein in cerebrospinal fluid, or electroencephalography showing periodic sharp waves, can be diagnostic of Creutzfeldt–Jakob disease.
84. Mitoxantrone therapy is of modest benefit in slowing progression of secondary progressive or severe relapsing–remitting multiple sclerosis.
85. The primary concern about mitoxantrone therapy is the risk for cardiotoxicity.
86. Progressive supranuclear palsy is characterized by parkinsonism with early gait and balance involvement, vertical gaze palsy, severe dysarthria, and dysphagia.
87. Normal pressure hydrocephalus is characterized by the classic triad of gait impairment, cognitive decline, and urinary incontinence.
88. Patients with idiopathic intracranial hypertension present with signs and symptoms of increased intracranial pressure without a mass lesion on brain imaging.
89. In patients with possible idiopathic intracranial hypertension, a diagnostic and potentially therapeutic lumbar puncture is indicated after brain imaging excludes a mass lesion.
90. Severe cerebral anoxia from cardiac arrest can cause severe diffuse cerebral hemispheric cortical injury with relative preservation of brainstem function, leading to the development of a vegetative state.
91. A vegetative state is a condition of complete unawareness of self or the environment, accompanied by sleep–wake cycles and preservation of brainstem and hypothalamic functions.
92. Intracerebral hemorrhage with extensive subarachnoid hemorrhage is the hallmark of a ruptured arteriovenous malformation.
93. Conventional angiography is the definitive diagnostic procedure for detecting arteriovenous malformations and berry aneurysms.
94. In a patient with status epilepticus, after the airway is stabilized and plasma glucose determined to be normal, parenteral antiepileptic medications should be started.
95. Lorazepam is the preferred benzodiazepine for initial therapy for a patient in status epilepticus.
96. Myasthenia gravis crisis is characterized by dysphagia requiring nasogastric feeding and/or severe respiratory muscle weakness necessitating ventilation.
97. Myasthenia gravis crisis is treated with either plasmapheresis or intravenous immunoglobulin.
98. Radiation-induced leukoencephalopathy is a subcortical process affecting white matter and characterized by the triad of gait apraxia, dementia, and urinary incontinence, like NPH.
99. Radiation-induced leukoencephalopathy may occur months to years after radiation and is more common after whole-brain compared with focal brain irradiation.
100. Mild cognitive impairment consists of isolated mild amnesia with no impairment of interpersonal, occupational, or daily living activities.
101. The conversion rate from mild cognitive impairment to mild dementia is 10% to 15% per year.
102. Amantadine is the first-line pharmacologic agent for treatment of multiple sclerosis-related fatigue.
103. Multiple system atrophy is characterized by orthostatic hypotension, neurogenic bladder, constipation, and impotence, with gait-predominant parkinsonism and corticospinal tract signs.
104. Carbamazepine is the appropriate treatment for trigeminal neuralgia.
105. Patients with the locked-in syndrome are quadriplegic, have paralysis of horizontal eye movements and bulbar muscles, and can communicate only by moving their eyes vertically or blinking.
106. The locked-in state is due to a lesion of the base of the pons, usually from pontine infarction due to basilar artery occlusion.
107. Antiplatelet therapy, statins, and ACE inhibitors each reduce the risk of recurrent stroke even in the absence of chronic hypertension or a lipid disorder.
108. Headache may be a limiting factor in the use of the combination of aspirin and extended-release dipyridamole for secondary stroke prevention.
109. Nonepileptic seizures of psychogenic origin can be differentiated from epilepsy by their longer duration, normal electroencephalogram findings, and maintenance of consciousness.
110. Nonepileptic psychogenic seizures are often associated with moaning, crying, and arrhythmic shaking of the body.
111. Absence seizures are characterized by a brief loss of awareness with no movement or very subtle movements of the lips and fingers.
112. Juvenile myoclonic epilepsy is characterized by myoclonic seizures and often accompanied by absence and generalized tonic–clonic seizures.
113. Amyotrophic lateral sclerosis is characterized by pathologic hyperreflexia, spasticity, extensor plantar responses, along with atrophy, fasciculations, and weakness.
114. Muscle weakness in amyotrophic lateral sclerosis usually begins distally and asymmetrically in the upper or lower extremities or may be limited initially to the bulbar muscles, resulting in dysarthria and dysphagia.
115. Surgical resection is indicated for an accessible solitary brain metastasis in patients with limited or no systemic tumor.
116. Cholinesterase inhibitors have modest efficacy on cognitive and global function in mild to moderate Alzheimer's disease.
117. Vitamin E and selegiline may delay the progression of Alzheimer's disease, but do not alleviate cognitive or psychiatric symptoms.
118. In patients with possible multiple sclerosis, new MRI white-matter lesions or new gadolinium-enhancing lesions on serial brain or spinal cord MRI at least 3 months after an initial scan, indicate dissemination of demyelination, even without a new clinically evident attack.
119. Carbidopa-levodopa is the first-line treatment for patients older than 70 years with new-onset Parkinson's disease.
120. Complications associated with the use of dopamine agonists, such as somnolence, drug-induced psychosis, and dizziness, are more common in patients older than 70 years.
121. The risk of rupture of a small intracranial aneurysm is less than the risk of complications with clipping or endovascular coiling of the aneurysm.
122. Incidentally discovered small aneurysms should be re-evaluated periodically for enlargement.
123. Oxcarbazepine is effective monotherapy for partial onset seizures.
124. Risk factors for recurrent seizures include multiple previous seizures, a history of significant head trauma, focal electroencephalogram abnormalities, and structural abnormality on MRI.
125. Amyotrophic lateral sclerosis causes progressive respiratory muscle weakness that may present with supine dyspnea, frequent arousals, daytime fatigue, or morning headache.
126. Noninvasive positive-pressure ventilation should be started in patients with amyotrophic lateral sclerosis whose forced vital capacity is less than 50% or who has symptoms of nocturnal hypoventilation.
127. Neurologic symptoms in conjunction with normal brain imaging and the detection of a systemic cancer are most likely due to an immune-mediated paraneoplastic neurologic syndrome.
128. Memantine may alleviate cognitive symptoms and improve global function in moderate to severe Alzheimer's disease when added to cholinesterase inhibitor therapy.
129. Estrogen replacement in post-menopausal women with Alzheimer's dementia has not been shown to alleviate cognitive symptoms or delay disease progression.
130. Drug-induced psychosis in Parkinson's disease consists primarily of visual hallucinations, evolving at times into paranoid-type delusions.
131. Infection with fever can temporarily exacerbate a chronic neurologic defect in a patient with a previous stroke.
132. Partial complex epilepsy consists of stereotyped nonconvulsive seizures with loss of awareness and amnesia for events.
133. Myotonic dystrophy is an autosomal dominant disorder that presents with distal weakness and muscle stiffness and is characterized by cataracts, frontal balding, temporal muscle atrophy, sustained handgrip, and cognitive dysfunction.
134. Cardiac disease resulting in arrhythmias and respiratory failure due to diaphragmatic weakness are common features of myotonic dystrophy.
135. Lambert-Eaton myasthenic syndrome is characterized by symmetrical proximal muscle weakness and autonomic dysfunction.
136. Lambert-Eaton myasthenic syndrome is diagnosed by motor nerve conduction studies with repetitive stimulation.
137. Cognitive impairment accompanied by fluctuating lethargy and inattention, hallucinations, and asterixis is likely the result of a toxic encephalopathy.
138. Drugs that block dopamine receptors can induce acute dystonic reactions.
139. In acute ischemic stroke, tissue plasminogen activator is indicated if therapy is started within 3 hours of onset of symptoms, there is no hemorrhage on CT scan, and all other eligibility criteria are met.
140. All states require that an episode of loss of awareness be reported to government authorities, either to the Department of Health or to the Department of Motor Vehicles.
141. Hypothyroid myopathy is characterized by muscle pain, cramps, stiffness, fatigue, and paresthesias.
142. In hypothyroid myopathy, creatine kinase levels may be 10 to 100 times normal, but thyroid function tests should be performed before electromyography or muscle biopsy.
143. Paraneoplastic limbic encephalitis is most commonly associated with small-cell lung cancer.
144. Paraneoplastic limbic encephalitis is characterized by rapidly progressive decline in short-term memory and seizures.
145. The most common heritable form of Alzheimer's disease results from a mutation in presenilin-1.
146. Testing for presenilin-1 may be useful when a heritable form of Alzheimer's disease is suspected.
147. CT scan of the brain is indicated to diagnose suspected intracerebral hemorrhage.
148. Head trauma increases the relative risk for epilepsy by 10 only if there is penetration of the dura or loss of consciousness for more than 30 minutes.
149. Critical illness myopathy is common in ventilator-dependent patients who have been treated with corticosteroids and neuromuscular blocking agents.
150. Critical illness myopathy is characterized by ventilator dependence, generalized or proximal flaccid paralysis, muscle atrophy, and high creatine kinase levels.
151. Primary impairment of concentration and attention, as opposed to memory, is likely the result of depression rather than a neurodegenerative condition.
152. Carotid endarterectomy is the appropriate intervention in patients with symptomatic carotid artery stenosis, especially within the first few weeks after initial symptoms.
153. Depression is a possible side effect of many antiepileptic drugs, including phenobarbital, phenytoin, valproate, levetiracetam, and topiramate.
154. Selective serotonin reuptake inhibitors, moclobemide, venlafaxine, and nefazodone do not increase the seizure threshold in patients with epilepsy and therefore are the preferred pharmacologic agents in depression.
155. Polymyositis is characterized by proximal muscle weakness, elevated creatine kinase levels, and needle electromyography showing diffuse fibrillations and myopathic motor unit potentials.
156. Results of creatine kinase measurement and needle electromyography are invariably normal in steroid myopathy but abnormal in inflammatory myopathy.
157. Antiplatelet therapy is the mainstay of secondary stroke prevention in patients with cryptogenic stroke.
158. Clopidogrel is the preferred antiplatelet therapy for aspirin-allergic patients with a history of stroke.
My Cardiology Note:
160. Right ventricular infarction should be suspected in patients with inferior myocardial infarction who present with hypotension, clear lung fields, and elevated jugular venous pressure. Treatment is fluid loading.
161. An echocardiogram establishes the diagnosis of right ventricular infarction by demonstrating right ventricular enlargement and hypokinesis.
162. Implantable cardioverter-defibrillator therapy reduces risk of sudden death in survivors of cardiac arrest due to ventricular tachycardia or ventricular fibrillation without a reversible cause.
163. Spontaneous coronary dissection may occur during pregnancy.
164. In patients with ST-elevation myocardial infarction, successful fibrinolysis is suggested by resolution of chest pain and ST-segment elevation and/or transient ventricular arrhythmias early after reperfusion.
165. In patients with ST-elevation myocardial infarction, reperfusion arrhythmias, typically manifested as a transient accelerated idioventricular arrhythmia, usually do not require additional antiarrhythmic therapy.
166. Thrombosis of mechanical valves may present with valve dysfunction rather than embolic events.
167. Intravenous heparin should be started immediately while diagnostic evaluation is in progress.
168. Chest CT scan with contrast is indicated to detect acute aortic dissection. Some say TEE.
169. In patients at risk for radiocontrast nephropathy and contraindication to MRI, transesophageal echocardiography is the test of choice for possible aortic dissection.
170. Breast and lung carcinoma are the most common causes of malignant pericardial disease.
171. The epicardium is the most common location of metastatic cardiac neoplasm.
172. An ACE inhibitor and a β-blocker are indicated in all patients with systolic heart failure, including asymptomatic patients. Spironolactone also has survival benefit in symptomatic patients.
173. Spironolactone and digoxin are not indicated in patients with asymptomatic systolic heart failure.
174. Fixed splitting of the S2 is the auscultatory hallmark of atrial septal defect.
175. A divergence between electrocardiography showing low-voltage and echocardiography demonstrating a substantial increase in left ventricular wall thickness is a useful diagnostic clue for cardiac amyloidosis.
176. Abdominal fat aspiration biopsy is a safe and reasonably sensitive test for the diagnosis of amyloidosis.
177. Physical examination is helpful is identifying the presence, but not the severity, of valve disease.
178. The most sensitive sign on physical examination to exclude the diagnosis of severe aortic stenosis is a physiologically split S2.
179. Most patients with peripheral vascular disease have an ABI less than 0.9, and those with severe disease (rest ischemia), an ABI of less than 0.4.
180. An ABI >1.3 indicates vascular calcification.
181. A hydralazine/nitrate combination should be considered in patients with heart failure who develop hyperkalemia while taking an ACE inhibitor or an ARB.
182. Ventricular tachycardia without structural heart disease carries a good prognosis.
183. For idiopathic ventricular tachycardia with refractory symptoms, radiofrequency catheter ablation has an excellent cure rate.
184. PR-segment depression is virtually pathognomonic for acute pericarditis.
185. Echocardiography is neither sensitive nor specific for the diagnosis of acute pericarditis
186. Survival in patients with severe asymptomatic aortic stenosis is similar to that of age-matched normal adults.
187. At symptom onset, patients with severe aortic stenosis may have only subtle symptoms, such as dyspnea on exertion or a decrease in exercise tolerance.
188. Mediastinal radiation therapy may result in cardiac disease 10 to 20 years later.
189. Radiation heart disease includes constrictive pericarditis, myocardial fibrosis, valve dysfunction, and premature coronary artery disease.
190. Midsystolic murmurs in the elderly are usually benign and due to minor, age-related changes of the aortic valve (aortic sclerosis).
191. An echocardiogram is warranted in patients with cardiac symptoms or systolic murmurs that are >grade 3/6 in intensity, continuous murmurs, or any diastolic murmur.
192. Surgery for native valve endocarditis is indicated if there is significant hemodynamic instability or evidence of paravalvular extension.
193. Factors favoring earlier timing of surgery include significant congestive heart failure, resistant infections, and large mobile vegetations.
194. Even if active bacteremia is still present or if the antibiotic treatment course is ongoing, surgery for endocarditis should not be delayed if surgical criteria are met.
195. Medical therapy for acute, recent myocardial infarction includes β-blockers, aspirin, angiotensin-converting enzyme inhibitors, and statins.
196. Smoking cessation is the single most effective intervention for patients with peripheral vascular disease.
197. β blockade does not promote clinical claudication.
198. Cilostazol is relatively contraindicated in patients with congestive heart failure.
199. Patients with heart failure who have severe symptoms and evidence for ventricular dyssynchrony benefit from implantation of a biventricular pacemaker.
200. Biventricular pacing improves cardiac performance and quality of life and may also improve survival.
201. Glycoprotein receptor blockade is indicated for patients with acute coronary syndrome who will undergo coronary angiography and intervention.
202. Patients with ST-elevation myocardial infarction treated with stents require aspirin and clopidogrel both at discharge. They require abciximab acutely after the procedure, or before it.
203. Patients with ST-elevation myocardial infarction treated without stents may be managed with aspirin alone or with warfarin if indicated for atrial fibrillation or anterior akinesis or aneurysm.
204. In low-risk patients with lone atrial fibrillation, warfarin anticoagulation is not required. Aspirin or no therapy is recommended.
205. A systolic murmur, an S3 gallop, and mild peripheral edema are normal findings during pregnancy.
206. In the absence of significant mitral regurgitation, primary mitral valve prolapse has a benign prognosis.
207. Antibiotic prophylaxis for endocarditis is indicated in mitral valve prolapse if there is more than mild mitral regurgitation, if a murmur is heard on auscultation, or if the patient has high-risk echocardiographic features.
208. Initial management of acute coronary syndrome related to a systemic process, such as anemia, is treatment of the precipitating factor, eg blood transfusion.
209. Medical therapy for NSTEMI in patients with TIMI low-risk status has acceptable outcomes.
210. Patients with atrial fibrillation and risk factors for stroke require anticoagulation with warfarin.
211. Risk factors for stroke in nonrheumatic atrial fibrillation include prior embolic event or stroke, hypertension, advanced age, congestive heart failure, coronary artery disease, and diabetes mellitus.
212. β-blockers should not be initiated in heart failure patients who are acutely decompensated or volume overloaded.
213. Patients with atrial fibrillation and minimal symptoms can usually be managed with rate control alone (without rhythm control).
214. Echocardiography is indicated when a new murmur, a systolic murmur ≥grade 3/6, or any diastolic murmur is heard.
215. Physiologic valvular regurgitation does not pose a risk of endocarditis and does not require antibiotic prophylaxis.
216. Antibiotic prophylaxis for endocarditis is tailored to the risk of the procedure and the risk of the patient.
217. Although pericardiectomy is the most effective treatment for constrictive pericarditis, it is unnecessary in patients with early disease.
218. Atrial flutter is characterized by saw-tooth pattern flutter waves most noticeable in the inferior leads.
219. The preferred treatment for recurrent atrial flutter is radiofrequency catheter ablation.
220. Aspirin-allergic patients with ST-elevation myocardial infarction can be treated with clopidogrel as part of postinfarction medical therapy.
221. Angiotensin-converting enzyme inhibitors are indicated for all patients with systolic heart failure, regardless of ejection fraction or functional status, barring contraindications.
222. Patients with STEMI should undergo coronary reperfusion in the most expeditious manner.
223. STEMI patients who cannot be reperfused by direct coronary intervention within 90 to 120 minutes should receive fibrinolytic therapy if there are no contraindications. So stenting takes precedence to fibrinolysis.
224. The decision to implant a pacemaker for sinus node dysfunction depends on the presence of symptoms rather than heart rate alone.
225. Subacute cardiac tamponade may be caused by acute viral pericarditis.
226. Echocardiography is a useful diagnostic modality for the delineation of pericardial hemodynamics.
227. • Papillary muscle dysfunction or rupture should be suspected in patients with clinical signs of acute mitral regurgitation in the setting of a myocardial infarction.
228. • An echocardiogram should be performed if papillary muscle dysfunction is suspected.
229. • Mitral regurgitation due to papillary muscle dysfunction often improves following coronary revascularization
230. Syncope in a patient with cardiomyopathy may be due to potentially fatal ventricular arrhythmia.
231. An ICD is indicated for patients with left ventricular dysfunction and hemodynamically significant ventricular arrhythmias.
232. Coronary artery bypass grafting improves survival in patients with obstructive left main and/or multivessel coronary artery disease.
233. Coronary artery bypass grafting improves survival in comparison to percutaneous intervention in diabetic patients with multivessel coronary artery disease.
234. Atrioventricular nodal re-entrant tachycardia is characterized by a narrow QRS complex and lack of visible P waves.
235. The first treatment of choice for atrioventricular tachycardia is carotid sinus massage.
236. If carotid sinus massage is unsuccessful, adenosine is the drug of choice for the termination of narrow-complex supraventricular tachycardias.
237. The murmur of hypertrophic cardiomyopathy increases after a Valsalva maneuver and decreases after a sit-to-squat maneuver, performing passive recumbent leg lifts, or performing handgripping exercises. This is exactly opposite for AS murumu, or MR murmur.
238. Ascending aortic dissection may involve the coronary arteries, most commonly the right coronary artery.
239. Ascending aortic dissection may lead to disruption of the aortic valve, leading to aortic regurgitation.
240. Noonan syndrome is characterized by short stature, intellectual impairment, unique facial features, neck webbing, and congenital heart defects.
241. Noonan syndrome should always be considered in a patient with pulmonary valve stenosis.
242. The recommended initial treatment for acute viral pericarditis is a high-dose nonsteroidal anti-inflammatory medication, such as indomethacin.
243. Anticoagulation therapy is contraindicated in pericarditis because of the risk of hemopericardium.
244. Perioperative β blockade decreases cardiovascular risk in patients undergoing noncardiac surgery.
245. Hypertension (blood pressure >180/110 mm Hg) is a relative contraindication to fibrinolysis in patients with STEMI.
246. Revascularization should proceed expeditiously with concomitant medical therapy for hypertension complicating STEMI.
247. Restrictive cardiomyopathy is a late complication of radiation therapy.
248. A normal left ventricular wall thickness in radiation-induced restrictive cardiomyopathy helps to differentiate this entity from other cardiomyopathies characterized by ventricular hypertrophy.
249. In asymptomatic patients with chronic aortic regurgitation, surgery should be considered when left ventricular ejection fraction drops below 60% or the left ventricular systolic dimension reaches 55 mm.
250. In asymptomatic patients with aortic regurgitation, nifedipine may delay the timing of surgical intervention.
251. Aortic coarctation is associated with a continuous murmur (often posterior thorax) and elevated but equal blood pressure in both upper extremities.
252. A bicuspid aortic valve is often seen in association with aortic coarctation, presenting with aortic regurgitation or aortic stenosis.
253. Physical findings of mitral regurgitation include holosystolic murmur at the apex radiating to the axilla, without respiratory variation.
254. In healthy adults, premature ventricular contractions are common and are not a cause for concern.
255. Suppression of premature ventricular contractions is indicated only in patients with severe and disabling symptoms.
256. Smoking, hypertension, advanced age, and male sex are risk factors for abdominal aortic aneurysm.
257. Most abdominal aortic aneurysms are asymptomatic, but abdominal pain is the most common symptom.
258. Patients at high risk for a subsequent coronary event after a myocardial infarction include those with multivessel coronary artery disease, anterior myocardial infarction, or a left ventricular ejection fraction 0.5 cm/year) increase in aneurysm size.
307. Severe hemolytic anemia in a patient with a mechanical valve suggests paravalvular leakage due to partial dehiscence of the valve or infection.
308. Prosthetic valve dehiscence or dysfunction should be suspected in patients that develop symptoms of congestive heart failure, particularly if these symptoms occur in the first 6 months following surgery.
309. Right ventricular infarction is a cause of hypotension following inferior infarction and typically requires appropriate volume infusion.
310. Right ventricular infarction should be suspected as a cause of hypotension when findings of right heart failure coincide with an absence of evidence of pulmonary congestion.
311. Implantation of a cardioverter-defibrillator is an important prophylactic treatment in patients with hypertrophic cardiomyopathy and high risk for sudden death.
312. Clinical features that predict high risk for sudden death in patients with hypertrophic cardiomyopathy include family history of sudden death, syncope, marked left ventricular septal hypertrophy, nonsustained ventricular tachycardia, and exertional hypotension.
313. Papillary muscle rupture and ventricular septal defect are recognized mechanical complications that occur early after myocardial infarction.
314. Both papillary muscle rupture and ventricular septal defect present with hypotension and acute dyspnea.
315. Annual echocardiography is appropriate in a patient with asymptomatic severe mitral regurgitation.
316. The timing of surgery for severe mitral regurgitation is based on symptoms and measures of left ventricular size and systolic function.
317. Classic features of Marfan's syndrome includes tall stature, high arched palate, joint hypermobility, scoliosis, and positive “wrist sign.”
318. Patients with Marfan's syndrome are at increased risk for asymptomatic thoracic aortic aneurysm and associated aortic valve incompetence.
319. Intravenous amiodarone is the drug of choice for shock-resistant ventricular fibrillation.
320. The risk of coronary artery disease in diabetic patients is 2 to 4 times higher than in nondiabetic patients.
321. The pretest likelihood of disease should be calculated using available algorithms in patients with coronary risk factors.
322. In patients with chest pain and intermediate risk of coronary artery disease, non-invasive testing is indicated.
323. Patients with chest pain and low coronary artery disease risk with a normal electrocardiogram and a normal exercise electrocardiogram can be discharged without coronary angiography.
324. Although uncommon, left atrial myxoma should be considered in young patients with embolic stroke.
325. Echocardiography is an important imaging modality for diagnosis of an intracardiac tumor.
326. Women with Marfan syndrome are at increased risk of aortic dissection during pregnancy.
327. Aortic dissection should be considered in the differential diagnosis of chest pain in pregnancy.
328. The tachycardia rate in atrioventricular nodal reentrant tachycardia is typically 160–180/min with the P wave buried in the QRS complex.
