Usmle Students Notes Triplehelix Notes

7/27/2019 Usmle Students Notes Triplehelix Notes

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مشار 0 إلكترون الم ونة اإللكترون ة التال ة»المز تسج ل ال خوإنشاء م ونة

Usmle Students Notes

Th ur sday , Apri l 23, 2009

triplehelix notes

Notes by triplehelix.

I did MKSAP 1 4 qu estions and made notes based on the key points,

and I plan to rev iew th is note before m y test. I thought to share th is

notes with y ou gu y s.

MKSAP 14 neur ology notes:

1 . A spinal cord disorder should be considered in an y patient w ith

bilateral motor and sensory dy sfunct ion in the extrem it ies in th e

absence of signs or sy mptoms of brain or brainstem dy sfun ction.

2. Spinal cord compression due to epidur al m etastasis is a neur ologic

emerg ency for wh ich u rg ent MRI of the entir e spine is appropriate.

3. Vertebral ar tery dissection ty pically presents with neck or h ead

pain, Horner's syndrome, dysarthria, dysphagia, decreased pain andtemperatu re sensation, dy smetria, ataxia, and v ertigo.

4. Magnetic r esonan ce ang iogr aphy is a sensitiv e diagn ostic test for

v ertebr al artery dissection as a ca use of str oke.

5. Ju v enile my oclonic epilepsy is a primar y , genetic, generalized

epilepsy that ty pically m anifests with m y oclonic jerks followed by a

generalized tonic–clonic seizure

6. Guillain–Barr é sy ndrome is char acterized by proxima l an d distal

weakn ess, autonomic sy mptoms, cr ania l nerv e inv olv em ent, and

respiratory failur e.

7 . Treatm ent of Guillain–Barré sy ndrom e with either intrav enous

imm unoglobulin or plasmapheresis is indicated in patients wh o

cannot walk independently or who have impaired respiratory

function or ra pidly progr essiv e weakn ess.

8. Sma ll, stable, asy mptomatic m eningiomas can be followed with

serial neur oima ging.



9. In larg e, sy m ptom atic, or progressiv e m eningioma s, surg ical

resection offers an 80% ch ance of cur e.

1 0. Personality chan ge, lost initiativ e, and slowing of though t, w ith

relat iv e preserv ation of recent m emory , suggest frontotemporal

dementia.

1 1 . Frontotempora l dementia is usua lly associated with

disproportionate atrophy of the anterior frontal and temporal lobes,a finding that is usually clearly demonstra ted on MRI.

1 2. Elevation of the cerebrospinal fluid 1 4-3-3 protein in a patient

with rapidly progr essiv e dem entia and norm al str uctural im aging

suggests Cr eutzfeldt–Jakob disease.

1 3 . Treat ment w ith in terferon-beta decreases the incidence of

additional a tta cks in patients with m onosy mptomatic

dem y elination, including optic neuritis and my elopathy .

1 4. Propra nolol and prim idone are first-line drug s in th e treatm ent

of essentia l tr emor (postura l an d action tremor).

1 5. The diagn osis of Par kinson's disease requires the presence of at

least two of the followin g: trem or at rest, brady kinesia, rigidity , and

postur al reflex abnorm ality .

1 6. The characteristics of migra ine headache without a ur a include

worsen in g of th e headach e w ith m ov em ent, limitation of act iv it ies,

and photo- and phonophobia

1 7 . Tran sv erse my elitis is an acu te or subacute demy elinativ e or

inflam matory disorder of the spinal cord that causes motor, sensory ,and au tonomic dy sfun ction below a spinal cord lev el.

18. High-dose intravenous corticosteroids are indicated for initial

treatm ent of acute transv erse my elitis.

19. Secondary prevention of cardioembolic stroke consists of

warfarin with a target INR of 2.0 to 3.0.

20. Hepar in has no established role in th e acut e treatment of stroke.

21 . Th e m anifestat ions of partia l seizur es depend on their

neur oana tomic location.

22 . Fronta l seizur es ar e brief and are usually not associated with

aura or postictal confusion.

23. Hereditary sensorimotor neuropathy is an autosomal dominant

disorder that usually presents with clumsiness or difficulty running

in t he first decade of life.

24. Hereditary sensorimotor neuropathy is characterized by distal

muscle atrophy , w eakness, an d sensory loss associated with high

arches (pes cav us) and ham mert oes



25. Cell ty pe and tum or gr ade are the most im portan t determin ants

of sur v iv al in gliom a.

26 . Higher-gra de glioma s are m ore ag gressiv e than lower gra de.

27 . A lzheimer's disease is char acterized by primar y dem entia with

prom inent am nesia.

28. Dem entia with Lewy bodies, cha racterized by fluctu ating

cognit ion, parkinsonism, and/or v isua l hallu cinat ions, often coexists with Alzheim er's disease.

29 . All patients with r elapsing mult iple sclerosis should be

considered for im m un omodulatory therapy with either a form of

interferon-beta or glatiramer acetate.

30. Adult-onset idiopathic dy stonia is usually focal or segm ental a nd

does not genera lize to other par ts of the body .

31. Botulinum toxin injections can correct the abnormal posture

and allev iate the pain associated with cerv ical dy stonia.

32 . Approxim ately 20% of patients with migr aine hav e headache

with aura, that is, neurologic problem s such as v isual h allucinations

or n um bness or t inglin g before or dur ing h eadache.

33 . Lherm itte's sign, an “electric shock”–like sensation down the

neck, back, or extr emities occur rin g with n eck flexion, is a helpful

historica l clu e to a cerv ical spinal cord disorder.

34 . Cerv ical spondy losis is a ch ronic disorder of degenerativ e and

hypertrophic changes of the vertebrae, ligaments, and disks that

ma y nar row th e spinal cana l and cause cerv ical spinal cordcompression.

35. In patients with stroke not eligible for th romboly tic therapy ,

aspirin m odestly reduces both the short-term risk of recur rent stroke

and the long-term risk of stroke-related death and disability .

36 . In patients with acute stroke, thromboly tic therapy mu st be

star ted within 3 hours of the onset of sy m ptom s or of the time the

patient w as last known to be well.

37 . Elderly patients may be particular ly sensitiv e to the cognitiv e,

motor, and coordination side effects of phenytoin, even if the serum

pheny toin lev el is in the therapeutic ra nge.

38. Gabapentin, lam otrigine, an d carbam azepine are equally

effectiv e at controlling par tial onset seizur es in th e elderly , but

gabapentin and lam otr igine are better tolerat ed.

39 . Peripheral nerv ous sy stem v asculitis usually presents with

asy mm etric w eakness and sensory loss in specific nerv e

distributions.



40. In an elderly patient with recurrent g lioblastoma and poor

perform ance status, r eferra l for hospice care is prefera ble to

additional a ntitum or t reatm ent.

41 . The three specific criteria for dementia with Lewy bodies ar e

fluctu ating encephalopathy , parkinsonism , an d v isual

hallucinations.

42 . A centrally acting anticholinesterase agent may allev iate theinattention, hallu cinations, and fluctu ating encephalopathy of

dem entia w ith Lewy bodies.

43 . Wom en taking imm unomodulatory treatm ent for m ultiple

sclerosis should use effectiv e contr aception, or if they wa nt to

become pr egnant, stop therapy sev eral m onths before attem pting to

conceive.

44 . Inv olunta ry brief, irregular , un predictable mov ements fleeting

from one body part t o another a re ha llm ar ks of chorea.

45. Chorea can occur as a hereditary and degenerativ e disease or

secondary to dru gs, m etabolic disorders, infections, im mun e-

mediated diseases, and vascular lesions.

46 . Tension-ty pe headache is disting uished from m igraine by the

fact that pat ients with tension headache ar e not disabled and can

carr y out activ ities of daily liv ing in a norma l, expedient m ann er.

47 . Vita min B1 2 deficiency can ca use dy sfunction of the posterior

colum ns and cort icospinal tracts of the spinal cord, ca using

paresthesias, loss of v ibra tion and position sense, sensory atax ia, weakn ess, and upper motor neuron signs.

48. Neurologic signs of v itam in B1 2 deficiency ma y m anifest in th e

absence of hema tologic signs of v itam in B1 2 deficiency .

49 . In a patient w ith a tran sient ischemic attack, car otid artery

ult rasonography showin g a > 50% stenosis of the intern al carotid

artery m ay be an indication for car otid endarterectomy .

50. A single antiepileptic dru g should be used in pregnant w om en

with epilepsy ; m ult iple dr ug th erapy incr eases the r isk for bir th

defects.

51 . Chronic inflamm atory demy elinating poly neuropathy , th e

chr onic form of Guillain–Barré sy ndrome, is character ized by

proxim al and distal w eakness, a reflexia, a nd distal sensory loss.

52. Chronic inflamm atory dem y elinating poly neuropathy

progresses in a stepwise or r elapsing cour se for a t least 8 weeks and

can occur early in the cour se of HIV in fection.

53. In a y oung patient with totally resected low-grade gliom a,



postsur gical managem ent consists of observ ation with seria l

neuroimaging.

54. V ascular dem entia is sugg ested by a h istory of v ascular risk

factors, abru pt onset with subsequent im prov ement ,

periv entricular white matter ischemia on imag ing, and focal

neurologic findings.

55. Intr av enous methy lprednisolone thera py followed by an oralprednisone taper speeds recov ery of v isua l acu ity in optic neur itis

56. The restless legs syndrome consists of abnormal sensations in the

legs and restlessness reliev ed by mov ement.

57 . Patients are at r isk for dev eloping an algesic ov eruse headache if

they use prescription or ov er-the-coun ter m edication for headache

more than 2 day s a week.

58. Pseudotumor cerebri is char acter ized by papilledema, postura l

chang e with headache, v isual chan ges, r ecent report of rapid weight

gain , or int roduct ion of ora l contr aceptiv es or tetr acy cline.

59. Infarction of the spinal cord ty pically presents as sudden spinal

cord dy sfunction.

60. Spinal cord infarction usually affects the territory of the

ant erior spinal ar tery , cau sing w eakness and pinprick loss of

sensation with sparing of vibration and position sense.

61 . CT scan m ay miss subara chnoid hemorr hag e, especially when

there is a delay in presentation a fter the initial h emorr hag e.

62 . Focal neur ologic sy mptoms 3 to 7 day s after a subara chnoidhemorrha ge ma y be due to va sospasm with cerebral ischemia.

63 . Patients with epilepsy wh o ar e most likely to rem ain seizur e free

after m edication w ithdraw al ar e those with no stru ctur al brain

lesion, no epileptiform or focal abnorm alit ies on

electroencephalogram, a sustained seizure-free period, and no

abnorma lities on neurologic exam inat ion.

64 . Patients with epilepsy wh o discontin ue antiepileptic m edication

should stop driv ing for at least 3 m onth s and preferably 6 m onth s

from the star t of the taper.

65. Cr itical illness poly neur opathy is a com mon cau se of failure to

wean from a v enti la tor in a patien t with associated m ult iorgan

failure a nd sepsis.

66. Critical illness polyneuropathy is characterized by generalized

or distal flaccid paraly sis, depressed or absent reflexes, and distal

sensory loss with sparing of cranial nerv e fun ction.

67 . Patients with primary central n erv ous sy stem ly mphoma



should be ev aluat ed for v itreal or uv eal inv olv ement before therapy

is begun .

68. Aggr essiv e resection is not r ecomm ended in primar y central

nerv ous sy stem ly m phom a; methotrexate chemotherapy is primar y

therapy.

69. Donepezil, an acetylcholinesterase inhibitor, may cause mild

peripheral ch olinerg ic side effects, including incr eased v agal tone, with brady ca rdia , and occasionally atr iov entricula r block.

70. In at least 50% of patients with relapsing–remitting multiple

sclerosis, disease will evolve to a secondary progressive course.

7 1 . In a t least 50% of patients with r elapsing–remitting m ultiple

sclerosis, disease will evolve to a secondary progressive course.

7 2. Metoclopram ide, w hich blocks dopamine receptors both in the

periphery and inside the central nerv ous sy stem, ca n induce

parkinsonism.

73. Prednisone is the most appropriate treatment for episodic cluster

headache.

7 4. Acu te cerv ical spinal cord compression due to hy perextension

injury is comm on in elderly patients.

7 5. Em ergent MRI of the cerv ical spinal cord is indicated in a ny

patient with quadriparesis after a fall.

7 6. The classic sy m ptom s of cerebellar stroke ar e headache, v ertigo,

and ataxia.

7 7 . Patients with epilepsy wh o fail to respond to three trials of ant iepileptic dru gs are un likely to ev er become seizur e free with

drug therapy .

78. Treatment-resistant patients with epilepsy should be evaluated

for a surgically rem ediable epilepsy syndrome.

7 9. My asthenia grav is is an autoimm une disease caused by

ant ibodies aga inst the acety lcholine receptor, w hich results in

impaired neuromuscular transmission.

80. My asthenia grav is is char acterized by fatigable weakness with a

predilection for ocular, bulbar, proximal-extremity, neck, and

respiratory muscles.

81 . Leptomeningeal spread of sy stemic car cinom a m anifests as a

cranial neuropathy or spinal poly radiculopathy , or as

encephalopathy, diffuse brain infiltration, or communicating

hydrocephalus.

82 . Creutzfeldt–Jakob disease is sugg ested by subacu te progression

of dementia with m y oclonus and other motor signs and a norma l



brain MRI.

83 . In th e setting of subacu tely progr essiv e dementia , the presence

of 1 4-3-3 protein in cerebrospinal fluid, or electroencephalography

showing periodic shar p wa v es, ca n be diagn ostic of

Creutzfeldt–Jakob disease.

84. Mitoxantrone therapy is of modest benefit in slowing progression

of secondary progr essiv e or sev ere relapsing–r emitt ing m ult iplesclerosis.

85. The prima ry concern a bout mitoxantrone therapy is the risk for

cardiotoxicity.

86. Progressiv e supra nu clear palsy is cha racterized by

parkinsonism w ith early gait and balance inv olv ement, v ertical

gaze palsy , sev ere dy sart hr ia, and dy sphagia.

87. Normal pressure hydrocephalus is characterized by the classic

triad of gait im pairment, cognitiv e decline, and ur inary

incontinence.

88. Patients with idiopathic intracranial hypertension present with

signs and symptoms of increased intra cra nial pressur e without a

mass lesion on brain im agin g.

89. In patients with possible idiopathic in tracr ania l hy pertension, a

diagnostic and potentially therapeutic lumbar puncture is indicated

after bra in im agin g exclu des a mass lesion.

90. Sev ere cerebral an oxia from cardiac arr est can cause sev ere

diffuse cerebral hem ispheric cortical inju ry with relativ epreserv ation of brainstem function, leading to the development of a

v egetativ e state.

91 . A v egetativ e state is a condition of com plete un aw ar eness of self

or the environment, accompanied by sleep–wake cycles and

preservation of brainstem and hypothalamic functions.

92 . Intr acerebral h emorr hag e with extensiv e subara chnoid

hemorrha ge is the ha llmar k of a ru ptured arteriov enous

malformation.

93. Conventional angiography is the definitive diagnostic procedure

for detecting ar teriov enous m alform ations and berry aneur y sm s.

94 . In a patient w ith statu s epilepticus, after th e airw ay is stabilized

and plasma g lucose determ ined to be norm al, par entera l

antiepileptic medications should be started.

95. Lorazepam is the preferred benzodiazepine for initial therapy for

a patient in status epilepticus.

96 . My asthenia grav is crisis is char acterized by dysphagia



requir ing nasogastr ic feeding and/or severe respiratory m uscle

weakn ess necessitating v entilation.

97. Myasthenia gravis crisis is treated with either plasmapheresis or

intrav enous imm unoglobulin.

98. Radiation-induced leukoencephalopathy is a subcortical process

affecting wh ite matt er and cha racterized by the tr iad of gait

apraxia, dementia, an d urinar y incontinence.99. Radiation-induced leukoencephalopathy may occur months to

y ears after radia tion and is m ore com mon a fter whole-brain

compared with focal brain irr adiation.

1 00. Mild cognitiv e impair ment consists of isolated m ild am nesia

with no im pair ment of interpersonal, occu pational, or daily liv in g

activities.

1 01 . The conv ersion r ate from mild cognitiv e impairment t o m ild

dem entia is 1 0% to 1 5% per y ear.

1 02. Am anta dine is the first-line pharm acologic ag ent for treatm ent

of mu ltiple sclerosis-rela ted fatigue.

1 03. Multiple sy stem a trophy is char acterized by orth ostatic

hy potension, neur ogenic bladder, constipation, and impotence, w ith

gait -predominan t par kinsonism a nd cort icospinal tra ct signs.

1 04. Carbama zepine is the appropriate treatm ent for trigemina l

neuralgia.

1 05. Patients with the locked-in sy ndrome a re quadriplegic, h av e

paraly sis of horizonta l ey e movements and bulbar muscles, and cancomm unicate only by mov ing their ey es v ertically or blinking.

1 06 . Th e locked-in sta te is due to a lesion of the base of the pons,

usually from pontin e infarction due to basilar ar tery occlusion.

1 07 . An tiplatelet therapy , statins, and ACE inhibitors each reduce

the r isk of recur rent stroke ev en in the absence of chronic

hypertension or a lipid disorder.

1 08. Headache m ay be a lim iting factor in the use of the

combination of aspirin and extended-release dipyridam ole for

secondary stroke prev ention.

1 09. Nonepileptic seizur es of psy chogenic orig in can be

different iated from epilepsy by their longer dura tion, norm al

electr oencephalogr am findings, and m aint enance of consciousness.

1 1 0. Nonepileptic psy chogenic seizur es are often associated with

moaning, cry ing, and arrhy thm ic shaking of the body .

1 1 1 . Absence seizur es ar e char acter ized by a br ief loss of awa reness

with no mov em ent or v ery subtle m ov em ents of th e lips a nd fin gers.



1 1 2. Juv enile my oclonic epilepsy is char acterized by m y oclonic

seizures and often accompanied by absence and generalized tonic–

clonic seizures.

113. Amyotrophic lateral sclerosis is characterized by pathologic

hy perr eflexia, spasticity , extensor plan tar responses, along w ith

atr ophy , fascicula tions, and weakn ess.

1 1 4. Muscle weakn ess in am y otrophic latera l sclerosis usually begins distally and asy m metrically in the upper or lower

extremities or ma y be limited initially to the bulbar mu scles,

resulting in dy sarth ria and dy sphagia.

1 1 5. Sur gical resection is indicated for a n accessible solitar y brain

metastasis in patients with limited or no systemic tum or.

1 1 6. Cholinesterase inhibitors hav e modest efficacy on cognit iv e and

global function in mild to moderate Alzheimer's disease.

1 1 7 . Vitam in E and selegiline may delay the progression of

Alzheim er's disease, but do not allev iate cognit iv e or psy ch iatric

symptoms.

118. In patients with possible multiple sclerosis, new MRI white-

matter lesions or new gadoliniu m-enha ncing lesions on serial brain

or spinal cord MRI at least 3 m onth s after a n initial scan, indicate

dissem inat ion of demy elination, even with out a n ew clinically

ev ident attack.

1 1 9. Carbidopa-lev odopa is th e first-line t reatment for patients older

tha n 7 0 y ears with new-onset Par kinson's disease.120. Complications associated with the use of dopamine agonists,

such as somnolence, dru g-induced psy chosis, an d dizziness, ar e more

comm on in patients older t han 7 0 y ears.

1 21 . The risk of rupture of a sma ll intracr anial an eury sm is less

tha n the r isk of complications with clipping or endov ascular coiling

of the aneury sm.

1 22 . Incidentally discov ered sm all an eury sms should be

re-evaluated periodically for enlargement.

1 23. Oxcar bazepine is effectiv e monotherapy for par tial onset

seizures.

1 24. Risk factors for r ecurrent seizur es inclu de mult iple prev ious

seizur es, a h istory of significant head tr aum a, focal

electroencephalogram abnorm alities, and stru ctur al abnorm ality

on MRI.

1 25. Am y otrophic lateral sclerosis causes progressiv e respiratory

mu scle weakness that m ay present w ith supine dy spnea, frequent



arousals, day time fatigue, or m orning headache.

1 26. N oninv asiv e positiv e-pressure v entilat ion should be started in

patients with am y otrophic lateral sclerosis whose forced v ital

capacity is less than 50% or w ho has sy m ptom s of nocturn al

hypoventilation.

1 27 . Neurologic sy m ptom s in conjunction with n orm al brain

ima ging a nd the detection of a sy stemic cancer ar e most likely dueto an im mun e-mediated par aneoplastic neurologic sy ndrome.

1 28. Memantine may allev iate cognitive sy mptoms and improv e

global function in moderate to severe Alzheimer's disease when

added to cholinesterase inhibitor therapy .

1 29. Estrogen replacement in post-menopausal women with

Alzheim er's dementia has not been shown to allev iate cognit iv e

sym ptom s or delay disease progression.

1 30. Drug -induced psy chosis in Par kinson's disease consists

primar ily of v isual hallucinat ions, ev olv ing at tim es into

paranoid-ty pe delusions.

1 31 . Infection with fev er can temporar ily exacerbate a chr onic

neur ologic defect in a patient w ith a prev ious stroke.

1 32. Partia l complex epilepsy consists of stereoty ped nonconv ulsiv e

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

char acterized by catar acts, frontal balding, temporal m uscleatrophy , an d cognitiv e dy sfunction.

1 34 . Cardiac disease resulting in ar rhy thm ias and respiratory

failure due to diaphr agm atic w eakness ar e com mon featur es of

my otonic dy strophy .

1 35. Lam bert-Eaton my asthenic sy ndrome is char acterized by

sy m metrical proxima l m uscle weakness and autonom ic

dysfunction.

1 36. Lam bert-Eaton m y asthenic syndrome is diagnosed by m otor

nerv e conduct ion studies with repetitiv e stim ula tion.

1 37 . Cognitive im pairment a ccompanied by fluctuating lethargy

and inat tention, hal lucin ations, and asterixis is likely the result of a

toxic encephalopathy.

1 38. Dru gs that block dopamine receptors can induce acu te dystonic

reactions.

1 39. In acute ischemic stroke, tissue plasminogen activ ator is

indicated if therapy is star ted within 3 hours of onset of sy m ptom s,



ther e is no hem orr ha ge on CT scan, a nd all other eligibility criteria

are met.

1 40. A ll states require tha t an episode of loss of awar eness be

reported to gov ernm ent au thorit ies, either t o the Departm ent of

Health or to the Departm ent of Motor Vehicles.

1 41 . Hypothy roid m y opathy is char acterized by m uscle pain,

cram ps, stiffness, fatigu e, and par esthesias.1 42 . In h y pothy roid my opathy , creatine kinase lev els may be 1 0 to

1 00 tim es norma l, but t hy roid funct ion tests should be perform ed

before elect romy ogr aphy or m uscle biopsy .

1 43 . Paran eoplastic limbic encephalitis is m ost com monly associated

with small-cell lu ng ca ncer.

1 44 . Paraneoplastic limbic encephalitis is cha ra cterized by rapidly

progr essiv e decline in short-term memory and seizur es.

1 45. The m ost comm on h eritable form of Alzheimer's disease results

from a mutation in presenilin-1.

1 46 . Testing for presenilin-1 m ay be useful w hen a heritable form of

Alzheim er's disease is su spected.

1 47 . CT scan of the bra in is indicated to diagn ose suspected

intracerebral hemorrhage.

1 48. Head trau ma increases the relativ e risk for epilepsy by 1 0 only

if there is penetr at ion of the dur a or loss of consciousness for more

than 3 0 minutes.

1 49 . Critical illness my opathy is comm on in v entilator-dependentpatients who hav e been tr eated with cort icosteroids and

neuromuscular blocking agents.

1 50. Critical illness my opathy is char acterized by v entilator

dependence, genera lized or proxim al flaccid paraly sis, mu scle

atrophy , an d high cr eatine kinase lev els.

1 51 . Prim ar y impairm ent of concentr ation and attention, as opposed

to memory , is likely the result of depression rath er than a

neur odegenerativ e condition.

1 52. Carotid endart erectomy is the appropriate interv ention in

patients with symptomatic carotid artery stenosis, especially within

the first few w eeks after init ial sy m ptoms.

1 53 . Depression is a possible side effect of ma ny antiepileptic dru gs,

including phenobarbital, pheny toin, v alproate, lev etiracetam, a nd

topiramate.

1 54. Selectiv e serotonin reuptake inhibitors, m oclobemide,

v enla faxine, and nefazodone do not incr ease the seizur e threshold in



patients with epilepsy and th erefore ar e the preferr ed

pharmacologic agents in depression.

1 55. Poly my ositis is cha racterized by proxim al m uscle weakness,

elev ated creatine kinase lev els, and needle electromy ogr aphy

showing diffuse fibrilla tions and m y opathic motor unit potentia ls.

1 56. Results of creatine kina se measur ement a nd needle

electromy ography are inv ariably norm al in steroid my opathy butabnorm al in inflamm atory my opathy .

1 57 . Ant iplatelet thera py is the m ainstay of secondary stroke

prev ention in patients with cr y ptogenic stroke.

1 58. Clopidogr el is the preferred ant iplatelet therapy for a spirin-

allerg ic patients with a history of stroke.

My Cardiology Note:

1 60. Right v entr icula r infar ction should be suspected in patients

with in fer ior m y ocardia l infarct ion who present with hy poten sion,

clear lu ng fields, and elevated jugular v enous pressur e.

1 61 . An echocar diogram establishes the diagn osis of right

v entr icula r in farct ion by dem onstrating right v entricula r

enlargement and hypokinesis.

162. Implantable cardioverter-defibrillator therapy reduces risk of

sudden death in sur v iv ors of car diac arr est due to v entr icula r

tachy cardia or v entricular fibrillation w ithout a rev ersible cause.

1 63 . Spontan eous coronary dissection m ay occur during pregnan cy .

164. In patients with ST-elevation myocardial infarction, successfulfibrinoly sis is sug gested by resolution of chest pain and ST-segm ent

elevation and/or transient v entricular arrh y thm ias early after

reperfusion.

1 65. In patients with ST-elev ation my ocardial infarction,

reperfusion ar rhy thm ias, ty pically ma nifested as a tran sient

accelerat ed idiov entricular arr hy thm ia, usually do not require

additional antiarr hy thm ic therapy .

1 66 . Thrombosis of mechanical v alv es may present with v alv e

dysfunction rath er than embolic ev ents.

1 67 . Intr av enous heparin should be start ed imm ediately wh ile

diagnostic ev alu ation is in progress.

1 68 . Chest CT scan with contra st is indicated to detect acu te aortic

dissection.

1 69 . In patients at risk for radiocontr ast nephr opathy and

contr aindication to MRI, transesophageal echocardiogr aphy is the

test of choice for possible aortic dissection.



1 7 0. Breast an d lung carcinom a ar e the m ost comm on cau ses of

malignant pericardial disease.

1 7 1 . The epicardium is the most common location of metastatic

cardiac neoplasm.

1 7 2. An ACE inhibitor an d a β-blocker are indicated in all patients

with sy stolic heart failure, includin g asy m ptomatic patients.

1 7 3. Spironolactone and digoxin are not indicated in patients withasym ptoma tic systolic heart failur e.

1 7 4. Fixed splitting of the S2 is the auscultatory hallm ark of atrial

septal defect.

1 7 5. A div ergence between electrocardiogra phy showing

low-voltage and echocardiography demonstrating a substantial

increase in left v entr icula r w all th ickness is a useful diagnostic clue

for cardiac amyloidosis.

1 7 6. Abdominal fat aspiration biopsy is a safe and reasonably

sensitiv e test for the diagn osis of am y loidosis.

1 7 7 . Phy sical examina tion is helpful is identify ing th e presence, but

not the sev erity , of v alv e disease.

1 7 8. The most sensitiv e sign on phy sical exam ination t o exclude the

diagn osis of sev ere aort ic stenosis is a phy siologically split S2 .

1 7 9. Most patients with peripheral v ascular disease hav e an ABI

gra de 3/6 in intensity , continu ous mu rm ur s, or a ny diastolic

murmur.

1 92 . Surg ery for n ativ e v alv e endocarditis is indicated if there issignificant h emodyn am ic instability or ev idence of para v alv ular

extension.

1 93 . Factors fav oring earlier timing of sur gery include significant

congestiv e heart failu re, resistant infections, and lar ge mobile

v egetations.

1 94 . Ev en if activ e bacteremia is still present or if the antibiotic

treatm ent course is ongoing, sur gery for endocar ditis should not be

delay ed if sur gical criteria a re m et.

1 95. Medical therapy for acute, r ecent m y ocardial infarction

includes β-blockers, aspirin, ang iotensin-conv erting enzy me

inhibitors, an d stat ins.

1 96 . Smoking cessation is the single m ost effectiv e interv ention for

patients with peripheral v ascular disease.

1 97 . β blockade does not promote clinica l claudication.

1 98 . Cilostazol is relat iv ely contr aindicated in patients with

congestiv e heart failure.



1 99 . Patients with h eart failure who hav e sev ere sy mptoms and

ev idence for v entricular dyssy nchr ony benefit from implantation of

a biventricular pacemaker.

200. Biv entricular pacing im prov es cardiac perform ance and

quality of life and ma y also improv e sur v iv al.

201 . Gly coprotein r eceptor blockade is indicated for patients with

acute coronar y sy ndrom e who will un dergo coronar y angiogra phy and interv ention.

202 . Patients with ST-elev ation m y ocardial infarction t reated with

stents require aspirin a nd clopidogr el at discharg e.

203 . Patients with ST-elev ation m y ocardial infarction treated

without stents may be m anaged w ith aspir in alone or with warfarin

if indicated for a tr ial fibrillation or a nter ior a kinesis or a neur y sm.

204. In low-risk patients with lone atr ial fibrilla tion, w arfarin

ant icoagu lation is not required. Aspirin or no therapy is

recommended.

205. A sy stolic mu rm ur , an S3 ga llop, and mild peripheral edem a

are norm al findings during pregnancy .

206 . In t he absence of significant mitr al r egurgita tion, primar y

mitra l v alv e prolapse has a benign prognosis.

207 . An tibiotic prophy lax is for endocar ditis is indicated in mitr al

v alv e pr olapse if there is more than mild m itral regurgitation, if a

mu rm ur is heard on a uscultation, or if the patient has high -risk

echocar diogr aphic featu res.208. Initial m anag ement of acute coronar y sy ndrom e related to a

sy stem ic process, such as anemia, is treatm ent of the precipitat ing

factor.

209. Medical therapy for NSTEMI in patients with TIMI low-risk

status has acceptable outcomes.

21 0. Patients with a tr ial fibrillation and risk factors for stroke

require anticoagu lation with w arfarin.

21 1 . Risk factors for stroke in nonrheum atic at ria l fibrilla tion

include prior em bolic ev ent or stroke, hy pertension, a dv anced age,

congestive heart failure, coronary artery disease, and diabetes

mellitus.

21 2. β-blockers should not be initiated in hear t failur e patients who

are acutely decompensated or v olum e ov erloaded.

21 3. Patients with atr ial fibrillation and m inima l sy m ptom s can

usually be ma naged with ra te contr ol alone (without r hy thm

control).



21 4. Echocardiogra phy is indicated wh en a new mu rm ur , a sy stolic

mu rm ur ≥gr ade 3/6, or an y diastolic murm ur is heard.

21 5. Phy siologic v alv ular r egur gitation does not pose a r isk of

endocarditis and does not require antibiotic prophylaxis.

21 6. Antibiotic prophy laxis for endocar ditis is tailored to the risk of

the procedure an d the r isk of the patient.

21 7 . Alth ough pericar diectomy is the m ost effective tr eatment forconstrictiv e pericar ditis, it is un necessary in patients with ear ly

disease.

21 8. A trial flutter is chara cterized by saw -tooth pattern flutter

wav es m ost noticeable in the in fer ior leads.

21 9. The preferr ed treatm ent for r ecurrent at rial flutter is

radiofrequency catheter ablation.

22 0. Aspirin-allergic patients with ST-elev ation m y ocardial

infarct ion can be treat ed with clopidogr el as part of postinfarction

medical therapy.

221. Angiotensin-converting enzyme inhibitors are indicated for all

patients with sy stolic heart failur e, rega rdless of ejection fraction or

functional status, barring contraindications.

22 2. Patients with STEMI should undergo coronary reperfusion in

the m ost expeditious m ann er.

22 3. STEMI patients who cannot be reperfused by direct coronary

interv ention w ithin 9 0 to 12 0 m inutes should receiv e fibrinoly tic

ther apy if ther e are no contr aindicat ions.22 4. The decision to implan t a pacemaker for sinu s node dy sfun ction

depends on th e presence of sy m ptom s rath er th an hear t r ate alone.

22 5. Subacute cardiac tam ponade may be caused by acute v iral

pericarditis.

22 6. Echocar diogr aphy is a useful diagn ostic modality for th e

delineation of pericar dial hem ody namics.

22 7 . • Papillary m uscle dy sfun ction or rupture should be suspected

in patients with clinical signs of acute m itral r egurgita tion in the

setting of a m y ocar dial infarction.

22 8. • An echocar diogr am should be perform ed if papillary muscle

dy sfun ction is suspected.

22 9. • Mitral r egurg itation due to papillary m uscle dy sfunction

often improv es followin g coronar y rev ascular ization

23 0. Sy ncope in a patient with cardiomy opathy ma y be due to

potentially fatal v entricular arr hy thm ia.

23 1 . An ICD is indicated for patients with left v entr icula r



dysfunction and hemody nam ically significant v entricular

arrhythmias.

23 2. Coronary artery bypass grafting improv es surv iv al in patients

with obstr uct iv e left main and/or m ult iv essel coronary artery

disease.

23 3. Coronary artery bypass grafting improv es surv iv al in

comparison to percu tan eous interv ention in diabetic patients withmu ltiv essel coronary art ery disease.

23 4. At riov entricular n odal re-entrant ta chy cardia is char acterized

by a narrow QRS com plex and lack of v isible P wav es.

23 5. The first treatm ent of choice for a triov entricular tachy cardia

is carotid sinus massage.

23 6. If car otid sinus massage is u nsuccessful, adenosine is the drug

of choice for the term inat ion of nar row-com plex suprav entr icula r

tachycardias.

23 7 . The mur m ur of hy pertr ophic cardiomy opathy increases after

a V alsalv a m aneuv er an d decreases after a sit-to-squat m aneuv er,

perform ing passiv e recum bent leg lifts, or perform ing handgripping

exercises.

23 8. Ascending aortic dissection m ay inv olv e the coronar y arteries,

most comm only the right coronary artery .

23 9. Ascending aort ic dissection m ay lead to disru ption of the aort ic

v alv e, leadin g to aort ic regurgitation.

240. Noonan syndrome is characterized by short stature,intellectual impairm ent, un ique facial features, neck w ebbing, and

congenit al h eart defects.

24 1 . Noonan sy ndrome should alway s be considered in a patient

with pulm onary v alv e stenosis.

24 2. The recomm ended initial treatm ent for a cute v iral pericarditis

is a high -dose nonsteroidal ant i-inflam matory medication, such a s

indomethacin.

24 3. Anticoagu lation t herapy is contr aindicated in pericarditis

because of th e r isk of hem opericardiu m .

24 4. Periopera tiv e β blockade decreases cardiov ascular risk in

patients un dergoing noncar diac sur gery .

24 5. Hy pertension (blood pressur e >1 80/1 1 0 m m Hg) is a r elativ e

contr aindication to fibrinoly sis in patients with STEMI.

24 6. Rev ascular ization should proceed expeditiously with

concomitan t m edical th erapy for h y pertension complicating STEMI.

247. Restrictive cardiomyopathy is a late complication of radiation



therapy.

24 8. A norm al left v entricular wa ll thickness in r adiation-induced

restrictiv e cardiomy opathy helps to different iate this entity from

other car diomy opathies char acterized by v entricular hy pertr ophy .

24 9. In asy m ptom atic patients with ch ronic aortic r egurg itation,

sur gery should be considered when left v entr icula r ejection fra ction

drops below 60% or t he left v entr icula r sy stolic dimension r eaches55 mm .

250. In asym ptoma tic patients with a ortic regur gitation, nifedipine

ma y delay the timing of sur gical interv ention.

251. Aortic coarctation is associated with a continuous murmur

(often posterior thora x) and elev ated but equal blood pressure in

both upper extrem it ies.

252. A bicuspid aort ic v alv e is often seen in a ssociation with aortic

coar ctat ion, presentin g w ith a ort ic regu rgitat ion or aort ic stenosis.

253. Phy sical findings of mitral regu rgitat ion inclu de holosystolic

mu rm ur at the apex radiating to the axilla, w ithout r espirat ory

v aria tion.

254 . In healthy adults, prema tur e v entricular contractions are

comm on and ar e not a cau se for concern.

255. Suppression of prem atu re v entr icular contra ctions is indicated

only in patients with severe and disabling sy mptoms.

256 . Smoking, hy pertension, adv anced age, and ma le sex are risk

factors for abdominal aort ic aneur y sm.257 . Most abdom inal aortic aneury sms are asy m ptom atic, but

abdom inal pain is the most comm on sy m ptom .

258. Patients at h igh r isk for a subsequent coronar y ev ent after a

myocardial infarction include those with multivessel coronary

artery disease, anterior m y ocardial infarction, or a left v entricular

ejection fraction 0.5 cm/year) increase in aneurysm size.

307 . Sev ere hemoly tic anemia in a patient with a mechanical v alv e

sugg ests para v alv ular leakage due to part ial dehiscence of the v alv e

or infection.

308. Prosthetic v alv e dehiscence or dy sfunct ion should be suspected

in patients tha t dev elop sy mptoms of congestiv e heart failur e,

particu lar ly if these sym ptom s occur in the first 6 m onth s followin g

surgery.

309. Right v entr icula r infar ction is a cause of hy potension followin g

inferior infarction and ty pically requires appropriate v olum e

infusion.



31 0. Right v entr icula r infarction should be suspected as a cause of

hy potension when findings of right hear t failur e coincide with an

absence of evidence of pulmonary congestion.

31 1 . Im planta tion of a cardiov erter-defibrillator is an important

prophy lactic treatm ent in patients with h y pertr ophic

cardiomyopathy and high risk for sudden death.

31 2. Clinical featu res that predict high r isk for sudden death inpatients with h y pertr ophic cardiomy opathy include fam ily history

of sudden death, syncope, ma rked left v entr icular septal

hy pertr ophy , nonsustained v entricular t achy cardia, and exertional

hypotension.

31 3. Papillary mu scle ru pture and v entricular septal defect are

recognized mechan ical complications that occur ear ly after

my ocardial infarction.

31 4. Both papillary mu scle rupture and v entricular septal defect

present with h y potension an d acute dy spnea.

31 5. An nua l echocardiogra phy is appropriate in a patient with

asym ptoma tic sev ere mitr al regurg itation.

31 6. Th e timing of sur gery for severe m itral r egurgita tion is based

on sy mptom s and measur es of left v entr icular size and sy stolic

function.

31 7 . Classic featu res of Marfan's sy ndrome includes tall statur e,

high ar ched palate, joint h y perm obility , scoliosis, and positiv e

“w rist sign.”31 8. Patients with Marfan's sy ndrome are at in creased risk for

asym ptoma tic thoracic aortic aneury sm and associated aortic v alv e

incompetence.

31 9. Intr av enous am iodarone is the dru g of choice for shock-

resistant v entricular fibrillation.

32 0. The risk of coronary ar tery disease in diabetic patients is 2 to 4

tim es higher th an in n ondiabetic patients.

321. The pretest likelihood of disease should be calculated using

av ailable algorithm s in patients with coronary risk factors.

32 2. In patients with chest pain and interm ediate risk of coronary

artery disease, non-inv asiv e testing is indicated.

32 3. Patients with chest pain a nd low coronar y artery disease risk

with a norm al electrocardiogram and a norm al exercise

electr ocar diogram can be discharg ed without coronary

angiography.

32 4. Although uncomm on, left atrial my xoma should be considered



in y oun g patients with embolic stroke.

32 5. Echocardiogra phy is an im portan t im aging modality for

diagnosis of an intr acardiac tu m or.

32 6. Women with Marfan sy ndrome are at incr eased risk of aort ic

dissection during pregnancy.

327. Aortic dissection should be considered in the differential

diagnosis of chest pain in pregnancy .32 8. The tachy cardia r ate in atriov entricular nodal r eentrant

tachy cardia is ty pically 1 60–180/min w ith the P wav e buried in

the QRS complex.

32 9. • If atriov entricular nodal reentrant tachy cardia does not

respond to v aga l m aneuv ers, adenosine is the tr eatm ent of choice

33 0. Contin uous effectiv e anticoagulation is needed throughout

pregnancy in women with m echanical heart v alv es.

33 1 . Radiofrequency cath eter ablation is the most effectiv e

treatm ent for atr iov entricular n odal reentrant tach y cardia.

33 2. Calcium -cha nnel blockers may be used for prophy lax is of

recurr ent atriov entricular n odal reentran t tachy cardia but ar e less

effective than radiofrequency catheter ablation.

33 3. The cardiac output is low in prima ry cardiogenic shock, and

inotropic agents m ay be needed to augm ent m y ocar dial

contr actility and thu s cardiac output.

33 4. Exercise (or phar macologic) stress testing is the most sensitiv e

noninv asiv e meth od to establish the diagnosis of coronary ar tery disease.

33 5. Exercise (or pharm acologic) stress car diac imaging can be used

to ev alu ate for coronar y ar tery disease if the resting

electrocardiogram is abnormal.

33 6. The role of electr on-beam CT coronary calciu m scores is not y et

established in th e assessm ent of coronary ar tery disease.

33 7 . Prolonged imm obility followed by a stroke or t ra nsient

ischem ic a ttack should raise the suspicion of a paradoxical

embolism.

33 8. Tr ansesophageal echocardiography is the test of choice to

confirm the diagnosis of a suspected patent foram en ovale or car diac

source of embolus.

33 9. • Systemic lupus ery thema tosus is a cau se of prema tur e

atherosclerotic coronary disease.

34 0. • Other causes of acu te my ocar dial infarction in y oun g persons

include coronary spasm , em bolic coronary occlusion, and Kawa saki's



disease.

34 1 . High risk patients that require a heparin anticoagu lation

bridg e after stopping warfarin prior to surgery include those with a

mitr al m echanical v alv e, atrial fibrillation, or prev ious embolism .

34 2. Low risk patients do not require a hepar in br idge after stopping

warfarin prior to sur gery and in clude patien ts with a bileaflet aort ic

v alv e and no other high risk features.34 3. Aspirin a lone is not a sufficient r eplacem ent for w ar farin, a nd

is used only as a chronic adjunct in patients wh o manifest sy stemic

emboli despite therapeutic warfarin therapy.

34 4. Radial-fem oral delay is a char acteristic phy sical finding in

aort ic coar ctat ion.

34 5. Bicuspid aortic v alv es are comm on in patients with aortic

coar ctat ion and ar e associated with a sy stolic ejection click and

sy stolic mu rm ur noted ov er the aortic area.

34 6. Elev ated B-ty pe natriur etic peptide lev els occur with renal

failur e, acute coronary sy ndrome or my ocardial infarction, a nd

acute v olum e or pressur e ov erload.

34 7 . Adenosine is the treatm ent of choice for n ar row-complex

tachycardia.

34 8. Neither adenosine nor other atr iov entr icular nodal blocking

agents should be giv en to patients with preexcited tach y car dias.

349. Procainamide is the drug of choice for wide-complex

tachy cardia of unclear etiology .350. Coronar y angiography is indicated in patients with a history of

unstable ang ina or non-ST-elev ation my ocardial infarction.

351 . In patients with a h igh pretest probability of coronary art ery

disease, a negativ e str ess test result is most likely to be false.

352. Spinal stenosis is character ized by pain with stan ding or

walking th at is r eliev ed by sitting or bendin g forw ard and is further

supported by a n orm al A BI.

353 . Leg ischem ia is characterized by pain with exertion a nd with a

decrease in ABI of at least 20 % with exercise.

354. The use of angiotensin-conv erting enzy m e inhibitors should be

av oided during pregnancy .

355. Hy dralazine and nitr ates are the v asodilators of choice to treat

heart failure during pregnancy .

356. Induction of mild hy potherm ia im prov es 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 dy spnea.

359 . A lcoholic cardiomy opathy is a dilated cardiomy opathy .

36 0. Therapy for a lcoholic cardiomy opathy mu st include total

abstinence from alcohol.

36 1 . In chr onic angina, coronary artery bypass graft surgery isindicated for patients refractory to m edical therapy ; a large area of

ischemic m y ocardium ; high-risk coronar y anat omy ; and reduced

left v entricular sy stolic function.

36 2. A trial tach y cardia with v ariable block is a classic

electr ocar diographic finding in digitalis toxicity .

363. The first-line treatment for life-threatening digitalis toxicity is

admin istration of digoxin-specific a ntibody fragments.

36 4. Iron deficiency is a comm on cause for dy spnea an d fatigue in

patients with cy anotic heart disease.

36 5. The most com mon cause of iron deficiency in patients with

cy anotic heart disease is recurr ent phlebotom y .

36 6. Mitral v alv e sur gery is indicated for sy mptoma tic patients

with ch ronic, sev ere m itral r egurgitation.

36 7 . In asy m ptom atic patients with ch ronic, sev ere mitral

regur gitation, criteria for m itral v alv e sur gery include an

end-sy stolic dimension >45 mm , a n end-diastolic dimension >6 0

mm, an d an ejection fra ction 5 mm of indura tion is considered apositiv e test.

654 . Dengu e fev er is chara cterized by the abrupt onset of sev ere

headache, high fev er, my algias, arthr algias, leukopenia, and

thrombocytopenia.

655. Dengu e hemorrha gic fev er is associated with hemorrha ge and

capillary fragility .

656 . Bronchiectasis is a r isk factor for the dev elopment of

Pseudomonas aeru ginosa comm un ity -acquir ed pneum onia.

657 . Administration of ganciclov ir or v algan ciclov ir has greatly

reduced, but not eliminated, the occurrence of cytomegalovirus

infections in transplant recipients.

658. Person-to-person t ra nsmission of menin gococcal organisms

occurs by the r espiratory route.

659 . Prophy laxis of health car e workers exposed to a patient with a

meningococcal infection is needed only after contact w ith t he

patient's respiratory secretions.



66 0. MRI and CT scans ar e the im agin g procedur es of choice in the

diagn osis of patient s with suspected osteomy elitis.

66 1 . The m ost appropriate empiric therapy for Streptococcus

pneum oniae m eningitis is v ancom y cin plus ceftriax one and

dexamethasone.

66 2. Africa n tick bite fev er is the most common r ickettsial infection

in hum ans.66 3. Sy m ptoms of African tick bite fev er are relativ ely m ild and are

char acterized by a v esicular rash w ith an inoculation eschar .

66 4. Sy m ptoms of Creut zfeldt–Jakob disease ty pically inclu de

cognitiv e chan ges (dementia), behav ioral and personality chang es,

difficulty with m ov ement an d coordination, a nd v isual and

constitut ional symptoms.

66 5. Th e cour se of Creut zfeldt–Jakob disease is rapid and

progr essiv e; 90% of patients die within 1 y ear of diagnosis.

66 6. Th e most appropriate therapy for a patient w ith Listeria

meningitis and a sev ere allergy to penicillin is trimethoprim –

sulfamethoxazole.

66 7 . When initiating antituberculous therapy , a four -drug regim en

must be used if the probability of resistance to isonia zid is great er

than 4%.

66 8. The recomm ended empiric therapy for a patient w ith

comm unity -acquir ed pneum onia w ho is hospitalized on a g eneral

medical floor is either m onotherapy with an intra v enousfluoroquinolone or combination therapy with an intravenous

β-lacta m plus either an intrav enous or oral m acr olide or

doxycycline.

66 9. The recomm ended empiric therapy for a patient w ith

comm unity -acquir ed pneum onia w ho is hospitalized in an intensiv e

care unit is an int rav enous β-lactam plus either an intr av enous

macr olide or an intr av enous fluoroquin olone.

67 0. Penicillin is the t reatm ent of choice for all form s of sy philis.

67 1 . Treatm ent of a pregnan t patient w ith newly diagnosed sy philis

is essential in order to prev ent congenital syphilis in the fetus.

67 2. A pregnant patient w ith newly diagnosed sy philis wh o m ay be

allerg ic to penicillin should un derg o skin testing for a penicillin

allergy.