329. • If atrioventricular nodal reentrant tachycardia does not respond to vagal maneuvers, adenosine is the treatment of choice
330. Continuous effective anticoagulation is needed throughout pregnancy in women with mechanical heart valves.
331. Radiofrequency catheter ablation is the most effective treatment for atrioventricular nodal reentrant tachycardia.
332. Calcium-channel blockers may be used for prophylaxis of recurrent atrioventricular nodal reentrant tachycardia but are less effective than radiofrequency catheter ablation.
333. The cardiac output is low in primary cardiogenic shock, and inotropic agents may be needed to augment myocardial contractility and thus cardiac output.
334. Exercise (or pharmacologic) stress testing is the most sensitive noninvasive method to establish the diagnosis of coronary artery disease.
335. Exercise (or pharmacologic) stress cardiac imaging can be used to evaluate for coronary artery disease if the resting electrocardiogram is abnormal.
336. The role of electron-beam CT coronary calcium scores is not yet established in the assessment of coronary artery disease.
337. Prolonged immobility followed by a stroke or transient ischemic attack should raise the suspicion of a paradoxical embolism.
338. Transesophageal echocardiography is the test of choice to confirm the diagnosis of a suspected patent foramen ovale or cardiac source of embolus.
339. • Systemic lupus erythematosus is a cause of premature atherosclerotic coronary disease.
340. • Other causes of acute myocardial infarction in young persons include coronary spasm, embolic coronary occlusion, and Kawasaki's disease.
341. High risk patients that require a heparin anticoagulation bridge after stopping warfarin prior to surgery include those with a mitral mechanical valve, atrial fibrillation, or previous embolism.
342. Low risk patients do not require a heparin bridge after stopping warfarin prior to surgery and include patients with a bileaflet aortic valve and no other high risk features.
343. Aspirin alone is not a sufficient replacement for warfarin, and is used only as a chronic adjunct in patients who manifest systemic emboli despite therapeutic warfarin therapy.
344. Radial-femoral delay is a characteristic physical finding in aortic coarctation.
345. Bicuspid aortic valves are common in patients with aortic coarctation and are associated with a systolic ejection click and systolic murmur noted over the aortic area.
346. Elevated B-type natriuretic peptide levels occur with renal failure, acute coronary syndrome or myocardial infarction, and acute volume or pressure overload.
347. Adenosine is the treatment of choice for narrow-complex tachycardia.
348. Neither adenosine nor other atrioventricular nodal blocking agents should be given to patients with preexcited tachycardias.
349. Procainamide is the drug of choice for wide-complex tachycardia of unclear etiology.
350. Coronary angiography is indicated in patients with a history of unstable angina or non-ST-elevation myocardial infarction. No exercise testing needed if the patient already presented with acute cor syndrome.
351. In patients with a high pretest probability of coronary artery disease, a negative stress test result is most likely to be false.
352. Spinal stenosis is characterized by pain with standing or walking that is relieved by sitting or bending forward and is further supported by a normal ABI.
353. Leg ischemia is characterized by pain with exertion and with a decrease in ABI of at least 20 % with exercise.
354. The use of angiotensin-converting enzyme inhibitors should be avoided during pregnancy.
355. Hydralazine and nitrates are the vasodilators of choice to treat heart failure during pregnancy.
356. Induction of mild hypothermia improves outcomes in comatose survivors of out-of-hospital cardiac arrest.
357. Aortic valve replacement is recommended once symptom onset occurs, regardless of patient age.
358. Symptom onset in aortic stenosis is often insidious and may include exertional dyspnea.
359. Alcoholic cardiomyopathy is a dilated cardiomyopathy.
360. Therapy for alcoholic cardiomyopathy must include total abstinence from alcohol.
361. In chronic angina, coronary artery bypass graft surgery is indicated for patients refractory to medical therapy; a large area of ischemic myocardium; high-risk coronary anatomy; and reduced left ventricular systolic function.
362. Atrial tachycardia with variable block is a classic electrocardiographic finding in digitalis toxicity.
363. The first-line treatment for life-threatening digitalis toxicity is administration of digoxin-specific antibody fragments.
364. Iron deficiency is a common cause for dyspnea and fatigue in patients with cyanotic heart disease.
365. The most common cause of iron deficiency in patients with cyanotic heart disease is recurrent phlebotomy.
366. Mitral valve surgery is indicated for symptomatic patients with chronic, severe mitral regurgitation.
367. In asymptomatic patients with chronic, severe mitral regurgitation, criteria for mitral valve surgery include an end-systolic dimension >45 mm, an end-diastolic dimension >60 mm, and an ejection fraction
654. Dengue fever is characterized by the abrupt onset of severe headache, high fever, myalgias, arthralgias, leukopenia, and thrombocytopenia.
655. Dengue hemorrhagic fever is associated with hemorrhage and capillary fragility.
656. Bronchiectasis is a risk factor for the development of Pseudomonas aeruginosa community-acquired pneumonia.
657. Administration of ganciclovir or valganciclovir has greatly reduced, but not eliminated, the occurrence of cytomegalovirus infections in transplant recipients.
658. Person-to-person transmission of meningococcal organisms occurs by the respiratory route.
659. Prophylaxis of health care workers exposed to a patient with a meningococcal infection is needed only after contact with the patient's respiratory secretions.
660. MRI and CT scans are the imaging procedures of choice in the diagnosis of patients with suspected osteomyelitis.
661. The most appropriate empiric therapy for Streptococcus pneumoniae meningitis is vancomycin plus ceftriaxone and dexamethasone.
662. African tick bite fever is the most common rickettsial infection in humans.
663. Symptoms of African tick bite fever are relatively mild and are characterized by a vesicular rash with an inoculation eschar.
664. Symptoms of Creutzfeldt–Jakob disease typically include cognitive changes (dementia), behavioral and personality changes, difficulty with movement and coordination, and visual and constitutional symptoms.
665. The course of Creutzfeldt–Jakob disease is rapid and progressive; 90% of patients die within 1 year of diagnosis.
666. The most appropriate therapy for a patient with Listeria meningitis and a severe allergy to penicillin is trimethoprim–sulfamethoxazole.
667. When initiating antituberculous therapy, a four-drug regimen must be used if the probability of resistance to isoniazid is greater than 4%.
668. The recommended empiric therapy for a patient with community-acquired pneumonia who is hospitalized on a general medical floor is either monotherapy with an intravenous fluoroquinolone or combination therapy with an intravenous β-lactam plus either an intravenous or oral macrolide or doxycycline.
669. The recommended empiric therapy for a patient with community-acquired pneumonia who is hospitalized in an intensive care unit is an intravenous β-lactam plus either an intravenous macrolide or an intravenous fluoroquinolone.
670. Penicillin is the treatment of choice for all forms of syphilis.
671. Treatment of a pregnant patient with newly diagnosed syphilis is essential in order to prevent congenital syphilis in the fetus.
672. A pregnant patient with newly diagnosed syphilis who may be allergic to penicillin should undergo skin testing for a penicillin allergy.
673. Immunosuppressed transplant recipients are at high risk for development of bacterial infections during the first month after surgery.
674. In patients with a contiguous foot ulcer and possible osteomyelitis, bone biopsy with cultures and histopathologic examination should be performed before initiating antimicrobial therapy.
675. Intravascular catheter–associated bloodstream infections are preventable if proper insertion procedures are used.
676. Chlorhexidine is superior to povidone-iodine for cleaning a catheter insertion site.
677. Vancomycin is the antimicrobial agent of choice for treatment of methicillin-resistant Staphylococcus aureus infections.
678. All β-lactam agents are inactive against methicillin-resistant Staphylococcus aureus infections.
679. HIV genotype resistance testing is indicated for patients with HIV infection who may have developed resistance to one or more antiretroviral agents.
680. No currently available test can differentiate true-positive from false-positive tuberculin skin test reactions in a person who previously received bacille Calmette–Guérin vaccine.
681. The recommended treatment for latent tuberculosis is isoniazid for 9 months.
682. Infection due to Pseudomonas aeruginosa, which is often found between layers of rubber soles in sneakers, may occur following puncture wounds of the foot.
683. Contacts of patients with possible smallpox should receive smallpox vaccine.
684. Contacts of patients with possible smallpox should take their temperature twice daily for 17 days; a contact who develops a temperature over 38 °C (100.4 °F) during this time should be isolated.
685. Acyclovir is effective in preventing reactivation of varicella zoster virus in stem-cell transplant recipients.
686. Noninfectious skin lesions can be differentiated from infectious disorders because the former are not associated with fever and other systemic signs and symptoms or abnormal laboratory studies and culture results.
687. The most appropriate empiric therapy for a patient with purulent meningitis following neurosurgery is vancomycin plus cefepime.
688. The finding of 14-3-3 protein in cerebrospinal fluid has a specificity and sensitivity of greater than 90% for diagnosing sporadic Creutzfeldt–Jakob disease.
689. Live attenuated influenza vaccine is contraindicated in an immunosuppressed patient.
690. All family members of an immunosuppressed patient should be immunized against influenza to decrease the patient's risk of exposure to this virus.
691. Doxycycline in a single dose is highly effective for preventing erythema migrans in patients from areas endemic for Lyme disease who present with an embedded, engorged tick.
692. Contact isolation is most effective for reducing spread of Clostridium difficile in hospitals.
693. The treatment of choice for patients with symptomatic babesiosis is atovaquone plus azithromycin.
694. A positive Western blot analysis confirms the diagnosis of HIV infection; a negative test rules out this diagnosis.
695. An indeterminate Western blot analysis may indicate either HIV seroconversion or the presence of cross-reactive antibodies.
696. Stained specimens of vaginal discharge from patients with candidal vaginitis show pseudohyphae and budding yeast.
697. Stained specimens of vaginal discharge from patients with bacterial vaginosis show gram-negative bacilli attached to squamous epithelial cells (clue cells).
698. In patients with catheter-associated bloodstream infections, the catheter should be removed whenever possible.
699. Echinocandins such as caspofungin, micafungin, and anidulafungin are effective in treating patients with candidemia.
700. Patients with Mycobacterium tuberculosis infection may be considered noninfectious after they are placed on effective antituberculous therapy, demonstrate clinical improvement, and have three different sputum smears that are negative for acid-fast bacilli.
701. Brain abscesses that result from contiguous spread of head and neck infections may contain multiple organisms.
702. Ceftriaxone plus metronidazole is the most appropriate empiric antimicrobial therapy for a brain abscess resulting from contiguous spread of an otitic focus of infection.
703. Vancomycin plus clindamycin is the most appropriate empiric antibiotic regimen for a patient with suspected streptococcal or staphylococcal toxic shock syndrome.
704. Gram-positive bacteria (staphylococci and streptococci) are the most common causes of nongonococcal septic arthritis in adults.
705. Because amantadine is excreted by the kidneys, dosage adjustment is required in patients with renal compromise.
706. Although oseltamivir and zanamivir are excreted by the kidneys, dosage adjustment is not required in a patient with renal compromise.
707. A highly effective vaccine is available for hepatitis A, which must be administered at least 2 weeks before a potential exposure.
708. Patients taking anti–tumor necrosis factor-α inhibitors are at increased risk for developing latent tuberculosis.
709. Patients about to begin therapy with anti–tumor necrosis factor-α inhibitors should undergo tuberculin skin test screening.
710. Transplant recipients are at risk for development of opportunistic infections such as fungal pneumonia.
711. Almost all patients with amebic abscesses will have high levels of antibodies directed against Entamoeba histolytica.
712. In a patient with sickle cell disease and osteomyelitis, potential causative organisms are staphylococci, streptococci, and Salmonella species.
713. Penicillin is the only antimicrobial agent approved for treatment of neurosyphilis.
714. Patients who are allergic to penicillin but for whom alternative antimicrobial agents cannot be prescribed require desensitization to penicillin.
715. Genital herpes simplex virus in a male patient is generally characterized by a limited number of genital vesiculoulcerative lesions without systemic symptoms.
716. Subdural empyema is a medical and surgical emergency.
717. Antimicrobial therapy and neurosurgical drainage are the most appropriate initial management for a patient with a subdural empyema.
718. Surgical site infections are a common complication of operations, especially coronary artery bypass graft surgery.
719. The appropriate dose, timing, and duration of prophylactic perioperative antibiotics help decrease the risk of surgical site infections.
720. Deep fungal infections such as histoplasmosis are a risk to travelers to endemic areas.
721. Reactivation of human herpesviruses 6 and 7 is being increasingly recognized in immunosuppressed patients.
722. Reactivation of human herpesviruses 6 and 7 may cause hepatitis and meningoencephalitis.
723. Treatment of latent tuberculosis is indicated for any person with a known tuberculin skin test conversion, regardless of the person's age.
724. Most cases of toxic shock syndrome are caused by Staphylococcus aureus or Streptococcus pyogenes.
725. Ceftriaxone provides effective empiric therapy for patients with possible disseminated gonococcal infection.
726. Health care workers in contact with a patient with possible smallpox require gown, gloves, and a personal respirator for protection.
727. A qualitative assay for hepatitis C virus RNA viral load is the most sensitive test for diagnosing hepatitis C infection.
728. Penicillin resistance is categorized as either intermediate-level resistance (minimal inhibitory concentration [MIC] between 0.1 and 1 μg/mL) or high-level resistance (MIC >1 μg/mL).
729. • Organisms that are resistant to penicillin generally remain sensitive to fluoroquinolones and are uniformly sensitive to vancomycin and linezolid
730. Polyomavirus BK is associated with nephropathy and deteriorating renal function in renal transplant recipients.
731. The presence of intranuclear inclusions in tubular epithelial cells or transitional cells is highly indicative of polyomavirus BK.
732. Acute retinal necrosis occurs most often in patients with HIV infection or AIDS.
733. Intravenous acyclovir is the preferred treatment for acute retinal necrosis.
734. In contrast to patients with sporadic, genetic, or iatrogenic Creutzfeldt–Jakob disease, patients with the variant form of the disorder tend to be younger and have psychiatric symptoms rather than dementia early in the disease, more prominent sensory findings, and MRI abnormalities in pulvinar area of the thalamus rather than in the basal ganglia and putamen.
735. Ninety percent of urinary tract infections are associated with indwelling catheters.
736. Administering prophylactic antibiotics, acidifying the urine, or using disinfecting washes have not been shown to prevent urinary tract infections.
737. Vancomycin plus cefepime is the most appropriate empiric antimicrobial therapy for a patient with an epidural abscess and a history of injection drug use.
738. The development of focal lymphadenitis in a patient with HIV infection is most commonly caused by mycobacteria, Streptococcus species, or Staphylococcus species.
739. Cryptococcal infection in transplant recipients is associated with high morbidity and mortality.
740. Flucytosine plus a lipid formulation of amphotericin B is usually effective for treating cryptococcal infections in transplant recipients.
741. Empiric antibiotic therapy while awaiting culture results is required for patients with an infected clenched-fist injury.
742. Oral valacyclovir is the most appropriate antiviral agent for a patient with genital herpes simplex virus infection without systemic complications.
743. The four “D's” that characterize botulism are diplopia, dysphonia, dysarthria, and dysphagia.
744. Fatal familial insomnia is the rarest of the prion diseases.
745. • Fatal familial insomnia is characterized by severe insomnia, confusion, other signs of dementia, and autonomic nervous system instability
746. Anaplasmosis (formerly human granulocytic ehrlichiosis) is characterized by fever, flu-like symptoms, leukopenia, thrombocytopenia, liver chemistry abnormalities, and a peripheral blood smear showing morulae.
747. Doxycycline is the treatment of choice for anaplasmosis.
748. A patient with suspected herpes simplex virus encephalitis requires polymerase chain reaction of the cerebrospinal fluid and MRI of the brain to confirm the diagnosis.
749. Acyclovir is the preferred initial therapy for a patient with herpes simplex virus encephalitis.
750. Keeping mechanically ventilated patients semi-recumbent (at a 45-degree angle) helps prevent development of ventilator-associated pneumonia.
751. Thrombocytopenia may occur in patients who take linezolid for 2 or more weeks.
752. The decision about whether admission to an intensive care unit is needed for patients with community-acquired pneumonia is based on the presence of specific major and minor criteria.
753. Because Legionella pneumonia is of particular concern in a patient with severe community-acquired pneumonia, testing for urinary Legionella antigen is indicated.
754. Whenever possible, outpatient parenteral therapy should use drugs that can be given once daily for convenience and patient comfort.
755. In patients with HIV infection and Kaposi's sarcoma, the sarcoma frequently regresses and sometimes resolves completely after successful treatment with highly active antiretroviral therapy.
756. Oral levofloxacin rather than intravenous levofloxacin is indicated for empiric treatment of a highly compliant patient with acute pyelonephritis who can eat and drink.
757. The most appropriate treatment for a cat bite in a patient with a penicillin allergy is trimethoprim–sulfamethoxazole plus clindamycin.
758. Patients with progressive massive fibrosis are at increased risk for developing tuberculosis.
759. The most appropriate diagnostic studies for suspected tuberculosis are tuberculin skin testing and sputum for acid-fast stain and culture.
760. Staphylococcus aureus and Pseudomonas aeruginosa are the most likely causes of septic arthritis in an injection drug user.
761. Enterotoxigenic Escherichia coli is the most common cause of diarrhea in travelers to developing countries.
762. Diarrhea due to enterotoxigenic E. coli is usually a mild and self-limited illness.
763. West Nile virus encephalitis is most likely to occur in patients 65 years of age and older.
764. Findings in patients with West Nile virus encephalitis include fever, severe headache, marked muscle weakness involving the lower motor neurons, mental status changes, and possibly seizures.
765. The need for isolation precautions is based on the route of transmission of the suspected pathogen or the clinical symptoms of the patient.
766. Because Francisella tularensis is not transmitted from person to person, only standard precautions, rather than isolation procedures, are required for patients with tularemia.
767. Esophagitis in an immunosuppressed patient is most often caused by Candida.
768. Echinocandins and triazoles are both effective for treating Candida esophagitis.
769. Shiga toxin–producing Escherichia coli is associated with development of the hemolytic uremic syndrome.
770. Administration of foscarnet is indicated for a patient with acyclovir-resistant herpes simplex virus infection.
771. Administration of foscarnet may be associated with significant electrolyte abnormalities.
772. Prophylaxis is not required for household contacts of patients with an invasive streptococcal infection.
773. If two or more cases of invasive streptococcal disease occur in postpartum or postsurgical patients hospitalized within 6 months in the same institution, an epidemiologic investigation is required to determine if a hospital worker is a carrier.
774. Immunosuppressed patients are at increased risk for developing nosocomial pneumonia even when mechanical ventilation is not required.
775. A “halo sign” (a nodular lesion with a surrounding ground-glass appearance) on chest radiographs is characteristic of Aspergillus pneumonia.
776. Bactericidal agents such as daptomycin are mandatory for treatment of endocarditis.
777. Emergence of resistance to daptomycin is rare, and daptomycin is not correlated with cross-resistance to any other drug class.
778. Current recommendations do not support use of tuberculin skin testing as a screening test in otherwise healthy persons with no personal or occupational exposure to persons with tuberculosis.
779. Pneumococcal strains are becoming increasingly resistant to penicillins and macrolides.
780. Most experts and guidelines support the use of a third-generation cephalosporin plus a macrolide for treatment of community-acquired pneumonia.
781. West Nile virus can be transmitted by blood transfusions.
782. West Nile virus can be transmitted to transplant recipients from organ donors.
783. he primary pathogens associated with bloodborne exposures in health care workers are HIV, hepatitis B, and hepatitis C.
784. • Two or three antiretroviral agents are recommended when a health care worker sustains a deep, penetrating injury from a source patient who is HIV seropositive.
785. Oral valganciclovir is as effective as intravenous ganciclovir for treating patients with cytomegalovirus retinitis.
786. A maculopapular rash, especially on the palms and soles, is characteristic of disseminated (secondary) syphilis.
787. A patient with possible neurosyphilis should receive intravenous aqueous crystal penicillin G for 14 days.
788. Patients with osteomyelitis and an epidural abscess who do not have focal neurologic deficits can usually be treated with antimicrobial therapy alone, but must be monitored carefully.
789. Aspiration and culture of joint fluid is the most appropriate test for determining whether a prosthetic joint is infected.
790. Patients with pneumonic plague typically present with high fever, headache, myalgias, dyspnea, hemoptysis, and watery sputum.
791. Patients with pneumonic plague have a mortality rate approaching 100% if not treated with streptomycin within 24 hours of development of symptoms.
792. Angiostrongylus cantonensis (the rat lungworm) is the most common cause of eosinophilic meningitis worldwide.
793. Prevention of nosocomial mycobacterial infections requires airborne isolation of the patient and personal respirators for health care workers.
794. The most common distribution of herpes zoster (shingles) is a unilateral rash in the thoracic region.
795. Famciclovir and valacyclovir have replaced acyclovir as the treatment of choice for patients with herpes zoster.
796. Cutaneous Mycobacterium marinum infection is most often associated with exposure to fish tanks.
797. The most appropriate diagnostic study is biopsy of a nodule for histopathologic examination, acid-fast stain, and culture.
798. Trimethoprim–sulfamethoxazole is the preferred antimicrobial therapy for a patient with a brain abscess caused by Nocardia species.
799. Patients with a presumptive diagnosis of Rocky Mountain spotted fever should receive treatment with doxycycline even before the diagnosis is confirmed.
800. Campylobacter jejuni is the most common cause of bacterial diarrheal disease in the United States.
801. C. jejuni often causes disease by cross-contamination of cooking utensils or surfaces such as countertops.
802. A complete history of antiretroviral drug use is essential for a patient with HIV infection who has been on many drugs and is not benefiting from the current treatment regimen.
803. Aspergillosis is the most common pulmonary mold infection in immunosuppressed patients in the United States.
804. Aspergillus infection cannot be distinguished from infection caused by Pseudallescheria before culture results are available
805. Nosocomial outbreaks of Clostridium difficile and norovirus have been well documented in recent years.
806. Nosocomial outbreaks of C. difficile and norovirus require contact isolation and increased cleaning of all patients' rooms.
807. Options for treatment of community-acquired pneumonia in an outpatient without additional risk factors include an advanced-generation macrolide or a ketolide or doxycycline.
808. Treatment of an outpatient with community-acquired pneumonia should be started without waiting for results of Gram stain and culture.
809. Patients with central nervous system Lyme disease who are allergic to β-lactam antibiotics should be given doxycycline.
810. Corticosteroids have been shown to significantly alleviate acute pain in patients with herpes zoster (shingles).
811. Corticosteroids are contraindicated in patients with poorly controlled plasma glucose levels, osteoporosis, or hypertension.
812. Hospitalized patients with community-acquired pneumonia can usually be changed from an intravenous to an oral antibiotic regimen when fever, cough, and dyspnea have resolved; oral intake is satisfactory; and the leukocyte count is returning towards normal.
813. Asymmetric migratory joint pain and pustular lesions are characteristic of disseminated gonococcal infection.
814. Cultures of the pharynx, cervix, and anus should be obtained for a woman with suspected disseminated gonococcal infection.
815. Approximately 50% of patients with AIDS and progressive multifocal leukoencephalopathy will survive the latter disease if highly active antiretroviral therapy is administered.
816. Polymerase chain reaction of cerebrospinal fluid is the preferred test for diagnosing herpes simplex virus encephalitis.
817. Acute cellulitis in an immunosuppressed patient may be due to unusual pathogens, such as Cryptococcus neoformans.
818. Administration of zidovudine to a pregnant patient with HIV infection is believed to reduce the risk of maternal-to-child transmission of HIV.
819. Efavirenz is contraindicated in a pregnant patient with HIV infection.
820. Cyclosporiasis is associated with positive acid-fast–stained stool specimens and copious diarrhea without fever.
821. The treatment of choice for cyclosporiasis is trimethoprim– sulfamethoxazole.
822. The incidence of fluoroquinolone-resistant N. gonorrhoeae has been increasing, especially on the West Coast of the United States and in Hawaii.
823. The most appropriate treatment for concurrent gonorrhea and a chlamydial infection is a single dose of intramuscular ceftriaxone plus oral azithromycin.
824. Patient-administered antibiotic therapy is usually appropriate for women with recurrent episodes of uncomplicated urinary tract infections.
825. Risk factors for aspiration pneumonia include difficulty swallowing, episodes of depressed consciousness, and mechanical factors such as esophageal obstruction.
826. Clindamycin provides effective treatment for anaerobic aspiration pneumonia.
827. Necrotizing fasciitis in an injection drug user may be due to many different organisms.
828. The most effective initial empiric antibiotic regimen for necrotizing fasciitis in an injection drug user is vancomycin plus piperacillin–tazobactam plus clindamycin.
829. The most successful therapy for treating infected prosthetic joints involves removal of the prosthesis and a 6-week course of antimicrobial therapy followed by reimplantation of a new prosthesis.
830. Aztreonam can be used safely in patients who are allergic to penicillin.
831. The U.S. Centers for Disease Control and Prevention include aerosolized viruses that cause Ebola, Marburg, and Lassa fevers; Argentine hemorrhagic fever; and Bolivian hemorrhagic fever as most likely to be used as biochemical weapons.
832. Influenza virus resistance develops rapidly following exposure to rimantadine.
833. If one family member develops resistance after taking rimantadine for treatment of influenza, the resistant virus can be transmitted to other family members.
834. Hyponozoites of Plasmodium vivax malaria may remain in the liver for long periods and become reactivated at a later date.
here is the Gastroenterology and hepatology notes:
Gastroenterology and hepatology
839. Crohn's disease is more common in current smokers, whereas ulcerative colitis occurs more often in former smokers and nonsmokers.
840. Colonoscopic findings in Crohn's disease include deep ulcerations separated by areas of normal mucosa (skip lesions) and rectal sparing.
841. Colonoscopic findings in ulcerative colitis include continuous inflammation, typically including the rectum, but without deep ulcerations or skip lesions.
842. Approximately 70% of patients with gastric or duodenal ulcer disease also have Helicobacter pylori infection.
843. Patients with dyspepsia without alarm features (vomiting, weight loss, anemia) can usually be treated empirically for H. pylori infection.
844. Patients with acute gallstone pancreatitis present with elevated serum aminotransferase values and pancreatic enzyme values that rapidly return toward normal.
845. Patients with hepatitis C and cirrhosis are at increased risk for development of hepatocellular carcinoma.
846. The finding of a new mass with vascular enhancement in a patient with hepatitis C and cirrhosis almost certainly indicates hepatocellular carcinoma.
847. The most common cause of odynophagia (pain on swallowing) is pill-induced esophagitis.
848. Gastroparesis is a well-recognized complication of diabetes mellitus.
849. Patients with gastroparesis should be started on small, frequent feedings of a diet low in fiber, fat, and refined sugar.
850. Patients with choledocholithiasis typically have moderate to severe epigastric or right upper quadrant abdominal pain that is usually intermittent, inconsistently associated with nausea or vomiting, and occasionally nocturnal.
851. Symptomatic patients with choledocholithiasis almost always have elevated serum aminotransferase values.
852. Upper endoscopy with small bowel biopsies is the definitive test to confirm or exclude a diagnosis of celiac sprue.
853. Antimitochondrial antibody titers of more or equal to 1:40 occur in approximately 90% of patients with primary biliary cirrhosis.
854. Marked volume depletion is a poor prognostic sign in a patient with acute pancreatitis.
855. Vigorous hydration is critical in a patient with acute pancreatitis and marked volume depletion in order to maximize pancreatic perfusion and reduce subsequent complications.
856. Patients who have had pancolitis for 10 or more years should undergo colonoscopy with biopsies every 1 to 2 years for colorectal cancer surveillance.
857. Elevated serum aminotransferase values and a positive assay for antibody to hepatitis C virus (anti-HCV) in a patient with risk factors for HCV are highly suggestive of the presence of hepatitis C.
858. Patients with a positive assay for antibody to hepatitis C virus (anti-HCV) should be tested for HCV RNA to determine if viremia is present.
859. A Dieulafoy lesion is an abnormally large artery located just below the gastric mucosa that is prone to rupture and cause large-volume bleeding.
860. Proton pump inhibitors are most effective for treating an active nonsteroidal anti-inflammatory drug (NSAID)–induced ulcer when the NSAID cannot be discontinued.
861. Patients with oropharyngeal dysphagia typically have difficulty swallowing both solid foods and liquids, coughing and choking during meals, and changes in voice quality.
862. A videofluoroscopy study is the most appropriate initial test in patients with suspected oropharyngeal dysphagia.
863. Gastrointestinal bleeding, fever, abdominal pain, and leukocytosis in a patient with an abdominal prosthetic vascular graft should raise suspicion for an aortoenteric fistula.
864. Upper endoscopy is the initial diagnostic study for evaluation of a possible aortoenteric fistula.
865. If upper endoscopy is normal despite a strong clinical suspicion for an aortoenteric fistula, a contrast-enhanced CT scan of the abdomen should be done next.
866. Patients with severe cholangitis generally present with fever, jaundice, and altered mental status; abdominal pain is usually, but not invariably, present.
867. Patients with cholangitis require endoscopic retrograde cholangiopancreatography to determine the presence of common bile duct stones and provide endoscopic therapy, if indicated.
868. Endoscopic ultrasonography is the most sensitive test for diagnosing an insulinoma of the pancreas.
869. In patients with chronic ulcerative colitis, the finding of low-grade dysplasia on surveillance colonoscopy is associated with an increased risk of progression to high-grade dysplasia or cancer.
870. Patients with chronic ulcerative colitis and dysplasia of any grade detected on surveillance colonoscopy should be referred for colectomy.
871. Liver biopsy should be considered for selected patients with suspected nonalcoholic fatty liver disease.
872. Rosiglitazone or pioglitazone may be indicated for patients with nonalcoholic steatohepatitis and features of the metabolic syndrome in order to prevent progression of the liver disease.
873. Intraoperative endoscopy may be needed for a patient with unexplained severe recurrent gastrointestinal bleeding that cannot be diagnosed by less invasive studies.
874. Patients with short bowel syndrome associated with less than 115 cm of small intestine in the absence of a colon will most likely require continuous total parenteral nutrition.
875. A proton pump inhibitor or an H2-receptor antagonist may help reduce excessive gastric secretions and stomal fluid losses in patients with short bowel syndrome.
876. Bariatric surgery is effective for reducing morbidity associated with obesity-related disorders, such as type 2 diabetes mellitus, hypertension, obstructive sleep apnea, and hyperlipidemia.
877. • Development of gallstones is a common complication following bariatric surgery
878. The incidental finding of indirect (unconjugated) hyperbilirubinemia in an asymptomatic patient with a normal hemoglobin level and otherwise normal liver tests is indicative of Gilbert's syndrome.
879. Tenesmus (a sensation of incomplete evacuation of the bowels) indicates the presence of proctitis.
880. Neisseria gonorrhoeae infection should be considered as a cause of proctitis in sexually active patients.
881. A patient with acute pancreatitis should be evaluated for the presence of hypertriglyceridemia.
882. Patients with diabetes mellitus and associated neuropathy are at increased risk for development of small bowel bacterial overgrowth.
883. Patients with small bowel bacterial overgrowth often have secondary lactose intolerance
884. Patients with acute gastrointestinal bleeding associated with decreased consciousness, an absent gag reflex, and continued hematemesis require airway protection as the initial step in management.
885. Preoperative endoscopic retrograde cholangiopancreatography is indicated prior to laparoscopic cholecystectomy only for patients with gallstones and possible concomitant common bile duct stones.
886. Patients with a high-risk polypoid lesion detected and removed during screening colonoscopy should undergo surveillance colonoscopy in 3 years.
887. Symptoms of noncardiac chest pain frequently mimic those of cardiac chest pain.
888. The diagnosis of noncardiac chest pain can only be made after a thorough evaluation has ruled out cardiac causes for the pain.
889. Low-dose antidepressants may be helpful in treating patients with noncardiac chest pain.
890. Antinuclear antibody and anti–smooth muscle antibody titers more or equal to 1:80 support a diagnosis of autoimmune hepatitis.
891. Antimitochondrial antibody is the serologic marker for primary biliary cirrhosis.
892. Gastrinoma (Zollinger-Ellison syndrome) and gastric distention related to gastric outlet obstruction are causes of hypergastrinemia.
893. A helical CT scan of the abdomen is a reasonable initial test when evaluating a patient for a possible gastrinoma.
894. Patients who have had two or more episodes of diverticulitis are more likely to develop complications such as abscesses, strictures, and perforation.
895. Patients who have had two or more episodes of diverticulitis should undergo surgical resection of the affected intestine.
896. An asymptomatic patient with a single positive fecal occult blood test on routine screening requires follow-up with colonoscopy.
897. Candidiasis is the most common esophageal disorder in patients with HIV infection.
898. Patients with HIV infection associated with dysphagia and odynophagia should receive an empiric trial of fluconazole.
899. Nonulcer dyspepsia is the most common cause of epigastric pain in a young, otherwise healthy patient.
900. A trial of a proton pump inhibitor is warranted in a young patient with a first episode of nonulcer dyspepsia and a negative serologic test for Helicobacter pylori.
901. Chronic intestinal pseudo-obstruction may be associated with a paraneoplastic syndrome.
902. The hallmark of mesenteric ischemia is the presence of pain that is out of proportion to the physical examination findings.
903. The most common cause of mesenteric ischemia is a prothrombotic state due to an inherited or acquired coagulation disorder or malignancy.
904. CT angiography is usually done to establish the diagnosis of mesenteric ischemia.
905. Patients with severe, acute pancreatitis require enteral, rather than parenteral, nutrition.
906. Fulminant hepatic failure is the clinical syndrome of severe acute liver failure and encephalopathy in a patient without pre-existing liver disease.
907. Patients with fulminant hepatic failure require immediate evaluation for liver transplantation.
908. Patients with inflammatory bowel disease have an increased risk for developing primary sclerosing cholangitis and superimposed cholangiocarcinoma.
909. A decreasing hemoglobin level in a stable patient with a recent episode of upper gastrointestinal bleeding may be due to redistribution of fluid into the vascular space rather than to continuing bleeding.
910. Ultrasonographic findings of gallstones, a thickened gallbladder wall, pericholecystic fluid, and a positive sonographic Murphy's sign are highly specific for a diagnosis of acute cholecystitis.
911. Initial management of a patient with acute cholecystitis includes pain medication, broad-spectrum antibiotics, and surgical consultation for elective cholecystectomy.
912. Artificial sweeteners that contain poorly absorbed carbohydrates (e.g., sorbitol, mannitol) may cause flatulence and diarrhea.
913. Anal fissures generally cause rectal outlet bleeding and pain with defecation.
914. Anal fissures may occur after a period of constipation.
915. Nutcracker esophagus is a spastic condition characterized by high-amplitude peristaltic waves on esophageal manometry.
916. Patients with nutcracker esophagus should be evaluated for the presence of gastroesophageal reflux disease.
917. A person who has a first-degree relative with colorectal cancer should initially undergo colorectal cancer screening 10 years before the age of diagnosis of the affected relative or at age 40 years, whichever comes first.
918. Patients with chronic pancreatitis often require narcotics for pain control.
919. Patients with acute hepatitis generally have more symptoms, are more likely to be jaundiced, and have higher serum aminotransferase values than those with chronic hepatitis.
920. Adults with hepatitis A are generally jaundiced, whereas many infants and children with this infection do not have jaundice.
921. A Mallory-Weiss tear is a laceration near the gastroesophageal junction that often results from forceful retching.
922. Bleeding from a Mallory-Weiss tear stops spontaneously in more than 90% of patients.
923. Mesalamine enemas are the most effective initial treatment for patients with ulcerative proctosigmoiditis.
924. The most common finding in patients with peptic ulcer disease is gnawing epigastric pain.
925. Pulmonary infiltrates, hepatomegaly, and a high alkaline phosphatase value are indicative of hepatic sarcoidosis.
926. Recurrent attacks of pancreatitis in a postcholecystectomy patient are most often caused by sphincter of Oddi dysfunction or pancreas divisum.
927. Fever, alcoholism, findings consistent with chronic liver disease, and a serum aspartate aminotransferase to serum alanine aminotransferase ratio (AST:ALT) more than 2 are associated with alcoholic hepatitis.
928. Self-limited hematochezia is a common cause of ischemic colitis in elderly patients.
929. Diagnostic studies, other than colonoscopy or flexible sigmoidoscopy, are usually not needed after an episode of ischemic colitis.
930. Patients with documented gallbladder stones and unexplained, nonspecific gastrointestinal symptoms should undergo diagnostic studies to identify other potential causes before cholecystectomy is performed.
931. Elderly patients with chronic hepatitis C virus infection who have other comorbid illnesses may not be candidates for treatment of hepatitis.
932. The age of a patient with obscure gastrointestinal bleeding helps guide the choice of diagnostic studies to be performed.
933. A young patient with obscure gastrointestinal bleeding should undergo diagnostic studies for Meckel's diverticulum.
934. An older patient with obscure gastrointestinal bleeding should undergo studies for angiectasias.
935. An intra-abdominal infection should be excluded before beginning immunosuppressive agents in a patient with a severe flare of Crohn's disease.
936. Hepatic adenomas are the most likely benign liver tumor to cause bleeding.
937. Hepatic adenomas should be resected whenever possible because of their potential for becoming malignant and their risk for bleeding.
938. Cameron's erosions are most often found in patients with large hiatal hernias and iron deficiency anemia.
939. Barrett's esophagus is a risk factor for the development of esophageal adenocarcinoma.
940. Patients with Barrett's esophagus without dysplasia should undergo surveillance upper endoscopy with esophageal biopsies every 3 years after the original diagnosis.
941. Patients with secretory diarrhea of unknown cause should be evaluated for the presence of microscopic colitis.
942. Biopsies of the colonic mucosa at the time of flexible sigmoidoscopy or colonoscopy are the definitive study for diagnosing microscopic colitis.
943. Cavernous hemangiomas are benign lesions that are found in 2% of the general population.
944. Cavernous hemangiomas are usually found incidentally when patients have imaging studies for other indications.
945. Patients who have diarrhea associated with fever, abdominal pain, and leukocytosis should be evaluated for the presence of an invasive or inflammatory bowel disease.
946. Visualization and biopsies of the colonic mucosa at the time of flexible sigmoidoscopy or colonoscopy are the definitive studies for diagnosing the cause of invasive or inflammatory diarrhea.
947. Upper endoscopy is the most appropriate initial diagnostic study for a patient with suspected peptic ulcer disease and one or more alarm features (vomiting, weight loss, anemia) suggestive of a possible ulcer-related complication.
948. Marked elevations in serum aspartate aminotransferase and alanine aminotransferase values may occur in patients with a skeletal muscle injury.
949. The least invasive palliative procedure for a patient with metastatic pancreatic adenocarcinoma and malignant obstructive jaundice is placement of an expandable metal stent during endoscopic retrograde cholangiopancreatography.
950. Cholangitis is the most common cause of liver abscesses.
951. Percutaneous aspiration is helpful for both diagnosis and treatment of pyogenic liver abscesses.
952. Patients with amyloidosis frequently have diarrhea and bleeding in addition to other signs and symptoms.
953. Patients with primary sclerosing cholangitis have a 10% to 30% lifetime risk of developing cholangiocarcinoma.
954. Eosinophilic esophagitis is occurring more often in adults, especially those with other atopic disorders.
955. Treatment of eosinophilic esophagitis includes an elemental diet and either oral or topical corticosteroids.
956. A patient with suspected AIDS cholangiopathy should undergo endoscopic retrograde cholangiopancreatography (ERCP) to confirm the diagnosis.
957. A patient with AIDS cholangiopathy associated with extrahepatic bile duct obstruction should undergo ERCP with sphincterotomy.
958. Hepatic ischemia is characterized by marked elevations in serum aminotransferase values that rapidly improve within several days.
959. Patients with nonulcer dyspepsia in whom H2-receptor antagonists have been ineffective should be treated with a proton pump inhibitor.
960. Common variable immunodeficiency should be suspected in a patient with recurrent gastrointestinal infections (especially giardiasis) and respiratory infections.
961. Pneumatic dilation is the initial treatment for patients with achalasia.
962. Patients with achalasia who do not respond to pneumatic dilation may require myotomy.
963. Patients with cirrhosis should undergo upper endoscopy to determine the presence of esophageal varices.
964. Patients with large esophageal varices should receive a nonselective β-blocker for prophylaxis against variceal bleeding.
965. Certain medications, including antidepressant agents and calcium channel blockers, increase colonic transit time and may cause constipation.
966. Triple therapy (a proton pump inhibitor and two antibiotics) is the most effective regimen for eradication of Helicobacter pylori.
967. Triple therapy for eradication of H. pylori should be given for 10 to 14 days.
968. Patients with hereditary hemochromatosis usually present with abnormal liver tests, arthropathy, fatigue, and impotence.
969. • The most appropriate initial diagnostic study for a patient with suspected hereditary hemochromatosis is determination of transferrin saturation
970. A low-dose antidepressant may be effective for treating patients with nonulcer dyspepsia.
971. CT enterography is the most appropriate study for a patient with possible Crohn's disease but with a normal colonoscopic examination.
972. Persons with one or more adenomatous colorectal polyps have an increased risk for developing colorectal cancer.
973. Persons with one or more adenomatous colorectal polyps should undergo periodic colonoscopic surveillance to detect colorectal cancer.
974. In patients with chronic hepatitis B and cirrhosis, one of the oral agents is preferred to pegylated interferon because interferon may be associated with more serious complications, such as hepatic decompensation and infection.
975. Patients with cirrhosis and gastrointestinal bleeding should receive a 7-day course of norfloxacin as prophylaxis against spontaneous bacterial peritonitis.
976. Patients with ischemic colitis may have a hypotensive episode followed by abdominal pain and subsequently by hematochezia.
977. Fundic gland polyps are the most common type of non-neoplastic polyp found in the stomach.
978. Fundic gland polyps are asymptomatic and do not present a risk for malignant transformation.
979. The treatment of choice for a patient with the HELLP syndrome (hemolysis, elevated liver enzymes, low platelets) is prompt delivery of the infant.
980. Administration of oral pancreatic enzyme supplements must be spaced out during a meal (one third at the start of the meal, one third during the meal, and one third directly after the meal) in order to be effective.
981. Either azathioprine or 6-mercaptopurine provides effective maintenance therapy following a corticosteroid-induced remission in patients with ulcerative colitis.
982. Early detection and surgical resection provide the only chance for cure in a patient with gastric cancer.
983. New-onset obstructive jaundice in an elderly patient is most often due to pancreatic or biliary tract cancer.
984. Pseudoachalasia may be associated with the presence of a malignant disorder.
985. Elderly patients with achalasia should undergo upper endoscopy to rule out pseudoachalasia.
986. The symptoms of pseudoachalasia may mimic those of idiopathic (benign) achalasia.
987. The most common causes of serum aminotransferase values more than 5000 U/L are acetaminophen hepatotoxicity, hepatic ischemia, and hepatitis due to unusual viruses.
988. Persons with alcoholism can develop acetaminophen hepatotoxicity when taking lower doses of acetaminophen than those necessary to cause liver damage in persons without alcoholism.
989. Endoscopic treatment of pancreatic duct strictures may reduce abdominal pain.
990. Radiation colitis typically occurs 9 months to 4 years after radiation therapy for prostate, gynecologic, or other pelvic malignancies.
991. Symptoms of radiation colitis include tenesmus, diarrhea, and hematochezia.
992. Acute colonic pseudo-obstruction is a frequent postoperative complication that is aggravated by electrolyte imbalances and administration of narcotics.
993. The major complications of acute colonic pseudo-obstruction are cecal ischemia and possible perforation of the cecum.
994. Patients over 40 years of age who have had chronic symptoms of gastroesophageal reflux disease for more than 5 years should undergo screening for Barrett's esophagus.
995. Upper endoscopy is the test of choice for patients with gastroesophageal reflux disease who are undergoing screening for Barrett's esophagus.
996. Budesonide is the drug of choice for treating a Crohn's disease flare that is limited to the ileum.
997. Colorectal cancer screening for average-risk persons should begin at 50 years of age.
998. Recommended colorectal cancer screening studies for average-risk persons include fecal occult blood testing, flexible sigmoidoscopy, barium enema examination, and colonoscopy.
999. Most patients with primary sclerosing cholangitis also have ulcerative colitis.
1000. The diagnosis of primary sclerosing cholangitis is established by imaging studies that show a “string of beads” pattern in the biliary tree.
1001. Pancreaticoduodenectomy (Whipple procedure) offers the best chance of cure for a patient with cancer of the head of the pancreas.
1002. For immunosuppressed transplant recipients who develop odynophagia, upper endoscopy to establish the cause should be considered rather than empiric therapy.
1003. Bismuth subsalicylate is effective for inducing prolonged remissions in patients with collagenous colitis.
1004. The 14C-urea breath test is the most sensitive and specific noninvasive study for documenting active Helicobacter pylori infection.
1005. A positive serologic test for H. pylori indicates only past exposure to the organism; this test does not determine active infection.
1006. Findings of vasculitis and positive antibody to hepatitis C virus (anti-HCV) are consistent with cryoglobulinemia associated with hepatitis C.
1007. Angiectasias (vascular malformations) are most often diagnosed in elderly patients with chronic occult gastrointestinal bleeding.
1008. Angiectasias may occur anywhere in the gastrointestinal tract and may be beyond the reach of standard upper endoscopes and colonoscopes.
1009. A helical CT scan of the abdomen is the most sensitive and specific initial imaging study for a patient with possible pancreatic adenocarcinoma.
1010. The first step in evaluating a patient with recurrent nausea is to rule out common systemic disorders such as thyroid disease, diabetes mellitus, and electrolyte abnormalities.
1011. Spontaneous bacterial peritonitis is an ascitic fluid infection that is a common complication in patients with cirrhosis.
1012. Spontaneous bacterial peritonitis should be suspected in any patient with cirrhosis and new or worsening decompensation.
1013. The choice of diagnostic studies for a patient with obscure gastrointestinal bleeding should take into account the patient's age and the presence of significant comorbid conditions.
1014. Drug–drug interactions are common in patients taking tacrolimus or cyclosporine plus other medications.
1015. Calcium channel blockers may interfere with the metabolism of tacrolimus.
1016. Dyssenergic defecation (pelvic floor dysfunction) refers to impaired defecation caused by inappropriate contraction or impaired relaxation of the puborectalis and external anal sphincter muscles.
1017. Anorectal manometry is the most appropriate study for diagnosing dyssenergic defecation.
1018. The most common symptoms of paraesophageal hernia are postprandial fullness, pain, and vomiting.
1019. A paraesophageal hernia may be associated with gastric ischemia as a result of torsion of the stomach.
1020. The recommended treatment for a symptomatic paraesophageal hernia is urgent repair of the hernia.
1021. Eradication of Helicobacter pylori is associated with a significant decrease in the risk of developing a recurrent ulcer.
1022. Eradication of H. pylori does not reduce the risk of developing gastric cancer.
1023. Because patients with celiac sprue are at increased risk for osteoporosis and osteomalacia, monitoring of serum vitamin D and calcium levels is required.
1024. The most appropriate treatment for primary biliary cirrhosis is ursodeoxycholic acid.
1025. Approximately 3% to 5% of patients found to have one colorectal cancer will have one or more synchronous cancers in other areas of the colon.
1026. A patient diagnosed with colorectal cancer requires evaluation of the entire colon either preoperatively or postoperatively to detect possible synchronous lesions.
1027. Patients with longstanding ulcerative colitis have an increased risk of developing colorectal cancer.
1028. • Proctocolectomy should be considered for patients with ulcerative colitis associated with colonic dysplasia
1029. The overall risk of maternal–fetal transmission of hepatitis C is approximately 5%.
1030. Mothers infected with both hepatitis C and HIV have an increased risk of transmitting hepatitis C to their newborns.