67 3. Imm un osuppressed transplant r ecipients are at hig h r isk for

dev elopment of bacterial in fections during th e first m onth after

surgery.



67 4. In pat ients with a contigu ous foot u lcer and possible

osteomy elitis, bone biopsy with cult ur es and h istopathologic

exam inat ion should be perform ed before init iating a ntim icrobial

therapy.

67 5. Intr av ascular cath eter–associated bloodstream in fections are

preventable if proper insertion procedures are used.

676. Chlorhexidine is superior to povidone-iodine for cleaning acath eter insertion site.

67 7 . Va ncomy cin is the antim icrobial agent of choice for tr eatment

of m ethicillin-resistant Staphy lococcus a ur eus infections.

67 8. All β-lactam agents are inactiv e against methicillin-resistant

Staphy lococcus a ur eus infections.

67 9. HIV g enoty pe resistan ce testing is indicated for pat ients with

HIV in fection w ho ma y ha v e dev eloped resistance to one or m ore

antiretroviral agents.

680. No cur rent ly av ailable test can differentia te tru e-positiv e from

false-positiv e tubercu lin skin test r eactions in a person wh o

prev iously receiv ed bacille Calmette–Guérin v accine.

681 . The r ecom mended treatm ent for la tent tubercu losis is isoniazid

for 9 m onth s.

682. Infection due to Pseudomonas aeruginosa, which is often found

between la y ers of rubber soles in sneakers, m ay occu r following

punctu re w oun ds of the foot.

683. Conta cts of patients w ith possible smallpox should r eceiv esm allpox v accine.

684. Contacts of patients with possible smallpox should take their

temperatu re tw ice daily for 1 7 day s; a contact wh o dev elops a

temperatu re ov er 3 8 °C (100.4 °F) during this time should be

isolated.

685. A cy clov ir is effectiv e in prev enting reactiv ation of va ricella

zoster v iru s in stem-cell transplant r ecipients.

686. Noninfectious skin lesions can be differentiated from infectious

disorders because the former are not associated with fever and other

sy stem ic signs and symptoms or abnorm al laboratory studies and

cultur e results.

687 . The m ost appropriate empiric therapy for a patient w ith

purulent m eningitis following neurosur gery is v ancomy cin plus

cefepime.

688. Th e finding of 14 -3-3 protein in cerebrospinal fluid has a

specificity and sensitiv ity of greater than 9 0% for diagn osing



spora dic Creutzfeldt–Jakob disease.

689 . Liv e attenuated influenza v accine is contr aindicated in an

imm unosuppressed patient.

69 0. All fam ily m embers of an immun osuppressed patient should be

imm unized against influenza to decrease the patient's risk of

exposure to this v iru s.

69 1 . Doxy cy cline in a single dose is highly effectiv e for preventingery thema m igrans in patients from ar eas endem ic for Ly me disease

who present with an em bedded, engorg ed tick.

692. Contact isolation is most effective for reducing spread of

Clostridium difficile in hospitals.

69 3. The treatm ent of choice for patients with sy m ptom atic

babesiosis is atov aquone plu s azithromy cin.

694. A positive Western blot analysis confirms the diagnosis of HIV

infection; a negat iv e test r ules out this diagn osis.

69 5. An indetermina te Western blot an aly sis m ay indicate either

HIV seroconv ersion or the presence of cross-reactiv e antibodies.

69 6. Sta ined specimens of vagin al discha rge from patients with

candidal v agin itis show pseudohy phae and budding y east.

69 7 . Stained specimens of v agin al discha rge from patients with

bacteria l v agin osis show gram-neg ativ e bacill i a ttach ed to

squam ous epithelial cells (clue cells).

69 8. In patients with cath eter-associated bloodstream infections, th e

cath eter should be rem ov ed whenev er possible.69 9. Echinocandins such as caspofungin, micafung in, a nd

anidulafungin are effective in treating patients with candidemia.

7 00. Patients with My cobacterium tuberculosis infection m ay be

considered noninfectious a fter th ey ar e placed on effectiv e

antitu berculous therapy , demonstra te clinical improv ement, an d

hav e three different sputum smears tha t are negativ e for acid-fast

bacill i.

7 01 . Bra in abscesses that result from contiguous spread of head and

neck infections may contain multiple organisms.

7 02. Ceftriaxone plus metronidazole is the m ost appropriate empiric

ant imicr obial therapy for a bra in abscess resulting from contigu ous

spread of an otitic focus of infection.

7 03. Vancomy cin plus clindam y cin is the m ost appropriate empiric

antibiotic regimen for a patient with suspected streptococcal or

staphy lococcal toxic shock syndrome.

7 04. Gram-positiv e bacter ia (staphy lococci and streptococci) are the



most common causes of nongonococcal septic arthritis in adults.

7 05. Because am ant adine is excreted by the kidney s, dosage

adjustment is requir ed in patients with rena l compromise.

7 06. A lthough oseltamiv ir and zanam iv ir are excreted by the

kidney s, dosage adjustm ent is not required in a patient with rena l

compromise.

7 07 . A high ly effectiv e va ccine is av ailable for hepatitis A, w hichmust be administered at least 2 weeks before a potential exposure.

7 08. Patients taking an ti–tum or n ecrosis factor-α inhibitors are at

increased risk for dev eloping latent tuberculosis.

7 09. Patients about to begin therapy with anti–tum or necrosis

factor-α inhibitors should u ndergo tubercu lin skin test screening.

7 1 0. Tra nsplant recipients are at r isk for dev elopment of

opportun istic in fections such as fungal pneum onia.

7 1 1 . Alm ost all patients with am ebic abscesses will ha v e high lev els

of antibodies directed against Entam oeba histoly tica.

7 1 2. In a patient w ith sickle cell disease and osteomy elitis, potentia l

causativ e org anisms are staphy lococci, streptococci, an d Salmonella

species.

7 1 3. Penicillin is the only antim icrobial agent a pprov ed for

treatm ent of neur osyphilis.

7 1 4. Patients wh o are allergic to penicillin but for w hom alternativ e

ant imicr obial a gents cannot be prescribed require desensitization to

penicillin.7 1 5. Genital herpes simplex v irus in a m ale patient is generally

char acterized by a lim ited num ber of genital v esiculoulcerativ e

lesions with out systemic sy mptoms.

7 1 6. Subdural empy ema is a medical and surgical emergency .

7 1 7 . Antim icrobial therapy and neurosurgical drainage are the

most appropriate initial m anag ement for a patient w ith a subdural

empyema.

7 1 8. Sur gical site infections are a comm on com plication of

operations, especially coronar y artery by pass graft surgery .

7 1 9. Th e appropriate dose, tim ing, a nd dur ation of prophy lactic

perioperativ e antibiotics help decrease the r isk of surgical site

infections.

7 20. Deep fungal in fections such as histoplasm osis are a risk to

trav elers to endemic areas.

7 21 . Reactiv ation of hum an h erpesv iruses 6 an d 7 is being

increasingly recognized in imm unosuppressed patients.



7 22 . Reactiv ation of hum an h erpesv iruses 6 and 7 may cause

hepatitis and m eningoencephalitis.

7 23. Treatm ent of latent tu berculosis is indicated for any person

with a kn own tuber cu lin skin test conv ersion, regardless of the

person's age.

724. Most cases of toxic shock syndrome are caused by

Staphylococcus aureus or Streptococcus pyogenes.7 25. Ceftr iaxone prov ides effectiv e empiric thera py for patients

with possible dissem inated gonococcal infection.

7 26 . Health car e workers in contact with a patient with possible

sm allpox r equir e gown , g lov es, and a personal respirator for

protection.

7 27 . A qualitativ e assay for hepatitis C v irus RNA v iral load is the

most sensitive test for diagnosing hepatitis C infection.

7 28. Penicillin resistan ce is categorized as either in term ediate-lev el

resistan ce (minim al inh ibitory concentr ation [MIC] between 0.1

and 1 μg /mL) or high-lev el resistan ce (MIC >1 μg /mL).

7 29 . • Orga nism s that are resistant t o penicillin generally rema in

sensitiv e to fluoroquinolones and ar e uniform ly sensitiv e to

v ancom y cin and linezolid

7 30. Poly oma v irus BK is associated with nephropathy and

deteriorating renal function in renal transplant recipients.

7 31 . The presence of intran uclear inclusions in tu bular epithelial

cells or t ra nsitional cells is highly indicativ e of poly omav iru s BK.7 32. Acu te retina l necrosis occur s most often in patients with HIV

infection or AIDS.

7 33 . Intr av enous acy clov ir is the preferred treatment for acu te

retina l necrosis.

7 34. In contra st to patients with spora dic, genetic, or ia trogenic

Creutzfeldt–Jakob disease, patients with the v ar iant form of the

disorder tend to be y oung er an d hav e psy chiatr ic sym ptoms ra ther

tha n dementia ear ly in the disease, m ore prom inent sensory

findings, and MRI abnorma lities in pulv inar ar ea of the thala mus

rath er than in the basal gang lia and putam en.

7 35. Ninety percent of ur inary tra ct infections are associated with

indwelling catheters.

7 36 . Administering prophy lactic antibiotics, acidify ing the urine,

or u sing disinfecting w ashes ha v e not been shown to prev ent

ur inary tract infections.

737. Vancomycin plus cefepime is the most appropriate empiric



ant imicr obial therapy for a patient w ith an epidura l abscess and a

history of injection drug use.

7 38. The dev elopment of focal ly m phadenitis in a patient with HIV

infection is most comm only cau sed by m y cobacteria, Streptococcus

species, or Staphy lococcu s species.

7 39. Cry ptococcal infection in t ra nsplant recipients is associated

with high m orbidity and m ortality .7 40. Flucy tosine plus a lipid form ula tion of am photericin B is

usually effectiv e for tr eating cr y ptococcal infections in tran splant

recipients.

7 41 . Em piric antibiotic therapy w hile awaiting cultu re results is

required for patient s with a n infected clenched-fist inju ry .

7 42 . Oral v alacy clov ir is the most appropriate antiv iral agent for a

patient with genital herpes simplex virus infection without systemic

complications.

7 43 . The four “D's” that cha ra cterize botulism ar e diplopia,

dysphonia, dy sart hr ia, and dysphag ia.

7 44 . Fatal familia l insomnia is the rarest of the prion diseases.

7 45. • Fatal familial insom nia is char acterized by sev ere insomn ia,

confusion, other signs of dementia, and aut onomic nerv ous sy stem

instability

7 46 . An aplasmosis (form erly hu m an g ran ulocy tic ehrlichiosis) is

chara cterized by fev er, flu-like symptoms, leukopenia,

thr ombocy topenia, liv er chem istry abnorm alities, an d a peripheral blood sm ear showing m oru la e.

7 47 . Doxy cy cline is the treatm ent of choice for an aplasmosis.

748. A patient with suspected herpes simplex virus encephalitis

requires poly m erase chain reaction of the cerebrospinal fluid and

MRI of the brain t o confirm the diagn osis.

7 49 . Acy clov ir is the preferred initial therapy for a patient with

herpes simplex v iru s encephalitis.

7 50. Keeping m echanically v entilated patients semi-recum bent (at

a 4 5-degree angle) helps prev ent dev elopment of v entilator-

associated pneumonia.

7 51 . Thr om bocy topenia m ay occur in patients who take linezolid for

2 or more w eeks.

7 52 . The decision about wh ether admission to an intensiv e care un it

is needed for patients with comm unity -acquir ed pneum onia is based

on the presence of specific m ajor an d minor cr iteria.

7 53 . Because Legionella pneum onia is of par ticular concern in a



patient with severe community-acquired pneumonia, testing for

urinary Legionella antigen is indicated.

754. Whenever possible, outpatient parenteral therapy should use

drug s tha t can be giv en once daily for conv enience and patient

comfort.

7 55. In pat ients with HIV infection and Kaposi's sar com a, the

sar com a frequently regr esses and som etimes resolv es completely after successful treatment with high ly activ e antir etrov iral

therapy.

7 56. Oral levofloxacin r ather t han intrav enous lev ofloxacin is

indicated for empiric treatm ent of a h ighly com pliant patient with

acute py elonephrit is wh o can eat and drink.

7 57 . The m ost appropriate treatment for a cat bite in a patient with

a penicillin a llergy is tr imeth oprim–sulfam ethoxazole plus

clindamycin.

7 58. Patients with progr essiv e ma ssiv e fibrosis ar e at increased risk

for developing tuberculosis.

759. The most appropriate diagnostic studies for suspected

tubercu losis are tu berculin skin testing and sputum for acid-fast

stain an d culture.

7 60. Staphy lococcus aur eus and Pseudom onas aeru ginosa ar e the

most likely cau ses of septic ar thritis in an in jection dru g u ser.

7 61 . Enterotoxigenic Escherichia coli is the most comm on ca use of

diarrhea in tr av elers to dev eloping coun tr ies.7 62 . Diarrh ea due to enterotoxigenic E. coli is usually a m ild and

self-lim ited illness.

7 63 . West Nile v iru s encepha litis is most likely to occur in patients

65 y ears of age and older.

764. Findings in patients with West Nile virus encephalitis include

fev er, sev ere headache, m arked mu scle weakness inv olv ing th e

lower m otor neur ons, m ental status chang es, and possibly seizur es.

7 65. Th e need for isolat ion precau tions is based on the route of

transmission of the suspected path ogen or the clinica l sy m ptom s of

the patient.

7 66 . Because Francisella tu lar ensis is not tr ansm itted from person

to person, only stan dard precaut ions, ra ther th an isolation

procedur es, ar e required for patients with tu lar emia.

7 67 . Esophagit is in an imm un osuppressed patient is most often

caused by Candida.

7 68 . Echinocandins and tria zoles ar e both effectiv e for t reat ing



Candida esophagit is.

7 69 . Shiga toxin–producin g Escherich ia coli is associated with

dev elopment of the hemoly tic ur emic sy ndrom e.

7 7 0. Administra tion of foscarnet is indicated for a patient w ith

acy clov ir-resistan t herpes simplex v iru s infection.

771. Administration of foscarnet may be associated with significant

electrolyte abnormalities.7 7 2. Prophy lax is is not required for household conta cts of patients

with an inv asiv e streptococca l infection.

7 7 3. If two or more ca ses of inv asiv e streptococcal disease occur in

postpartum or postsurg ical patient s hospitalized within 6 m onth s in

the sam e institution, an epidemiologic inv estigation is required to

determ ine if a hospital w orker is a car rier.

7 7 4. Im mun osuppressed patients are at incr eased risk for

developing nosocomial pneumonia even when mechanical

v enti la tion is not r equir ed.

7 7 5. A “ halo sign” (a nodular lesion w ith a sur rounding

groun d-glass appear ance) on chest ra diogr aphs is char acter istic of

Aspergillu s pneumonia.

7 7 6. Bactericidal agents such a s daptomy cin are m andatory for

treatm ent of endocar ditis.

7 7 7 . Emergence of resistance to daptom y cin is rare, an d

daptom y cin is not correlated with cross-resistan ce to any other dru g

class.7 7 8. Curr ent recommendations do not support use of tubercul in skin

testing as a screening test in otherw ise healthy persons with no

persona l or occupational exposure to persons wit h t uberculosis.

7 7 9. Pneum ococcal strains are becom ing incr easingly resistant to

penicillins and m acr olides.

7 80. Most experts and guidelines support the use of a t hir d-

generation cepha losporin plus a m acr olide for treatm ent of

comm unity -acquired pneum onia.

7 81 . West Nile v iru s can be tra nsmitt ed by blood tran sfusions.

7 82. West Nile v irus can be tran smitted to tra nsplant recipients

from orga n donors.

7 83 . h e prima ry pathogens associated with bloodborn e exposures in

health care workers are HIV, h epatitis B, and hepatitis C.

7 84. • Two or th ree antiretrov iral a gents are recomm ended when a

health care w orker sustains a deep, penetra ting in jury from a sour ce

patient w ho is HIV seropositiv e.



7 85. Oral v algan ciclov ir is as effectiv e as intra v enous ganciclov ir

for treating patients with cy tomegalovir us retinitis.

7 86 . A m acu lopapular r ash, especially on the palm s and soles, is

chara cteristic of dissem inat ed (secondary ) sy philis.

7 87 . A patient with possible neur osyphilis should receiv e

intrav enous aqueous cry stal penicillin G for 1 4 day s.

7 88. Patients with osteomy elitis and an epidura l abscess who do nothav e focal neurologic deficits can u sually be treated with

antim icrobial therapy alone, but m ust be monitored carefully .

7 89 . Aspiration and cultur e of joint flu id is the most appropriate test

for determ ining wh ether a prosthetic joint is infected.

7 90. Patients with pneumonic plague ty pically present with h igh

fev er, headache, my algias, dy spnea, hemopty sis, and wa tery

sputum.

7 91 . Patients with pneumonic plague hav e a mortality rate

approaching 1 00% if not tr eated with streptomy cin with in 24 h our s

of dev elopment of sy m ptom s.

7 92 . An giostrongy lus cantonensis (the r at lu ngw orm ) is the most

common cause of eosinophilic meningitis worldwide.

7 93 . Prev ention of nosocom ial m y cobacterial 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 th e thoracic r egion.7 95. Famciclov ir and v alacy clov ir hav e replaced acyclov ir as the

treatment of choice for patients with herpes zoster.

7 96 . Cuta neous Mycobacterium ma rinu m infection is most often

associat ed with exposure to fish tanks.

7 97 . Th e most a ppropriate diagnostic study is biopsy of a nodule for

histopathologic exam inat ion, a cid-fast stain, and cu lture.

798. Trimethoprim–sulfamethoxazole is the preferred antimicrobial

ther apy for a pat ient with a br ain abscess caused by Nocardia

species.

7 99 . Patients with a presumptiv e diagn osis of Rocky Moun tain

spotted fev er should receiv e treatm ent with doxy cy cline even before

the diagnosis is confirm ed.

800. Cam py lobacter jejuni is the most comm on cau se of bacteria l

diarrheal disease in the United States.

801 . C. jejuni often ca uses disease by cross-contam ina tion of cooking

utensils or sur faces such as coun tertops.



#1

802 . A complete history of antir etrovira l drug use is essential for a

patient with HIV infection w ho has been on m any drug s and is not

benefit ing from the current treatm ent regim en.

803 . Aspergillosis is the m ost comm on pulm onary mold infection in

immunosuppressed patients in the United States.

804 . A spergillu s infection cannot be disting uished from infection

caused by Pseudallescheria before cult ur e results ar e av ailable805. Nosocomial outbreaks of Clostridium difficile and norovirus

hav e been well docum ented in r ecent y ears.

806. Nosocomial outbreaks of C. difficile and norovirus require

contact isolation and increased cleaning of all patients' rooms.

807 . Options for tr eatm ent of comm unity -acquir ed pneumonia in

an outpatient w ithout additional r isk factors include an adv anced-

generation m acr olide or a ketolide or doxy cy cline.

808. Treatm ent of an outpatient with comm unity -acquired

pneumonia should be started without w aiting for results of Gram

stain an d culture.

809. Patients with centra l nerv ous sy stem Ly me disease who are

allerg ic to β-lacta m ant ibiotics should be giv en doxy cy cline.

81 0. Cort icosteroids ha v e been shown to significantly allev iate acute

pain in patients with herpes zoster (shingles).

81 1 . Cort icosteroids are contra indicated in patients w ith poorly

controlled plasma glu cose levels, osteoporosis, or hy pertension.

81 2. Hos

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812. Hospitalized patients with community-acquired pneumonia

can u sually be chan ged from an intra v enous to an oral an tibiotic

regimen w hen fev er, cough , and dy spnea ha v e resolv ed; oral intake



is satisfactory ; and the leukocy te coun t is retu rn ing towar ds

normal.

81 3. A sy m metric m igrat ory joint pain and pustular lesions are

characteristic of disseminated gonococcal infection.

81 4. Cultur es of the phary nx, cerv ix, an d anus should be obtained

for a woman with suspected disseminated gonococcal infection.

81 5. Approxim ately 50% of patients with AIDS and progressiv emultifocal leukoencephalopathy will survive the latter disease if

highly active antiretroviral therapy is administered.

81 6. Poly merase chain r eaction of cerebrospinal flu id is the

preferred test for diagnosing herpes simplex v iru s encepha litis.

81 7 . Acu te cellulitis in an imm unosuppressed patient m ay be due to

unusual pathogens, such a s Cry ptococcus neoform ans.

81 8. Administra tion of zidov udine to a pregna nt patient w ith HIV

infection is believed to reduce the risk of maternal-to-child

tr ansmission of HIV.

81 9. Efav irenz is contr aindicated in a pregnant patient with HIV

infection.

820. Cyclosporiasis is associated with positive acid-fastâ€“stained

stool specimens and copious diarrhea without fever.

821 . The tr eatm ent of choice for cy closporiasis is tr imethoprim â€“

sulfamethoxazole.

822. The in cidence of fluoroquinolone-resistan t N. gonorr hoeae has

been in cr easing, especia lly on the West Coast of the United Statesand in Hawaii.

823 . The most a ppropriate treatm ent for concur rent g onorr hea an d

a chlam y dial infection is a single dose of intra muscular ceftriax one

plus oral azithromy cin.

824. Patient-administered antibiotic therapy is usually appropriate

for w om en with recur rent episodes of un com plicated ur inar y tract

infections.

825. Risk factors for aspiration pneum onia inclu de difficulty

swallowing , episodes of depressed consciousness, an d m echa nica l

factors such as esophageal obstr uction.

826 . Clindamy cin prov ides effectiv e treatm ent for anaerobic

aspiration pneum onia.

827 . Necrotizing fasciitis in an injection dru g u ser m ay be due to

ma ny different orga nisms.

828. The most effectiv e initial empiric antibiotic regim en for

necrotizing fasciitis in an injection drug user is v ancomy cin plus



piperacillinâ€“ta zobactam plus clindamy cin.

829. The m ost successful therapy for t reat ing in fected prosthetic

joints inv olv es rem ov al of the pr osthesis and a 6-week course of

ant imicr obial therapy followed by reim plantation of a new

prosthesis.

83 0. Aztreonam ca n be used safely in patients who ar e allergic to

penicillin.83 1 . The U.S. Centers for Disease Contr ol an d Prev ention in clude

aerosolized v iru ses tha t ca use Ebola, Marbur g, and Lassa fev ers;

Argentine hem orr hagic fev er; and Boliv ian hem orr hagic fev er as

most likely to be used as biochemical w eapons.

83 2. Influenza v iru s resistan ce dev elops rapidly followin g exposure

to riman tadine.

83 3. If one family m ember develops resistan ce after ta king

rim anta dine for treatm ent of influenza, t he resistant v irus can be

tran smitted to other family mem bers.

834 . Hy ponozoites of Plasmodium v iv ax m alar ia ma y rema in in the

liv er for long periods and become reactiv ated at a la ter date.

here is th e Gastroenterology and h epatology notes:

Gastroenterology and hepatology

83 9. Crohn 's disease is more comm on in cur rent sm okers, wh ereasulcerativ e colitis occur s more often in form er smokers an d

nonsmokers.

84 0. Colonoscopic findings in Crohn's disease include deep

ulcerations separated by ar eas of norm al mucosa (skip lesions) and

rectal sparing .

841 . Colonoscopic findings in ulcerativ e colitis include contin uous

inflamm ation, ty pically including the rectum, but w ithout deep

ulcera tions or skip lesions.

842 . Approxim ately 7 0% of patients with g astric or duodenal u lcer

disease also have Helicobacter pylori infection.

843 . Patients with dyspepsia w ithout alar m featur es (v om iting,

weig ht loss, a nem ia) can usually be treated em pir ically for H. py lori

infection.

844. Patients with acute gallstone pancreatitis present with

elev ated serum am inotra nsferase v alues and pancr eatic enzy m e

v alu es that rapidly return toward norm al.



845. Patients with hepatitis C and cirr hosis are at increased risk for

dev elopment of hepatocellular car cinoma.

846 . The finding of a new ma ss with v ascular enhancem ent in a

patient with hepatit is C and cirrh osis alm ost certainly indicates

hepatocellular carcinoma.

847 . The most comm on cau se of ody nopha gia (pain on swallowin g)

is pill-induced esophagit is.84 8. Gastroparesis is a w ell-recogn ized complicat ion 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

sev ere epigastric or right u pper quadran t abdomina l pain that is

usually intermittent, inconsistently associated with nausea or

v omit ing, and occasiona lly nocturnal.