1031. To determine the occurrence of maternal–fetal transmission of hepatitis C, the newborn should be checked for HCV RNA at 2 to 6 months of age.
1032. Patients with postcholecystectomy bile leak usually present with diffuse abdominal pain, nausea, fever, and mild hyperbilirubinemia.
1033. • Postcholecystectomy bile leaks can be identified by endoscopic retrograde cholangiopancreatography
1034. The presence of a hypervascular hepatic mass in a patient with cirrhosis and a high serum α-fetoprotein level is diagnostic of hepatocellular carcinoma.
1035. Patients with advanced liver disease and hepatocellular carcinoma should usually be evaluated for liver transplantation.
1036. Patients with familial pancreatitis are at increased risk for developing pancreatic adenocarcinoma.
1037. The initial test in a patient with possible gastric outlet obstruction is upper endoscopy.
1038. A serum–ascites albumin gradient (SAAG) more than or equal to 1.1 g/dL is consistent with portal hypertension.
1039. Portal hypertension is most often due to cirrhosis.
1040. Fundoplication should be considered for a patient with severe iron deficiency anemia associated with Cameron's erosions who cannot tolerate oral iron therapy.
1041. The great majority of recurrent colorectal cancers develop within 2 years postoperatively.
1042. A patient who has undergone resection for colorectal cancer requires surveillance colonoscopy 3 years postoperatively to detect the possible presence of metachronous lesions.
1044. Pill-induced esophagitis is characterized by the acute onset of painful swallowing (odynophagia) shortly after a patient begins taking a drug.
1045. Treatment of pill-induced esophagitis involves discontinuing the causative drug.
1046. Wilson's disease should be considered in a young patient with abnormal liver chemistry studies, cognitive changes, and hemolysis.
1047. A low serum ceruloplasmin value ( less than 20 mg/dL) is indicative of Wilson's disease.
1048. Patients with acute diverticulitis who are able to take liquids and are not dehydrated can usually be managed on an outpatient basis.
1049. The initial steps in managing outpatients with acute diverticulitis are administration of oral antibiotics and re-evaluation in several days.
1050. The preferred treatment of gastroparesis in the United States is administration of metoclopramide.
1051. Erythromycin should be considered for patients with gastroparesis who cannot tolerate metoclopramide.
1052. Obesity, hyperlipidemia, and hyperglycemia are risk factors for nonalcoholic fatty liver disease.
1053. Nearly 40% of patients with nonalcoholic fatty liver disease do not have obvious risk factors for this condition.
1054. A mucinous cystic neoplasm of the pancreas is often asymptomatic and is detected as an incidental finding during abdominal imaging studies for other causes.
1055. Because of its malignant potential, a mucinous cystic neoplasm of the pancreas should be surgically resected.
1056. Patients who have undergone gastrectomy may develop dumping syndrome, which is characterized by nausea, abdominal pain and distention, lightheadedness, and diaphoresis.
1057. Patients with dumping syndrome should initially be treated conservatively with a diet consisting of six small meals daily.
1058. A Dieulafoy lesion is an unusually large aberrant submucosal artery that can cause significant gastrointestinal bleeding.
1059. A Dieulafoy lesion may be missed on upper endoscopy unless active bleeding is occurring at the time of the endoscopic examination.
1060. A proton pump inhibitor is the agent of choice for healing a nonsteroidal anti-inflammatory drug (NSAID)–induced gastric ulcer after the NSAID has been discontinued.
1061. Prostaglandin analogues may prevent NSAID-induced lesions but do not treat an active ulcer.
1062. Patients with either chronic mesenteric ischemia or a malignancy may present with similar findings of postprandial pain, weight loss, and anorexia.
1063. The diagnosis of chronic mesenteric ischemia is established by the clinical history and findings of compromised mesenteric vessels on imaging studies.
1064. The treatment of chronic mesenteric ischemia is either a surgical or an interventional radiologic revascularization procedure.
1065. Patients with chronic hemolysis may develop secondary iron overload.
1066. Manifestations of systemic lupus erythematosus include arthralgias, photosensitive rash, malar rash, oral ulcers, pancytopenia, and serositis.
1067. The most common joints involved in osteoarthritis are the knee, hip, distal and proximal interphalangeal, and first carpometacarpal.
1068. Osteoarthritis is characterized by pain that worsens with activity and morning joint stiffness that lasts less than 30 minutes.
1069. Postmenopausal women who use diuretics have an increased risk for tophaceous gout of the distal interphalangeal joints.
1070. Patients with diffuse cutaneous systemic sclerosis are at increased risk for developing interstitial lung disease.
1071. Anti–Scl-70 antibodies are most frequently associated with diffuse cutaneous systemic sclerosis and an increased risk for interstitial lung disease.
1072. Chest radiography frequently does not detect early interstitial fibrosis.
1073. The chronic inflammatory state of rheumatoid arthritis is associated with an increased risk for death from a coronary event.
1074. The erythrocyte sedimentation rate is useful for monitoring chronic inflammatory changes but may be elevated in the setting of advanced age, anemia, and other disease states.
1075. Takayasu's arteritis is a chronic, idiopathic, granulomatous inflammatory disease primarily of the aorta and its main branches that affects reproductive-age women.
1076. Constitutional symptoms and ischemic signs or symptoms in the territory of one or more large arteries in a woman 18 months of minocycline exposure.
1095. Liver involvement in minocycline-induced lupus often mimics autoimmune hepatitis.
1096. The clinical presentation of adult contacts of children with parvovirus B19 infection may mimic rheumatoid arthritis.
1097. Parvovirus B19–related arthritis is self-limited, may not have an associated rash, resolves within 1 to 2 months, and usually responds to nonsteroidal anti-inflammatory drugs.
1098. Polymyalgia rheumatica is characterized by pain or morning stiffness in the neck or torso, shoulders and upper arms, or hips and thighs in patients >50 years of age with an erythrocyte sedimentation rate >40 mm/h.
1099. Prednisone therapy rapidly alleviates symptoms of polymyalgia rheumatica.
1100. Olecranon bursitis may be infectious, crystalline, or traumatic.
1101. Bursa aspiration is indicated for patients with acute olecranon bursitis to guide therapy.
1102. Patients with fibromyalgia have widespread musculoskeletal pain and stiffness, paresthesias, nonrestorative sleep, fatigue, and multiple symmetrical painful tender points.
1103. Results of laboratory studies in patients with fibromyalgia are normal.
1104. Patients with a long history of Raynaud's phenomenon and diffuse or limited cutaneous scleroderma are at risk for pulmonary vascular disease.
1105. High-dose corticosteroid therapy in the setting of scleroderma may be associated with normotensive renal crisis.
1106. Invasive diagnostic studies or empirical treatment is not indicated in asymptomatic patients with an isolated elevated creatine kinase level.
1107. Anti–cyclic citrullinated peptide antibody positivity is strongly associated with rheumatoid arthritis and may have the best predictive value when combined with rheumatoid factor measurement.
1108. Patients taking prednisone, equal or more than 5 mg/d, for more than 3 months may benefit from calcium and vitamin D supplements and a bisphosphonate.
1109. Allopurinol is equally effective in the setting of inefficient excretion and overproduction of urate.
1110. Allopurinol at a dose of more than 300 mg/d is necessary for approximately 50% of patients with hyperuricemia in order to achieve urate levels less than 6 mg/dL.
1111. Antibiotics, such as ampicillin–sulbactam and others with broad-spectrum coverage, are indicated for animal bites.
1112. There is no treatment for scleroderma that is disease modifying.
1113. Therapy for scleroderma involves systematic management of end-organ involvement.
1114. In patients with scleroderma, high-dose corticosteroid therapy may be associated with normotensive renal crisis.
1115. Estrogen therapy is contraindicated in women with antiphospholipid antibodies.
1116. An unexplained prolonged activated partial thromboplastin time raises suspicion for the antiphospholipid antibody syndrome.
1117. Rheumatoid arthritis predisposes patients to secondary osteoarthritis.
1118. Immediate prednisone therapy is indicated for patients with clinical suspicion for giant cell arteritis before temporal artery biopsy to decrease the risk for visual loss.
1119. Low-dose aspirin may decrease visual loss and cerebrovascular incidents in the setting of giant cell arteritis.
1120. Left shoulder pain may be referred from the neck; chest; or subdiaphragmatic area, including the spleen.
1121. Intra-articular corticosteroid injections effectively relieve symptoms of knee osteoarthritis.
1122. Small-bowel bacterial overgrowth is a common cause of diarrhea in patients with scleroderma and is treated with intermittent broad-spectrum antibiotics.
1123. Opioid antidiarrheal therapy is not indicated for patients with scleroderma because it may worsen intestinal motility disorders.
1124. Psoriatic arthritis is associated with dactylitis and asymmetrical distal interphalangeal joint inflammation.
1125. The risk for malignant disease is increased in dermatomyositis and polymyositis and in inclusion body myositis.
1126. • Evaluation for an underlying malignancy is indicated in patients with refractory myositis
1127. Combination therapy with methotrexate and anti–tumor necrosis factor agents is the most likely regimen to improve function, limit further damage, and control disease in severe rheumatoid arthritis.
1128. Immunosuppressed patients have increased risk for developing primary or reactivation tuberculosis.
1129. Prophylactic isoniazid therapy is beneficial in patients who use prednisone, equal or more than 15 mg/d, or any other immunosuppressive agent and who have equal or more than 5 mm of induration on tuberculin skin testing.
1130. Urate levels in patients with tophaceous gout should be reduced to 6.0 mg/dL (0.36 mmol/L) to dissolve tophi and other urate depositions in the tissue.
1131. Because decreasing the urate level in a patient with tophaceous gout may induce a gouty attack, continuation of prophylactic doses of colchicine is indicated until the tophi resolve and the urate level stabilizes.
1132. Acetaminophen is an effective, safe, and inexpensive treatment for osteoarthritis.
1133. Patients with osteoarthritis who have high risk for nonsteroidal anti-inflammatory drug complications may use alternate therapy with acetaminophen, often without compromising pain control.
1134. Patients with joint abnormalities have an increased risk for joint infection.
1135. Intra-articular corticosteroid therapy is contraindicated until infection is excluded.
1136. Alveolar hemorrhage may develop in systemic lupus erythematosus even without hemoptysis.
1137. Amyloidosis is an uncommon but potentially severe side effect of chronic inflammatory diseases, such as rheumatoid arthritis.
1138. Rheumatoid arthritis–associated amyloidosis primarily involves the kidneys and may lead to the nephrotic syndrome and renal failure.
1139. Patients treated with cyclophosphamide have increased risk for transitional cell carcinoma of the bladder.
1140. Lifelong screening for bladder cancer is indicated for patients treated with cyclophosphamide.
1141. Adequate drainage and intravenous antibiotics are standard treatment for a “closed-space” joint infection.
1142. The malar rash of systemic lupus erythematosus is often photosensitive and spares the nasolabial folds and areas below the nares and lower lip.
1143. Rosacea is an inflammatory dermatitis characterized by erythema, telangiectasias, papules, pustules, and sebaceous hyperplasia that affects the central face, including the nasolabial folds.
1144. Anti–tumor necrosis factor-α therapy is contraindicated in patients with infection.
1145. Corticosteroid-induced myopathy is characterized by continued or worsening proximal muscle weakness, particularly in the lower extremities, after a decrease in or normalization of muscle enzyme levels.
1146. Tramadol is as effective as ibuprofen in alleviating pain in osteoarthritis of the hip and knee in patients in whom nonsteroidal anti-inflammatory drugs are contraindicated or do not provide adequate pain relief.
1147. Upper- and lower-extremity weakness and gait abnormalities associated with rheumatoid arthritis strongly suggest cervical spine impingement.
1148. Immediate MRI scanning is indicated in patients with rheumatoid arthritis with suspected cervical spine impingement.
1149. Postexposure prophylaxis may benefit immunocompromised patients exposed to influenza virus.
1150. Administration of antiviral therapy does not affect the immune response to inactivated influenza vaccine.
1151. Intranasal trivalent live-attenuated influenza vaccination is contraindicated in immunosuppressed patients.
1152. Colchicine toxicity may cause acute vacuolar myopathy and axonal neuropathy.
1153. Use of colchicine with inhibitors of CYP3A4 and P-glycoprotein, which metabolize and transport this agent, respectively, may increase the likelihood of drug toxicity.
1154. Calcification of the cartilage, particularly the fibrocartilage of the knee meniscus, symphysis pubis, and glenoid and acetabular labrum and the triangular cartilage of the wrist, is pathognomic for calcium pyrophosphate deposition disease.
1155. An atypical distribution of osteoarthritis without a history of trauma suggests calcium pyrophosphate deposition disease.
1156. Prednisone and hydroxychloroquine are the preferred anti-inflammatory drugs during pregnancy.
1157. Upward titration of prednisone may be indicated if other immunosuppressant agents are discontinued during pregnancy.
1158. Hemorrhagic cystitis and bladder cancer are uncommon side effects of cyclophosphamide therapy.
1159. Follow-up cystoscopy is indicated for patients with hematuria and a history of treatment with cyclophosphamide.
1160. Methotrexate remains a vital drug in the treatment of rheumatoid arthritis.
1161. Combination therapy with methotrexate and anti–tumor necrosis factor-α agents provides the best suppression of joint damage and leads to maximal clinical improvement in rheumatoid arthritis.
1162. Wegener's granulomatosis is a necrotizing granulomatous inflammation of small- to medium-sized vessels with a predilection for the upper and lower respiratory tracts and kidneys.
1163. Löfgren's syndrome, a variant of sarcoidosis, is characterized by the concomitant presence of acute erythema nodosum, hilar adenopathy, arthritis or periarthritis, and fever.
1164. Compared with physical examination, radiography of the hands is less sensitive and specific for symptomatic hand osteoarthritis.
1165. The most characteristic radiographic finding of osteoarthritis is osteophytes with joint-space narrowing.
1166. The most characteristic radiographic finding of psoriatic arthritis is the coexistence of erosive changes and new bone formation in the distal joints.
1167. Methotrexate is metabolized by the liver and excreted by the kidneys and should be reduced or discontinued in the setting of renal insufficiency.
1168. Inclusion body myositis is characterized by proximal and distal muscle involvement, asymmetrical muscle weakness and atrophy, falls, and mixed neuropathic and myopathic findings on electromyography.
1169. Muscle biopsy is the diagnostic study of choice for myositis.
1170. Characteristic radiographic changes of the hands associated with rheumatoid arthritis include juxta-articular osteoporosis and marginal erosions in the metacarpophalangeal joints.
1171. Propylthiouracil use is strongly associated with the development of antineutrophil cytoplasmic antibodies directed against myeloperoxidase and associated vasculitis.
1172. Antineutrophil cytoplasmic antibody–positive drug-induced vasculitis may continue to progress after discontinuation of the inciting medication.
1173. Whipple's disease is a chronic infection with multiorgan manifestations, including uveitis, diplopia, asymmetrical inflammatory arthritis, and weight loss.
1174. Corticosteroid therapy often resolves polymyalgia rheumatica symptoms within 24 hours.
1175. The mean duration of therapy for polymyalgia rheumatica is 2.4 years at an average prednisone dose of 9.6 mg/d.
1176. Hydroxychloroquine therapy is associated with retinal toxicity.
1177. Antinuclear antibody positivity may occur in 10% to 15% of healthy young women, in pregnancy, and with increasing age.
1178. An antinuclear antibody assay is indicated only if there is a high pretest probability of systemic lupus erythematosus or another connective tissue disease.
1179. Inflammatory changes in ankylosing spondylitis begin in the T12 to L1 region of the spine and eventually lead to ossification of the outer fibers of the annulus fibrosis and the development of syndesmophytes.
1180. Cryoglobulinemic vasculitis is characterized by palpable purpura, arthritis, weakness, neuropathy, and a membranoproliferative glomerulonephritis.
1181. Laboratory findings in cryoglobulinemic vasculitis include circulating cryoglobulins, rheumatoid factor positivity, hypocomplementemia, and an elevated erythrocyte sedimentation rate.
1182. Hepatitis C is a common cause of cryoglobulinemic vasculitis.
1183. Arthritis associated with hepatitis C infection may occur early or late in the disease course of this infection and may mimic rheumatoid arthritis.
1184. Even in the absence of arthritis, patients with hepatitis C infection often are rheumatoid factor positive.
1185. Primary Raynaud's phenomenon is not typically associated with damaging digital ischemia.
1186. The preferred initial treatment for primary Raynaud's phenomenon is nonpharmacologic.
1187. Concomitant use of sulfamethoxazole and methotrexate is contraindicated.
1188. Manifestations of inflammatory myositis may include elevated antinuclear antibody titers and creatine kinase levels, abnormal electromyography findings, proximal muscle weakness, interstitial lung disease, arthritis, and skin rashes.
1189. Reactive arthritis is a systemic inflammatory disorder triggered by a mucosal infection in the urethra or the bowel and is manifested by a nonseptic oligoarticular arthritis; enthesitis; and, occasionally, eye, skin, or mucosal inflammation.
1190. Sjögren's syndrome is characterized by oral and ocular dryness and anti-Ro/SSA and/or anti-La/SSB antibody positivity in women between 40 and 60 years of age.
1191. Sjögren's syndrome is associated with an increased risk for non-Hodgkin's lymphoma and other lymphoproliferative conditions.
1192. A complete response to appropriate antibiotic therapy for disseminated gonorrhea may take up to 72 hours.
1193. Patients with nongonococcal septic arthritis may have positive blood cultures and extra-articular sites of infection.
1194. Hemorrhagic cystitis is a possible complication of cyclophosphamide therapy.
1195. Mononeuritis multiplex is a common presenting feature of polyarteritis nodosa.
1196. Extra-articular manifestations of ankylosing spondylitis include aortitis with aortic insufficiency, upper-lobe pulmonary fibrocystic disease, amyloidosis, cardiac conduction disease, and recurrent uveitis.
1197. Relapsing polychondritis is characterized by inflammation and destruction of cartilaginous structures.
1198. The most common presenting feature associated with relapsing polychondritis is auricular pain and swelling.
1199. Reactive arthritis is characterized by large-joint oligoarthritis; enthesitis involving tendon insertion sites; and extra-articular manifestations, including uveitis.
1200. Reactive arthritis is triggered by infections in the intestines; urogenital tract; and, less commonly, throat or respiratory tract.
1201. Needle aspiration is the least invasive method for draining an easily accessible joint, such as the knee.
1202. In the setting of septic arthritis, a decrease of fluid volume and leukocyte and neutrophil counts in serial samples suggests adequate needle drainage, whereas persistence of inflammatory fluid after 7 days of therapy suggests treatment failure.
1203. Anti–tumor necrosis factor-α therapy increases the risk for reactivation tuberculosis.
1204. Evaluation for possible septic arthritis is indicated for all patients with acute monoarticular arthritis.
1205. Patients with previously damaged joints and immunosuppression are at particularly high risk for septic arthritis.
1206. Peripheral joint disease in psoriatic arthritis responds to methotrexate and sulfasalazine, whereas related spinal inflammation does not.
1207. Psoriatic spinal inflammation responds to anti–tumor necrosis factor therapy.
1208. Behçet's disease is characterized by recurrent aphthous oral ulcers and at least two or more of the following features: recurrent genital ulceration, eye or cutaneous lesions, or positive findings on pathergy testing.
1209. Synovial fluid in osteoarthritis usually is clear, viscous, and noninflammatory with a leukocyte count less than 2000/µL (2 × 109/L).
1210. Gout and pseudogout are associated with inflammatory synovial fluid with a leukocyte count between 2000/µL (2 × 109/L) and 50,000/µL (50 × 109/L) but may be higher.
1211. Synovial fluid in septic arthritis is generally highly inflammatory with a leukocyte count between 10,000/µL (10 × 109/L) and 50,000/µL (50 × 109/L) and is often higher.
1212. Patients with the clinical triad of asthma, nasal polyps, and aspirin allergy also may have cross-reactivity to nonsteroidal anti-inflammatory drugs.
1213. Nonacetylated salicylate agents may be safely used in patients with aspirin sensitivity and asthma.
1214. Anteroposterior plain radiography of the pelvis is the initial imaging test of choice for suspected sacroiliitis.
1215. If findings on plain radiography are unequivocal or normal, MRI may detect subchondral osteitis and bone marrow edema associated with early sacroiliitis and enthesitis.
Here is the Hematology Oncology notes:
1211. Patients with acute venous thromboembolism and metastatic cancer are at higher risk for recurrent venous thrombosis than those without malignancy.
1212. Chronic low-molecular-weight heparin at therapeutic doses reduces the risk for thrombotic recurrence compared with standard-intensity warfarin in patients with venous thromboembolism and cancer.
1213. Hematologic findings in iron-deficiency anemia consist of microcytic, hypochromic red blood cells; abnormalities in erythrocyte size and shape; and occasional bizarre-shaped red blood cells.
1214. Iron-deficiency anemia is treated with iron therapy.
1215. Transfusion-related acute lung injury is an inflammatory infusion reaction in the pulmonary vasculature manifested primarily by hypoxemia.
1216. Major diagnostic criteria of polycythemia vera include an elevated red blood cell mass, a normal blood oxygen saturation, and the presence of splenomegaly.
1217. Low-dose aspirin reduces the risk of thrombotic complications in polycythemia vera.
1218. The electrophoretic gel in patients with hemoglobin SC disease is characterized by two bands of equal intensity that are slow-migrating.
1219. Monoclonal gammopathy of unknown significance (MGUS) is characterized by the presence of serum monoclonal gammaglobulin without the clinical features of multiple myeloma, a paraprotein level less than 3.5 g/dL (35 g/L), and less than 10% plasmacytosis in the bone marrow.
1220. Management of MGUS requires routine follow-up to identify signs of progression to multiple myeloma and periodic measurement of serum monoclonal protein concentration.
1221. Intraoperative acute normovolemic hemodilution ensures delivery of autologous blood with a hematocrit higher than the blood lost during surgery and has none of the clerical risks associated with blood banking.
1222. Peripheral neuropathy is a common side effect of bortezomib therapy, occurring in approximately 30% of patients who take this agent.
1223. A rapidly falling platelet count occurring within days of heparin administration is indicative of heparin-induced thrombocytopenia (HIT).
1224. In patients with HIT, heparin therapy must stopped and alternative anticoagulation with a direct thrombin inhibitor instituted immediately.
1225. Estrogen-containing oral contraceptives confer a fourfold increased relative risk for venous thromboembolism in women of childbearing age without heritable thrombophilia and a 35-fold increased risk in women who are heterozygous for the factor V Leiden mutation.
1226. Oral progestin-only–containing contraceptives appear to confer little, if any, increased risk for venous thrombosis.
1227. No other intervention is required in handling a delayed hemolytic transfusion reaction except for avoidance of the incompatible antigen.
1228. Signs suggestive of disease transformation from myelodysplastic syndrome to acute myeloid leukemia (AML) include severe pancytopenia and circulating myeloid blasts on peripheral blood smear.
1229. Patients with transformed versus de novo AML have poorer response rates and disease-free survival, despite receiving the same chemotherapeutic regimen.
1230. Patients with the α-thalassemia trait have a two-gene defect ([α,--]/[α,--]) in the α-globin gene chain of chromosome 16.
1231. Patients who have α-thalassemia trait have mild microcytic anemia with prominent target cells on peripheral blood smear.
1232. Routine blood transfusion during pregnancy in patients with sickle cell disease is not necessary unless mandated by other high-risk conditions.
1233. The risk for recurrent venous thrombosis in patients with the factor V Leiden mutation is not greater than that in those without an underlying thrombophilic abnormality.
1234. Patients at high risk for recurrent thrombosis should receive long-term anticoagulation therapy with warfarin.
1235. Patients with delayed-onset heparin-induced thrombocytopenia (HIT) can present with typical manifestations of HIT as late as 3 to 4 weeks after heparin exposure.
1236. Patients with delayed-onset HIT require anticoagulation therapy with a direct thrombin inhibitor and no further exposure to heparin.
1237. Acute chest syndrome (ACS) is characterized by fever, chest pain, shortness of breath, hypoxia, and a chest infiltrate in a patient with a sickling disorder.
1238. Patients with ACS require erythrocyte transfusion to achieve a target hemoglobin of 10 g/dL (100 g/L).
1239. Erythropoietin therapy has been shown to improve anemia and reduce transfusion requirements in some patients with transfusion-dependent myelodysplastic syndrome.
1240. Patients with a drug-induced antibody reaction do not have indications of hemolysis or evidence of complement activation on direct antibody testing.
1241. Factor V Leiden and prothrombin G20210A mutations are the most common mutations predisposing to venous thrombosis in white populations, but are rare in Asian and black populations.
1242. Levels of protein S are reduced during pregnancy, making testing for deficiency of this protein unreliable.
1243. Bone marrow aspirate and biopsy should be performed in patients with suspected idiopathic thrombocytopenic purpura who do not respond to prednisone therapy.
1244. Immunosuppressive therapy with antithymocyte globulin and cyclosporine is effective in reducing transfusion requirements in more than 70% of patients with aplastic anemia.
1245. Inflammatory anemia is characterized by a low or normal serum iron concentration, reduced serum total iron-binding capacity, and serum ferritin that is not decreased.
1246. Hypercalcemia, bone pain, anemia, and clusters of large plasma cells on bone marrow aspirate smear are diagnostic of multiple myeloma.
1247. The risk for thrombosis in asymptomatic pregnant women who are heterozygous for the factor V Leiden mutation is low.
1248. Complete hematologic remission rates for patients with CML who received imatinib mesylate compared with interferon and low-dose cytarabine were 95% and 56%, respectively.
1249. Thrombotic thrombocytopenia purpura (TTP) is characterized by fever, neurologic abnormalities, thrombocytopenia, microangiopathic hemolytic anemia, and renal insufficiency.
1250. The treatment of choice for TTP is emergent plasma exchange, followed by plasma infusion when the former is not immediately available.
1251. Patients with heart failure and hemolysis require immediate transfusion, even when only incompatible blood is available, to avoid cardiovascular collapse.
1252. The initial treatment in patients with warm antibody autoimmune hemolytic anemia is corticosteroid therapy.
1253. Patients whose first thrombotic events are associated with transient risk factors are at relatively low risk for a spontaneous recurrent venous thrombotic episode.
1254. Incidental thrombocytopenia of pregnancy requires careful follow-up monitoring of the platelet count.
1255. Patients with incidental thrombocytopenia of pregnancy require further diagnostic evaluation when platelet values decrease to lower than 70,000/μL (70× 109/L).
1256. Drug-induced agranulocytosis is the most likely diagnosis in patients with sepsis, severe neutropenia, and relatively well-preserved hematocrit and platelet counts after ingestion of trimethoprim–sulfamethoxazole
1257. A history of mucosal bleeding and a mildly prolonged activated partial thromboplastin time is consistent with a diagnosis of von Willebrand's disease.
1258. Factor V Leiden mutation is associated with venous, not arterial, thromboses.
1259. Erythropoietin failure in patients receiving dialysis can be caused by iron deficiency, folate deficiency, ongoing blood loss, or iron overload.
1260. Supplemental vitamin C can improve the response to erythropoietin in patients receiving dialysis.
1261. Patients with iron-deficiency anemia require iron-replacement therapy, not blood transfusion.
1262. Primary (AL) amyloidosis should be suspected in patients with nephrotic-range proteinuria in the presence of monoclonal gammaglobulin in serum or urine.
1263. A diagnosis of primary (AL) amyloidosis can be established by kidney biopsy.
1264. Bleeding symptoms and hematologic abnormalities in patients with autoimmune disorders, malignancy, or in the postpartum setting may be suggestive of an acquired factor VIII inhibitor.
1265. Fondaparinux administered for 28 days results in a low frequency of venous thromboembolism after hip-fracture repair and is FDA approved for extended thromboprophylaxis following this procedure.
1266. Patients with hereditary spherocytosis have predominantly spherocytic red cells on the peripheral blood smear; a mild, Coomb's-negative, hemolytic anemia; and an elevated mean cellular hemoglobin concentration.
1267. A new alloantibody is not always detectable in patients with sickle cell disease who have adverse transfusion reactions.
1268. Patients with sickle cell disease may experience infusion-related reactions that are manifested by lower, rather than higher, reticulocyte counts.
1269. Fatigue, weight loss, massive splenomegaly, and teardrop-shaped erythrocytes on peripheral blood are consistent with myelofibrosis.
1270. Chronic transfusion therapy is an appropriate management option for some patients with myelofibrosis.
1271. Isolated thrombocytopenia in an otherwise-healthy young patient is most commonly due to idiopathic thrombocytopenic purpura (ITP).
1272. Patients with ITP and low risk for bleeding as demonstrated by a platelet count >40,000 require only periodic monitoring of the platelet count.
1273. Patients with venous thromboembolism associated with oral contraceptives are generally at low risk for recurrent venous thromboembolism.
1274. Long-term oral anticoagulation is recommended in patients with unprovoked venous thrombotic events in association with antiphospholipid antibody syndrome.
1275. Patients with asymptomatic inflammatory anemia do not require additional diagnostic testing.
1276. Nonhemolytic transfusion reactions result in inflammatory-type symptoms without evidence of hemolysis.
1277. Stopping the blood transfusion is the only intervention required in the management of nonhemolytic transfusion reactions and should result in quick symptomatic resolution.
1278. A disease-free and overall survival benefit is observed in patients receiving high-dose chemotherapy and autologous stem cell transplantation during first remission from multiple myeloma.
1279. The HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets) usually resolves within several days after delivery of the fetus.
1280. An inherited thrombocytopenic disorder should be suspected in otherwise-healthy patients with a low platelet count, giant platelets on peripheral blood smear, a family history of thrombocytopenia, and who are refractory to corticosteroids
1281. Patients with vitamin B12 deficiency have elevated serum lactate dehydrogenase and unconjugated bilirubin and may have increased forgetfulness.
1282. Supplemental vitamin B12 does not always reverse the neurologic findings of B12 deficiency but may prevent further deterioration of mental status.
1283. Patients with pulmonary hemorrhage and those undergoing most types of major surgery need sustained platelet counts of 40,000 (40 × 109/L) to 50,000/μL (50 × 109/L).
1284. The symptoms of serotonin syndrome may include tachycardia, hypertension, hyperthermia, mydriasis, hyperactive bowel sounds, diaphoresis, hyperreflexia, clonus, and changes in mental status.
1285. Warfarin with a target INR of 2 to 3 is adequate for preventing recurrent venous thrombosis in patients with antiphospholipid antibody syndrome.
1286. Patients with thalassemia may experience secondary iron overload due to increased iron absorption from the gut.
1287. Deferoxamine is a parenteral iron chelator that is used to decrease the tissue iron in patients with thalassemia.
1288. Leukoreduced blood should be used in pregnant patients in whom the cytomegalovirus infection status is not known.
1289. Imatinib mesylate can cause a mild, maculopapular rash that is most prominent over the extremities and trunk, and typically resolves within a week of interruption of therapy.
1290. For most patients who experience an imatinib-induced rash, the drug can be re-instituted after the rash resolves, without recurrence.
1291. Consumptive coagulopathy is often accompanied by thrombocytopenia and a prolonged prothrombin time.
1292. All stages of Hodgkin's lymphoma now are treated with systemic chemotherapy and no longer require invasive testing to identify the extent of disease.
1293. Mortality in patients with stage III colon cancer treated with surgical resection and adjuvant chemotherapy is decreased by as much as 33%.
1294. Patients with BRCA1/2 mutations have a higher risk for breast and ovarian cancer compared with the general population.
1295. Patients with a family history suggestive of germline-susceptibility cancer should be referred for genetic counseling.
1296. Gonadotropin-releasing hormone agonists such as leuprolide may result in bone loss in the lumbar spine in patients with prostate cancer.
1297. β-Carotene is associated with an increased risk for lung cancer in patients who already have an elevated risk for this disease because of smoking history.
1298. Serum α-fetoprotein has a half-life of 1 week and requires re-measurement at 14 to 21 days after surgery.
1299. Surgery alone is curative for patients with early-stage ovarian cancer in 90% of cases.
1300. Lymphadenopathy in the supraclavicular region almost always indicates an infectious or neoplastic cause and requires an immediate diagnostic procedure.
1301. A complete lymph node excision is always preferred over a percutaneous needle biopsy in patients with suspected Hodgkin's or non-Hodgkin's lymphoma.
1302. Patients with colon cancer and unresectable liver metastases require systemic treatment with chemotherapy.
1303. Additional diagnostic testing for extrahepatic metastases is necessary only when surgical resection of hepatic metastases is a consideration.
1304. A diet high in fruits and vegetables is associated with a lower risk for cardiovascular disease but not for cancer.
1305. Hyperviscosity syndrome must be considered in patients who have lymphoplasmacytic lymphoma (Waldenström's macroglobulinemia) with an elevated serum IgM concentration and symptoms suggestive of congestive heart failure.
1306. Emergent plasmapheresis and immediate systemic chemotherapy is required in patients with lymphoplasmacytic lymphoma and a serum viscosity concentration more than 3.0 with suspicious symptoms, or a value of more than 4.0 without suspicious symptoms.
1307. Patients with prostate cancer are generally asymptomatic at diagnosis.
1308. Patients with recently diagnosed prostate cancer and a prostate-specific antigen concentration less than 10 ng/mL (10 μg/L) have a low incidence of bony metastasis.
1309. Only women who are at high risk for ovarian cancer should consider prophylactic bilateral oophorectomy.
1310. Lung cancer screening does not decrease mortality and is not supported by evidence.
1311. In patients with adenocarcinoma of unknown primary site, the workup should be guided by the patient's history and physical and laboratory findings.
1312. Gemcitabine is Food and Drug Administration approved for the treatment of metastatic pancreatic cancer and results in improved clinical benefit and overall survival compared with 5-fluorouracil.
1313. Hodgkin's lymphoma survivors who receive extended-field radiation have a 1% risk/year for developing solid tumors.
1314. Tumor lysis syndrome is a consideration in patients who have bulky Burkitt's lymphoma and symptoms of vomiting and dehydration.
1315. Patients with symptomatic bulky lymphoma require hydration, urinary alkalinization, and administration of a xanthine oxidase inhibitor before chemotherapy to prevent tumor lysis syndrome.
1316. Breast-conserving surgery results in similar and sometimes superior survival in patients with early-stage breast cancer regardless of patient age compared with mastectomy.
1317. Re-excision is indicated in patients with positive tumor margins detected after breast-conserving surgery.
1318. Avoiding direct sunlight during peak hours and other sun-avoidance strategies are associated with a decreased risk for squamous cell carcinoma and malignant melanoma.
1319. Sunscreen may decrease the risk for developing squamous cell carcinoma but not malignant melanoma.
1320. Selenium has been associated with an increased risk for nonmelanomatous skin cancer compared with placebo.
1321. Treatment of patients with testicular cancer metastatic to the brain consists of whole-brain radiation therapy and combination chemotherapy.
1322. Preoperative radiation therapy plus chemotherapy can reduce tumor size and facilitates sphincter-preserving surgery in patients with distal rectal tumors.
1323. Gastric mucosa-associated lymphoid tissue (MALT) lymphoma is almost always associated with Helicobacter pylori infection.
1324. Disease in most patients with MALT lymphoma regresses after treatment with antibiotics alone within several months.
1325. Most patients with small-cell lung cancer respond dramatically to combination chemotherapy and whole-brain radiation therapy.
1326. Bisphosphonates such as pamidronate or zolendronate help reduce skeletal-related events in patients with metastatic lung cancer.
1327. Patients with abnormal breast findings on physical examination and normal mammogram should undergo further evaluation with breast ultrasonography and biopsy.
1328. Sensitivity of mammography ranges from 75% to 90%, with false-negative results most likely in women with dense breasts.
1329. Patients with stage T1c prostate cancer and a PSA less than 10 ng/mL (10 μg/L) rarely have metastatic disease and don't need extensive staging
1330. Ovarian cancer screening does not result in decreased mortality in general or high-risk populations.
1331. The infrequency of ovarian cancer occurrence and invasiveness of the associated diagnostic procedures make routine ovarian cancer screening inappropriate.
1332. The risks of chemotherapy in bedbound patients with colorectal cancer who have a poor performance status outweigh its benefits because of poor likelihood for response and therapy-induced toxicity.
1333. Patients with histologically confirmed adenocarcinoma of the axillary lymph nodes but no clinically or radiologically detected breast abnormalities should be treated for stage II breast cancer.
1334. Watchful waiting is appropriate for patients with advanced-stage follicular lymphoma unless the disease progresses rapidly or poses an imminent threat to well-being.
1335. Although there is no current cure for patients with advanced-stage follicular lymphoma, the median survival ranges from 10 to 14 years.
1336. Tamoxifen decreases breast cancer risk by approximately 50% in pre- and postmenopausal women who have an elevated risk for this disease.
1337. Tamoxifen is the only Food and Drug Administration–approved medication for use in decreasing breast cancer risk.
1338. Infection with hepatitis B or C is associated with an increased risk for hepatocellular carcinoma.
1339. Hepatitis B and C are endemic to many parts of the developing world, especially Southeast Asia.
1340. In the Gleason histologic scoring system, grade 1 represents the most well-differentiated tumors, and grade 5 represents the most poorly differentiated tumors.
1341. Gleason scores consist of two scores derived from the most prevalent and second most prevalent differentiated tumors, which results in a combined score.
1342. The first of the two reported Gleason scores in the combined score may be most predictive of outcome.
1343. Mixed seminomatous and nonseminomatous germ cell tumors should be managed as though they were nonseminomatous tumors.
1344. Chemotherapy is indicated in the treatment of mixed seminomatous and nonseminomatous germ cell tumors.
1345. Flow cytometry of the peripheral blood is the best and least invasive way to establish a diagnosis in patients with suspicious lymphocytosis.
1346. Small-cell lung cancer is presumed to be a systemic disease with micrometastases, even when it appears to be isolated and resectable.
1347. Systemic chemotherapy is a required component of therapy in patients with small-cell lung cancer, even in those with limited-stage disease.
1348. The concomitant use of chemotherapy and radiation therapy confers a small survival benefit over sequential use of these modalities or chemotherapy alone.
1349. Finasteride reduces prostate cancer prevalence by 25%.
1350. Finasteride is associated with higher-grade tumors and more sexual side effects but fewer symptoms of urinary obstruction compared with placebo.
1351. Patients with squamous cell carcinoma (SCC) of unknown primary site and upper or midcervical lymph node involvement should be treated for locally advanced SCC of the head and neck.
1352. Aromatase inhibitors are more effective versus tamoxifen in preventing breast cancer recurrence in postmenopausal women.
1353. Marginal-zone B-cell lymphoma has been associated with hepatitis C virus in some patients; treatment of the underlying infection may result in remission of the lymphoma.
1354. Young, male patients with poorly differentiated midline carcinoma containing germ cell cancer markers and isochromosome 12p are likely to have extragonadal germ cell cancer and may respond to cisplatin-based chemotherapy.
1355. Docetaxel plus prednisone improves survival in men with metastatic prostate cancer refractory to hormonal ablation therapy when compared with mitoxantrone plus prednisone.
1356. Most patients become azoospermic shortly after chemotherapy for testicular germ cell cancer, but they may regain normalized sperm counts within 2 years; however, many remain infertile or subfertile.
1357. Sperm storage is offered to men with testicular cancer before they undergo chemotherapy.
1358. In patients with metastatic HER2-positive breast cancer, trastuzumab and chemotherapy result in prolonged survival compared with chemotherapy alone.
1359. In patients with early-stage resectable non–small-cell lung cancer, the use of adjuvant chemotherapy is a new standard of care replacing the former approach of providing no further therapy.
1360. Diffuse large B-cell lymphoma requires systemic therapy even when results of CT scans and positron emission tomography (PET) are negative.
1361. Rituximab and CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone), with or without radiation therapy, is curative for most patients with diffuse large B-cell lymphoma.
1362. Follow-up evaluation of postmenopausal women with breast cancer who undergo successful treatment consists of annual mammography.
1363. Smoking cessation is the most effective cancer prevention strategy for patients who are at high risk for lung cancer.
1364. Bronchioloalveolar cell carcinoma has a distinct pattern of presentation and responds uniquely to therapy with the new epidermal growth factor receptor inhibitors.
1365. Some patients with primary or recurrent bronchioloalveolar cell carcinoma who receive daily oral erlotinib or gefitinib have periods of disease reduction lasting from 1 to 2 years.
1366. Combination hormone replacement therapy has been shown to increase the risk for breast cancer.
1367. Follow-up examinations for patients with successfully treated testicular cancer should include studies focused only on new symptoms rather than an arbitrary schedule of imaging or workups.
1368. Patients with a poor performance status and widely metastatic non–small-cell lung cancer of squamous cell histology almost never respond to any type of therapy and require hospice care.
1369. Women with a history of ovarian cancer have a higher risk for breast cancer than that of the average population.
1370. Ovarian cancer metastasizes commonly to the pleura and peritoneum, rarely to bone or liver, and almost never to breast.
1371. Breast cancer metastasizes commonly to the pleura, peritoneum, liver and bone.
Endocrinology and metabolism
1372. The insulin sensitizing drugs metformin and the thiazolidinediones are contraindicated in patients with advanced heart failure.
1373. Thyroid hormone increases the metabolism of warfarin but increases the turnover of clotting proteins even more, resulting in a decreased dose requirement of warfarin.
1374. In an asymptomatic patient with mild hypercalcemia and an inappropriately normal parathyroid hormone level, the main differential includes primary hyperparathyroidism versus benign familial hypocalciuric hypercalcemia.
1375. Familial hypocalciuric hypercalcemia is diagnosed by a urinary calcium/creatinine clearance ratio less than 0.01 measured in a fasting morning urine spot collection.
1376. Severe hypogonadism in a young male with an elevated serum prolactin level strongly suggests pituitary macroadenoma and warrants evaluation of the entire pituitary.
1377. Patients with Cushing's syndrome produce three to four times the amount of urine free cortisol that unaffected persons produce.
1378. The three screening tests for Cushing's syndrome are measurement of urine free cortisol, the overnight dexamethasone suppression test, and the late-evening salivary cortisol test.
1379. Risk factors for hypopituitarism include previous macroadenoma, pituitary surgery, and brain radiation.
1380. Multiple endocrine neoplasia type 2A is characterized by pheochromocytoma, medullary thyroid carcinoma, and hyperparathyroidism due to parathyroid hyperplasia.
1381. The goal of preoperative blood pressure control in patients with pheochromocytoma is less than 140/90 mm Hg.
1382. α-Adrenergic blockade is used to reduce preoperative blood pressure in patients with pheochromocytoma.
1383. No pharmacologic therapy is more effective than diet and exercise in preventing the progression to type 2 diabetes in patients with prediabetes.
1384. The indications for parathyroidectomy in a patient with mild, asymptomatic hypercalcemia secondary to primary hyperparathyroidism are age less than 50 years, serum calcium level more than 1.0 mg/dL (0.25 mmol/L) above the upper limit of normal, 24-hour urine calcium excretion more than 400 mg (10 mmol), creatinine clearance reduced by more than 30%, and a bone mineral density T score less than 2.5 at any site.
1385. The cause of primary hyperparathyroidism in most cases is a single parathyroid adenoma.
1386. Substernal goiter results in a narrowed thoracic inlet, which is further compromised by extension of the arms over the head, resulting in compression of the great veins of the neck and the marked facial plethora known as Pemberton's sign.
1387. Pituitary apoplexy is the sudden onset of headache, visual disturbances, opthalmoplegia, and mental status changes caused by the acute hemorrhage or infarction of the pituitary gland.
1388. Urgent neurosurgical evacuation of the hemorrhage is generally indicated for patients with pituitary apoplexy and rapidly progressing visual disturbances and/or mental status changes.
1389. A noncontrast CT scan can distinguish between pituitary apoplexy and subarachnoid hemorrhage as patients with pituitary apoplexy will demonstrate acute hemorrhage in the region of the sella turcica.
1390. In a patient with androgen-dependent hirsutism who does not wish to become pregnant, antiandrogen and ovarian suppression therapy is usually effective.
1391. The 25-hydroxyvitamin D level is a marker of body stores of vitamin D and is measured as the initial step in the evaluation of suspected nutritional vitamin D deficiency.
1392. Coronary artery disease may be silent in patients with long-standing diabetes mellitus or present atypically.
1393. Dyspnea in a patient with an extensive history of complicated diabetes should be considered an anginal equivalent.
1394. Subclinical hypothyroidism is an elevated serum TSH level with a free T4 that is still within the population reference range.
1395. Patients with subclinical hypothyroidism who have a serum TSH value above 10 µU/mL (10 mU/L) have been shown to have reductions in their LDL cholesterol concentrations when treated with levothyroxine.
1396. Hypomagnesemia in the patient with alcoholism can mimic hypoparathyroidism, including severe hypocalcemia and hyperphosphatemia.
1397. New-onset hirsutism with virilization, particularly in an older woman, and accompanied by a serum total testosterone level more than 200 ng/dL (6.9 nmol/L) is almost always due to a tumor.
1398. Excision of a cortisol-producing adrenal adenoma results in rapid clearance of cortisol within the first 24 hours after surgery and subsequent acute adrenal insufficiency; corticosteroid replacement is the appropriate therapy
1399. Growth hormone stimulation testing is more sensitive and specific for determining growth hormone deficiency than measuring basal hormone levels.
1400. Because of the potential nephrotoxicity of intravenous radiocontrast agents, metformin, which accumulates in renal insufficiency, should not be administered when any radiographic procedure using an intravenous contrast agent is performed.
1401. Inhibition of the renin-angiotensin axis reduces proteinuria and preserves renal function in patients with diabetes mellitus.
1402. A dominant thyroid nodule shown to be benign by fine-needle aspiration biopsy should be followed by serial monitoring with ultrasound to assess size stability.
1403. Pseudo-Cushing's syndrome consists of hypercortisolism in patients with such disorders as depression and alcohol use that alter hypothalamic - pituitary - adrenal function enough to perturb screening tests for Cushing's syndrome.
1404. If standard screening tests are equivocal in a patient with a strong pretest probability for Cushing's syndrome, the combined dexamethasone - CRH stimulation test may distinguish Cushing's syndrome from pseudo-Cushing's syndrome.
1405. The therapy of choice for uncomplicated Paget's disease is an oral bisphosphonate.
1406. In men, excessive production of glucocorticoids causes hypogonadotropic hypogonadism with diminished libido and loss of secondary sexual characteristics, in conjunction with commonly recognized manifestations of Cushing's syndrome.
1407. On CT scan of the adrenal glands, adenomas usually have smooth borders, are less than 4 cm in diameter, unilateral, homogenous in consistency, and less than 10 Hounsfield units in density.
1408. The serum TSH cannot be used to monitor thyroid hormone replacement therapy in patients with central hypothyroidism
1409. On patients with central hypothyroidism, the goal of thyroid hormone replacement is to titrate the dose to normalize the free T4 (or total T4 and free thyroxine index) not to normalize the TSH.
1410. Patients with type 2 diabetes taking monotherapy often require multidrug therapy as the duration of disease increases and beta-cell destruction progresses.
1411. The addition of one class of drug to another is the current favored approach in the patient with type 2 diabetes and progressive hyperglycemia despite monotherapy.
1412. Measurement of TSH-receptor autoantibodies, which are present in more than 90% of patients with Graves' disease but are not present in postpartum thyroiditis, can distinguish between the two disorders in a patient with postpregnancy thyrotoxicosis.
1413. Patients with gestational diabetes mellitus have a 50% risk of developing type 2 diabetes mellitus in the 5 to 10 years after the diagnosis of gestational diabetes.