851 . Sy mptoma tic patients with choledocholithiasis almost alwa y s

hav e elev ated serum am inotran sferase va lues.

852 . Upper endoscopy with small bowel biopsies is the definit iv e test

to confirm or exclude a diagn osis of celiac sprue.

853 . An tim itochondrial antibody titers of more or equal to 1 :40

occur in approximately 90% of patients with primar y biliary

cirrhosis.

854 . Marked v olum e depletion is a poor prognostic sign in a patient

with acu te pancr eatit is.855. Vigorous hy dration is critical in a patient w ith acu te

pancreatitis and marked v olum e depletion in order to maxim ize

pancreatic perfusion and reduce subsequent com plications.

856 . Patients wh o ha v e had pancolitis for 1 0 or m ore y ears should

underg o colonoscopy with biopsies ev ery 1 to 2 y ears for colorecta l

cancer sur v eillance.

857. Elevated serum aminotransferase values and a positive assay

for antibody to hepatitis C v iru s (anti-HCV) in a patient w ith r isk

factors for HCV ar e high ly suggestiv e of the presence of hepatitis C.

858. Patients with a positiv e assay for antibody to hepatitis C v iru s

(ant i-HCV) should be tested for HCV RNA to determ ine if v irem ia is

present.

859. A Dieulafoy lesion is an a bnorm ally larg e artery located just

below the gastr ic m ucosa that is pr one t o ru pture and cause la rge-

v olume bleeding.

860. Proton pum p inhibitors are most effectiv e for t reatin g an



active nonsteroidal anti-inflammatory drug (NSAID)â€“induced

ulcer wh en th e NSAID cann ot be discontin ued.

861 . Patients with orophary ngeal dy sphagia ty pically hav e

difficulty swallowing both solid foods and liquids, coughing and

choking during meals, and changes in v oice quality .

862. A v ideofluoroscopy study is the most appropriate initia l test in

patients with suspected oropharyngeal dysphagia.863. Gastrointestinal bleeding, fever, abdominal pain, and

leukocy tosis in a patient with an abdominal prosthetic v ascular

graft should raise suspicion for an aortoenteric fistula.

864. Upper endoscopy is the initia l diagnostic study for ev alu ation of

a possible aort oenter ic fistula.

86 5. If upper endoscopy is norm al despite a strong clinical suspicion

for an aortoenteric fistula, a contrast-enha nced CT scan of the

abdom en should be done next.

866 . Patients with sev ere cholangitis generally present with fev er,

jaundice, and altered m enta l statu s; abdominal pain is u sually , but

not inv ariably , present.

867 . Patients with cholangit is require endoscopic retrograde

cholangiopancreatogr aphy to determ ine the presence of com mon

bile du ct stones and prov ide endoscopic t herapy , if indicated.

868. Endoscopic ultrasonography is the most sensitive test for

diagnosing an insulinoma of the pancr eas.

869. In patients with chr onic ulcerativ e colitis, the finding of low-grade dysplasia on surveillance colonoscopy is associated with

an increased risk of progression to high-grade dysplasia or cancer.

87 0. Patients with chronic ulcerat iv e colitis and dy splasia of any

gr ade detected on sur v eillan ce colonoscopy should be referred for

colectomy.

871. Liver biopsy should be considered for selected patients with

suspected nonalcoholic fatty liv er disease.

87 2. Rosiglita zone or pioglitazone m ay be indicated for patients with

nonalcoholic steatohepatit is and features of the m etabolic sy ndrome

in order to prev ent progr ession of the liv er disease.

87 3. Intr aoperat iv e endoscopy m ay be needed for a pat ient with

unexplained severe recurrent gastrointestinal bleeding that cannot

be diagnosed by less inv asiv e studies.

87 4. Patients with short bowel sy ndrome associated with less than

1 1 5 cm of sm all in testine in the absence of a colon w ill m ost likely

require continuous total parenteral nutrition.



87 5. A proton pum p inhibitor or an H2-receptor anta gonist m ay

help reduce excessiv e gastr ic secretions and stomal flu id losses in

patients with short bowel sy ndrome.

87 6. Bariatric sur gery is effective for reducing m orbidity associated

with obesity -rela ted disorder s, su ch as ty pe 2 dia betes m ell itus,

hy pertension, obstruct iv e sleep apnea, an d hy perlipidemia.

87 7 . â€¢ Dev elopment of gallstones is a comm on complicationfollowing bariatric surgery

87 8. The incidental finding of indirect (un conjugat ed)

hy perbilirubinemia in an asy mptoma tic patient with a norm al

hem oglobin lev el and otherwise norm al liv er tests is indicativ e of

Gilbert's syndrome.

87 9. Tenesmus (a sensation of incomplete ev acu ation of the bowels)

indicates the presence of proctit is.

880. Neisseria gonorr hoeae infection should be considered as a ca use

of proctitis in sexu ally activ e patients.

881 . A patient w ith acu te pancr eatitis should be ev aluat ed for t he

presence of hypertriglyceridemia.

882 . Patients with diabetes mellitus and associated neuropath y ar e

at incr eased risk for dev elopment of small bowel bact erial

overgrowth.

883 . Patients with sma ll bowel bacterial ov ergrowth often ha v e

secondary lactose intolera nce

884 . Patients with acute gastrointestina l bleeding associated withdecreased consciousness, an absent gag reflex, and continued

hem atem esis requir e airw ay protection as the initia l step in

management.

885. Preopera tiv e endoscopic retrograde cholang iopancreatography

is indicated prior to laparoscopic cholecy stectom y only for patients

with gallstones and possible concom itant com mon bile du ct stones.

886 . Patients with a h igh-risk poly poid lesion detected and rem ov ed

during screening colonoscopy should u ndergo sur v eillance

colonoscopy in 3 y ears.

887 . Sy m ptom s of noncardiac chest pain frequently m imic th ose of

cardiac chest pain.

888. The diagnosis of noncardiac ch est pain ca n only be made after a

thorough ev aluation has ru led out ca rdiac cau ses for th e pain.

889 . Low-dose ant idepressants may be helpful in treating patients

with noncardia c chest pain .

890. Antinu clear an tibody and an tiâ€“smooth m uscle antibody



titers m ore or equal to 1 :80 support a diagnosis of aut oimmun e

hepatitis.

891 . Ant imitochondrial ant ibody is the serologic m ar ker for

primary biliary cirrhosis.

892. Gastrinoma (Zollinger-Ellison sy ndrome) and gastric

distention related to gastric outlet obstruction are causes of

hypergastrinemia.893. A helical CT scan of the abdom en is a reasonable initia l test

when ev alu ating a patien t for a possible gastr inoma.

894. Patients who hav e had tw o or more episodes of div erticu litis are

more likely to develop complications such as abscesses, strictures,

and perforation.

895. Patients wh o ha v e had two or m ore episodes of diverticu litis

should undergo surgical resection of the affected intestine.

896 . An a sy m ptoma tic patient with a single positiv e fecal occult

blood test on r out ine scr eening requir es follow-up with colonoscopy .

897 . Can didiasis is the m ost comm on esophageal disorder in patients

with HIV infection.

898. Patients with HIV infection associated with dy sphagia a nd

ody nophagia should r eceiv e an empiric t ria l of fluconazole.

899. Nonulcer dy spepsia is the most comm on ca use of epigastr ic

pain in a y oung , otherw ise healthy patient.

900. A tr ial of a proton pum p inhibitor is war ran ted in a y oung

patient w ith a first episode of nonu lcer dy spepsia a nd a negat iv eserologic t est for Helicobacter py lori .

901 . Chr onic int estina l pseudo-obstruct ion m ay be associated with a

paran eoplastic sy ndrome.

902 . The hallm ark of mesenter ic ischem ia is the presence of pain

tha t is out of proport ion t o the phy sical exa m inat ion findings.

903 . The most comm on ca use of mesenter ic ischem ia is a

prothrombotic state due to an inherited or acquir ed coagu lation

disorder or ma lignancy .

904 . CT an giogr aphy is usually done to establish t he diagnosis of

mesenteric ischemia.

905. Patients with sev ere, acute pancreatitis require enteral, rath er

than parenteral, nu trition.

906 . Fulmina nt hepatic failure is the clinical sy ndrome of sev ere

acute liv er failure and encephalopathy in a patient without

pre-existing liver disease.

907 . Patients with fulminan t hepatic failure require imm ediate



ev aluat ion for liv er tr ansplantat ion.

908. Patients with inflamm atory bowel disease hav e an increased

risk for dev eloping prim ar y sclerosing cholangit is and superim posed

cholangiocarcinoma.

909 . A decreasing h emoglobin level in a stable patient w ith a recent

episode of upper gastrointestinal bleeding may be due to

redistr ibution of fluid into the vascular space rat her th an tocontin uing bleeding.

91 0. Ultrasonographic findings of gallstones, a th ickened gallbladder

wall , per icholecy stic fluid, and a positiv e sonographic Murphy 's sign

are highly specific for a diagnosis of acute cholecy stitis.

91 1 . Initial m anag ement of a patient with acute cholecystitis

includes pain m edication, broad-spectru m antibiotics, and sur gical

consultation for electiv e cholecy stectom y .

91 2. Ar tificial sweeteners that contain poorly absorbed

carbohy drates (e.g., sorbitol, m annitol) may cause flatulence and

diarrhea.

91 3. Ana l fissur es generally cause rectal outlet bleeding and pain

with defecation.

91 4. Anal fissures may occur after a period of constipation.

91 5. Nu tcracker esophagu s is a spastic condition ch ar acter ized by

high-amplitude peristaltic waves on esophageal manometry.

916. Patients with nutcracker esophagus should be evaluated for the

presence of gastroesophageal reflux disease.91 7 . A person wh o has a first-degr ee relat iv e with colorecta l cancer

should initially un derg o colorectal ca ncer screening 1 0 y ears before

the age of diagn osis of the affected relativ e or a t ag e 40 y ears,

whichev er com es fir st.

91 8. Patients with ch ronic pancreat itis often require nar cotics for

pain contr ol.

91 9. Patients with acute hepatitis generally hav e more sy m ptom s,

are m ore likely to be jaundiced, and hav e higher serum

aminotransferase values than those with chronic hepatitis.

92 0. Adults with hepatitis A ar e generally jaundiced, whereas

ma ny infants and children w ith t his infection do not hav e jaundice.

92 1 . A Mallory -Weiss tear is a laceration near the ga stroesophageal

ju nct ion that often result s from forceful retch in g.

92 2. Bleeding from a Mallory -Weiss tear stops sponta neously in

more than 90% of patients.

923. Mesalamine enemas are the most effective initial treatment for



patients with ulcera tiv e proctosigm oiditis.

92 4. The m ost common finding in patients with peptic ulcer disease

is gnawing epigastric pain.

92 5. Pulm onar y infiltra tes, hepatomegaly , and a high alkaline

phosphatase value are indicative of hepatic sarcoidosis.

92 6. Recurr ent at tacks of pancr eatitis in a postcholecy stectom y

patient are most often caused by sphincter of Oddi dysfunction orpancreas div isum .

927. Fever, alcoholism, findings consistent with chronic liver

disease, and a serum aspartate aminotransfera se to seru m a lanine

am inotransferase ratio (AST:ALT) m ore than 2 are associated with

alcoholic hepatitis.

92 8. Self-limited hematochezia is a common cause of ischem ic colitis

in elderly patients.

92 9. Diagnostic studies, other t ha n colonoscopy or flexible

sigmoidoscopy , ar e usually not needed after an episode of ischemic

colitis.

93 0. Patients with docum ented gallbladder stones and unexplained,

nonspecific gastrointestinal symptoms should undergo diagnostic

studies to identify other potential causes before cholecystectomy is

performed.

93 1 . Elderly patients with chronic hepatitis C v irus infection w ho

hav e other comorbid illnesses m ay not be candidates for treatm ent

of hepat itis.93 2. The age of a patient with obscur e gastrointestinal bleeding

helps gu ide the choice of diagn ostic studies to be perform ed.

933. A young patient with obscure gastrointestinal bleeding should

undergo diagnostic studies for Meckel's diverticulum.

93 4. An older patient with obscur e gastrointestinal bleeding should

undergo studies for angiectasias.

93 5. A n intr a-abdominal infection should be excluded before

beginning im munosuppr essiv e agents in a patien t with a sev ere

flar e of Crohn 's disease.

93 6. Hepatic adenom as are the most likely benign liv er tum or to

cause bleeding.

93 7 . Hepatic adenomas should be resected whenev er possible

because of th eir poten tia l for becom ing malignant and their risk for

bleeding.

93 8. Cam eron's erosions are most often foun d in patients w ith lar ge

hiatal hernias and iron deficiency anemia.



93 9. Barr ett's esophagus is a r isk factor for the dev elopment of

esophageal adenocar cinom a.

94 0. Patients with Barr ett's esophagus with out dy splasia should

underg o sur v eillance u pper endoscopy with esophageal biopsies

ev ery 3 y ears after the original diagnosis.

94 1 . Patients with secretory diarr hea of un known cau se should be

ev alu ated for the presence of microscopic colitis.94 2. Biopsies of the colonic m ucosa at the tim e of flexible

sigmoidoscopy or colonoscopy ar e the definitiv e stu dy for diagn osing

microscopic colitis.

94 3. Cav ernous hema ngiom as are benign lesions that are found in

2% of the genera l population.

94 4. Cav ernous hemang iom as are usually found incidentally wh en

patients hav e imaging studies for other indications.

94 5. Patients who hav e diarr hea associated with fever, abdomina l

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 sigm oidoscopy or colonoscopy ar e the definit iv e studies for

diagnosing th e cause of inv asiv e or inflamm atory diarr hea.

94 7 . Upper endoscopy is the m ost appropriate in itial 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 com plicat ion.94 8. Marked elev ations in serum aspart ate am inotran sferase and

alanine am inotran sferase va lues m ay occur in patients with a

skeletal m uscle injury .

94 9. The least inv asiv e palliativ e procedur e for a patient w ith

metastatic pancreatic adenocarcinom a an d malign ant obstru ctiv e

jaundice is pla cem ent of an expandable m etal stent durin g

endoscopic retr ogr ade cholangiopancreatogr aphy .

950. Cholangitis is the most common cause of liver abscesses.

951 . Percutaneous aspiration is helpful for both diagnosis and

treatm ent of py ogenic liv er abscesses.

952 . Patients with am y loidosis frequently hav e diarr hea and

bleeding in addit ion to oth er signs and sy m ptoms.

953 . Patients with primar y sclerosing cholangitis hav e a 1 0% to

30% lifetim e risk of dev eloping cholang iocarcinoma.

954. Eosinophilic esophagitis is occurring more often in adults,

especially those with other atopic disorders.



955. Tr eatm ent of eosinophilic esophagit is includes an elemental

diet and either ora l or topical cort icosteroids.

956 . A patient w ith suspected AIDS cholangiopathy should un dergo

endoscopic retrograde cholangiopancreatography (ERCP) to confirm

the diagnosis.

957. A patient with AIDS cholangiopathy associated with

extra hepatic bile duct obstruct ion should u ndergo ERCP withsphincterotomy.

958 . Hepatic ischem ia is cha racterized by m arked eleva tions in

serum am inotra nsferase v alues that r apidly improv e within sev eral

days.

959 . Patients with n onu lcer dy spepsia in w hom H2-receptor

ant agonists hav e been ineffectiv e should be treated with a proton

pump inhibitor.

96 0. Comm on v ariable imm unodeficiency should be suspected in a

patient wit h r ecurr ent ga strointestinal infections (especially

giar diasis) and r espiratory infections.

96 1 . Pneum atic dilation is the initial treatm ent for patients with

achalasia.

96 2. Patients with achalasia w ho do not respond to pneum atic

dilation m ay require my otomy .

96 3. Patients with cirr hosis should undergo upper endoscopy to

determ ine th e presence of esophageal v ar ices.

964. Patients with large esophageal varices should receive anonselectiv e Î²-blocker for prophy laxis ag ainst v ar iceal bleeding.

965. Certain medications, including antidepressant agents and

calcium ch ann el blockers, increase colonic tr ansit tim e and may

cause constipation.

96 6. Tr iple therapy (a proton pum p inhibitor an d tw o antibiotics) is

the most effectiv e regim en for eradication of Helicobacter py lori.

96 7 . Tr iple therapy for eradication of H. py lori should be giv en for

1 0 to 1 4 day s.

96 8. Patients with hereditary hemochroma tosis usually present

with abnorm al l iv er tests, a rthropathy , fatigue, and im potence.

96 9. â€¢ The most appropriate initial diagnostic study for a patient

with suspect ed heredit ary hem ochromatosis is determin ation of

tran sferr in satur ation

97 0. A low-dose antidepressant m ay be effectiv e for t reat ing

patients with nonulcer dy spepsia.

97 1 . CT enterogra phy is the most a ppropriate study for a patient



with possible Crohn 's disease but with a norm al colonoscopic

examination.

97 2. Persons with one or m ore adenomatous colorecta l poly ps ha v e

an incr eased risk for dev eloping colorecta l cancer.

97 3. Persons with one or m ore a denomatous colorecta l poly ps should

un dergo periodic colonoscopic surv eillan ce to detect colorectal

cancer.97 4. In patients with ch ronic hepatitis B and cirrh osis, one of the

ora l agents is preferred to pegy lated interferon because interferon

may be associated with m ore serious com plications, such as hepatic

decompensation and infection.

97 5. Patients with cir rh osis and gastrointestinal bleeding should

receiv e a 7 -day cour se of norfloxacin as prophy lax is aga inst

spontaneous bacterial peritonitis.

97 6. Patients with ischem ic colitis ma y hav e a hy potensiv e episode

followed by abdom inal pain and subsequently by hem atochezia.

97 7 . Fundic gland poly ps are th e most comm on t y pe of

non-neoplastic polyp found in the stomach.

97 8. Fundic glan d poly ps ar e asy m ptom atic an d do not present a

risk for m alignan t tran sform ation.

97 9. The treatm ent of choice for a pat ient with th e HELLP sy ndrome

(hem oly sis, elev ated liv er enzy mes, low platelets) is prom pt deliv ery

of the infant.

980. Adm inistrat ion of ora l pancreat ic enzy me supplements must be spaced out during a meal (one t hir d at the start of th e m eal, one

third during the m eal, and one third directly after th e meal) in

order to be effectiv e.

981 . Either azath ioprine or 6 -mercaptopur ine prov ides effectiv e

maintenance therapy followin g a cort icosteroid-induced rem ission

in patients with ulcerative colitis.

982 . Early detection a nd sur gical r esection provide the only chan ce

for cu re in a patient with gastric cancer.

983. New-onset obstruct iv e jaundice in an elderly patient is most

often due to pancreatic or biliary tract can cer.

984. Pseudoachalasia m ay be associated with the presence of a

malignant disorder.

985. Elderly patients with achalasia should undergo upper

endoscopy to rule out pseudoach ala sia.

986. The symptoms of pseudoachalasia m ay mimic those of

idiopathic (benign) acha lasia.



987 . The most common cau ses of serum am inotransferase v alu es

more tha n 5000 U/L ar e acetaminophen hepatotoxicity , hepatic

ischem ia, an d hepatitis due to un usual v iru ses.

988. Persons with alcoholism can dev elop acetam inophen

hepatotoxicity wh en taking lower doses of acetam inophen than those

necessary to cau se liv er dam age in persons with out alcoholism .

989. Endoscopic treatment of pancreatic duct strictures may reduceabdom inal pain.

99 0. Radiation colitis ty pically occur s 9 m onth s to 4 y ears after

radiation th erapy for prostate, gy necologic, or other pelv ic

malignancies.

991. Symptoms of radiation colitis include tenesmus, diarrhea, and

hematochezia.

992. Acute colonic pseudo-obstruction is a frequent postoperative

complication th at is aggr av ated by electroly te imbalances and

admin istration of narcotics.

99 3. The ma jor complicat ions of acute colonic pseudo-obstr uction

are cecal ischemia and possible perforation of the cecum.

99 4. Patients ov er 40 y ears of age who hav e had chronic sy m ptom s

of gastroesophageal reflux disease for more t han 5 y ears should

undergo screening for Barrett's esophagus.

99 5. Upper endoscopy is the test of choice for patient s with

gastroesophageal reflux disease who ar e un derg oing screening for

Barrett's esophagu s.99 6. Budesonide is the drug of choice for t reating a Cr ohn 's disease

flare tha t is limited to the ileum .

99 7 . Colorectal cancer screening for av erage-risk persons should

begin at 50 y ears of ag e.

998. Recommended colorectal cancer screening studies for

average-risk persons include fecal occult blood testing, flexible

sigm oidoscopy , bar ium enema exam inat ion, and colonoscopy .

999. Most patients with primary sclerosing cholangitis also have

ulcerative colitis.

1 000. The diagn osis of prima ry sclerosing cholangit is is established

by im aging stu dies th at show a â€œstring of beadsâ€� pattern in

the biliary tree.

1 001 . Pancreat icoduodenectom y (Whipple procedure) offers the best

chance of cure for a patient w ith cancer of the head of the pancreas.

1 002 . For im mun osuppressed tran splant recipients wh o dev elop

odynophagia, upper endoscopy to establish the cause should be



considered rather than empiric therapy .

1 003 . Bism uth subsalicy late is effectiv e for inducing prolonged

remissions in patients with collagenous colitis.

1 004 . The 1 4C-urea breath test is the most sensitiv e and specific

noninv asiv e study for docum enting a ctiv e Helicobacter py lori

infection.

1 005. A positiv e serologic t est for H. py lori indicates only pastexposure to the organism; th is test does not determ ine act iv e

infection.

1 006 . Findings of v asculitis and positiv e antibody to hepatitis C

v ir us (anti-HCV ) a re consistent with cr y oglobulinem ia associated

with hepatitis C.

1 007 . An giectasias (va scular m alform ations) are m ost often

diagnosed in elderly patients with chr onic occult ga strointestinal

bleeding.

1 008. Ang iectasias may occur an y where in the gastrointestinal

tract a nd m ay be bey ond the reach of stan dard upper endoscopes

and colonoscopes.

1 009 . A h elical CT scan of the abdomen is the most sensitiv e and

specific initial im agin g study for a patient w ith possible pancreatic

adenocarcinoma.

1 01 0. The first step in ev aluat ing a patient with recurr ent nausea is

to rule out common systemic disorders such as thyroid disease,

diabetes mellitus, and electroly te abnorma lities.1 01 1 . Sponta neous bacteria l peritonitis is an ascitic fluid infection

tha t is a comm on complication in patients with cirr hosis.

1 01 2. Sponta neous bacteria l peritonitis should be suspected in an y

patient w ith cirr hosis and new or worsening decom pensation.

1 01 3. The choice of diagn ostic studies for a patient w ith obscur e

gastrointestina l bleeding should ta ke into account the patient's age

and the presence of significant comorbid conditions.

1 01 4. Dru gâ€“drug interactions are comm on in patients taking

tacr olim us or cy closporine plus other medications.

1 01 5. Calcium ch annel blockers ma y interfere with t he metabolism

of ta crolimus.

1 01 6. Dy ssenergic defecation (pelv ic floor dy sfun ction) r efers to

impair ed defecation cau sed by inappropriate contr action or

impair ed relax ation of the puborectal is and external ana l sphincter

muscles.

1 01 7 . An orectal m anometry is the m ost appropriate study for



diagnosing dyssenergic defecation.

1 01 8. The m ost comm on sy m ptom s of paraesophageal hernia a re

postprandial fullness, pain, and v omiting.

1 01 9. A paraesophageal hernia m ay be associated with gastric

ischemia as a result of torsion of the stomach.

1 020. The recomm ended treatm ent for a sy m ptom atic

paraesophageal hernia is ur gent r epair of the hernia.1 021 . Eradication of Helicobacter py lori is associated with a

significant decrease in th e risk of dev eloping a r ecurr ent u lcer.

1 022. Era dication of H. py lori does not r educe t he r isk of dev eloping

gastric cancer.

1 023. Becau se patients with celiac sprue ar e at increased risk for

osteoporosis and osteomalacia, monitoring of serum vitamin D and

calcium lev els is required.

1 024 . The most appropriate treatm ent for prim ary biliary cirrh osis

is ursodeoxycholic acid.

1 025. Approxim ately 3% to 5% of patients found to ha v e one

colorecta l cancer w ill hav e one or m ore sy nchronous cancers in

other areas of the colon.

1026. A patient diagnosed with colorectal cancer requires

ev alu ation of the entire colon either preoperativ ely or

postoperat iv ely to detect possible sy nch ronous lesions.

1 027 . Patients with longstanding ulcerativ e colitis hav e an

increased risk of developing colorectal cancer.1028. â€¢ Proctocolectomy should be considered for patients with

ulcerativ e colitis associated w ith colonic dy splasia

1029. The overall risk of maternalâ€“fetal transmission of hepatitis

C is approxim ately 5%.

1 03 0. Mothers infected with both h epatitis C and HIV hav e an

increased risk of transmitt ing hepatitis C to their new born s.

1 031 . To determ ine the occurr ence of matern alâ€“fetal

tr ansmission of hepat itis C, the newborn should be checked for HCV

RNA a t 2 to 6 m onth s of age.

1 032 . Patients with postcholecystectomy bile leak usually present

with diffu se abdominal pain, nausea, fev er, and m ild

hyperbilirubinemia.

1 03 3. â€¢ Postcholecy stectomy bile leaks can be identified by

endoscopic retr ogr ade cholangiopancreatogr aphy

1 034 . The presence of a hy perv ascular hepatic mass in a patient

with cirrhosis an d a high serum Î±-fetoprotein lev el is diagnostic of



hepatocellular carcinoma.

1 035. Patients with adv anced liv er disease and hepatocellular

carcinoma should usually be ev alua ted for liv er tra nsplantat ion.

1036. Patients with familial pancreatitis are at increased risk for

dev eloping pancreatic adenocar cinoma.

1 03 7 . The initial test in a patient w ith possible gastr ic out let

obstr uction is upper endoscopy .1 038 . A seru mâ €“ascites albumin gra dient (SAAG) m ore than or

equa l to 1 .1 g/dL is consistent w ith portal hy pertension.

1 03 9. Portal h y pertension is m ost often due to cirrh osis.

1 040. Fundoplication should be considered for a patient with sev ere

iron deficiency anem ia associated with Cameron's erosions who

cannot tolerate oral iron therapy.

1 041 . The gr eat m ajority of recurr ent colorectal cancers dev elop

within 2 y ears postoperativ ely .

1 042. A patient wh o has undergone resection for colorecta l cancer

requires surv eillance colonoscopy 3 y ears postoperat iv ely to detect

the possible presence of metachronous lesions.

1 044. Pill-induced esophagit is is cha racterized by the acute onset of

painful swallowing (odynophagia) shortly after a patient begins

taking a drug.

1 045. Tr eatm ent of pill-induced esophagitis inv olv es discontin uing

the causativ e drug.

1046. Wilson's disease should be considered in a young patient withabnorm al liv er chemistry studies, cognitiv e changes, and

hemolysis.

1 047 . A low seru m ceruloplasmin v alue ( less tha n 20 m g/dL) is

indicativ e of Wilson's disease.

1 048. Patients with a cute div erticulitis who are able to take liquids

and are not dehy drated can usually be manag ed on an outpatient

basis.

1 049 . The initial steps in ma naging outpatients with acute

diverticu litis are administration of ora l ant ibiotics and

re-ev alua tion in sev eral day s.

1 050. Th e preferred treatm ent of gastroparesis in th e United States

is administration of metoclopramide.

1 051 . Ery thr omy cin should be considered for patients with

gastropar esis wh o cannot tolerate m etoclopram ide.

1 052. Obesity , hy perlipidemia, and hy pergly cemia are risk factors

for nonalcoholic fatty liv er disease.



1 053. Nearly 40% of patients with nonalcoholic fatty liv er disease

do not ha v e obv ious risk factors for t his condition.

1 054. A m ucinous cy stic neoplasm of the pancr eas is often

asy mptomatic and is detected as an incidental finding dur ing

abdom inal imagin g studies for other causes.

1 055. Because of its m align ant potential , a mucin ous cy stic

neoplasm of the pan creas should be surg ically resected.1 056. Patients who hav e undergone gastrectom y ma y dev elop

dumping sy ndrom e, which is char acterized by nau sea, abdomina l

pain and distention, lightheadedness, and diaphoresis.

1 057 . Patients with dum ping sy ndrome should initially be treated

conserv ativ ely with a diet consisting of six small m eals daily .

1 058. A Dieulafoy lesion is an u nusually large aberra nt submu cosal

artery tha t can cause significant gastrointestinal bleeding.

1 059. A Dieula foy lesion m ay be missed on u pper endoscopy un less

activ e bleeding is occur ring a t the tim e of the endoscopic

examination.

1 060. A proton pum p inhibitor is the agent of choice for h ealing a

nonsteroidal anti-inflammatory drug (NSAID)â€“induced gastric

ulcer after t he NSAID has been discontin ued.

1061. Prostaglandin analogues may prevent NSAID-induced lesions

but do not treat an act iv e u lcer.

1 062 . Patients with either chronic mesenteric ischemia or a

ma lignancy m ay present w ith similar findings of postprandial pain, weig ht loss, a nd anorexia.

1 063. The diagnosis of chr onic m esenteric ischem ia is established by

the clin ical h istory and findings of comprom ised mesenteric v essels

on im aging studies.

1 064 . The tr eatment of chronic mesenteric ischemia is either a

surgical or an interventional radiologic revascularization

procedure.

1 065. Patients with chronic hemoly sis may dev elop secondary iron

overload.

RHEUMATOLOGY

1 066. Manifestat ions of sy stemic lupus ery them atosus include

arth ralg ias, photosensitiv e rash, m alar rash, oral u lcers,

pancytopenia, and serositis.



1 067 . The m ost comm on joints inv olv ed in osteoarth ritis are the

knee, hip, distal an d proxima l interpha langeal, an d first

carpometacarpal.

1 068. Osteoarth ritis is char acterized by pain that worsens with

activ ity and m ornin g joint stiffness that lasts less than 30 min utes.

1 069. Postmenopausal women who use diuretics hav e an increased

risk for tophaceous gout of the distal interphalangeal joints.1 07 0. Patients with diffuse cutaneous sy stemic sclerosis are at

increased risk for dev eloping in terstitial lun g disease.

1 07 1 . A ntiâ€“Scl-7 0 an tibodies are m ost frequently associated with

diffuse cutan eous sy stemic sclerosis and an in creased risk for

interstitial lun g disease.

1 07 2. Chest r adiogra phy frequently does not detect early

interstitial fibrosis.

1 07 3. The chronic inflam ma tory state of rheuma toid arth ritis is

associated with an in creased risk for death from a coronar y ev ent.

1 07 4. The ery thr ocy te sedimentation r ate is useful for monitoring

chronic inflam ma tory chang es but m ay be elev ated in th e setting of

adv anced age, an emia , and other disease states.

1 07 5. Takay asu's arteritis is a ch ronic, idiopathic, gr anu lom atous

inflamm atory disease prim arily of the aorta and its main branches

tha t affects reproductiv e-age w om en.

1076. Constitutional symptoms and ischemic signs or symptoms in

the terr itory of one or m ore lar ge arteries in a w om an 1 8 m onth s of minocy cline exposure.

1 095. Liv er inv olv ement in minocy cline-induced lupus often

mim ics autoimm une h epatitis.

1 096. Th e clinical presentat ion of adult contacts of children with

parv ov irus B1 9 infection m ay mim ic rheuma toid arthritis.

1 097 . Parv ov irus B1 9â €“related arth ritis is self-limited, ma y not

hav e an associated rash, r esolv es within 1 to 2 m onths, and u sually

responds to nonsteroidal anti-inflamm atory drug s.

1 098. Poly m y algia rheuma tica is char acterized by pain or m ornin g

stiffness in the neck or torso, shoulders and upper a rm s, or h ips an d

thighs in patients >50 y ears of age with a n ery thr ocy te

sedimentation rate >4 0 mm /h.

1 099 . Prednisone thera py rapidly allev iates sy mptoms of

polymyalgia rheumatica.

1 1 00. Olecran on bur sitis may be infectious, cry stalline, or

traumatic.



1 1 01 . Bursa aspiration is indicated for patients with a cute olecran on

bursitis to gu ide therapy .

1 1 02. Patients with fibromy algia h av e widespread mu sculoskeletal

pain a nd stiffness, par esthesias, nonrestorativ e sleep, fatigue, an d

mu ltiple sym metrical painful tender points.

1 1 03. Results of laborat ory studies in patients with fibrom y algia are

normal.1 1 04. Patients with a long h istory of Ray nau d's phenom enon and

diffuse or limited cutaneous scleroderm a a re a t r isk for pulm onary

v ascu la r disea se.

1 1 05. High-dose cort icosteroid therapy in t he setting of scleroderm a

may be associated with n orm otensiv e renal cr isis.

1106. Invasive diagnostic studies or empirical treatment is not

indicated in asy mptomatic patients with a n isolated elev ated

creatine kinase level.

1 1 07 . Ant iâ€“cy clic citru llinated peptide antibody positiv ity is

strongly associated with r heum atoid arth ritis and may hav e the

best predictiv e v alu e w hen com bin ed w ith rheumatoid factor

measurement.

1 1 08. Patients taking prednisone, equal or m ore than 5 m g/d, for

more than 3 months ma y benefit from calcium and v itam in D

supplements and a bisphosphonate.

1 1 09. Allopur inol is equally effectiv e in the setting of inefficient

excretion a nd ov erproduct ion of urate.1 1 1 0. Allopurin ol at a dose of more than 3 00 m g/d is necessar y for

approxim ately 50% of patients with hy peru ricemia in order to

achiev e ura te lev els less than 6 m g/dL.

1 1 1 1 . Antibiotics, such a s am picillinâ€“sulbactam and others with

broad-spect rum cov erage, are indicated for anim al bites.

1 1 1 2. There is no treatm ent for scleroderm a that is disease

modifying.

1 1 1 3. Thera py for scleroderm a inv olv es sy stematic m anag ement of

end-orga n inv olv ement.

1 1 1 4. In patients with scleroderm a, h igh-dose cort icosteroid therapy

may be associated with n orm otensiv e renal cr isis.

1 1 1 5. Estrogen th erapy is contr aindicated in women w ith

antiphospholipid antibodies.

1 1 1 6. An unexplained prolonged activ ated part ial throm boplastin

time raises suspicion for the antiphospholipid antibody syndrome.

1 1 1 7 . Rheum atoid ar thritis predisposes patients to secondary



osteoarthritis.

1 1 1 8. Imm ediate prednisone thera py is indicated for patients with

clinical suspicion for gian t cell a rteritis before tem pora l ar tery

biopsy to decr ease the r isk for v isual loss.

1 1 1 9. Low-dose aspirin m ay decrease v isua l loss and cerebrovascular

incidents in th e setting of giant cell art eritis.

1 1 20. Left shoulder pain m ay be referred from th e neck; chest; orsubdiaphrag ma tic ar ea, including the spleen.

1 1 21 . Intr a-articu lar corticosteroid injections effectiv ely reliev e

symptoms of knee osteoarthritis.

1 1 22 . Sm all-bowel bacterial ov ergrowth is a comm on ca use of

diarrhea in patients with scleroderm a and is treated with

interm ittent broad-spectru m ant ibiotics.

1 1 23 . Opioid antidiarrheal thera py is not indicated for patients with

scleroderm a because it may worsen int estina l m otility disorders.

1 1 24 . Psoriatic a rthritis is associated with dacty litis and

asym m etrical distal interphalan geal joint inflamm ation.

1 1 25. The risk for m align ant disease is incr eased in derm atomy ositis

and poly my ositis and in inclusion body my ositis.

1 1 26 . â€¢ Ev aluation for an u nderly ing m alignancy is indicated in

patients with refractory m y ositis

1 1 27 . Combination th erapy with methotrexate and antiâ€“tum or

necrosis factor agents is the most likely regim en to improv e

function, limit furt her dam age, an d contr ol disease in sev ererheuma toid arth ritis.

1 1 28 . Im mun osuppressed patients hav e increased risk for

developing primary or reactivation tuberculosis.

1 1 29 . Prophy lactic isoniazid therapy is beneficial in patients wh o

use prednisone, equal or m ore than 1 5 mg/d, or any other

imm unosuppressiv e agent and wh o hav e equal or m ore than 5 m m

of indura tion on tuberculin skin testing.

1 1 30. Urate lev els in patients with tophaceous gout should be

reduced to 6.0 mg/dL (0.36 mm ol/L) to dissolv e tophi and other

ur ate depositions in the t issue.

1 1 31 . Because decreasing the ur ate lev el in a patient w ith

tophaceous gout may induce a gouty attack, continuation of

prophylactic doses of colchicine is indicated until the tophi resolve

and the urate lev el stabilizes.

1 1 32 . Acetaminophen is an effectiv e, safe, an d inexpensiv e

treatm ent for osteoarthritis.



1 1 33 . Patients with osteoart hr itis wh o hav e high risk for

nonsteroidal ant i-inflamm atory drug complications m ay use

alternate therapy with acetaminophen, often w ithout

comprom ising pain control.

1 1 34 . Patients with joint a bnorm alities hav e an increased risk for

joint in fect ion.

1 1 35. Intr a-articu lar corticosteroid therapy is contr aindicated unt ilinfection is excluded.

1 1 36 . Alv eolar hemorrhage may dev elop in systemic lupus

ery thema tosus even without hemopty sis.

1 1 37 . Am y loidosis is an u ncomm on but potential ly sev ere side effect

of chr onic inflam m atory diseases, such as rheumatoid ar thr itis.

1138. Rheumatoid arthritisâ€“associated amyloidosis primarily

inv olv es the kidney s and may lead to the nephrotic sy ndrome an d

renal failure.

1 1 39 . Patients treated with cy clophosphamide hav e increased risk

for transitional cell carcinom a of the bladder.

1 1 40. Lifelong screening for bladder can cer is indicated for pat ients

treated with cy clophospham ide.

1 1 41 . Adequate draina ge and intrav enous antibiotics are standard

treatment for a â€œclosed-spaceâ€� joint infection.

1 1 42 . The m alar rash of sy stemic lupus ery thema tosus is often

photosensitiv e and spar es the nasolabia l folds an d areas below the

nar es and lower lip.1 1 43 . Rosacea is an inflam ma tory derm atitis characterized by

ery thema, telangiectasias, papules, pustules, and sebaceous

hyperplasia that affects the central face, including the nasolabial

folds.

1 1 44 . A ntiâ€“tu mor necrosis factor-Î± therapy is contr aindicated in

patients with infection.

1 1 45. Corticosteroid-induced my opathy is chara cterized by

continued or worsening proximal muscle weakness, particularly in

the lower extr emities, after a decrease in or n orm alization of muscle

enzy m e levels.

1 1 46 . Tr am adol is as effective a s ibuprofen in allev iating pain in

osteoarthrit is of the hip an d knee in patients in w hom nonsteroidal

ant i-inflam matory drug s ar e contr aindicated or do not prov ide

adequa te pain relief.

1 1 47 . Upper- and lower-extremity weakness and gait abnorm alities

associated with rheumatoid arthritis strongly suggest cervical spine



impingement.

1 1 48. Im mediate MRI scanning is indicated in patients with

rheuma toid arthritis with suspected cerv ical spine impingement.

1149. Postexposure prophylaxis may benefit immunocompromised

patients exposed to influenza virus.

1 1 50. Administration of antiv iral t herapy does not affect the

immune response to inactivated influenza vaccine.1 1 51 . Intra nasal triv alent liv e-attenua ted influenza v accination is

contr aindicated in immun osuppressed patients.

1 1 52. Colchicine toxicity may cause acute v acuolar m y opathy and

axonal neuropathy .

1 1 53. Use of colchicin e with inhibitors of CYP3A4 and

P-gly coprotein, w hich metabolize and tr ansport this agent,

respectiv ely , may increase the likelihood of drug toxicity .

1 1 54. Calcification of the car tilage, particular ly the fibrocartilag e of

the knee meniscus, sy m phy sis pubis, and glenoid and acetabular

labrum and the tr iangu lar cartilag e of the wr ist, is pathognom ic for

calcium py rophospha te deposition disease.

1 1 55. An a ty pical distribution of osteoar thr itis without a history of

trauma suggests calcium py rophosphate deposition disease.

1 1 56. Prednisone an d hy droxy chloroquine are t he preferred

anti-inflamm atory drugs during pregnancy .

1 1 57 . Upwa rd titr ation of prednisone may be indicated if other

immunosuppressant agents are discontinued during pregnancy.1 1 58. Hemorr hag ic cy stitis and bladder ca ncer ar e uncomm on side

effects of cyclophosphamide therapy.

1 1 59. Follow-up cy stoscopy is indicated for patients with hem atu ria

and a history of treatment with cyclophosphamide.

1 1 60. Methotrexate rema ins a v ital dru g in the treatment of

rheuma toid arth ritis.

1 1 61 . Combination th erapy with methotrexate and antiâ€“tum or

necr osis factor-Î± agents pr ov ides the best suppression of joint

damage an d leads to ma xima l clinical improv ement in r heum atoid

arthritis.

1 1 62 . Wegener's gran uloma tosis is a necrotizing gra nulomatous

inflammation of small- to medium-sized vessels with a predilection

for th e upper and lower r espiratory tracts and kidney s.

1 1 63 . LÃ¶fgr en's syn drom e, a v ar iant of sarcoidosis, is cha racterized

by the concomitant presence of acute er y them a nodosum , hilar

adenopathy , ar thr itis or periar thr itis, an d fev er.



1 1 64 . Compar ed with phy sical exam ination, ra diogra phy of the

hands is less sensitiv e 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 erosiv e changes and n ew boneform ation in the distal joints.

1 1 67 . Methotrexate is metabolized by the liv er and excreted by the

kidney s and should be reduced or discontin ued in the setting of rena l

insufficiency.

1 1 68. Inclusion body my ositis is characterized by proxima l an d

distal m uscle inv olv ement, asy m metrical m uscle weakness and

atr ophy , falls, and mixed neur opathic an d my opathic findings on

electromyography.

1 1 69 . Muscle biopsy is the diagnostic study of choice for my ositis.

1170. Characteristic radiographic changes of the hands associated

with rheumatoid arthrit is include juxta-ar ticula r osteoporosis and

mar gina l erosions in the m etacar pophalangeal joints.

1 1 7 1 . Propy lthiour acil use is strongly associated with the

dev elopment of antineut rophil cy toplasm ic antibodies directed

aga inst m y eloperoxidase and associated v asculitis.

1 1 7 2. An tineutrophil cy toplasm ic antibodyâ €“positiv e

drug -induced v asculitis may contin ue to progress afterdiscontin uation of the in citing medication.

1 1 7 3. Whipple's disease is a chronic infection w ith m ult iorg an

manifestations, including uveitis, diplopia, asymmetrical

inflamm atory arth ritis, and weight loss.

1 1 7 4. Corticosteroid therapy often r esolv es poly my algia r heum atica

sy m ptom s within 2 4 hour s.

1 1 7 5. The mean duration of therapy for poly my algia rheumatica is

2. 4 y ears at an a v erage prednisone dose of 9.6 m g/d.

1 1 7 6. Hy droxy chloroquine therapy is associated with retinal

toxicity.

1 1 7 7 . Antinuclear antibody positivity may occur in 1 0% to 1 5% of

healthy y oung women, in pregnancy , and with increasing age.

1 1 7 8. An a ntinu clear a ntibody a ssay is indicated only if there is a

high pretest probability of sy stem ic lupus ery thematosus or another

conn ectiv e tissue disease.

1 1 7 9. Inflamm atory chan ges in anky losing spondy litis begin in the



T1 2 to L1 region of the spine and eventua lly lead to ossification of the

out er fibers of the an nu lus fibrosis and the dev elopment of

syndesmophytes.

1 1 80. Cry oglobulinemic v asculitis is char acterized by palpable

purpura, a rth ritis, weakness, neuropathy , and a

membranoproliferative glomerulonephritis.

1 1 81 . Laborat ory findings in cry oglobulinemic v asculitis includecirculating cry oglobulins, r heum atoid factor positiv ity ,

hy pocomplementemia, a nd an elev ated ery thr ocy te sedimentation

rate.

1 1 82. Hepatit is C is a common cau se of cry oglobulin emic v asculitis.

1 1 83. Art hr itis associated with h epatitis C infection m ay occur

early or la te in the disease cour se of this infection and may m imic

rheuma toid arth ritis.

1 1 84. Ev en in the absence of arthritis, patients with hepatitis C

infection often ar e rh eum atoid factor positiv e.

1 1 85. Primar y Ray nau d's phenom enon is not ty pically associated

with damaging dig ital ischem ia.

1 1 86. The preferred initial treatment for prima ry Ray nau d's

phenom enon is nonpharm acologic.

1 1 87 . Concomitan t use of sulfameth oxazole and methotrexat e is

contraindicated.

1 1 88. Manifestations of inflam ma tory my ositis ma y include

elev ated antinu clear an tibody titers and creatine kinase lev els,abnorm al electrom y ogra phy findings, proximal m uscle weakness,

interstitial lu ng disease, arth ritis, and skin rashes.

1 1 89. Reactiv e arthritis is a sy stemic inflamm atory disorder

tr iggered by a m ucosal infection in the urethra or the bowel and is

manifested by a nonseptic oligoarticu lar ar thritis; enth esitis; and,

occasionally, eye, skin, or mucosal inflammation.

1 1 90. SjÃ¶gren's sy ndrom e is char acterized by oral and ocular

dry ness and ant i-Ro/SSA and/or anti-La/SSB antibody positiv ity in

women between 40 and 60 y ears of ag e.

1 1 91 . SjÃ¶gren's syndrome is associated with an in creased risk for

non-Hodgkin's ly mphoma and other ly mphoprolifera tiv e conditions.

1 1 92 . A complete response to appropriate antibiotic th erapy for

disseminated gonorr hea m ay take up to 7 2 hour s.

1 1 93 . Patients with n ongonococcal septic arthritis ma y hav e

positive blood cultures and extra-articular sites of infection.

1 1 94 . Hemorrhagic cy stitis is a possible complication of



cyclophosphamide therapy.

1 1 95. Mononeuritis mu ltiplex is a common presenting featu re of

polyarteritis nodosa.

1 1 96 . Extr a-art icular m anifestations of anky losing spondy litis

include aortitis with aortic insufficiency , upper-lobe pulm onary

fibrocystic disease, amyloidosis, cardiac conduction disease, and

recurrent uveitis.1 1 97 . Relapsing poly chondritis is chara cterized by inflamm ation

and destruct ion of car tilag inous struct ur es.

1 1 98. The most common presenting featu re associated with

relapsing poly chondritis is au ricu lar pain and swelling .

1 1 99 . Reactiv e arthr itis is char acterized by large-joint

oligoar thritis; enthesitis inv olv ing tendon insert ion sites; and extr a-

articu lar ma nifestations, including uv eitis.

1 200. Reactiv e arth ritis is tr iggered by infections in the intestines;

ur ogenital tr act; and, less comm only , th roat or r espiratory tract.

1 201 . Needle aspiration is the least inv asiv e method for draining a n

easily accessible joint, such as the kn ee.

1 202. In th e setting of septic art hr itis, a decrease of fluid v olum e

and leukocy te and neutr ophil coun ts in seria l samples sug gests

adequa te needle drainage, w hereas persistence of inflamm atory

fluid after 7 day s of therapy sugg ests treatment failure.

1 203 . Ant iâ€“tum or necrosis factor-Î± th erapy incr eases the risk for

reactivation tuberculosis.1 204. Ev alu ation for possible septic ar thr itis is indicated for a ll

patients with a cute m onoarticu lar a rth ritis.

1 205. Patients with prev iously damaged joints and

immunosuppression are at particularly high risk for septic arthritis.

1 206. Periphera l joint disease in psoriatic arthr itis responds to

methotrexate an d sulfasalazine, whereas related spinal

inflam mation does not.

1 207 . Psoriatic spinal inflam mation responds to ant iâ€“tum or

necrosis factor thera py .

1 208. BehÃ§et's disease is cha ra cterized by recur rent aphth ous ora l

ulcers and at least tw o or m ore of the followin g featur es: recur rent

genita l u lcerat ion, ey e or cutaneous lesions, or positiv e findings on

pathergy testing.