1414. Non–parathyroid hormone–mediated hypercalcemia is characterized by suppressed parathyroid hormone levels.
1415. In most cases of malignancy-associated hypercalcemia, the tumor produces parathyroid hormone–related peptide, which shares significant homology with many of the metabolic actions of parathyroid hormone.
1416. A gradual decline in strength, cognitive and sexual function, and anhedonia in an elderly male suggests testosterone deficiency, and replacement therapy may be offered.
1417. Electrolyte abnormalities are generally not observed in patients with central adrenal insufficiency due to the fact that the aldosterone system is still functional.
1418. Multiple endocrine neoplasia (MEN) type 2A is an autosomal dominant syndrome in which adult carriers of the RET mutation are predisposed to medullary thyroid carcinoma, unilateral or bilateral pheochromocytomas, and hyperparathyroidism.
1419. Pendred's syndrome is an autosomal-recessive disorder of iodine organification characterized by congenital sensorineural hearing loss combined with goiter.
1420. Osteomalacia is a metabolic bone disease with failure of the organic matrix (osteoid) of bone to mineralize normally in adults.
1421. Looser's zones or Milkmans' fractures (pseudofractures) on radiography are pathognomonic of osteomalacia.
1422. In patients with type 1 diabetes and suboptimal glucose control, more complex regimens with more frequent injections of both short/rapid and long/intermediate acting insulins usually provide more effective control.
1423. The ADA recommended goals for management of adults with diabetes are hemoglobin A1C less than 7.0%, preprandial plasma glucose 90-130 mg/dL (5-7.22 mmol/L), peak (2 hour) postprandial plasma glucose less than 180 mg/dL (9.99 mmol/L), blood pressure less than 130/80 mm Hg, triglycerides less than 150 mg/dL (1.69 mmol/L), HDL cholesterol more than 40 mg/dL (1.03 mmol/L), and LDL cholesterol less than 100 mg/dL (2.59 mmol/L).
1424. Benign adrenal adenomas generally have smooth borders, attenuation values less than 10 Hounsfield units, and are homogenous in consistency.
1425. The size of an adrenal lesion is predictive of malignant potential; 25% of lesions more than 6 cm are carcinomas.
1426. In patients with malignancy-associated hypercalcemia, therapy with zoledronate, a long-acting intravenous nitrogen-containing bisphosphonate, induces rapid and long-lasting hypocalcemic response.
1427. Multiple endocrine neoplasia (MEN) 2a syndrome consists of medullary thyroid cancer, pheochromocytoma, and hyperparathyroidism due to four-gland hyperplasia.
1428. In patients with hyperglycemic hyperosmolar syndrome, the preservation of vascular volume is critical, and normal saline is the initial fluid of choice, even before intravenous insulin.
1429. The differential diagnosis in patients with apparently inappropriate TSH secretion includes a TSH-producing pituitary adenoma and congenital thyroid hormone resistance.
1430. he American Diabetes Association criteria for the diagnosis of diabetes mellitus are a fasting plasma glucose more or equal 126 mg/dL (6.99 mmol/L), a 2-hour plasma glucose more or equal 200 mg/dL (11.1 mmol/L) after a 75-g oral glucose load, or a random glucose more or equal 200 mg/dL (11.1 mmol/L) plus symptoms of diabetes.
1431. Thiazide diuretics stimulate renal tubular calcium reabsorption and in some patients lead to a mild hypercalcemia, which usually resolves when the diuretic therapy is discontinued.
1432. Primary hypothyroidism is a common secondary cause of hyperprolactinemia, likely caused by increased stimulation of the pituitary gland by thyrotropin-releasing hormone.
1433. Serum TSH should be measured with prolactin in the evaluation of a patient with galactorrhea and irregular menses.
1434. Causes of ACTH-dependent Cushing's syndrome can be distinguished by the dexamethasone 8-mg (high-dose) overnight suppression test and the corticotropin-releasing hormone (CRH) stimulation test.
1435. The average patient with type 1 diabetes mellitus who does not have coexisting insulin resistance requires a total daily dose of about 0.4 to 0.5 units of insulin per kg of body weight.
1436. In the water deprivation test, impaired ability to concentrate urine is consistent with either nephrogenic or central diabetes insipidus.
1437. In the water deprivation test, a large increase in urine osmolarity after the administration of desmopressin is indicative of central diabetes insipidus; no such increase occurs in nephrogenic diabetes insipidus.
1438. Hypocalcemia frequently occurs after removal of a hyperfunctioning parathyroid adenoma because of deficient secretion of parathyroid hormone by the remaining previously suppressed parathyroid tissue.
1439. Permanent hypoparathyroidism after an initial neck exploration for primary hyperparathyroidism is rare, but the incidence is greatly increased with repeated neck surgery for recurrent or persistent hyperparathyroidism and after subtotal parathyroidectomy for parathyroid hyperplasia
1440. In a patient with unstable coronary artery disease and hypothyroidism, therapy with thyroid hormone could increase myocardial metabolic demand and precipitate a myocardial infarction.
1441. Hyperprolactinemia can cause hypogonadism because prolactin directly suppresses gonadotropin-releasing hormone secretion and thus luteinizing hormone and testosterone production.
1442. The initial treatment for prolactin-producing macroadenomas is a dopamine agonist, such as bromocriptine or cabergoline, which decreases prolactin level, shrinks the tumor, and improves visual fields and pituitary function in most patients.
1443. Inferior petrosal sinus sampling is a confirmatory test for Cushing's syndrome in patients with ambiguous results in screening tests; the technique is very sensitive and specific, but extremely costly, technically difficult, and somewhat hazardous.
1444. Metformin should not be used in men with creatinine levels greater than 1.5 mg/dL (132.63 µmol/L) or in women with creatinine levels greater than 1.4 mg/dL (123.79 µmol/L).
1445. A thiazolidinedione should not be used in patients with class III congestive heart failure and will often cause worsening edema even in patients with less severe congestive heart failure.
1446. In euthyroid patients, amiodarone therapy results in high free and total T4, low-normal T3, and high-normal TSH.
1447. Osteoporosis is diagnosed by the presence of fragility fractures or by a bone mineral density value less than −2.5 in patients who have not experienced a fragility fracture.
1448. The classic characteristics of prolactinoma are amenorrhea and galactorrhea.
1449. Serum prolactin levels greater than 200 ng/mL (200 mg/L) in a nonpregnant woman usually suggest a tumor instead of another cause of hyperprolactinemia.
1450. Secondary diabetes mellitus may be the direct result of such underlying disease states as other endocrinopathies, islet cell neoplasms, and disorders of the exocrine pancreas such as pancreatitis, pancreatic malignancies, and cystic fibrosis.
1451. Localizing the ectopic source of ACTH in a patient with evidence of ACTH-dependent Cushing's syndrome may require combination CT/MRI/octreotide imaging of chest/abdomen/pelvis.
1452. In patients with severe primary hypothyroidism, decreased negative feedback of thyroid hormone at the level of the hypothalamus leads to release of thyrotropin-releasing hormone, which stimulates expansion of TSH-producing pituitary cells, causing pituitary hyperplasia.
1453. Exenatide, an incretin mimetic that increases insulin secretion, is an alternative to insulin therapy in patients who have not achieved optimal glycemic control with multi-agent oral therapy.
1454. Tertiary hyperparathyroidism is a rare disorder that usually occurs after many years of chronic renal insufficiency and secondary hyperparathyroidism.
1455. Cinacalcet hydrochloride is a calcimimetic agent that has been shown to significantly parathyroid hormone levels in patients with chronic kidney disease and uncontrolled secondary hyperparathyroidism.
1456. The classic presentation of hereditary hemochromatosis includes hypogonadism, diabetes mellitus, liver dysfunction, and skin hyperpigmentation.
1457. The most commonly affected organs in hereditary hemochromatosis are the pituitary gland, pancreas, liver, and heart.
1458. Postprandial glucose excursions in patients with diabetes should ideally be 30 to 50 mg/dL (1.67 to 2.78 mmol/L) above premeal glucose values.
1459. Significant postprandial hyperglycemia can be managed by using a bolus of short-acting insulin (lispro or aspart) just before or with each meal.
1460. The absence of menses for several months after dilation and curretage raises the possibility of endometrial damage or formation of scar tissue causing an outflow tract obstruction (Asherman's syndrome).
1461. Pheochromocytomas usually occur within the adrenal medulla, are rarely bilateral, occur more commonly in the right adrenal, are rarely metastatic to the local lymphatic vessels and /or liver, and are usually more or equal to 2 cm in diameter and heterogeneous in consistency.
1462. Computed tomography of the abdomen with thin sections through the adrenals is the preferred initial localizing study for pheochromocytoma.
1463. Patients with Hashimoto's thyroiditis are at risk for other autoimmune endocrine disorders, including adrenal insufficiency, pernicious anemia, type 1 diabetes mellitus, vitiligo, and premature ovarian failure.
1464. The classic symptoms of renal osteodystrophy are vague bone pain localized to the lower back, hips, or legs; muscle weakness often occurs with normal muscle enzymes and nonspecific electromyography changes.
1465. The main radiographic feature of renal osteodystrophy is increased bone resorption, most commonly in the subperiosteal surfaces of the hands, neck of femur, and clavicle.
1466. The presence of three or more pituitary hormone deficiencies has a positive predictive value for growth hormone deficiency of 95%.
1467. Replacement of growth hormone in hormone-deficient adults has been shown to improve body composition, lipid parameters, and bone mineral density.
1468. Therapy with an angiotensin II receptor blocker delays the progression of nephropathy in diabetic patients with hypertension, macroalbuminuria, and renal insufficiency.
1469. β-Blocker therapy to reduce thyrotoxic symptoms is the most appropriate therapy during the hyperthyroid phase of postpartum thyroiditis.
1470. Approximately 75% of patients with postpartum thyroiditis recover, whereas 25% develop permanent hypothyroidism.
1471. Hemochromatosis can result in various endocrinopathies, including hypogonadism, adrenal insufficiency, and diabetes mellitus.
1472. Growth hormone replacement is started at a low dose and titrated up based on the patient's insulin-like growth factor 1 level, symptom control, and side effects of therapy.
1473. The goal of growth hormone replacement is to normalize the insulin-like growth factor 1 level and alleviate symptoms without causing adverse side effects.
1474. Adverse effects of growth hormone replacement therapy include parasthesias, myalgias, edema, and joint pain.
1475. In patients with bilateral adrenal hyperplasia, spironolactone therapy reduces blood pressure and eliminates the requirement for potassium supplementation.
1476. In men with bilateral adrenal hyperplasia in whom spironolactone therapy causes painful gynecomastia, epleronone may be substituted for spironolactone.
1477. Paget's disease is a focal disorder of bone remodeling that leads to greatly accelerated rates of bone turnover, disruption of the normal architecture of bone, and sometimes to gross deformities of bone (enlargement of the skull, bowing of the femur or tibia).
1478. Osteomalacia usually presents with an elevation of alkaline phosphatase in association with hypocalcemia and hypophosphatemia.
1479. In patients with the empty sella syndrome, the pituitary gland is not usually damaged and pituitary function is usually normal.
1480. Fasting blood glucose levels, which are due primarily to excessive hepatic glucose production, are controlled mainly by the basal insulin dose.
1481. Patients on basal bolus insulin therapy often take 40% to 50% of their total daily dose as basal insulin (glargine) and 50% to 60% as meal boluses (lispro or aspart).
1482. Postmenopausal women with subclinical hyperthyroidism and an undetectable TSH have an increased risk of developing osteoporosis.
1483. Hypoglycemia unawareness, a dangerous sequela of long-standing insulin-treated diabetes mellitus, is an adaptive central nervous system response and is exacerbated by recurrent episodes of hypoglycemia.
1484. In patients with type 1 diabetes mellitus and hypoglycemic unawareness, insulin dose should be reduced and treatment goals relaxed.
1485. The classic triad of symptoms for pheochromocytoma consists of headaches, palpitation and diaphoresis.
1486. The sensitivity of fractionated plasma metanephrines for catecholamine-producing tumors is nearly 97%; however, the specificity is 85%.
1487. The first step in the evaluation of a thyroid nodule is measurement of serum TSH; if TSH is normal, the nodule is most likely nonfunctioning or “cold”; if TSH is low, the nodule is more likely to be hyperfunctioning or “hot.”
1488. Measurement of serum thyroglobulin is useful for following thyroid cancers in response to treatment, but a serum thyroglobulin level is not useful in distinguishing benign from malignant nodules.
1489. Very high levels of human chorionic gonadotropin (hCG) are sufficient to stimulate the thyroid gland to release excess thyroid hormone.
1490. Risk factors for osteoporosis in men include a BMI less than 18, a history of smoking or excessive alcohol consumption, family history of osteoporotic fractures, hypogonadism, history of corticosteroid use, vitamin D deficiency, and medications causing osteomalacia or hypogonadism.
1491. Hypogonadism increases the skeletal sensitivity to parathyroid hormone and decreases intestinal calcium absorption, predisposing to osteoporosis.
1492. The objectives in evaluating pituitary incidentalomas are to determine whether they are secreting pituitary hormones, causing deficiencies of pituitary hormones, and growing.
1493. Close observation of the tumor to detect growth and pituitary hormone deficiency is the treatment choice for clinically silent small adenomas.
1494. DEXA scanning has the best correlation of procedures for measuring bone loss with fracture risk, requires a short scanning time, and measures the bone mineral density of all areas of the skeleton with high accuracy and reproducibility and low exposure to radiation.
1495. Features of the euthyroid sick syndrome include a precipitous drop in serum total and free T3 levels, and a concomitant increase in reverse T3.
1496. The changes in thyroid hormone levels during an acute illness are likely adaptive, as a means of protecting the body from catabolic illness; thyroid hormone therapy in patients with euthyroid sick syndrome has not been shown to be beneficial.
1497. Hyperglycemia after cardiac surgery and during critical illness is a strong predictor of adverse outcomes, including infectious complications and death.
1498. Intravenous insulin infusion in hyperglycemic patients in the intensive care unit reduces mortality.
1499. Potential complications of Paget's disease of the bone include osteogenic sarcoma in affected bone, hypercalcemia, high-output congestive heart failure, deafness, and excessive bleeding during surgery as a result of hypervascular bone.
1500. Non-tumor causes of elevated prolactin levels are typically associated with levels less than 100 ng/dL (100 mg/L).
1501. • Psychotropic medications may raise serum prolactin levels modestly; patients with hyperprolactinemia and severe psychiatric illnesses requiring continued therapy with psychotropic agents can be treated with estrogen- and progesterone-containing oral contraceptives to restore normal menses and prevent bone loss
1502. Primary hypogonadism in a young male may be due to Klinefelter's syndrome; therefore, any young male with a high serum FSH level should have a karyotype study.
1503. The most sensitive screening test for primary aldosteronism is the plasma aldosterone-plasma renin activity ratio.
1504. Secondary causes of hypertension include primary aldosteronism, acromegaly, pheochromocytoma, and Cushing's syndrome.
1505. During a normal pregnancy, thyroid hormone production must be increased to provide thyroid hormone to the developing fetus; most women who are taking thyroid hormone replacement require a 30% to 50% increase in their thyroid hormone dose during their pregnancy.
1506. Risk factors for gestational diabetes mellitus include obesity, a family history of type 2 diabetes, and a history of gestational diabetes in previous pregnancies.
1507. The diagnosis of gestational diabetes mellitus requires any two of the following four values in a 3-h, 100-g oral glucose tolerance test: fasting equal or more than 95 mg/dL (5.27 mmol/L); 1-h equal or more than 180 mg/dL (9.99 mmol/L); 2-h equal or more than 55 mg/dL (3.05 mmol/L); 3-h equal or more than 140 mg/dL (7.77 mmol/L).
1508. Therapy for gestational diabetes mellitus consists of restricted diet, with insulin if glycemic target values are not achieved.
1509. In hypercalcemia secondary to production of parathyroid hormone-related peptide by a carcinoid, the serum parathyroid hormone level is suppressed.
1510. In patients with Graves' ophthalmopathy and blurry vision, the presence of an afferent pupillary defect (Marcus Gunn pupil) and greatly diminished unilateral visual acuity suggest optic nerve impingement by enlarged extraocular muscles.
1511. Parathyroidectomy causes rapid improvement in the bone mineral density in patients with osteoporosis associated with primary hyperparathyroidism.
1512. The use of antiresorptive agents is not recommended in osteoporosis secondary to primary hyperparathyroidism.
1513. Obese, insulin-resistant men generally have a reduced serum total testosterone concentration, primarily as a result of a low sex-hormone binding globulin concentration.
1514. Orthostatic hypotension is a common manifestation of diabetic autonomic neuropathy, reflecting loss of normal vasoconstrictor tone, with deranged compensation to upright posture.
1515. Fludrocortisone therapy expands the plasma volume, thereby raising blood pressure and improving symptoms in diabetic autonomic neuropathy.
1516. After biochemical confirmation of primary aldosteronism, localization procedures differentiate aldosterone-producing adenomas from bilateral adrenal hyperplasia; aldosteronism-producing adenomas are amenable to laparoscopic resection, whereas bilateral adrenal hyperplasia is medically treated.
1517. Radiographic imaging rarely differentiates aldosterone-producing adenomas from bilateral adrenal hyperplasia in patients with primary aldosteronism.
1518. Intestinal calcium absorption is reduced and osteoclastic activity is increased in hyperthyroidism, and the high levels of free T4 and free T3 likely produce hypercalcemia through excessive osteoclastic activity.
1519. Hypercalcemia associated with thyrotoxicosis usually resolves when the patient becomes euthyroid.
1520. Exogenous testosterone suppresses sperm production, resulting in infertility.
1521. Treatment with exogenous testosterone at normal doses does not normally cause permanent infertility, but restoration of sperm production requires gonadotropins.
1522. Silent thyroiditis is an autoimmune disorder characterized by high levels of antithyroid peroxidase antibodies, painless enlargement of the thyroid gland, and a triphasic course with early thyrotoxicosis followed by hypothyroidism and then a return to euthyroidism in most patients.
1523. Most patients with interferon alfa–associated thyroid dysfunction recover after the drug is discontinued.
1524. Hypopituitarism is a frequent outcome of patients treated with irradiation of the thyroid gland.
1525. In a patient with hypopituitarism, documentation and therapy of adrenal insufficiency takes priority over other anterior pituitary hormonal deficiencies.
1526. Infection is a common precipitant of myxedema coma, and pan-culture and empiric antibiotic therapy with broad-spectrum antibiotics is recommended for all affected patients.
1527. Signs of androgen excess (increased muscle mass, irritability, and pustular acne) with small testes and low serum testosterone and gonadotropins in a young male suggest androgenic anabolic steroid abuse.
1528. In patients with macroprolactinoma and normal visual fields, dopamine agonist therapy effectively reduces prolactin secretion and tumor size.
1529. ACE inhibitors reduce albuminuria and retard the progression of renal disease in diabetic patients with and without hypertension.
1530. Angiotensin II receptor blockers prevent progression of nephropathy in patients with type 2 diabetes and macroalbuminuria and hypertension.
1531. Breast enlargement in a young man occurs most commonly with drugs or substances or alterations in the androgen/estrogen ratio—either androgen deficiency or estrogen excess
1532. High concentrations of hCG in a man suggest the diagnosis of choriocarcinoma, an aggressive germ cell tumor.
1533. The measurement of insulin-like growth factor 1 is more sensitive than serum growth hormone measurements for acromegaly in patients with a high pretest probability for acromegaly.
1534. Corticosteroid therapy results in a decrease in intestinal calcium absorption and an increase in urinary calcium excretion; secondary hyperparathyroidism occurs.
1535. The prevention and treatment of corticosteroid-induced osteoporosis includes calcium and vitamin D supplementation, a DEXA scan at the initiation of therapy, and bisphosphonates in patients taking prednisone equal or more than 5 mg/d (or its equivalent) for more than 3 months.
1536. As many as 3% of patients with poorly controlled diabetes mellitus (hemoglobin A1c more than 8.0%) have Cushing's syndrome.
1537. The treatment of choice for a nonfunctioning pituitary adenoma is transsphenoidal tumor resection.
1538. Benign adrenal adenomas are homogenous and have smooth borders and attenuation values of less than 10 Hounsfield units on unenhanced CT.
1539. The classic presentation of thyroid lymphoma is an elderly woman with autoimmune thyroiditis and a rapidly expanding thyroid mass.
1540. Latent autoimmune diabetes of adulthood (LADA) occurs in lean patients with initially apparent type 2 diabetes who become insulin-dependent later in life and exhibit the labile glycemic tendencies and many of the autoimmune markers of patients with type 1 diabetes.
1541. Latent autoimmune diabetes of adulthood (LADA) is characterized by slowly progressive loss of beta-cell function, leading to severe insulin deficiency and labile glycemic control.
1542. Patients with latent autoimmune diabetes of adulthood (LADA) become refractory to oral agents and as insulin-dependent and ketosis-prone as patients with type 1 diabetes.
1543. Pericardial effusion is a consequence of moderate to severe hypothyroidism and is indicated by diminished heart sounds, low voltage on electrocardiography, and an enlarged cardiac silhouette.
1544. The “hypothyroid heart” refers to decreased contractility and pulse rate—both contributing to a decreased cardiac output at a time when peripheral vascular resistance is increased.
1545. In a patient with acromegaly based on elevated serum insulin-like growth factor 1 and growth hormone levels, MRI of the head is indicated to identify and characterize the causative pituitary tumor.
1546. Multiple endocrine neoplasia type 1 is characterized by pituitary tumors, pancreatic islet tumors, and hyperparathyroidism due to parathyroid hyperplasia.
1547. Familial hyperparathyroidism, which is almost always due to parathyroid hyperplasia, is treated with subtotal parathyroidectomy in which 3½ parathyroid glands are removed.
1548. Chemotherapy with alkylating agents often induces irreversible damage to sperm production in young men.
1549. Subacute thyroiditis is characterized by a prodrome of arthralgias, malaise, and anorexia followed by pain in the thyroid bed and thyrotoxicosis.
1550. Teriparatide (recombinant human parathyroid hormone [1-34]) stimulates osteoblastic bone formation; it significantly increases bone mass in patients with osteoporosis and can decrease the incidence of both vertebral and nonvertebral fractures.
1551. Kallman's syndrome is X-linked hypothalamic hypogonadism accompanied by anosmia.
1552. In patients with diabetes and severely impaired beta-cell secretory capacity, basal insulin is effective on fasting glucose but cannot adequately control post-prandial glucose.
1553. The overall goal of therapy for acromegaly is normalization of the serum growth hormone and insulin-like growth factor 1 levels.
1554. An increased dose requirement for levothyroxine may occur as due to malabsorption (for example, celiac disease), accelerated metabolism, or an increased occupancy of binding proteins
1555. Most adrenal nodules are hormonally silent and have no malignant potential.
1556. Patients with an incidentally detected adrenal mass should be screened for pheochromocytoma, Cushing's syndrome, and primary aldosteronism.
1557. In a patient with normal ovulation but autoimmune disease and repeated fetal loss, evaluation for a hypercoagulable state is indicated.
1558. In patients with concomitant autoimmune adrenal and thyroid failure (Schmidt's syndrome), adrenal failure is often unrecognized initially; as thyroxine deficiency is corrected, the patient develops clinical adrenal insufficiency, requiring glucocorticoid supplementation.
1559. Testosterone therapy does not cause prostate cancer but can stimulate the growth of occult tumors.
1560. In patients beginning testosterone therapy, a rectal examination of the prostate gland before the first dose and the serum prostate-specific antigen should be measured at 3, 6, and 12 months after the start of therapy.
1561. Vitamin D deficiency must be corrected before starting other active osteoporosis therapy because the response to the therapy will be impaired by the defective mineralization associated with vitamin D deficiency and osteomalacia.