1 209 . Sy nov ial fluid in osteoarth ritis usually is clear, v iscous, and

noninflamm atory with a leukocy te count less tha n 2000/ÂµL (2 Ã—

109/L).



1 21 0. Gout a nd pseudogout a re associated with inflamm atory

sy nov ial fluid with a leukocy te count between 2000/Âµ L (2 Ã—

1 09/L) and 50,000/ÂµL (50 Ã— 1 09/L) but ma y be higher.

1 21 1 . Sy nov ial fluid in septic arthr itis is generally highly

inflamm atory with a leukocy te count between 1 0,000/ÂµL (1 0 Ã—

1 09/L) and 50,000/Âµ L (50 Ã— 1 09/L) and is often higher.

1 21 2. Patients with the clinical triad of asthm a, na sal poly ps, andaspirin allergy also ma y hav e cross-reactiv ity to nonsteroidal

anti-inflammatory drugs.

1 21 3. N onacety lated salicy late agents m ay be safely used in

patients with a spirin sensitiv ity and asthma .

1 21 4. A nteroposterior plain radiography of the pelv is is the initia l

imaging test of choice for suspected sacr oiliit is.

1 21 5. If findings on plain r adiogra phy are u nequiv ocal or n orm al,

MRI may detect subchondral osteitis and bone m ar row edema

associated with early sacroiliitis and enthesitis.

Here is the Hematology Oncology notes:

1 21 1 . Patients with acut e v enous thromboembolism and metastatic

cancer a re at higher risk for recurrent v enous thr om bosis tha n those

without m alignancy .

1 21 2. Chronic low-molecular-weight heparin at therapeutic doses

reduces the r isk for thr ombotic recurr ence com pared with stan dard-

intensity war farin in patients with v enous thr om boembolism andcancer.

1 21 3. Hemat ologic findings in iron-deficiency anem ia consist of

microcy tic, h y pochr omic red blood cells; abnorm alities in

ery throcy te size and shape; and occasional bizar re-sha ped red blood

cells.

1 21 4. Iron-deficiency anemia is treated with iron th erapy .

1 21 5. Transfusion-related acute lung inju ry is an inflamm atory

infusion r eaction in the pulm onar y v asculatur e man ifested

primar ily by h y poxemia.

1 21 6. Major diagnostic criteria of poly cy themia v era include an

elev ated red blood cell mass, a norma l blood oxy gen satu ra tion, a nd

the presence of splenomegaly.

1 21 7 . Low-dose aspirin reduces the r isk of thrombotic complications

in poly cy themia v era.

1 21 8. Th e electrophoretic gel in patients with hem oglobin SC disease

is cha racterized by tw o bands of equal intensity that ar e



slow-migrating.

1 21 9. Monoclonal g am m opathy of unknown significance (MGUS) is

chara cterized by the presence of serum m onoclonal g am m aglobulin

without the clinical features of mult iple m y elom a, a paraprotein

lev el less than 3 .5 g/dL (35 g/L), and less than 1 0% plasmacy tosis in

the bone marrow.

1 220. Managem ent of MGUS requir es rout ine follow-up to identify signs of progression to mu ltiple my elom a a nd periodic measur ement

of serum monoclonal protein concentration.

1 22 1 . Intr aoperativ e acute normov olemic hem odilution ensures

deliv ery of autologous blood with a hematocrit h igher than the blood

lost during sur gery and has none of the clerica l r isks associated with

blood banking.

1 222. Periphera l neur opathy is a comm on side effect of bortezomib

therapy , occurr ing in approxim ately 30% of patients who take this

agent.

1 22 3. A rapidly falling platelet count occur ring w ithin day s of

heparin a dministra tion is indicativ e of hepar in-induced

thr ombocy topenia (HIT).

1 22 4. In patients with HIT, heparin t herapy mu st stopped and

alternativ e anticoagula tion w ith a direct thrombin inh ibitor

instituted imm ediately .

1 225. Estrogen-conta ining ora l contr aceptiv es confer a four fold

increased relativ e risk for v enous thromboembolism in w omen of childbearing a ge with out h eritable thr om bophilia and a 35-fold

increased risk in women who are heterozy gous for t he factor V

Leiden m uta tion.

1 22 6. Oral progestin-only â€“containing contr aceptiv es appear to

confer litt le, if any , increased risk for v enous thrombosis.

1 22 7 . No other interv ention is required in han dling a delay ed

hem oly tic tr ansfusion r eaction except for a v oidance of the

incompatible antigen.

1 228. Sign s sug gestiv e of disease transform ation from

my elody splastic sy ndrome to acu te my eloid leukemia (AML) include

sev ere pancy topenia an d circu latin g m y eloid blasts on peripheral

blood sm ear.

1 229. Patients with t ra nsform ed v ersus de novo AML ha v e poorer

response rates and disease-free sur v iv al, despite receiv ing the sam e

chemotherapeutic r egimen.

1 23 0. Patients with the Î±-thalassemia t rait hav e a tw o-gene defect



([Î±,--]/[Î±,--]) in the Î±-globin gene chain of chromosome 1 6.

1 23 1 . Patients wh o hav e Î±-thalassemia trait ha v e mild m icrocy tic

anem ia with prominent tar get cells on peripheral blood smear.

1 23 2. Routine blood tran sfusion during pregnancy in patients with

sickle cell disease is not necessary unless mandated by other

high-risk conditions.

1 23 3. The risk for r ecurrent v enous thr om bosis in patients with th efactor V Leiden muta tion is not gr eater th an tha t in th ose without

an underly ing thr om bophilic abnorm ality .

1 23 4. Patients at high risk for recurr ent throm bosis should receiv e

long-term anticoagu lation therapy with w arfarin.

1 235. Patients with delay ed-onset heparin-induced

thr ombocy topenia (HIT) can present with ty pical manifestat ions of

HIT as late as 3 to 4 weeks after heparin exposure.

1 236. Patients with delay ed-onset HIT require an ticoagu lation

therapy with a direct thr ombin inh ibitor a nd no fur ther exposur e to

heparin.

1 23 7 . Acu te chest sy ndrom e (ACS) is char acterized by fev er, chest

pain, shortness of breath, hy poxia, and a chest infiltrate in a patient

with a sicklin g disorder.

1 23 8. Patients with ACS require ery thr ocy te transfusion to achiev e

a targ et hem oglobin of 10 g/dL (1 00 g/L).

1 23 9. Ery thr opoietin therapy has been shown to improv e anemia

and reduce tr ansfusion r equirements in some patients withtransfusion-dependent my elody splastic syndrome.

1 24 0. Patients with a dru g-induced antibody reaction do not h av e

indications of hem oly sis or ev idence of complement activ ation on

direct antibody testing.

1 24 1 . Factor V Leiden and prothrombin G202 1 0A m utat ions are the

most com mon m uta tions predisposing to v enous th rombosis in w hite

populat ions, but a re r ar e in Asian a nd black populat ions.

1 24 2. Lev els of protein S are reduced dur ing pregnancy , m aking

testing for deficiency of this protein un reliable.

1 243 . Bone m ar row aspira te and biopsy should be perform ed in

patients with suspected idiopathic t hr ombocy topenic pur pura wh o

do not respond to prednisone ther apy .

1244. Immunosuppressive therapy with antithymocyte globulin

and cy closporin e is effectiv e in reducin g tr ansfusion r equir ements in

more than 7 0% of patients with aplastic anem ia.

1 24 5. Inflamm atory anemia is char acterized by a low or normal



serum iron concentr ation, reduced serum total iron-binding

capacity , and serum ferr itin that is not decreased.

1 24 6. Hy percalcemia, bone pain, an emia, an d clusters of large

plasma cells on bone marr ow aspirate smear are diagnostic of

multiple myeloma.

1 24 7 . The r isk for t hr om bosis in a sy m ptom atic pregnant women

who ar e heterozy gous for the factor V Leiden mutation is low.1 248 . Com plete hem atologic r emission r ates for pat ients with CML

who receiv ed imatinib mesy la te compared w ith interferon a nd

low-dose cy tar abine were 95% and 56%, r espectiv ely .

1 24 9. Thrombotic thr om bocy topenia pur pura (TTP) is

characterized by fever, neurologic abnormalities,

thr ombocy topenia, m icroangiopathic hemoly tic anem ia, an d renal

insufficiency.

1 250. The treatm ent of choice for TTP is emerg ent plasma exchang e,

followed by plasma in fusion w hen the form er is not im m ediately

available.

1 251 . Patients with heart failure and hemoly sis require immediate

transfusion, ev en wh en only incom patible blood is av ailable, to

av oid cardiov ascular collapse.

1 252 . The initial treatm ent in patients with w arm antibody

autoim mu ne hem oly tic an emia is corticosteroid therapy .

1 253. Patients whose first thrombotic ev ents are associated with

transient risk factors are at r elativ ely low r isk for a sponta neousrecur rent v enous th rombotic episode.

1 254 . Incidental thr om bocy topenia of pregnancy requires careful

follow-up monitoring of the platelet count.

1255. Patients with incidental thrombocytopenia of pregnancy

require further diagnostic ev alua tion wh en platelet v alues decrease

to lower tha n 7 0,000/Î¼L (7 0Ã— 1 09/L).

1 256. Drug -induced agra nu locy tosis is the most likely diagnosis in

patients with sepsis, sev ere neutr openia, a nd relativ ely

well-preserv ed hem atocrit and platelet counts a fter ingestion of

trimethoprimâ€“sulfamethoxazole

1 257 . A history of mu cosal bleeding and a mildly prolonged

activ ated partia l thromboplastin time is consistent w ith a diagnosis

of von Willebran d's disease.

1 258. Factor V Leiden m utation is associated with v enous, not

arterial , th romboses.

1 259 . Ery thr opoietin failure in patients receiv ing dialy sis can be



cau sed by iron deficiency , folat e deficiency , ongoing blood loss, or

iron ov erload.

1 26 0. Supplemental v itam in C can im prov e the response to

erythropoietin in patients receiving dialysis.

1 26 1 . Patients with iron-deficiency anemia r equire

iron-replacement therapy , n ot blood transfusion.

1 262 . Prim ary (AL) amy loidosis should be suspected in patients with nephrotic-range pr oteinuria in the pr esence of monoclonal

gam ma globulin in serum or ur ine.

1 263 . A diagnosis of prim ar y (AL) amy loidosis can be established by

kidney biopsy .

1 26 4. Bleeding sy m ptom s and hema tologic abnormalities in

patients with autoim mu ne disorders, m alignan cy , or in the

postpartum setting m ay be suggestiv e of an acquired factor VIII

inhibitor.

1 265. Fondaparin ux a dministered for 2 8 day s results in a low

frequency of v enous thr omboembolism after hip-fractu re repair and

is FDA approved for extended thromboprophylaxis following this

procedure.

1 26 6. Patients with hereditary spherocy tosis hav e predomina ntly

spher ocy tic r ed cells on th e peripheral blood smear; a mild, Coomb's-

negativ e, hemoly tic anemia; and an elev ated mean cellular

hem oglobin concentr ation.

1 26 7 . A n ew alloantibody is not alw ay s detectable in patients withsickle cell disease who hav e adv erse tran sfusion react ions.

1 268 . Patients with sickle cell disease may experience infusion-

related reactions that ar e man ifested by lower, r ather than higher,

reticulocyte counts.

1 26 9. Fatigue, weight loss, m assiv e splenom egaly , a nd teardrop-

sha ped ery thr ocy tes on periphera l blood are consistent with

myelofibrosis.

1 27 0. Chronic tra nsfusion therapy is an appropriate mana gement

option for some patients wit h m y elofibrosis.

1 27 1 . Isolated thrombocy topenia in an otherw ise-healthy y oung

patient is most comm only due to idiopathic thrombocy topenic

purpur a (ITP).

1 27 2. Patients with ITP and low risk for bleeding as demonstrated by

a platelet count > 40, 000 require only periodic monitorin g of the

platelet coun t.

1273. Patients with venous thromboembolism associated with oral



contr aceptiv es are generally at low risk for recurr ent v enous

thromboembolism.

1274. Long-term oral anticoagulation is recommended in patients

with unprov oked v enous thrombotic ev ents in association with

ant iphospholipid an tibody syndrome.

1 27 5. Patients with asy m ptom atic inflam ma tory anemia do not

require additional diagnostic t esting.1 27 6. Nonhem oly tic tra nsfusion r eactions result in

inflamm atory -ty pe sy m ptom s without ev idence of hemoly sis.

1 27 7 . Stopping th e blood transfusion is the only interv ention

required in the management of nonhemolytic transfusion reactions

and should result in qu ick symptomatic r esolut ion.

1 27 8. A disease-free and ov erall sur v iv al benefit is observ ed in

patients receiv ing high-dose chem other apy and au tologous stem cell

tran splantation during first r emission from mu ltiple m y elom a.

1 27 9. The HELLP sy ndrom e (hemoly sis, eleva ted liv er enzy m es,

and low platelets) usually resolv es within sev eral day s after

deliv ery of the fetus.

1 280. An inherited thr om bocy topenic disorder should be suspected

in otherwise-healthy patients with a low platelet count, giant

platelets on peripheral blood smear, a fam ily history of

thr ombocy topenia, and w ho are refractory to cort icosteroids

1 281 . Patients with v itamin B1 2 deficiency hav e elev ated serum

lactate dehy drogenase and unconjuga ted biliru bin and may hav eincr eased forg etfuln ess.

1 28 2. Supplemental v itam in B1 2 does not alway s rev erse the

neurologic findings of B1 2 deficiency but m ay prevent further

deterioration of mental status.

1 28 3. Patients with pulmonary hemorrha ge and those undergoing

most ty pes of ma jor surger y need sustained platelet counts of

40, 000 (40 Ã— 109/L) to 50,000/Î¼L (50 Ã— 109/L).

1 28 4. The sy m ptoms of serotonin sy ndrom e may include

tachy cardia, h y pertension, h y pertherm ia, m y driasis, h y peractiv e

bowel sounds, diaphoresis, hy perreflexia , clonu s, and changes in

mental statu s.

1 285. War farin w ith a tar get INR of 2 to 3 is adequa te for

prev enting r ecurrent v enous thr ombosis in patients with

ant iphospholipid an tibody syndrome.

1 28 6. Patients with th alassemia m ay experience secondary iron

overload due to increased iron absorption from the gut.



#2

1 28 7 . Deferoxam ine is a parenteral iron chelator that is used to

decrease the tissue iron in patients with tha lassemia.

1288. Leukoreduced blood should be used in pregnant patients in

whom the cy tomegalov ir us infection sta tus is not known .

1 28 9. Ima tinib mesyla te can cause a mild, maculopapular ra sh tha t

is most promin ent ov er the extremities and tr unk, and ty pically

resolv es within a week of interru ption of therapy .1 290. For m ost patients wh o experience an im atin ib-induced rash,

the drug can be re-instituted after the rash resolv es, without

recurrence.

1291. Consumptive coagulopathy is often accompanied by

thr ombocy topenia and a prolonged prothrombin tim e.

1 292 . All stages of Hodgkin's ly mphoma now are tr eated with

sy stemic chem otherapy and no longer r equire inv asiv e testing to

identify the extent of disease.

1 293 . Mortality in patients with stage III colon can cer treated with

sur gical r esection and adjuv ant chemotherapy is decreased by as

mu ch as 33 %.

1 29 4. Patients with BRCA1 /2 m utat ions hav e a higher r isk for

breast and ov arian ca ncer compared w ith the general population.

1 29 5. Patients with a family history sugg estiv e of germ line-

susceptibility cancer should be referr ed for genetic counseling.

1 296 . Gonadotropin-releasing h orm one ag onists such as leuprolide

may result in bone loss in th e lum bar spine in patients with prostatecancer.

1 297 . Î²-Carotene is associated with an incr eased risk for lung

cancer in patie


triplehelix - 01-12-09 23:55

1 297 . Î²-Carotene is associated with an incr eased risk for lungcancer in pat ients wh o alr eady hav e an elev ated risk for th is disease

because of smokin g history .

1 298 . Serum Î±-fetoprotein has a ha lf-life of 1 week and requir es

re-measurement at 1 4 to 21 days after surgery .

1 29 9. Sur gery alone is cur ativ e for patients with early -stage

ov arian ca ncer in 9 0% of cases.

1 300. Ly mphadenopathy in the supraclav icular r egion alm ost



alw ay s indicates an infectious or n eoplastic cause and requires an

imm ediate diagnostic procedur e.

1 301 . A complete ly mph node excision is alw ay s preferred ov er a

percutaneous needle biopsy in patient s with suspected Hodgkin 's or

non-Hodgkin's lymphoma.

1 302 . Patients with colon ca ncer an d unr esectable liv er m etastases

require sy stemic treatment with chemotherapy .1 303 . Additional diagnostic testing for extr ahepatic m etastases is

necessary only wh en surgical r esection of hepatic m etastases is a

consideration.

1 304. A diet high in fruit s and v egetables is associated with a lower

risk for car diov ascular disease but n ot for cancer.

1305. Hyperviscosity syndrome must be considered in patients who

have lymphoplasmacytic lymphoma (WaldenstrÃ¶m's

ma croglobulinemia) w ith an elev ated serum IgM concentrat ion and

sy m ptom s sug gestiv e of congestiv e heart failur e.

1 306 . Emergent plasmapheresis and im mediate sy stemic

chemotherapy is required in patients with ly mphoplasm acy tic

ly mphoma and a seru m v iscosity concentrat ion m ore than 3. 0 with

suspicious sy mptoms, or a v alu e of more than 4. 0 wit hout suspicious

symptoms.

1 307 . Patients with prostate cancer are generally asym ptom atic at

diagnosis.

1 308. Patients with recently diagnosed prostate cancer an d aprostate-specific ant igen concentr ation less than 1 0 ng /mL (1 0

Î¼g/L) hav e a low incidence of bony metastasis.

1 309 . Only w omen w ho are at high risk for ov arian ca ncer should

consider prophy lactic bilatera l oophorectomy .

1 31 0. Lung ca ncer screening does not decrease m ortality and is not

supported by ev idence.

1 31 1 . In patients with adenocarcinoma of unknown primar y site,

the w orku p should be guided by the patient's history and phy sical

and labora tory findings.

1 31 2. Gemcita bine is Food and Drug Administrat ion approv ed for

the tr eatment of metastatic pancreatic can cer and r esults in

improv ed clinical benefit and ov erall surv iv al compared with

5-fluorouracil.

1 31 3. Hodgkin's ly mphoma sur v iv ors wh o receiv e extended-field

radiation hav e a 1 % risk/y ear for dev eloping solid tum ors.

1 31 4. Tum or ly sis sy ndrome is a considerat ion in patients who hav e



bulky Burkitt's ly mphoma and sy m ptoms of v omit ing and

dehydration.

1 31 5. Patients with sy mptomatic bulky ly mphoma require

hy dration, ur inary alkalinization, an d administration of a xanthine

oxidase inhibitor before chem otherapy to prev ent tum or ly sis

syndrome.

1 31 6. Breast-conserv ing surgery results in similar and sometim essuperior sur v iv al in patients with early -stage breast cancer

regardless of patient a ge compared with m astectomy .

1 31 7 . Re-excision is indicated in patients with positiv e tum or

margins detected after breast-conserving surgery.

1 31 8. Av oiding direct sunligh t during peak hours and other

sun-avoidance strategies are associated with a decreased risk for

squam ous cell carcinoma an d maligna nt m elanoma .

1319. Sunscreen may decrease the risk for developing squamous cell

carcinoma but not malignan t melanoma.

1 320. Selenium ha s been associated with an in creased risk for

nonmelan omatous skin cancer com pared with placebo.

1 32 1 . Treatm ent of patients with testicular cancer m etastatic to the

brain consists of whole-brain radia tion therapy and com bin ation

chemotherapy.

1 32 2. Preoperat iv e radiation therapy plus chemotherapy can

reduce tum or size and facilita tes sphincter-preserv ing sur gery in

patients with distal rectal tumors.1 323. Gastric m ucosa-associated ly mphoid tissue (MALT)

ly mphoma is alm ost alway s associated with Helicobacter py lori

infection.

1 324. Disease in m ost patients with MALT ly m phoma regresses after

treatm ent w ith a ntibiotics alone with in sev eral m onths.

1 325. Most patients with small-cell lung ca ncer r espond

drama tically to combination chemotherapy and w hole-brain

radiation therapy .

1 326. Bisphosphonates such as pamidronate or zolendronat e help

reduce skeletal-related ev ents in patients with m etastatic lun g

cancer.

1 32 7 . Patients with abnorm al breast findings on phy sical

examina tion an d norm al m am mogram should undergo further

ev aluat ion w ith breast ultr asonogra phy and biopsy .

1 32 8. Sensitiv ity of mam mography ranges from 7 5% to 90%, with

false-negativ e results most likely in w omen with dense breasts.



1 32 9. Patients with stage T1 c prostate cancer an d a PSA less than 1 0

ng/m L (1 0 Î¼g/L) rar ely ha v e metastatic disease and don't need

extensiv e staging

1 330. Ov ar ian cancer screening does not result in decreased

mortality in genera l or high-risk populat ions.

1 33 1 . The infrequency of ov arian can cer occurr ence and

inv asiv eness of the associated diagnostic procedur es make routineov arian cancer screening ina ppropriate.

1 332. The risks of chemotherapy in bedbound patients with

colorecta l cancer w ho hav e a poor perform ance statu s outw eigh its

benefit s because of poor likelihood for response a nd therapy -induced

toxicity.

1333. Patients with histologically confirmed adenocarcinoma of the

axillary ly mph nodes but no clinically or radiologically detected

breast abnorm alities should be treated for sta ge II breast cancer .

1 33 4. Watchful w aiting is appropriate for patients with

adv anced-stage follicula r ly mphoma un less the disease progr esses

rapidly or poses an im minent thr eat to well-being.

1 33 5. Although there is no curr ent cur e for patients with

adv anced-stage follicular ly mphoma, the m edian sur v iv al ran ges

from 1 0 to 1 4 y ears.

1 33 6. Tam oxifen decreases breast can cer r isk by approxim ately

50% in pre- and postmenopau sal w om en wh o hav e an elev ated risk

for this disease.1 33 7 . Tam oxifen is the only Food and Dru g

Adm inistrationâ€“approv ed m edication for use in decreasing breast

cancer r isk.

1 338. Infection w ith hepatitis B or C is associated with an increased

risk for hepatocellula r car cinoma.

1 33 9. Hepatitis B and C are endem ic to m any parts of the

dev eloping w orld, especially South east Asia.

1 340. In th e Gleason h istologic scorin g sy stem , gr ade 1 represents

the most well-differentiat ed tum ors, and gr ade 5 r epresents th e m ost

poorly different iated tum ors.

1 341 . Gleason scores consist of two scores deriv ed from the m ost

prev alent a nd second most prev alent differentiat ed tumors, wh ich

result s in a combined score.

1 342 . The first of the two reported Gleason scores in th e com bined

score m ay be most predictiv e of outcome.

1343. Mixed seminomatous and nonseminomatous germ cell tumors



should be man aged as though they were nonseminomat ous tum ors.

1 34 4. Chem otherapy is indicated in th e treatment of mixed

seminom atous and nonseminomat ous germ cell tum ors.

1 345. Flow cy tometry of the peripheral blood is the best and least

inv asiv e way to establish a diagn osis in patients with suspicious

lymphocytosis.

1 346 . Sma ll-cell lung cancer is presum ed to be a sy stemic disease with m icrometasta ses, ev en when it appears to be isolated and

resectable.

1 34 7 . Sy stemic chemotherapy is a r equired com ponent of therapy

in patients with small-cell lung cancer, ev en in th ose with

lim ited-stage disease.

1 34 8. The concomita nt u se of chemotherapy and ra diation th erapy

confers a small sur v iv al benefit ov er sequential use of these

modalities or ch emotherapy alone.

1 34 9. Finasteride reduces prostate cancer preva lence by 25%.

1 350. Finasteride is associated with higher-gra de tum ors and more

sexual side effects but fewer sy m ptom s of ur inar y obstruct ion

compared with placebo.

1351. Patients with squamous cell carcinoma (SCC) of unknown

primar y site and upper or m idcerv ical ly mph node inv olv ement

should be treated for locally adv anced SCC of the h ead and neck.

1 352 . A romatase inhibitors ar e m ore effectiv e v ersus tam oxifen in

preventing breast cancer recurrence in postmenopausal women.1 353. Marginal-zone B-cell ly m phom a has been associated with

hepatitis C v iru s in some patients; treatm ent of the underly ing

infection m ay result in rem ission of the ly m phom a.

1 354 . Young, ma le patients with poorly differentiated midline

carcinoma containing germ cell cancer markers and isochromosome

1 2p are likely to hav e extr agonadal germ cell cancer and may

respond to cisplatin-based chemotherapy.

1 355. Docetaxel plus prednisone improves sur v iv al in men with

metastatic prostate cancer refractory to hormonal ablation therapy

when com pared w ith mitoxantrone plu s prednisone.

1 356. Most patients become azoosperm ic short ly after ch emotherapy

for testicular germ cell cancer, but they ma y regain normalized

sperm count s with in 2 y ears; howev er, ma ny rema in infertile or

subfertile.

1 357 . Sperm storage is offered to men with testicular cancer before

they undergo chemotherapy.



1 358. In patients with m etastatic HER2-positiv e breast cancer ,

trastuzumab an d chemotherapy result in prolonged sur v iv al

compar ed with ch emotherapy alone.

1359. In patients with early-stage resectable nonâ€“small-cell lung

cancer, th e use of adjuv ant chemotherapy is a n ew standard of care

replacing the former approach of providing no further therapy.

1 36 0. Diffuse larg e B-cell ly mphoma requires sy stemic th erapy even when results of CT scans and positron emission tomography

(PET) are negative.

1 361 . Ritux imab and CHOP (cy clophospham ide, doxorubicin,

v in cr istine, and prednisone), with or without radia tion therapy , is

cur ativ e for m ost patients with diffuse lar ge B-cell ly mphoma.

1 362 . Follow-up evalu ation of postmenopau sal w om en with breast

cancer wh o un derg o successful t reatment consists of annua l

mammography.

1 363 . Smoking cessation is the most effectiv e cancer prev ention

stra tegy for patients who are at h igh r isk for lung cancer.

1 36 4. Bronchioloalv eolar cell carcinom a h as a distinct pattern of

presentat ion an d responds un iquely to therapy with th e new

epiderm al g rowth factor r eceptor in hibitors.

1 36 5. Some patients with primar y or r ecurrent bronchioloalv eolar

cell car cinom a w ho receiv e daily oral erlotinib or gefitinib hav e

periods of disease reduction lasting from 1 to 2 years.

1 36 6. Com bination h orm one replacement therapy has been shownto increase the risk for breast cancer.

1 367 . Follow-up exam inat ions for patients with successfully treated

testicular cancer should include studies focused only on new

sy m ptom s rath er than an ar bitrary schedule of ima ging or

workups.

1 368 . Patients with a poor perform ance status and widely

metastatic nonâ€“smal l-cell lung ca ncer of squam ous cell histology

alm ost nev er respond to any ty pe of therapy and requir e hospice

care.

1 36 9. Women with a history of ov arian cancer hav e a higher risk

for breast cancer than that of the av erage population.

1 37 0. Ova rian can cer metastasizes comm only to the pleura an d

peritoneum , rarely to bone or liv er, and alm ost never to breast.

1 37 1 . Breast cancer m etastasizes comm only to the pleur a,

peritoneum , liv er and bone.



Endocrin ology and m etabolism

1 37 2. The insulin sensitizing drug s metform in and the

thia zolidinediones are contr aindicated in patients with adv anced

heart failure.

1 37 3. Thy roid horm one increases the metabolism of war farin butincreases the turnover of clotting proteins ev en more, resulting in a

decreased dose requirement of wa rfar in.

1 37 4. In an asy mptomatic patient w ith mild hy percalcemia and an

inappropriately norm al parath y roid horm one level, the main

differential includes prim ary hy perparat hy roidism v ersus benign

familial hypocalciuric hypercalcemia.

1 37 5. Fam ilial hy pocalciuric hy percalcemia is diagnosed by a

ur inary calcium /creatinine clearance ratio less tha n 0.01 m easur ed

in a fasting morn ing ur ine spot collection.

1 37 6. Severe hy pogonadism in a y oung m ale with an elev ated

serum prolactin lev el strongly sugg ests pituitar y ma croadenoma

and war ran ts ev alua tion of the entire pituitar y .

1 37 7 . Patients with Cushing's sy ndrome produce thr ee to four times

the amount of urine free cortisol that unaffected persons produce.

1378. The three screening tests for Cushing's syndrome are

measur ement of ur ine free cort isol, the ov ernig ht dexam ethasone

suppression test, a nd the late-ev ening saliv ar y cort isol test.1 37 9. Risk factors for hy popituitar ism include prev ious

ma croadenom a, pituitar y sur gery , and brain r adiation.

1 380. Mult iple endocrin e neoplasia ty pe 2A is char acterized by

pheochr omocy toma , medullary thy roid carcinom a, and

hy perparat hy roidism due to parathy roid hy perplasia.

1 381 . Th e goal of preopera tiv e blood pressure control in patients

with pheochromocy tom a is less than 1 40/90 mm Hg.

1382. Î±-Adrenergic blockade is used to reduce preoperative blood

pressure in patients with pheochr om ocy toma.

1 38 3. No pharm acologic thera py is m ore effectiv e than diet and

exercise in prev enting the progr ession to ty pe 2 diabetes in patients

with predia betes.

1 38 4. Th e indications for para thy roidectomy in a patient with m ild,

asym ptoma tic hy percalcemia secondary to primar y

hy perparat hy roidism are age less tha n 50 y ears, serum calcium

level m ore than 1 .0 m g/dL (0.25 mm ol/L) abov e the upper lim it of



norm al, 24 -hour u rine calcium excretion more than 4 00 mg (1 0

mm ol), creatinine clearance reduced by more than 30%, a nd a bone

minera l density T score less than 2.5 at an y site.

1 38 5. The cau se of prim ary hy perparat hy roidism in m ost cases is a

single para thy roid adenom a.

1 38 6. Substernal g oiter results in a n arr owed thoracic inlet, w hich

is fur ther comprom ised by extension of the arm s ov er th e head,resulting in compression of the great v eins of the neck and the

mar ked facial plethora known as Pemberton's sign.

1 38 7 . Pituitar y apoplexy is the sudden onset of headache, v isual

disturban ces, opthalm oplegia, and menta l status cha nges caused by

the acut e hemorr hag e or infarction of the pituitar y gland.

1 38 8. Urgent neurosur gical ev acuat ion of the hem orr hag e is

generally indicated for patients with pituitar y apoplexy and ra pidly

progr essing v isua l disturban ces and/or m ental statu s changes.

1 38 9. A n oncontr ast CT scan can distingu ish between pituitar y

apoplexy and subarachn oid hemorr hag e as patients with pituitar y

apoplexy will demonstrate acute hemorrh age in the region of the

sella tu rcica.

1 390. In a patient w ith androgen-dependent hir sutism w ho does not

wish to becom e pr egnant, antiandrogen and ov arian suppression

therapy is usually effectiv e.

1 39 1 . The 25-hy droxy v itam in D lev el is a m arker of body stores of

v itamin D and is m easured as the in it ia l step in the ev alu ation of suspected nutritional vitamin D deficiency.

1 39 2. Coronary art ery disease may be silent in patients with

long-standing diabetes mellitus or present a ty pically .

1 39 3. Dyspnea in a patient w ith an extensiv e history of complicated

diabetes should be considered an angina l equiv alent.

1 39 4. Subclinical hy pothy roidism is an elev ated serum TSH level

with a free T4 that is still within the popula tion refer ence range.

1 39 5. Patients with subclinical hy pothy roidism w ho hav e a serum

TSH v alue abov e 10 Â µU/mL (1 0 mU/L) hav e been shown t o hav e

reductions in their LDL cholesterol concentr ations when treated

with lev othy roxine.

1 39 6. Hy pom agnesemia in th e patient with a lcoholism can m imic

hy poparathy roidism , including sev ere hy pocalcemia and

hyperphosphatemia.

1 39 7 . New-onset hirsutism w ith v irilization, particularly in an

older w oman, an d accom panied by a seru m total t estosterone lev el



more than 200 ng/dL (6.9 nm ol/L) is almost alw ay s due to a tum or.

1 398 . Excision of a cortisol-producing adrenal adenoma results in

rapid cleara nce of cort isol with in the first 24 hours after sur gery

and subsequent acu te adrena l insufficiency ; cort icosteroid

replacement is the appropriate therapy

1 39 9. Growth hormone stim ulation t esting is more sensitiv e and

specific for determin ing growth h orm one deficiency than m easur ing basal horm one lev els.

1 400. Because of the potential n ephr otoxicity of intra v enous

radiocontr ast agents, m etform in, w hich accum ulates in renal

insufficiency , should not be administered wh en any ra diogr aphic

procedur e using an intr av enous contr ast agent is perform ed.

1 401 . Inhibition of the r enin-angiotensin axis reduces proteinur ia

and preserv es renal funct ion in pat ients with diabetes m ellitus.

1 402. A dom inan t thy roid nodule shown to be benign by fine-needle

aspiration biopsy should be followed by serial monitoring with

ultr asoun d to assess size stability .

1403. Pseudo-Cushing's syndrome consists of hypercortisolism in

patients with such disorders as depression and alcohol use that alter

hy potha lam ic - pituitar y - adrenal function enough to pertu rb

screening tests for Cushing's syndrome.

1 404 . If standard screening tests are equiv ocal in a patient w ith a

strong pretest probability for Cushing 's sy ndrome, the combined

dexam ethasone - CRH stim ula tion test m ay distinguish Cushing'ssyndrome from pseudo-Cushing's syndrome.

1 405. Th e therapy of choice for un com plicated Paget's disease is an

ora l bisphosphonate.

1 406. In men, excessive production of glu cocort icoids causes

hy pogonadotropic hy pogonadism w ith dimin ished libido and loss of

secondary sexual characteristics, in conjunction with commonly

recognized manifestations of Cushing's syndrome.

1 407 . On CT scan of the adrenal glan ds, adenoma s usually hav e

sm ooth borders, are less tha n 4 cm in diameter, unilateral,

homogenous in consistency , and less than 1 0 Houn sfield units in

density.

1 408. The serum TSH cannot be used to m onitor thy roid hormone

replacement therapy in patients with centr al hy pothy roidism

1 409 . On patients with centr al hy pothy roidism, the goal of thy roid

hormone r eplacem ent is to titr ate the dose to normalize the free T4

(or t otal T4 and free thy roxine index) not to norm alize the TSH.



1 41 0. Patients with ty pe 2 diabetes taking m onotherapy often

require multidru g therapy as the durat ion of disease incr eases and

beta-cell destruct ion progr esses.

1 41 1 . The addition of one class of dru g to another is the cur rent

fav ored approach in th e patient w ith ty pe 2 diabetes and progressive

hy pergly cemia despite monotherapy .

1 41 2. Measurem ent of TSH-receptor au toantibodies, which arepresent in m ore than 90% of patients with Gr av es' disease but ar e

not present in postpartum t hy roiditis, can disting uish between the

two disorders in a patient w ith postpregn ancy thy rotoxicosis.

1 41 3. Patients with gestational diabetes m ellitus hav e a 50% r isk of

dev eloping ty pe 2 diabetes m ellitus in the 5 to 1 0 y ears after the

diagn osis of gestat ional diabetes.

1 41 4. Nonâ€“parat hy roid horm oneâ€“mediated hy percalcemia is

chara cterized by suppressed parat hy roid horm one lev els.

1415. In most cases of malignancy-associated hypercalcemia, the

tum or produces par ath y roid hormoneâ€“r elated peptide, which

sha res significant homology with m any of the metabolic actions of

parathy roid horm one.

1 41 6. A gra dual decline in strength, cognitiv e and sexual function,

and an hedonia in an elderly male suggests testosterone deficiency ,

and replacement therapy m ay be offered.

1 41 7 . Electroly te abnorm alities are generally not observ ed in

patients with central adrenal insufficiency due to the fact tha t thealdosterone system is still functional.

1 41 8. Multiple endocrine neoplasia (MEN) ty pe 2A is an au tosomal

dom inant sy ndrome in which adult carr iers of the RET mut ation ar e

predisposed to medullary thyroid carcinoma, unilateral or bilateral

pheochr omocy toma s, and h y perparath y roidism.

1419. Pendred's syndrome is an autosomal-recessive disorder of

iodine org anification ch ar acter ized by congenital sensorin eura l

hear ing loss combined with goiter.

1 42 0. Osteomalacia is a m etabolic bone disease with failu re of the

organic m atr ix (osteoid) of bone to mineralize norm ally in adults.

1 421 . Looser's zones or Milkm ans' fractu res (pseudofractu res) on

radiogr aphy ar e pathognomonic of osteomalacia.

1 42 2. In patients with ty pe 1 diabetes and suboptimal glucose

contr ol, m ore complex regim ens with m ore frequent injections of

both short/r apid and long/in term edia te act ing insulins usually

provide more effective control.



1 42 3. The ADA r ecomm ended goals for ma nagem ent of adults with

diabetes are hemoglobin A1 C less tha n 7 .0%, preprandial plasma

glu cose 90-1 30 mg /dL (5-7 .22 m m ol/L), peak (2 h our ) postpra ndial

plasma g lucose less than 1 80 m g/dL (9.99 mmol/L), blood pressur e

less than 1 30/80 m m Hg, tr igly cerides less tha n 1 50 mg /dL (1 .69

mmol/L), HDL cholesterol more than 4 0 m g/dL (1 .03 m mol/L), and

LDL cholesterol less than 1 00 m g/dL (2.59 mm ol/L).1 42 4. Benign adrenal adenoma s generally hav e sm ooth borders,

attenuation v alu es less than 1 0 Hounsfield un its, and are

homogenous in consistency.

1 42 5. The size of an adrenal lesion is predictiv e of mal igna nt

potentia l; 25% of lesions more tha n 6 cm are carc inomas.

1 42 6. In patients with ma lignancy -associated hy percalcemia,

therapy with zoledronate, a long-acting intr av enous nitr ogen-

containing bisphosphonate, induces rapid and long-lasting

hy pocalcem ic response.

1 42 7 . Multiple endocrin e neoplasia (MEN) 2a sy ndrome consists of

medullary thy roid cancer, pheochromocy toma , and

hy perparat hy roidism due to four -gland hy perplasia.

1 42 8. In patients with hy pergly cemic hy perosmolar sy ndrome, the

preserv ation of va scular v olum e is critical, an d norm al saline is the

initial fluid of choice, ev en before intra v enous insulin.

1429. The differential diagnosis in patients with apparently

inappropriate TSH secretion includes a TSH-producing pituitar y adenoma an d congenital th y roid horm one resistan ce.

1 43 0. he Am erican Diabetes Association criteria for t he diagnosis of

diabetes mellitus are a fasting plasma glucose more or equal 1 26

mg/dL (6.99 mmol/L), a 2 -hour plasma glu cose m ore or equal 2 00

mg/dL (1 1 .1 mmol/L) after a 7 5-g ora l glu cose load, or a r andom

glu cose more or equal 2 00 m g/dL (1 1 .1 m mol/L) plus symptoms of

diabetes.

1 43 1 . Thiazide diuretics stimu late renal tubular calcium

reabsorption a nd in some patients lead to a mild hy perca lcemia ,

which usually resolv es when th e diuretic therapy is discontinued.

1 43 2. Prima ry hy pothy roidism is a comm on secondary cause of

hyperprolactinemia, likely caused by increased stimulation of the

pituitar y gland by thy rotropin-releasing h orm one.

1 43 3. Seru m TSH should be measured with prolactin in th e

ev aluat ion of a patient with galactorrhea a nd irregula r m enses.

1 43 4. Causes of ACTH-dependent Cushing's sy ndrome can be



disting uished by the dexam ethasone 8-mg (h igh-dose) ov ernight

suppression test and th e cort icotropin-releasing horm one (CRH)

stim ula tion test.

1 43 5. The av erage patient w ith ty pe 1 diabetes mellitus who does

not hav e coexisting insulin resistan ce requires a total daily dose of

about 0.4 to 0.5 units of insulin per kg of body weigh t.

1 43 6. In the wat er depriv ation test, im paired ability to concentrateur ine is consistent w ith either nephr ogenic or centra l diabetes

insipidus.

1 43 7 . In the wat er depriv ation test, a larg e increase in urin e

osmolar ity after t he administration of desmopressin is indicativ e of

central diabetes insipidus; no such increase occur s in n ephr ogenic

diabetes insipidus.

1 43 8. Hy pocalcemia frequently occurs after r emov al of a

hy perfun ctioning parathy roid adenom a because of deficient

secretion of parathyroid hormone by the remaining previously

suppressed parathyroid tissue.

1 43 9. Perma nent hy poparathy roidism after an initial neck

explorat ion for prim ary hy perparat hy roidism is rar e, but t he

incidence is gr eatly increased with r epeated neck sur gery for

recurr ent or persistent h y perparat hy roidism and after subtotal

parathy roidectomy for para thy roid hy perplasia

1 44 0. In a patient with u nstable coronar y art ery disease and

hy pothy roidism , therapy with thy roid horm one could increasemy ocardial m etabolic dem and and precipitate a m y ocardial

infarction.

1 44 1 . Hy perprolactinemia can cause hy pogonadism because

prolactin directly suppresses gonadotropin-releasing hormone

secretion and thus luteinizing hormone and testosterone production.

1 44 2. The initial tr eatment for prolactin-producing

macr oadenom as is a dopamin e ag onist, such as bromocriptine or

cabergoline, which decreases prolactin lev el, shr inks the tum or, a nd

improv es v isua l fields and pituitary function in most patients.

1 44 3. Inferior petrosal sinus sam pling is a confirm atory test for

Cushing's syn drom e in patients with am biguous results in screening

tests; the techn ique is v ery sensitiv e and specific, but ext rem ely

costly, technically difficult, and somewhat hazardous.

1 44 4. Metform in should not be used in m en with creatinine lev els

greater th an 1 .5 mg /dL (1 32 .63 Âµm ol/L) or in women w ith

creatinine lev els greater than 1 .4 m g/dL (1 23 .7 9 Âµm ol/L).



1445. A thiazolidinedione should not be used in patients with class III

congestiv e heart failu re and will often cause worsening edema ev en

in patients with less sev ere congestiv e heart failu re.

1 44 6. In euthy roid patients, am iodarone therapy results in high

free and total T4 , low-norm al T3 , and high-norm al TSH.

1 44 7 . Osteoporosis is diagnosed by the presence of fragility fractur es

or by a bone min eral density v alue less than âˆ’2. 5 in patients whohav e not experienced a fragility fractur e.

1 44 8. Th e classic cha racteristics of prolactinom a a re am enorr hea

and galactorr hea.

1 44 9. Serum prolactin levels greater tha n 200 ng /mL (200 m g/L)

in a nonpregnant woman usually sugg est a tum or instead of another

cause of hy perprolactinem ia.

1 450. Secondary diabetes m ellitus may be the direct result of such

underlying disease states as other endocrinopathies, islet cell

neoplasm s, and disorders of the exocrine pancr eas such a s

pancreatitis, pancreatic m align ancies, and cy stic fibrosis.

1 451 . Localizing th e ectopic sour ce of ACTH in a patient with

ev idence of ACTH-dependent Cushing 's sy ndrome m ay requir e

combination CT/MRI/octr eotide imaging of chest/abdomen/pelv is.

1 452 . In patients with sev ere prim ary hy pothy roidism, decreased

negat iv e feedback of thy roid horm one at t he lev el of the

hy pothalam us leads to release of thy rotropin-releasing h orm one,

which stimula tes expansion of TSH-producing pituitary cel ls,causing pituitary hyperplasia.

1 453 . Exenatide, an incretin m imetic that increases insulin

secretion, is an alt ernativ e to insulin th erapy in patients wh o hav e

not ach ieved optim al gly cemic contr ol w ith m ulti-agent oral

therapy.

1 454 . Tertiar y hy perparath y roidism is a rar e disorder that usually

occurs after m any y ears of chronic renal insufficiency and

secondary hy perparath y roidism.

1 455. Cinacalcet hy drochloride is a calcimim etic agent that ha s

been shown to significa ntly parathy roid horm one lev els in patien ts

with ch ronic kidney disea se and uncontrolled secondary

hyperparathyroidism.

1 456 . The classic presenta tion of hereditar y hem ochr omatosis

includes hy pogonadism, diabetes mellitus, liv er dy sfun ction, an d

skin h y perpigmentation.

1 457 . The m ost comm only affected orga ns in hereditary



hemochr oma tosis are the pituitar y gland, pancreas, liv er, and

heart.

1 458 . Postprandial g lucose excur sions in patient s with diabetes

should ideally be 30 to 50 m g/dL (1 .67 to 2.7 8 m m ol/L) abov e

premeal glu cose v alu es.

1 459 . Significant postprandial hy pergly cemia can be mana ged by

using a bolus of short-act ing insulin (l ispro or aspart ) just before or with each m eal.

1 46 0. The absence of menses for sev eral m onth s after dilation and

cur retage ra ises the possibility of endometrial damage or form ation

of scar tissue cau sing an out flow tract obstruct ion (Asherman's

syndrome).

1 46 1 . Pheochromocy toma s usually occur w ithin the adrenal

medulla, are rar ely bilateral, occur m ore comm only in the right

adrenal, ar e rar ely metastatic to the local ly mphat ic v essels and /or

liv er, and are usually m ore or equal to 2 cm in diameter and

heterogeneous in consistency .

1 46 2. Com puted tomography of the abdomen with thin sections

thr ough the adrena ls is the preferred initial localizing study for

pheochromocytoma.

1 46 3. Patients with Hashim oto's thy roiditis are at r isk for other

autoimmun e endocrin e disorders, including a drenal insufficiency ,

pernicious anemia, ty pe 1 diabetes mellitus, v itiligo, an d prema tur e

ovarian failure.1 46 4. Th e classic symptoms of renal osteody strophy ar e vagu e bone

pain localized to the lower back, hips, or legs; m uscle weakness often

occur s with n orm al m uscle enzy mes and nonspecific

electromyography changes.

1465. The main radiographic feature of renal osteodystrophy is

increased bone resorption, most commonly in the subperiosteal

sur faces of the hands, neck of femur , and clav icle.

1 46 6. Th e presence of three or m ore pituitary hormone deficiencies

has a positiv e predictiv e v alu e for growth hormone deficiency of

95%.

1 46 7 . Replacem ent of gr owt h horm one in horm one-deficient adults

has been shown to improv e body com position, lipid par am eters, and

bone m ineral density .

1 46 8. Therapy with an angiotensin II receptor blocker delay s the

progr ession of nephr opathy in diabetic patients with hy pertension,

ma croalbum inur ia, and renal insufficiency .



1 46 9. Î²-Blocker therapy to reduce thy rotoxic sy mptoms is the most

appropriate therapy during the hyperthyroid phase of postpartum

thyroiditis.

1 47 0. Approxima tely 7 5% of patients with postpartum thy roiditis

recov er, w hereas 25% develop perm anent hy pothy roidism.

1471. Hemochromatosis can result in various endocrinopathies,

including hypogonadism, adrenal insufficiency, and diabetesmellitus.

1 47 2. Growth hormone replacement is star ted at a low dose and

titr ated up based on the patient's insulin-like growt h factor 1 lev el,

sy m ptom contr ol, a nd side effects of therapy .

1 47 3. The goal of growth hormone replacement is to norm alize the

insulin-like growth factor 1 lev el and alleviat e sy mptoms with out

causing adverse side effects.

1 47 4. Adv erse effects of growth horm one replacem ent thera py

include parasthesias, myalgias, edema, and joint pain.

1 47 5. In patients with bilateral adrenal h y perplasia, spironolactone

ther apy reduces blood pressure an d elimina tes the requir ement for

potassium supplementation.

1 47 6. In men with bilateral adrenal hy perplasia in whom

spironolactone th erapy cau ses painful gy necom astia, epleronone

may be substituted for spironolactone.

1477. Paget's disease is a focal disorder of bone remodeling that leads

to greatly accelerat ed ra tes of bone turn ov er, disru ption of thenorm al a rchit ecture of bone, and sometim es to gross deformities of

bone (enla rgem ent of the skull , bowing of th e fem ur or tibia).

1 47 8. Osteoma lacia usually presents with an elev ation of alkaline

phosphatase in association with hy pocalcem ia an d

hypophosphatemia.