1562. Prediabetes glycemic states consist of impaired glucose tolerance, defined as a 2-hour glucose level of 140-199 mg/dL (7.77-11.04 mmol/L) during an oral glucose tolerance test, and impaired fasting glucose, defined as a fasting glucose level of 100-125 mg/dL (5.55-6.94 mmol/L).
1563. Narcotics suppress gonadotropins and testosterone production.
1564. The major storage form of vitamin D in the body is 25-dihydroxyvitamin D, and therefore this is the best test to assess for vitamin D deficiency.
1565. In a short young woman with primary amenorrhea, even in the absence of associated stigmata and comorbidities, Turner's syndrome (or mosaic) is the most likely diagnosis.
1566. High-risk patients with obesity and metabolic syndrome can most effectively reduce their risk of developing type 2 diabetes with a conscientious lifestyle modification program consisting of diet, exercise, and weight loss.
1567. The two causes of central hyperthyroidism are a TSH-producing adenoma and the resistance to thyroid hormone syndrome.
1568. The two causes of central hyperthyroidism, TSH-producing adenoma and the resistance to thyroid hormone syndrome, can be distinguished by measuring TSH α subunit.
1569. Testosterone stimulates production of erythropoietin, and the hematocrit and erythrocyte indices rise significantly during testosterone replacement therapy.
1570. The somatostatin analogue, octreotide, reduces growth hormone production and shrinks tumor in patients with acromegaly and is first-line therapy for patients not cured by surgery alone or surgery combined with radiation
1571. The humoral mediator of hypercalcemia of malignancy in most cases, especially in lung cancer, is parathyroid hormone–related peptide (PTHrp), which is secreted by the tumor.
1572. In gonadotropinoma, the gonadotropins are often detected on immunostaining of the surgical specimen but are rarely secreted into the bloodstream in meaningful amounts.
Pulmonology and critical care
1573. In a patient taking high-dose inhaled corticosteroids as part of therapy for persistent asthma whose disease is stable, reducing the dose of corticosteroids should be considered to prevent therapy-related side effects.
1574. High-resolution computed tomographic scanning (HRCT) is more sensitive than plain chest radiography for detecting interstitial lung disease and more specific for the potential diagnoses.
1575. In hepatic hydrothorax, underlying cirrhosis results in usually right-sided pleural effusion that is transudative as a result of hypoalbuminemia and reduced serum oncotic pressure.
1576. In patients with severe sepsis from nosocomial pneumonia, the ventilator should be adjusted by using a “protective lung strategy” with 6 mL/kg of ideal body weight and a plateau pressure less than 30 cm H2O.
1577. Low-dose dopamine has been shown to be of no benefit in critically ill patients with early renal dysfunction.
1578. Intermittent pneumatic compression is effective prophylaxis in patients at moderate to high risk for venous thrombosis in whom heparin and low-molecular-weight heparin are contraindicated.
1579. Inadequate amount of sleep is the most common cause of daytime somnolence in young adults; improved sleep hygiene and increased amount of sleep are the initial management.
1580. Noninvasive positive pressure ventilation in selected patients with moderate respiratory distress has been shown to improve heart and respiration rates, gas exchange; and to reduce morbidity and mortality rates, the need for intubation, and the length of hospital stay.
1581. Contraindications to noninvasive positive pressure ventilation in patients with moderate respiratory distress include excessive secretions, uncooperativeness, and acute ischemic changes on electrocardiography.
1582. The diagnosis of rhabdomyolysis is based on clinical findings and a history of a predisposing factor(s) and confirmed by the presence of myoglobinuria, an increased serum creatine kinase, and hyperkalemia.
1583. Early aggressive fluid therapy is essential in rhabdomyolysis to counteract fluid loss from sequestration into damaged muscle and to increase renal perfusion.
1584. The diagnostic yield of current imaging and biopsy methods in very small incidentally detected pulmonary lesions is very small.
1585. Incidentally detected very small pulmonary lesions should be monitored periodically to detect signs of growth compatible with lung cancer.
1586. The clinical presentation of hypersensitivity pneumonitis is typically recurrent acute episodes of fever, cough, and dyspnea that begin 4 to 6 hours after antigen exposure and resolve spontaneously 24 to 48 hours after antigen avoidance.
1587. Reversible airflow obstruction is a nonspecific finding that can occur with asthma, postinfectious bronchial hyperreactivity, endotoxin inhalation, or hypersensitivity pneumonitis
1588. In patients with persistent asthma not adequately controlled with daily low- or moderate-dose inhaled corticosteroids, adding a long-acting β-agonist improves asthma control and quality of life.
1589. In idiopathic pulmonary fibrosis, a characteristic HRCT pattern is seen in approximately 50% of patients and the extent of disease on HRCT is a predictor of survival.
1590. Patients with severe sepsis and refractory shock despite adequate fluid resuscitation should be treated with replacement-dose corticosteroids.
1591. High-dose corticosteroid therapy is ineffective and may be harmful in patients with severe septic shock and relative adrenal insufficiency.
1592. Pleural effusion in tuberculosis is usually associated with a lymphocytic pleocytosis.
1593. Tuberculous pleural effusion most often develops from a cell-mediated immune response to tuberculosis antigens.
1594. In patients with potentially operable non-small-cell lung cancer, pulmonary function tests are indicated to assess pulmonary reserve.
1595. Brain scan and bone scan are needed in patients with potentially operable non-small-cell lung cancer.
1596. Unfractionated and low-molecular-weight heparins reduce the risk of clinically important venous thromboembolism in critically ill patients by up to 60%.
1597. Aspirin has not been shown to reduce the incidence of thromboembolism in most populations at risk.
1598. In patients with cardiogenic pulmonary edema, continuous positive airway pressure (CPAP) and noninvasive positive pressure ventilation (NPPV) more rapidly improve dyspnea, vital signs and gas exchange, and avoid intubation more effectively than oxygen supplementation plus standard therapy.
1599. The standard of practice to determine the optimal continuous positive airway pressure level to manage obstructive sleep apnea is an attended laboratory polysomnography with CPAP pressure titration.
1600. The goal of therapy for hypertensive crisis is not to decrease the blood pressure to normal levels but to prevent further end-organ damage; precipitous reduction of blood pressure increases the risk for cerebral, cardiac, and renal ischemia.
1601. In prospectively evaluation by HRCT, up to 60% of patients with rheumatoid arthritis have radiographic abnormalities consistent with interstitial lung disease.
1602. In drug-induced interstitial lung disease, there are not specific pathologic patterns that would provide a definitive diagnosis.
1603. In patients with vocal cord dysfunction, oxygen saturation is normal during an acute exacerbation; laryngoscopy during an exacerbation shows adduction of the vocal cords during inspiration.
1604. Treatment of hepatic hydrothorax is directed to management of cirrhosis and ascites with salt restriction and diuretic therapy.
1605. Symptoms of anaphylaxis include flushing, urticaria, conjunctival pruritus, bronchospasm, nausea, and vomiting which develop within 30 minutes to 1 hour after the offending antigen is injected or up to 2 hours after the antigen is ingested.
1606. Patients with moderate to severe anaphylaxis should be monitored for at least 12 hours for a possible late recurrence (biphasic anaphylaxis)
1607. Risk factors for noninvasive ventilatory failure include the acute respiratory distress syndrome (ARDS) or severe community-acquired pneumonia, PaO2/FiO2 ratio less than 146, and age greater than 40 years.
1608. The CAM-ICU, a clinical instrument for use in evaluating a patient in the intensive care unit for delirium, takes less than a minute and is recommended for all mechanically ventilated patients.
1609. Pregnant women with deep venous thromboembolism or pulmonary embolism are treated with either unfractionated heparin or a low-molecular-weight heparin during the pregnancy and for 6 weeks post partum.
1610. Silicosis with small nodules in the lungs on radiographs is not associated with symptoms or physiologic abnormalities, but continued exposure and development of progressive massive fibrosis causes disabling symptoms.
1611. Screening for lung cancer with chest radiography or sputum cytology does not lower lung cancer mortality in the screened population and is not indicated.
1612. The anti-Xa test is a sensitive marker for anticoagulant activity of low-molecular-weight heparins and fondaparinux.
1613. More than 90% of patients with sarcoidosis have pulmonary involvement that is manifest radiographically as hilar and mediastinal lymphadenopathy, with or without parenchymal disease.
1614. Treatment of sarcoidosis is generally reserved for those with disabling symptoms, evidence for progressive lung disease, extrapulmonary disease, or complications such as hypercalcemia.
1615. Patients with radiographic stage 1 sarcoidosis (hilar and/or mediastinal lymphadenopathy without infiltrates) and no systemic symptoms have spontaneous remission rates of 50% to 90%.
1616. Exposure to nerve agents causes a cholinergic crisis by inhibiting cholinesterase and causing muscarinic, nicotinic, and central nervous system effects.
1617. Pralidoxime (2-PAM) reactivates acetylcholinesterase, and can reverse the muscle weakness, paralysis, and respiratory depression caused by exposure to nerve agents.
1618. Predictors of failure of noninvasive ventilation in patients with an exacerbation of COPD include a respiration rate more than 35/min, APACHE score more than 29, pH less than 7.25, and Glasgow coma score less than 11.
1619. Patients with predominant supine-dependent sleep apnea can be managed initially with a trial of restricting sleep to lateral recumbency.
1620. The advanced cardiac life support guidelines state that a single dose of vasopressin can be administered as a one-time alternative to epinephrine in patients with ventricular fibrillation or pulseless ventricular tachycardia.
1621. In patients with ventricular fibrillation or pulseless ventricular tachycardia, the guidelines for advanced cardiac life support recommend the following sequence of interventions: defibrillation, COTE [cardiopulmonary resuscitation, oxygen, tubes (endotracheal and intravenous), epinephrine (or vasopressin)], and more defibrillation.
1622. D-dimer reflects the presence of thrombosis (or inflammation), but does not reflect the activity of thrombosis.
1623. Hypocapnia is the cause of central sleep apnea in patients with Cheyne-Stokes respiration.
1624. A short course of oral corticosteroids may help restore asthma control in previously well-controlled patients who have developed unstable disease as a result of a respiratory tract infection
1625. Daily hemodialysis has been shown to significantly reduce in-hospital deaths in patients with acute renal failure in surgical and medical intensive care units.
1626. Inhaled corticosteroids with as-needed albuterol is the cornerstone of therapy for persistent asthma.
1627. In a patient with severe COPD and respiratory failure with severe carbon dioxide retention, inappropriately high rate and tidal volume of mechanical ventilation can cause 1) excessively rapid reduction in PaCO2 potentially causing severe alkalemia and 2) the induction of dynamic hyperinflation leading to a severe elevation of intrinsic positive end-expiratory pressure (auto-PEEP).
1628. Helical CT scanning without contrast enhancement is not sensitive for diagnosing pulmonary embolism.
1629. In a patient presenting with likely advanced metastatic lung cancer, a biopsy of an accessible site should be done to confirm the diagnosis of metastatic disease with a minimum of discomfort, risk, and expense.
1630. Lung disease is the most common cause of morbidity and mortality in systemic sclerosis.
1631. In scleroderma, both interstitial lung disease and pulmonary hypertension can develop (both independently or together) and have an adverse effect on outcome.
1632. Pulmonary disease can be the initial clinical manifestation of scleroderma.
1633. In a patient with potential smoke inhalation injury, the presence of facial burns, soot in the mouth, carbonaceous sputum, or singed nasal hairs may correlate with upper airway injury and a high risk of delayed airway compromise from edema.
1634. Approximately one fifth of adult patients with cystic fibrosis develop pneumothorax at some time in their lives.
1635. Tube thoracostomy is the preferred treatment for secondary pneumothorax.
1636. Patients with cystic fibrosis have a high rate of recurrent pneumothorax; therefore, parietal pleurectomy, pleural abrasion, and thoracoscopy with talc pleurodesis are reasonable interventions after initial management of the pneumothorax with tube thoracostomy.
1637. Placement of a pulmonary artery catheter in critically ill ICU patients has not been shown to have a benefit on mortality or other outcomes.
1638. The diagnosis of the acute respiratory distress syndrome (ARDS) requires a PaO2/FiO2 less than 200 in combination with bilateral infiltrates and the absence of other evidence for congestive heart failure.
1639. The “lung protective strategy” for intubation in patients with ARDS consists of the tidal volume at 6 mL/kg ideal body weight and plateau pressure kept less than 30 cm H2O.
1640. Nocturnal pulse oximetry can document nocturnal hypoxemia causing pulmonary hypertension in patients with obstructive lung disease.
1641. Intravenous heparin has immediate onset of action and has a half-life of under an hour after discontinuation.
1642. Low-molecular-weight heparins and fondaparinux have onset of action within about a half hour of subcutaneous administration, and the effect lasts throughout much of the subsequent day.
1643. The characteristic features of allergic bronchopulmonary aspergillosis include moderate to severe persistent asthma, bronchiectasis and chest radiographic abnormalities, elevated serum IgE, eosinophilia, and a positive skin test to Aspergillus fumigatus.
1644. The pathologic pattern nonspecific interstitial pneumonitis (NSIP) can occur in various clinical disorders, including infections, drug reactions, hypersensitivity pneumonitis, and connective tissue diseases.
1645. Patients in the intensive care unit generally require 25 to 30 nonprotein kcal/kg/d and 1.0 to 1.5 protein kcal/kg/d to meet the energy expenditures associated with critical illness
1646. In patients with advanced neuromuscular disease, inspiratory capacity is too small for an adequate cough, and cough assistance may be required in such patients with upper respiratory tract infection.
1647. Clinical findings of cocaine toxicity include tachycardia, hypertension, hyperthermia, mydriasis, agitation, and psychosis.
1648. Hypertension in cocaine toxicity usually responds to control of agitation.
1649. The Churg-Strauss syndrome is a small-vessel vasculitis typically associated with significant eosinophilia, pulmonary infiltrates in the setting of asthma, the use of a leukotriene receptor antagonist, and withdrawing oral corticosteroids.
1650. Extubation to noninvasive ventilation has been shown to improve outcomes in carefully selected intubated COPD patients who fail spontaneous breathing trials.
1651. Exercise-induced asthma is confirmed by exercise challenge (to more than 85% of maximal predicted heart rate) with post-exercise spirometry showing a 20% fall in FEV1.
1652. Treatment with short-acting inhaled β-agonists 5 to 10 minutes before exercise prevents exercise-induced asthma in >80% of patients.
1653. Metabolic signs of salicylate toxicity include respiratory alkalosis, anion gap metabolic acidosis, and hyperthermia; other signs and symptoms include depressed level of consciousness, noncardiogenic pulmonary edema, prolonged prothrombin time, hepatic toxicity, and hypoglycemia.
1654. Management of salicylate toxicity includes alkalinization of urine to enhance excretion of salicylates and hemodialysis for severe toxicity.
1655. Enoxaparin is cleared by the kidney, and if used in patients with chronic kidney disease, therapeutic drug monitoring is required for possible dosage adjustment.
1656. Malignant pleural effusions are typically lymphocytic and are usually exudative.
1657. Pleural fluid erythrocyte counts more than 100,000/μL (100 × 109/L), when not associated with trauma or pulmonary infarction, are suggestive of pleural malignancy.
1658. In patients with neuromuscular disease and chronic hypoventilation, noninvasive mechanical ventilation is required to maintain ventilation during sleep.
1659. Metastasectomy is indicated in patients with multiple lung metastases who have a resectable primary tumor, a low likelihood of other metastases, and normal pulmonary function.
1660. No medical therapy has been shown to clearly alter the natural history of idiopathic pulmonary fibrosis.
1661. Lung transplantation has been shown to improve survival, quality of life, and functional status in patients with end-stage fibrotic lung disease.
1662. Administration of type A equine antitoxin within 12 hours of diagnosis of wound botulism may significant shorten the duration of mechanical ventilation.
1663. In a patient with acute severe asthma, prompt administration of aerosolized bronchodilators is indicated after systemic corticosteroid therapy is started.
1664. Approximately 80% of effusions associated with pulmonary emboli are exudative, usually small and unilateral, and tend not to be progressive or to persist beyond 7 days after formation.
1665. In most patients treated with heparin for pulmonary embolism, a substantial portion of their perfusion defects resolve within the first week.
1666. CT scanning to follow the resolution of pulmonary embolism is not well standardized.
1667. No specific therapy is indicated for asymptomatic bronchial hyperresponsiveness.
1668. The co-presence of focal areas of fat and calcium are virtually pathognomonic of hamartoma.
1669. Malignant lung lesions tend to have a doubling time of between 30 and 400 days; benign lesions double in less than 30 days or over very long periods of slow growth.
1670. Patients with anaerobic bacterial infection involving the pleural space usually have subacute presentations with weight loss and a history of alcoholism, unresponsiveness, possible aspiration, and poor oral hygiene.
1671. Fibrinolytic therapy may be considered in patients with empyema who are poor surgical candidates.
1672. Organizing pneumonia is a pathologic pattern of lung injury that can occur in various settings, including infections, connective tissue diseases, and as a complication of treatments, such as amiodarone or radiation therapy.
1673. Urinary Legionella pneumophila antigen test should be done in patients with suspected Legionella pneumonia.
1674. Early therapy with azithromycin plus ceftriaxone is considered adequate initial coverage for a severe community-acquired pneumonia.
1675. A history of orthopnea, abdominal paradox, and a decrease in forced vital capacity more than 25% when the patient goes from the upright to supine position are diagnostic of diaphragm paralysis.
1676. Patients with hypoventilation secondary to diaphragm paralysis should be treated with nocturnal noninvasive positive airway pressure to augment their ventilation during sleep.
1677. Clinical findings in hydrogen cyanide toxicity include coma, hypotension, cardiac irritability, and profound anion gap metabolic acidosis in the setting of adequate volume resuscitation and oxygen administration.
1678. The treatment for cyanide poisoning is intravenous sodium thiosulfate.
1679. In patients with severe sepsis, early goal-directed therapy within the first 6 hours to maintain a central venous oxygen saturation of more than 70% and to resolve lactic acidosis improves survival over more delayed resuscitation attempts.
1680. Acute mountain sickness is characterized by poor sleep, anorexia, fatigue, nausea, and vomiting.
1681. Acetazolamide taken for 2 days before ascent to high altitude is effective prophylaxis for acute mountain sickness.
1682. Diffuse alveolar hemorrhage is characterized by dyspnea and diffuse alveolar infiltrates; it can be the initial manifestation of primary or secondary pulmonary vasculitis, drug reactions, coagulation disorders, and infection.
1683. The diagnosis of diffuse alveolar hemorrhage is made with bronchoalveolar lavage, with serial samplings showing a persistently bloody fluid.
1684. Malignant hyperthermia is a life-threatening inherited skeletal muscle disorder characterized by a hypermetabolic state precipitated by exposure to volatile inhalational anesthetics and depolarizing muscle relaxants.
1685. Heparin, low-molecular-weight heparins, and fondaparinux all catalyze antithrombin to neutralize clotting enzymes, and these drugs can be assayed by incubation of the patient's plasma with activated factor Xa.
1686. The reactive airway dysfunction syndrome follows a single, accidental inhalation of high levels of a nonspecific respiratory irritant in patients who typically do not have a history of asthma.
1687. The diagnosis of the reactive airways dysfunction syndrome is based on history and confirmed by positive methacholine challenge.
1688. The most common causes of chylothorax are cancer and trauma; other causes are pulmonary tuberculosis, chronic mediastinal infections, sarcoidosis, lymphangioleiomyomatosis, and radiation fibrosis.
1689. In a competent, severely ill patient in the ICU with a treatable condition but a clearly expressed preference for comfort measures rather than more aggressive intervention, comfort measures to provide good end-of-life care should be provided
1690. Although a fixed therapeutic dose of subcutaneous heparin may be appropriate for treatment of deep venous thrombosis and pulmonary embolism, aPTT monitoring and dose adjustment are required for patients at high risk of bleeding.
1691. Renal ultrasound with renal artery Doppler examination provides anatomic and functional assessment of the renal arteries, and has a sensitivity of 72% to 92% for renovascular hypertension.
1692. Idiopathic pulmonary fibrosis (IPF) is the most common of the idiopathic interstitial pneumonias, and by far more common than other members of the group.
1693. Sarcoidosis, the most common interstitial lung disease, is a systemic disorder and its radiographic presentation is generally dominated by mediastinal and hilar adenopathy with or without parenchymal changes.
1694. For ventilator-associated pneumonia manifesting clinical resolution of symptoms and signs of infection, radiologic improvement, and requirement for less ventilatory support with improving oxygenation, courses of no more than 8 days of antibiotic therapy are associated with as good outcomes as longer courses.
1695. Activated protein C has anticoagulant properties, and evidence of active bleeding is a contraindication to its use in patients with sepsis.
1696. Patients with COPD may experience a fall in PaO2 of as much as 25 to 30 mm Hg during air travel, and pre-flight assessment is useful to determine the need for in-flight oxygen supplementation with the goal of maintaining PaO2 either at equal or more than 50 mm Hg or, in high risk patients, at the PaO2 with which the patient is clinically stable at sea level.
1697. The neuroleptic malignant syndrome is a rare, but potentially fatal, complication of the administration of neuroleptic (antipsychotic) drugs such as haloperidol.
1698. Acute hypoxemia and systemic hypotension in combination with an increase in peak airway pressure and asymmetric chest wall expansion are cardinal features of an acute tension pneumothorax
1699. In patients taking theophylline as part of asthma therapy, concomitant ciprofloxacin therapy can decrease theophylline clearance in the liver, increasing theophylline blood levels and leading to potential theophylline toxicity.
1700. Theophylline clearance is decreased by various drugs as well as in the elderly and patients with congestive heart failure.
1701. Insertion of an inferior vena cava filter reduces the short-term incidence of pulmonary embolism in patients being anticoagulated for deep venous thrombosis.
1702. Lung transplant-related bronchiolitis obliterans, which is probably a form of chronic rejection, occurs in up to 50% of long-term survivors of transplantation.
1703. The typical findings of lung transplant-related bronchiolitis obliterans include cough, dyspnea, early inspiratory crackles, and severe airflow obstruction.
1704. Obstructive sleep apnea can exacerbate nocturnal asthma; CPAP therapy for sleep apnea can improve asthma control.
1705. Prompt intubation is indicated in patients with severe pneumonia whose condition is deteriorating on conventional therapy.
1706. Intubation rates are high in non-COPD patients with severe community-acquired pneumonia treated with noninvasive ventilation.
1707. Hyperglycemia should be treated in critically ill patients with aggressive insulin therapy to maintain tight glycemic control.
1708. Intermittent bolus dosing of sedatives titrated via a validated sedation scale is consistent with the guidelines for the use of sedation in critically ill patients.
1709. Antipsychotic agents may cause torsades de pointes in patients with prolonged QTc intervals.
1710. Patients with evidence of a physiologically severe and progressive fibrosing lung disease should be referred early for evaluation for lung transplantation.
1711. In patients with acute lung injury/ARDS on mechanical ventilation with a lung protective strategy, PEEP should be increased in 2- to 3-cm H2O increments to lower FiO2 to 60%, if possible, and to maintain an arterial oxygen saturation of ≥88% and ≤ 95%
1712. Vocal cord dysfunction mimics asthma, but unlike asthma, it begins and ends abruptly, does not respond to β-agonists, and airflow limitation is mainly during inspiration.
1713. The ultrasound may be abnormal for several months after a deep venous thrombosis, and the venous wall does not return to normal compressibility at all in some patients.
1714. The most common form of delirium in the ICU is hypoactive or “quiet” delirium.
1715. Delirium is a form of acute brain dysfunction that occurs in 50% to 80% of ventilated patients in the intensive care unit; it is associated with higher mortality rates, longer hospital and ICU stay, higher costs, and chronic cognitive deficits.
1716. The cardinal features of delirium are 1) acute onset or fluctuations in mental status over a 24 hour period, 2) inattention, 3) disorganization of thinking, and 4) an altered level of consciousness at the time of the evaluation.
1717. Patients with potential healthcare-acquired pneumonia (HCAP) require initial coverage for resistant organisms including methicillin-resistant Staphylococcus aureus and Pseudomonas.
1718. Segmental perfusion defects in patients with right heart failure and right ventricular hypertrophy strongly suggests the diagnosis of chronic thromboembolic pulmonary hypertension (CTEPH).
1719. Surgical pulmonary thromboendarterectomy can improve cardiac output, reduce mortality, and enhance quality of life in patients with thromboembolic pulmonary hypertension (CTEPH)
1720. Crytogenic organizing pneumonia is an idiopathic interstitial pneumonia that clinically resembles a flulike syndrome, and is characterized by crackles and patchy persistent infiltrates on chest radiograph, and restrictive lung defect with decrease in carbon monoxide diffusing capacity.
1721. Inability to protect the airway because of impaired swallowing or cough function is a contraindication to the use noninvasive positive pressure ventilation.
1722. In a neuromuscular disease patient who cannot manage airway secretions, severe restriction with a vital capacity of less than 15-20 mL/kg is an indicator of the need for intubation.
1723. No drug is FDA-approved for the treatment of delirium, but clinical practice guidelines recommend antipsychotic agents, such as haloperidol.
1724. All antipsychotics, and especially “typical” agents, pose a risk of torsades de pointes and extrapyramidal side-effects as well as the more rare neuroleptic malignant syndrome.
1725. Patient education and encouragement in the use of CPAP and management of associated adverse effects improves compliance with CPAP in severe sleep apnea.
1726. A highly elevated peak pulmonary artery pressure is consistent with pulmonary hypertension, but not necessary to confirm the diagnosis and may be inaccurate for evaluating severity.
1727. In patients in status asthmaticus, pulse oximetry is a good monitoring tool but is not a substitute for determining actual oxygenation by measuring arterial blood gases.
1728. The characteristic clinical features of interstitial lung disease are progressive dyspnea, diffuse radiographic pulmonary infiltrates, restrictive pulmonary physiology, and oxygen desaturation with exertion.
1729. In the correct clinical setting, bronchoscopy with bronchoalveolar lavage can provide a specific diagnosis in interstitial lung disease.
1730. Epoprostenol is first-line therapy for patients with severe pulmonary hypertension, and may be life-saving for patients in cor pulmonale.
1731. Bosentan causes pulmonary artery vasodilation and is associated with a reduction in mortality in patients with pulmonary artery hypertension
1732. Intubated patients should receive a tracheostomy as soon as it is deemed unlikely that they will wean from mechanical ventilation within 21 days.
1733. In patients with asthma who have increased nocturnal symptoms despite adequate daytime control, a trial of gastric acid suppression therapy is warranted.
1734. In selected immunosuppressed patients with respiratory failure, noninvasive positive pressure ventilation is associated with a lower mortality rate than conventional oxygen therapy and intubation.
1735. Hereditary hemorrhagic telangiectasia (HHT) is diagnosed clinically by the presence of three of the following four criteria: (1) recurrent epistaxis; (2) telangiectasias in the lips, oral cavity, fingers, or nose; (3) visceral lesions such as gastrointestinal telangiectasias, or arteriovenous malformations in the lung, liver, or brain; and (4) first-degree relatives with the syndrome.
1736. The propofol infusion syndrome in adults occurs primarily in patients with acute neurologic or acute inflammatory diseases complicated by severe infection or sepsis, and receiving catecholamines and/or corticosteroids in addition to propofol.
1737. The main features of the propofol infusion syndrome are cardiac failure, rhabdomyolysis, severe metabolic acidosis, and renal failure associated with hyperkalemia.
1738. Noninvasive positive pressure ventilation can reverse hypoventilation and alleviate cor pulmonale in patients with obesity hypoventilation syndrome.
1739. Methacholine challenge testing is most useful in evaluating patients with suspected asthma but who has episodic symptoms and normal baseline spirometry.
1740. The diagnosis of cough-variant asthma is suggested by the presence of airway hyperresponsiveness and confirmed when cough resolves with asthma therapy.
1741. A trial of inhaled albuterol can help control symptoms and confirm the diagnosis of cough-variant asthma.
1742. Poor technique in the use of a metered-dose inhaler (MDI) or other inhalation devices is a major reason patients do not respond well to medications.
1743. All patients with COPD who have intermittent symptoms should receive a short-acting bronchodilator.
1744. For patients with stage 3 COPD, especially those with frequent exacerbations, inhaled corticosteroids should be part of their regular therapy.
1745. In the staging of patients with dyspnea for therapy, the post-bronchodilator FEV1 is most relevant finding.
1746. A postbronchodilator FEV1/FVC ratio greater than 70% indicates stage 0 (at risk) chronic obstructive pulmonary disease.
1747. Chronic obstructive pulmonary disease is corticosteroid-insensitive, and inhaled corticosteroids do not change the rate of FEV1 decline in affected patients.
1748. In patients with COPD, cor pulmonale usually occurs in GOLD stage 3 or 4 in patients with an FEV1 equal or less than 1 L.
1749. In patients with end-stage chronic obstructive pulmonary disease, pulmonary rehabilitation improves symptoms, exercise endurance, and quality of life.
1750. Patients with GOLD stage 4 chronic obstructive pulmonary disease who have an acute exacerbation should be treated like patients with community-acquired pneumonia.
Last part of the notes, now it is COMPLETE !!
1751. Sleep apnea is associated with resistant hypertension and is particularly prevalent in obese patients.
1752. Hypertension associated with sleep apnea may be related to insulin resistance, increased activity of the sympathetic nervous system, and increased sodium retention.
1753. Referral to a nephrologist for education and evaluation for consideration of preemptive kidney transplantation is indicated for patients with chronic kidney disease when the glomerular filtration rate reaches the 30 mL/min range
1754. Minimal change disease is the most common cause of the nephrotic syndrome in children and young adults.
1755. The presence of numerous oval fat bodies on urinalysis is a hallmark of a proteinuric state.
1756. Decreased thresholds for arginine vasopressin in normal pregnancy cause relatively lower sodium levels.
1757. Increased vasodilation in pregnancy is associated with a decreased blood pressure measurement and an increased heart rate.
1758. In normal pregnancy, increases in the glomerular filtration rate and renal blood flow result in decreased creatinine and blood urea nitrogen levels.
1759. The sudden development of hyperkalemia in a patient on dialysis may be a sign of tissue necrosis.
1760. Abdominal pain, hematochezia, and lactic acidosis are suggestive of bowel infarction.
1761. Henoch–Schönlein purpura is a renal–dermal vasculitis syndrome that may present with intermittent episodes of mild abdominal pain.
1762. Patients with chronic kidney disease have increased risk for acute renal failure because of their use of osmotic agents such as dextran 40, mannitol, and sucrose-containing preparations of intravenous immune globulin.
1763. Reduction in blood pressure has been shown to influence the progression of renal disease and the development of cardiovascular disease in patients with diabetes.
1764. Dialysis should be considered early in the course of tumor lysis syndrome in patients with oliguric acute renal failure.
1765. Measurement of urine microalbumin is the screening test of choice for diabetic nephropathy.
1766. A 24-hour urine collection is no longer recommended to assess kidney function or quantify proteinuria.
1767. Combination therapy with angiotensin-converting enzyme inhibitors and angiotensin receptor blockers may be more renoprotective than single-agent therapy with either drug in patients with diabetic nephropathy.
1768. An anti–glomerular basement membrane antibody assay is indicated to diagnose Goodpasture's syndrome.
1769. In selected patients, ambulatory blood pressure monitoring should be used to diagnose white coat hypertension.
1770. The syndrome of inappropriate antidiuretic hormone secretion (SIADH) is defined as hypotonic hyponatremia with a urine osmolality more than 100 mosm/kg H2O in the absence of volume depletion, adrenal insufficiency, congestive heart failure, hypothyroidism, cirrhosis, and/or renal impairment.
1771. The classical triad of acute interstitial nephritis (fever, skin rash, and arthralgias) in the setting of acute or subacute renal failure is present in only a minority of affected patients.
1772. The presence of a slowly progressive nephrotic syndrome suggests the possibility of solid tumor–associated membranous nephropathy
1773. Nonsteroidal anti-inflammatory drugs can cause acute interstitial nephritis as well as prerenal acute renal failure through changes in local glomerular hemodynamics.
1774. Abdominal CT or ultrasonography are the recommended imaging modalities for uric acid stones.
1775. Patients with progressive chronic kidney disease should be referred for creation of a permanent vascular dialysis access when the glomerular filtration rate decreases below 30 mL/min.
1776. Blood pressure measurements in elderly patients who tolerate medication poorly may be higher in the office than at home.
1777. In selected patients, ambulatory blood pressure monitoring can exclude white coat hypertension.
1778. Ambulatory blood pressure monitoring can detect symptoms that may be related to excessive reduction of blood pressure.
1779. Elevated blood pressure in early pregnancy is most likely caused by a chronic condition.
1780. Glomerulonephritis, not preeclampsia, is the most likely diagnosis in patients with elevated creatinine levels and proteinuria early in pregnancy.
1781. Patients with membranous nephropathy are at increased risk for renal vein thrombosis.
1782. CT, MRI, or venography is indicated to definitively diagnose renal vein thrombosis.
1783. Hypertonic saline is not indicated for asymptomatic hyponatremia.
1784. Focal segmental glomerulosclerosis is the most common cause of the nephrotic syndrome in black patients, particularly those of younger age.
1785. Antiretroviral therapy and plasmapheresis are indicated for patients with HIV infection and thrombotic thrombocytopenic purpura.
1786. Listeria is a common cause of meningitis in renal transplant recipients.
1787. Increasing dietary calcium intake to 1 g/d to 4 g/d decreases the risk for recurrent calcium oxalate stones.
1788. High-protein and -sodium diets can worsen kidney stone disease by causing hypercalciuria and hyperuricosuria.
1789. A decrease in the bicarbonate level accompanied by an elevated anion gap is consistent with a primary metabolic acidosis.
1790. In a patient with a primary metabolic acidosis, a PCO2 that is much higher than would be expected based on the degree of acidemia indicates a condition that is secondary to inadequate ventilation.
1791. Compared with hemodialysis therapy, renal transplantation offers a survival advantage in patients with diabetic nephropathy and end-stage renal disease.
1792. Renal transplantation is most beneficial in young people and in patients with diabetes mellitus.
1793. Hyperaldosteronism should be considered in patients with difficult-to-control hypertension and hypokalemia in the absence of diuretic use.
1794. Hyperaldosteronism should be considered in patients with difficult-to-control hypertension even in the absence of hypokalemia.
1795. The aldosterone–renin ratio is a reasonable screening study for primary hyperaldosteronism.
1796. Rhabdomyolysis-associated acute renal failure presents with dipstick-positive hematuria but no intact erythrocytes on microscopic analysis of the urine sediment.
1797. Heparin therapy inhibits aldosterone synthesis and therefore may cause hyperkalemia.
1798. The development of the nephrotic syndrome in the setting of urinary reflux is most likely caused by focal segmental glomerulosclerosis.
1799. The fractional excretion of sodium may be more than 4% in patients with prerenal acute renal failure who use diuretics.
1800. Patients with the nephrotic syndrome are predisposed to develop deep venous and renal vein thrombosis.
1801. Staghorn calculi form as a result of chronic infections with urease-splitting organisms such as Proteus or Klebsiella.
1802. Stone removal in struvite stone disease often is indicated to prevent recurrence of infection and stone growth.
1803. Angiotensin-converting enzyme inhibitor therapy has been shown to prevent the development of microalbuminuria in patients who have diabetes and normoalbuminuria.
1804. Microalbuminuria is the first clinical sign of diabetic nephropathy and a major risk factor for the development of clinical proteinuria, chronic kidney disease progression, and cardiovascular death.
1805. The most common causes of primary hyperaldosteronism are aldosterone-producing adenoma (Conn's syndrome) and bilateral adrenal hyperplasia.
1806. Hypotonic fluids should not be used postoperatively.
1807. Normal saline (0.9%) is the most appropriate intravenous fluid when fluid therapy is indicated in the postoperative setting.
1808. Sjögren's syndrome is a common cause of interstitial nephritis.
1809. A collapsing form of focal segmental glomerulosclerosis is the most likely diagnosis in black patients with HIV infection who have the nephrotic syndrome.
1810. Postinfectious glomerulonephritis associated with hepatitis C typically presents with hematuria, proteinuria, and low C3 and C4 levels.
1811. Albumin infusions decrease the risk for acute renal failure in patients undergoing paracentesis with more than 5 L of volume removed and in patients with spontaneous bacterial peritonitis.
1812. Octogenarians with poor functional status are unlikely to experience improvement or benefit from dialysis.
1813. Increasing calcium intake decreases the risk for calcium oxalate stones because calcium binds to gastrointestinal sources of oxalate and therefore prevents absorption.
1814. Dietary modifications such as decreasing animal protein intake, decreasing sodium intake, and increasing citrate can reduce the risk for recurrent kidney stones without additional medical therapy.
1815. Clinical manifestations of autosomal dominant polycystic kidney disease include renal, hepatic, and pancreatic cysts; intracranial, thoracic, and abdominal aortic aneurysms; and colonic diverticulae.
1816. Certain manifestations of autosomal dominant polycystic kidney disease, such as intracranial aneurysms, tend to cluster in families.
1817. Patients with pheochromocytoma should receive an α-blocker 2 weeks before surgery.
1818. β-Blockade in the absence of α-blockade is contraindicated in patients with pheochromocytoma and may lead to hypertensive crisis.
1819. The combination of upper and/or lower respiratory tract disease and proteinase-3 antinuclear cytoplasmic antibody positivity at the time of diagnosis is associated with the highest likelihood of relapsing disease in antinuclear cytoplasmic antibody–associated small-vessel vasculitis.
1820. Hydrochlorothiazide can cause severe hyponatremia.
1821. Cryoglobulinemia is characterized by Raynaud's phenomenon, a purpuric rash, abnormal findings on liver function studies, and the presence of glomerulonephritis.
1822. Cryoglobulinemia typically decreases the C4 level, which indicates activation of the classical pathway of complement activation, more than the C3 level.
1823. Renal biopsy is indicated for patients with acute glomerulonephritis of unknown cause.
1824. Pulmonary hemorrhage associated with acute glomerulonephritis is associated with substantial morbidity and mortality.
1825. Atheroembolic disease can mimic vasculitis.
1826. The presence of livedo reticularis, Hollenhorst plaque, cyanotic toe, low C3 levels, and peripheral eosinophilia suggests a diagnosis of atheroembolic disease.
1827. Atheroembolic disease should be suspected in patients with erosive atherosclerosis presenting with acute renal failure.
1828. Asymptomatic hypercalcemia in a patient with a history of calcium stones warrants evaluation for primary hyperparathyroidism.
1829. Parathyroidectomy should be considered for patients with calcium-containing stones secondary to primary hyperparathyroidism.
1830. Alport's syndrome causes persistent microscopic hematuria, progressive nephritis with proteinuria, and progressive decline in renal function to end-stage renal disease.
1831. Alport's syndrome is an inherited condition that may present with high-frequency sensorineural hearing loss and/or ocular abnormalities.
1832. Isotonic saline is preferred over bicarbonate-containing solutions for resuscitation of patients with rhabdomyolysis.
1833. In the absence of renal failure or flash pulmonary edema, medical rather than invasive therapy is preferred for blood pressure control, even when renovascular hypertension is suspected.
1834. Solute diuresis secondary to a high urea load is a common cause of hypernatremia in the critical care setting.
1835. Simple cysts discovered on renal imaging studies require no therapy.
1836. Complex renal cysts on ultrasonography require follow-up imaging with CT or MRI.
1837. Kidney biopsy is contraindicated in patients with complex renal masses suspicious for malignancy.
1838. A paraprotein associated with systemic amyloidosis or multiple myeloma is a likely cause of the nephrotic syndrome in older patients.
1839. Angiotensin-converting enzyme inhibitor therapy is warranted in patients with stage III and stage IV chronic kidney disease unless the creatinine level rises >30% after initiation of therapy.
1840. Once-daily dosing of angiotensin-converting enzyme inhibitors can decrease the risk for hyperkalemia.
1841. Sarcoidosis may cause nephrolithiasis, nephrocalcinosis, and interstitial nephritis.
1842. Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers are the agents of choice for the treatment of hypertension in chronic kidney disease.
1843. An anion gap metabolic acidosis may be present in a patient with severe hypoalbuminemia and a “normal” anion gap.
1844. Renal ultrasonography can be normal early in the course of acute urinary tract obstruction.
1845. Urinary tract obstruction should be suspected in elderly men with acute renal failure.
1846. IgA glomerulonephritis is manifested by the nephritic syndrome and is associated with dysmorphic erythrocytes and erythrocyte casts.
1847. Diabetic ketoacidosis can lead to an anion gap metabolic acidosis and metabolic alkalosis simultaneously.
1848. Iatrogenic respiratory alkalosis may develop after initiation of mechanical ventilation.
1849. Antihypertensive agents such as diuretics and β-blockers have been associated with an increased risk for type 2 diabetes mellitus, whereas angiotensin-converting enzyme inhibitors and angiotensin receptor blockers may improve insulin sensitivity.
1850. Risk factors for contrast nephropathy include diabetic nephropathy, dehydration, heart failure, age more than 70 years, impaired kidney function, and concurrent use of nephrotoxic drugs and high-osmolar or high doses of radiocontrast medium.
1851. Prevention of contrast nephropathy in patients at increased risk for this condition involves discontinuing nephrotoxic drugs, using the lowest possible dose of low-osmolality contrast medium for the study, and administering intravenous therapy with 0.9% saline at 1 mL/kg/h for 24 hours beginning 12 hours before administration of contrast medium.
1852. Myeloma-related kidney disorders should be suspected in patients with anemia, a low serum anion gap, and renal failure.
1853. A low serum anion gap warrants evaluation for myeloma due to an increase in unmeasured cations such as calcium and immunoglobulins.
1854. Myeloma kidney is associated with a discrepancy in proteinuria detection between the dipstick urinalysis and a spot urine collection.
1855. Mathematical equations such as Cockcroft–Gault or Modification of Diet in Renal Disease are recommended for the assessment of glomerular filtration rate rather than 24-hour urine collections or radioimaging studies.
1856. Individuals with uncontrolled hypertension and recurrent episodes of flash pulmonary edema should be screened for renovascular disease.
1857. In patients with suspected renovascular disease and a glomerular filtration rate more than 60 mL/min, magnetic resonance angiography is the imaging study of choice to avoid the risk for contrast-induced acute renal failure.
1858. A low glomerular filtration rate is the main cause of phosphate retention and hyperphosphatemia in patients with chronic kidney disease.
1859. Diuretics are effective antihypertensive agents in elderly patients but may cause electrolyte abnormalities.
1860. The presentation of anion gap metabolic acidosis and respiratory alkalosis suggests salicylate toxicity.
1861. Immobilization in the exaggerated lithotomy position can result in rhabdomyolysis.
1862. An extremely elevated creatine kinase level and elevated urine myoglobin level suggest a diagnosis of pigment nephropathy.
1863. Combination therapy with an angiotensin-converting enzyme inhibitor and an angiotensin receptor blocker is associated with decreasing proteinuria in patients with nondiabetic renal disease.
1864. Thin basement membrane disease (benign familial hematuria) is characterized by glomerular hematuria with dysmorphic erythrocytes on microscopic analysis of the urine and no evidence of proteinuria.
1865. Patients with ethylene glycol poisoning presenting with both an increased anion and osmolar gap metabolic acidosis require dialysis in addition to either fomepizole or ethanol.
1866. Amyloidosis is a common cause of the nephrotic syndrome in nondiabetic patients >50 years of age.
1867. Phosphate binders may help to treat hyperphosphatemia in patients with chronic kidney disease.
1868. Black patients with kidney disease and hypertension have better renal outcomes after treatment with angiotensin-converting enzyme inhibitor therapy compared with amlodipine or β-blockers.
1869. In pregnancy, labetalol is preferable to pure β-blockers, which may be associated with low birthweight.
1870. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are contraindicated in pregnancy.
1871. A highly negative urine anion gap suggests that the kidney is appropriately excreting acid during metabolic acidosis.
1872. Alport's syndrome is associated with a glomerulonephritis with dysmorphic erythrocytes, mild proteinuria, and a high-frequency hearing loss.
1873. Wegener's granulomatosis is characterized by upper and lower airway disease, glomerulonephritis, and positive findings on a proteinase-3 antineutrophil cytoplasmic antibody assay.
1874. A disparity between the dipstick protein level and quantified urinary protein excretion, a low anion gap, and an increase in the globulin fraction of the total protein level suggests multiple myeloma.
1875. Microscopic polyangiitis is a nongranulomatous or small-vessel vasculitis occasionally accompanied by medium-sized vessel involvement that causes a pulmonary–renal syndrome.
1876. Renal transplant recipients who are Epstein–Barr virus–negative are at increased risk for post-transplant lymphoproliferative disorder, especially after receiving an organ from an Epstein–Barr virus–positive donor.
1877. One of the most important initial steps in the evaluation of microscopic hematuria is urine microscopy to assess erythrocyte morphology.
1878. Glomerular hematuria is associated with dysmorphic erythrocytes and erythrocyte casts on urinalysis.
1879. Obesity may lead to proteinuria and chronic kidney disease.
1880. Lowering blood pressure to appropriate targets is particularly important in patients with diabetes who have increased risk for cardiovascular and renal complications.
1881. Diuretics potentiate the blood pressure–lowering effects of angiotensin-converting enzyme inhibitors and β-blockers.
1882. Postinfectious glomerulonephritis may present 3 weeks after onset of the inciting infection and is associated with low C3 levels and normal C4 levels.
1883. Respiratory alkalosis commonly develops in end-stage liver disease.
1884. The refeeding syndrome is a potential complication in malnourished patients who suddenly receive a large calorie load.
1885. Rhabdomyolysis is a potentiallysevere complication of the refeeding syndrome.
1886. The antiphospholipid antibody syndrome is characterized by thrombosis in association with a lupus anticoagulant or persistently elevated levels of anticardiolipin antibodies.
1887. A peritoneal fluid cell count more than 100 total nucleated cells/µL is abnormal and consistent with the diagnosis of peritonitis.
1888. Antibiotic therapy covering both gram-negative and gram-positive pathogens should be started immediately in a patient with suspected peritoneal dialysis–related peritonitis.
1889. Acute tubular necrosis is the most common cause of acute renal failure after acetaminophen poisoning.
1890. Patients with chronic kidney disease should be educated to avoid venipuncture and intravenous catheters in veins above the level of the wrist in both arms to preserve veins for future creation of arteriovenous fistulas.
1891. Subclavian vein lines should be strictly avoided in patients with chronic kidney disease.
1892. Creation of an arteriovenous fistula is indicated months before initiation of dialysis.
1893. Patients more than 50 years of age with persistent hematuria should be evaluated for genitourinary tract malignancy.
1894. Nonsteroidal anti-inflammatory drug use is a common cause of resistance to antihypertensive therapy.
1895. Acetazolamide may cause non–anion gap metabolic acidosis.
1896. In addition to corticosteroids, the most appropriate treatment for lupus nephritis is intravenous cyclophosphamide followed by maintenance mycophenolate mofetil once remission is achieved.
1897. Infusion of normal saline before and after exposure to radiocontrast is the most effective method to decrease the risk for radiocontrast nephropathy.
1898. Calcific uremic arteriolopathy typically presents with painful violaceous nodules on the trunk, proximal extremities, and buttocks in patients with chronic kidney disease.
1899. Quantification of urinary protein in upright and recumbent positions to evaluate for orthostatic proteinuria is indicated for young adults with proteinuria and no other evidence of kidney disease.
1900. Acute glomerulonephritis is uncommon without hematuria and a bland urine sediment.
1901. Hospitalization and delivery are indicated for women with preeclampsia at term.
1902. The manifestations of the HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets) are features of severe preeclampsia.
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