1 47 9. In patients with the empty sella sy ndrome, the pituitar y

gland is not u sually damag ed and pituitary function is usually

normal.

1 480. Fasting blood glucose levels, which are due prima rily to

excessive hepatic glucose production, ar e contr olled mainly by the

basal insulin dose.

1 48 1 . Patients on basal bolus insulin therapy often take 40% to 50%

of their t otal daily dose as basal insulin (glargine) and 50% to 60% as

meal boluses (lispro or a spar t).

1 482 . Postm enopausal w omen with subclinical hy perth y roidism

and an un detectable TSH hav e an in creased risk of dev eloping



osteoporosis.

1 483 . Hy pogly cemia un awa reness, a dangerous sequela of

long-standing in sulin-treated diabetes m ellitus, is an adaptiv e

central nerv ous sy stem r esponse and is exacerbated by recurr ent

episodes of hy pogly cemia.

1 484 . In patients with ty pe 1 diabetes mellitus and hy pogly cemic

unaw areness, insulin dose should be reduced and treatment goalsrelaxed.

1 48 5. Th e classic tr iad of sy mptoms for pheochr om ocy toma consists

of headach es, palpita tion and diaphoresis.

1486. The sensitivity of fractionated plasma metanephrines for

catecholam ine-producing tum ors is nearly 97 %; howev er, the

specificity is 85%.

1 487 . The first step in the ev alua tion of a th y roid nodule is

measur ement of serum TSH; if TSH is normal, the nodule is most

likely nonfun ctioning or â€œcoldâ€�; if TSH is low, the nodule is

more likely to be hy perfun ctioning or â€œhot.â€�

1 48 8. Measur ement of seru m thy roglobulin is useful for followin g

thyroid cancers in response to treatment, but a serum thyroglobulin

lev el is not useful in disting uishing benign from malign ant nodules.

1 489 . Very high levels of hum an ch orionic gonadotropin (hCG) are

sufficient to stim ula te the thy roid glan d to release excess thy roid

hormone.

1 490. Risk factors for osteoporosis in m en include a BMI less than 1 8,a h istory of smoking or excessive alcohol consum ption, family

history of osteoporotic fractures, hypogonadism, history of

cort icosteroid use, v itam in D deficiency , an d medications causing

osteomalacia or hy pogonadism.

1 49 1 . Hy pogonadism increases the skeletal sensitiv ity to

parat hy roid horm one and decreases intestina l calciu m absorption,

predisposing to osteoporosis.

1 49 2. The objectives in ev aluat ing pituitary incidentaloma s are to

determ ine whether th ey are secreting pituitary horm ones, causing

deficiencies of pituitar y horm ones, and gr owin g.

1 49 3. Close observ ation of the tum or to detect growth and pituitary

hormone deficiency is the treatm ent choice for clinically silent sma ll

adenomas.

1 49 4. DEXA scann ing ha s the best correlat ion of procedures for

measur ing bone loss with fracture risk, requires a short scann ing

tim e, and m easures the bone minera l density of all ar eas of the



skeleton with high accuracy and reproducibility and low exposure to

radiation.

1 49 5. Featu res of the euthy roid sick syndrome include a precipitous

drop in serum total a nd free T3 lev els, an d a concomitan t incr ease in

rev erse T3.

1 49 6. The chan ges in thy roid horm one lev els during an a cute

illness are likely adaptiv e, as a m eans of protecting th e body fromcata bolic illness; thy roid horm one thera py in patients with

euthy roid sick sy ndrome ha s not been shown to be beneficial.

1 49 7 . Hypergly cemia after cardiac surgery and during critical

illness is a strong predictor of adverse outcomes, including infectious

complications an d death .

1 49 8. Intr av enous insulin infusion in hy pergly cemic patients in the

intensiv e care unit r educes mortality .

1 499. Potent ial complicat ions of Pag et's disease of the bone inclu de

osteogenic sarcoma in affected bone, hy perca lcemia , h igh-output

congestiv e heart failur e, deafness, and excessiv e bleeding durin g

sur gery as a result of hy perv ascular bone.

1 500. Non-tumor causes of elev ated prolactin lev els ar e ty pically

associated with lev els less than 1 00 ng/dL (1 00 m g/L).

1501. â€¢ Psychotropic medications may raise serum prolactin

levels modestly ; patients with hy perprolactinemia and sev ere

psychiatric illnesses requiring continued therapy with psychotropic

agents can be treated w ith estrogen- and progesterone-conta iningora l contra ceptiv es to restore n orm al m enses and prev ent bone loss

1 502. Primar y hy pogonadism in a y oung male may be due to

Klinefelter's sy ndrome; therefore, an y y oung ma le with a h igh

serum FSH level should hav e a kary oty pe study .

1 503 . The m ost sensitiv e screening t est for prim ar y aldosteronism is

the plasma aldosterone-plasma renin activity ratio.

1504. Secondary causes of hypertension include primary

aldosteronism, acromegaly , pheochr om ocy tom a, an d Cushing 's

syndrome.

1 505. During a norm al pregnancy , thy roid horm one production

must be increased to prov ide thy roid horm one to the dev eloping

fetus; m ost women who ar e taking th y roid hormone replacement

require a 30% to 50% increase in th eir thy roid horm one dose durin g

their pregnancy .

1 506. Risk factors for gestat ional diabetes m ellitus inclu de obesity , a

family history of ty pe 2 diabetes, and a h istory of gestat ional



diabetes in prev ious pregn ancies.

1 507 . The diagnosis of gestat ional diabetes mellitus requires any two

of the followin g four v alues in a 3-h, 1 00-g oral g lucose toleran ce

test: fasting equal or m ore than 95 m g/dL (5.27 m mol/L); 1 -h equal

or m ore than 1 80 m g/dL (9.9 9 m m ol/L); 2-h equal or m ore tha n 55

mg /dL (3.05 m mol/L); 3-h equal or m ore than 1 40 m g/dL (7 .7 7

mmol/L).1 508. Thera py for gestational diabetes mellitus consists of restricted

diet, with insulin if gly cemic target v alues are not achiev ed.

1509. In hypercalcemia secondary to production of parathyroid

hormone-related peptide by a car cinoid, the serum par ath y roid

horm one lev el is suppressed.

1 51 0. In patients with Grav es' ophthalm opathy and blurry v ision,

the presence of an afferent pupillary defect (Marcu s Gun n pupil) and

greatly dim inished unilatera l v isual acu ity sugg est optic nerv e

impingement by enlarged extra ocular mu scles.

1 51 1 . Para thy roidectom y causes rapid improvem ent in the bone

mineral density in patients with osteoporosis associated with

primar y hy perparathy roidism.

1 51 2. The u se of antir esorptiv e agents is not recommended in

osteoporosis secondary to primar y hy perpar ath y roidism.

1 51 3. Obese, insulin-resistant men g enerally hav e a reduced serum

total testosterone concentr ation, prim ar ily as a r esult of a low

sex-hormone binding globulin concentr ation.1 51 4. Orthostatic hy potension is a comm on m anifestat ion of diabetic

autonomic neuropath y , r eflecting loss of norm al v asoconstrictor

tone, w ith deranged com pensation t o uprig ht posture.

1 51 5. Fludrocortisone therapy expands the plasma v olum e, thereby

ra ising blood pressur e and im prov ing symptoms in diabetic

autonomic n europathy .

1516. After biochemical confirmation of primary aldosteronism,

localization procedures differentia te a ldosterone-producing

adenomas from bilatera l adrena l hy perplasia; aldosteronism-

producing adenomas are amenable to laparoscopic resection,

whereas bilateral a drenal hy perpla sia is m edica lly treated.

1 51 7 . Radiogra phic ima ging rar ely differentiates aldosterone-

producing a denomas from bilatera l adrenal hy perplasia in patients

with prim ary aldosteronism.

1 51 8. Intestinal calciu m absorption is reduced and osteoclastic

activ ity is increased in hy perth y roidism , an d the high lev els of free



T4 a nd free T3 likely produce hy percalcemia thr ough excessiv e

osteoclastic activity.

1 51 9. Hy percalcemia associated with thy rotoxicosis usually resolv es

when the patien t becomes euthy roid.

1 52 0. Exogenous testosterone suppresses sperm production,

resulting in in fertility .

1 521 . Tr eatm ent w ith exogenous testosterone at n orm al doses doesnot norm ally cause perm anent in fert ility , but restora tion of sperm

production requires gonadotropins.

1 522 . Silent thy roiditis is an autoimmu ne disorder cha racterized by

high lev els of antithy roid peroxidase antibodies, painless

enlargement of the thy roid gland, and a t riphasic cour se with early

thy rotoxicosis followed by hy pothy roidism a nd then a retur n to

euthy roidism in most patients.

1 523. Most patients with interferon alfaâ€“associated thy roid

dy sfun ction r ecov er after the drug is discontin ued.

1 524. Hy popituitarism is a frequent outcome of patients treated

with ir radiation of the thy roid gla nd.

1 525. In a patient w ith hy popituitar ism , docum entation an d

therapy of adrenal insufficiency takes priority over other anterior

pituitary hormonal deficiencies.

1 526. Infection is a comm on precipitan t of my xedema coma, an d

pan-culture and empiric antibiotic therapy with broad-spectrum

antibiotics is recomm ended for a ll affected patient s.1 527 . Signs of androgen excess (increased muscle mass, irr itability ,

and pustular acne) with small testes and low serum testosterone and

gonadotropins in a y oun g m ale sugg est androgenic ana bolic steroid

abuse.

1 528. In patients with m acroprolactinom a a nd norm al v isual fields,

dopamine agonist thera py effectiv ely reduces prolactin secretion

and tum or size.

1 529 . ACE inhibitors reduce albuminu ria an d retard the

progression of renal disease in diabetic patients with and without

hypertension.

1530. Angiotensin II receptor blockers prevent progression of

nephr opathy in patients with ty pe 2 diabetes and

ma croalbum inur ia and hy pertension.

1 531 . Breast enlargement in a y oung ma n occurs most comm only

with drugs or su bstances or a lterations in the androgen/estrogen

ratioâ€”either androgen deficiency or estrogen excess



1 53 2. High concentra tions of hCG in a m an sug gest the diagnosis of

choriocarcinom a, an aggr essiv e germ cell tu mor.

1 533 . The m easur ement 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.

1 53 4. Corticosteroid therapy results in a decrease in intestina lcalcium absorption an d an incr ease in ur inary calcium excretion;

secondary hy perparath y roidism occurs.

1 53 5. The prev ention an d treatm ent of cort icosteroid-induced

osteoporosis includes calcium and v itam in D supplementat ion, a

DEXA scan at the initiat ion of therapy , and bisphosphonates in

patients taking prednisone equal or m ore than 5 m g/d (or it s

equiv alent) for m ore than 3 m onths.

1 53 6. A s many as 3% of patients with poorly contr olled diabetes

mellitus (hemoglobin A1 c m ore than 8 .0%) hav e Cushing's

syndrome.

1 537 . The tr eatment of choice for a nonfunctioning pituitar y

adenoma is tra nssphenoidal tu mor resection.

1 53 8. Benign adrena l adenomas are homogenous and hav e sm ooth

borders and attenuation v alu es of less than 1 0 Hounsfield units on

unenha nced CT.

1 53 9. Th e classic presentat ion of thy roid ly m phom a is an elderly

woman with autoim m une thy roidit is and a rapidly expandin gthy roid ma ss.

1 540. Latent a utoimmun e diabetes of adulthood (LADA) occurs in

lean patients with initially apparent ty pe 2 diabetes wh o become

insulin-dependent la ter in life and exhibit the labile gly cemic

tendencies and many of the autoimm un e mar kers of patients with

ty pe 1 diabetes.

1 541 . Latent au toimmun e diabetes of adulthood (LADA) is

chara cterized by slowly progr essiv e loss of beta-cell function, leading

to sev ere insulin deficiency and labile gly cemic control.

1 542 . Patients with lat ent autoimmun e diabetes of adulthood

(LADA) become refract ory to ora l agents an d as insulin-dependent

and ketosis-prone as patients with type 1 diabetes.

1 543 . Pericardial effusion is a consequence of moderate to sev ere

hy pothy roidism and is indicated by diminished heart soun ds, low

v oltage on elect rocardiography , and an enla rged cardiac silhouett e.

1 544. The â€œhy pothy roid heartâ€� r efers to decreased



contr actility and pulse rateâ€”both contributing to a decreased

cardiac output at a time w hen peripheral v ascular r esistance is

increased.

1 545. In a patient w ith acr omegaly based on elev ated serum

insulin-like gr owt h factor 1 and growth hormone lev els, MRI of the

head is indicated to identify and chara cterize the causativ e

pituitary tum or.1 546 . Multiple endocrine neoplasia ty pe 1 is chara cterized by

pituitar y tum ors, pancreatic islet tum ors, and

hy perparat hy roidism due to parathy roid hy perplasia.

1 547 . Fam ilial hy perparat hy roidism , which is alm ost alway s due to

parathy roid hy perplasia, is treated with subtotal

parathy roidectomy in which 3 Â½ para thy roid glands are removed.

1 548. Chemotherapy w ith alky lating agents often induces

irr ev ersible dam age to sperm production in y oun g m en.

1 549 . Subacute thy roiditis is chara cterized by a prodrom e of

arth ralg ias, m alaise, an d anorexia followed by pain in the thy roid

bed and thy rotoxicosis.

1 550. Teriparatide (recombinant h um an parath y roid horm one

[1 -34]) stimulates osteoblastic bone form ation; it significantly

incr eases bone m ass in patients wit h osteoporosis and can decrease

the incidence of both v ertebral an d nonv ertebral fractures.

1551. Kallman's syndrome is X-linked hypothalamic hypogonadism

accompanied by anosmia.1 552 . In patients with diabetes and sev erely impaired beta-cell

secretory capacity , basal insulin is effectiv e on fasting g lucose but

cann ot adequately contr ol post-pra ndial glu cose.

1553. The overall goal of therapy for acromegaly is normalization of

the seru m growth horm one and insulin-like growth factor 1 lev els.

1 554. An increased dose requirement for lev othy roxine m ay occur

as due to malabsorption (for example, celiac disease), accelerated

metabolism, or an in creased occupancy of binding proteins

1 555. Most a drenal nodules are hormonally silent and ha v e no

ma lignant potential.

1 556. Patients with an in cidenta lly detected adrenal ma ss should be

screened for pheochromocy toma, Cushing's syndrome, and prim ary

aldosteronism.

1 557 . In a patient w ith norma l ov ulation but a utoimm une disease

and r epeated fetal loss, ev alu ation for a hy percoagulable state is

indicated.



1 558. In patients with concomita nt au toimm une adrenal an d

thy roid failur e (Schm idt's sy ndrome), adrena l failur e is often

unrecognized initially ; as thy roxine deficiency is corr ected, the

patient dev elops clinical adrenal insufficiency , requir ing

glucocorticoid supplementation.

1 559. Testosterone therapy does not cause prostat e cancer but ca n

stim ula te the growth of occult t um ors.1560. In patients beginning testosterone therapy, a rectal

examination of the prostate gland before the first dose and the serum

prostate-specific ant igen should be measured at 3 , 6 , an d 12 m onth s

after t he start of therapy .

1 561 . Vitam in D deficiency m ust be corr ected before startin g other

activ e osteoporosis thera py because the r esponse to the therapy will

be impair ed by the defect iv e m ineralizat ion associated w ith v itamin

D deficiency and osteomalacia.

1 562 . Prediabetes gly cemic states consist of impaired glucose

toleran ce, defined as a 2-hour g lucose level of 140-1 99 m g/dL

(7 .7 7 -1 1 .04 m mol/L) during an oral glu cose tolerance test, and

impaired fasting glucose, defined as a fasting glucose level of

1 00-1 25 m g/dL (5.55-6.9 4 m mol/L).

1563. Narcotics suppress gonadotropins and testosterone production.

1 564 . The m ajor storag e form of v itam in D in the body is

25-dihy droxy v itam in D, an d therefore th is is the best test to assess

for v itam in D deficiency .1 565. In a short y oung w oman with primary amenorrh ea, ev en in

the absence of associated stigmata and comorbidities, Turner's

sy ndrome (or m osaic) is th e most likely diagnosis.

1566. High-risk patients with obesity and metabolic syndrome can

most effectiv ely reduce their r isk of dev eloping ty pe 2 diabetes with

a conscientious lifestyle modification program consisting of diet,

exercise, and weight loss.

1 567 . The two causes of central hy perth y roidism a re a

TSH-producing adenoma a nd th e resistan ce to thy roid horm one

syndrome.

1 568 . The two cau ses of central hy perthy roidism, TSH-producing

adenoma an d the resistan ce to thy roid horm one sy ndrome, can be

disting uished by measur ing TSH Î± subun it.

1 569 . Testosterone stim ula tes product ion of ery thr opoietin, a nd the

hema tocrit an d ery thr ocy te indices rise significantly during

testosterone replacement th erapy .



1 57 0. The somatostat in an alogue, octr eotide, reduces growt h

hormone production and shr inks tum or in patients with a cromegaly

and is first-line therapy for patients not cured by surger y alone or

sur gery combined with radiation

1 57 1 . The hu moral mediator of hy percalcemia of ma lignancy in

most cases, especially in lun g can cer, is parathy roid

hormoneâ€“r elated peptide (PTHrp), which is secreted by thetumor.

1572. In gonadotropinoma, the gonadotropins are often detected on

imm unostaining of the surgical specim en but a re ra rely secreted

into the bloodstream in m eaning ful am oun ts.

Pulm onology and cr itical car e

1 57 3. In a patient taking high-dose inhaled cort icosteroids as part of

ther apy for persistent a sthm a w hose disease is stable, reducing t he

dose of cort icosteroids should be considered to prev ent therapy -

related side effects.

1 57 4. High-resolut ion computed tomographic scanning (HRCT) is

more sensitiv e than plain ch est ra diogr aphy for detecting

interstitial lung disease and more specific for the potential diagnoses.

1 57 5. In hepatic hy drothorax, un derly ing cirr hosis results inusually right-sided pleural effusion that is transudativ e as a result of

hy poalbum inemia and reduced serum oncotic pressur e.

1 57 6. In patients with sev ere sepsis from nosocom ial pneum onia, the

v enti la tor should be adju sted by using a â€œpr otectiv e lung

strategyâ€� with 6 m L/kg of ideal body weigh t and a plateau

pressure less than 30 cm H2O.

1 57 7 . Low-dose dopam ine has been shown to be of no benefit in

critically ill patients with early renal dy sfunction.

1578. Intermittent pneumatic compression is effective prophylaxis

in patients at m oderate to high risk for v enous thr ombosis in wh om

heparin and low-molecular-weight heparin are contraindicated.

1 57 9. Inadequate am ount of sleep is the m ost common cause of

day tim e som nolence in y oun g adults; improv ed sleep hy giene and

increased amount of sleep ar e the initial m ana gement.

1 580. Noninv asiv e positiv e pressur e ventilat ion in selected patients

with m oderate r espir atory distress has been shown to im prov e heart



and respiration rates, gas exchang e; and to reduce morbidity and

mortality ra tes, the need for int ubat ion, and the length of hospital

stay.

1581. Contraindications to noninvasive positive pressure ventilation

in patients with modera te respiratory distress include excessive

secretions, uncoopera tiv eness, and a cute ischem ic chang es on

electrocardiography.1 582 . Th e diagnosis of rhabdomy oly sis is based on c linical findings

and a history of a predisposing factor(s) an d confirm ed by the

presence of my oglobinuria , an in creased seru m creat ine kinase, and

hyperkalemia.

1 583. Early aggr essiv e fluid therapy is essential in rhabdom y oly sis

to coun teract flu id loss from sequestration into dam aged m uscle and

to increase renal perfusion.

1 584. The diagnostic y ield of curr ent im aging and biopsy methods

in v ery sma ll incidentally detected pulm onar y lesions is v ery sma ll.

1 585. Incidentally detected v ery sm all pulm onar y lesions should be

monitored periodically to detect signs of growth compatible with

lung cancer.

1 586. The clinical presentation of hy persensitiv ity pneum onitis is

ty pically recur rent acute episodes of fev er, cough, and dy spnea that

begin 4 to 6 hour s after antigen exposur e and resolv e spont aneously

24 to 48 h our s after antigen a v oidance.

1 587 . Rev ersible airflow obstruct ion is a nonspecific finding th at canoccur with asthma , postinfectious bronchial hy perr eactiv ity ,

endotoxin inhalation, or hypersensitivity pneumonitis

1 588. In patients with persistent asthm a not adequately contr olled

with daily low- or moderate-dose in haled corticosteroids, addin g a

long-actin g Î²-agonist im prov es asthm a control an d quality of life.

1 589 . In idiopathic pulm onar y fibrosis, a character istic HRCT

pattern is seen in approxim ately 50% of patients and the extent of

disease on HRCT is a predictor of sur v iv al.

1 590. Patients with sev ere sepsis and refractory shock despite

adequa te fluid r esuscitation should be t reated w ith replacement -dose

corticosteroids.

1 591 . High-dose cort icosteroid therapy is ineffectiv e and may be

har m ful in patients with severe septic shock an d relativ e adrenal

insufficiency.

1 592 . Pleur al effusion in t ubercu losis is usually associated with a

lymphocytic pleocytosis.



1 593 . Tu bercu lous pleura l effusion most often dev elops from a

cell-mediated immune response to tuberculosis antigens.

1 594 . In patients with potentia lly operable non-small-cell lun g

cancer , pulm onar y funct ion tests are indicated to assess pulm onar y

reserve.

1 595. Brain scan a nd bone scan a re needed in patients with

potentia lly operable non-small-cell lung cancer .1596. Unfractionated and low-molecular-weight heparins reduce

the r isk of clinically important v enous thr om boembolism in

critically ill patients by up to 60%.

1 597 . Aspirin has not been shown to reduce th e incidence of

thromboembolism in most populations at risk.

1 598. In patients with cardiogenic pulmonary edema, continuous

positiv e airw ay pressure (CPAP) and noninv asiv e positiv e pressur e

v enti la tion (NPPV) more rapidly im prov e dy spnea, v ital signs and

gas exchange, and av oid intu bation m ore effectiv ely tha n oxy gen

supplementation plus standard therapy.

1 599 . The standard of pra ctice to determ ine the optima l contin uous

positiv e airw ay pressure lev el to mana ge obstruct iv e sleep apnea is

an at tended labora tory poly som nography with CPAP pressur e

titration.

1 600. The goal of therapy for h y pertensiv e crisis is not to decrease

the blood pressure to norm al lev els but to prev ent fur ther end-org an

dam age; precipitous reduction of blood pressur e incr eases the risk forcerebral, car diac, an d renal ischemia.

1 601 . In prospectiv ely ev alu ation by HRCT, up to 60% of patients

with rheumatoid arthrit is h av e r adiographic abnorm alities

consistent w ith interstitial lun g disease.

1 602. In dru g-induced interstitial lu ng disease, there are not specific

pathologic patt erns that would prov ide a definitiv e diagnosis.

1 603 . In patients with v ocal cord dy sfunction, oxy gen saturat ion is

norm al during an a cute exacerbation; lary ngoscopy during a n

exacerbation shows adduction of the v ocal cords during in spiration.

1 604 . Treatm ent of hepatic hy drothorax is directed to m anag ement

of cirrh osis and ascites with salt r estr iction and diuretic th erapy .

1 605. Sy m ptom s of anaphy laxis include flushing, ur ticaria,

conjunctiv al prur itus, bronchospasm, nau sea, and v omiting which

dev elop within 3 0 min utes to 1 hour after th e offending ant igen is

injected or up to 2 hour s after t he an tigen is ingested.

1 606 . Patients with m oderate to sev ere anaphy laxis should be



monitored for at least 1 2 hours for a possible late r ecurrence

(biphasic a naphy laxis)

1 607 . Risk factors for n oninv asiv e v entilatory failur e include the

acute respiratory distress syndrome (ARDS) or sever e com mun ity -

acquired pneum onia, PaO2/FiO2 rat io less than 1 46 , an d age

greater than 4 0 y ears.

1 608. The CAM-ICU, a clinical instru ment for use in ev alua ting apatient in the intensiv e care unit for delirium , takes less than a

minu te and is recom mended for a ll mechan ically v entilated

patients.

1 609. Pregna nt w omen with deep v enous thr omboembolism or

pulmonar y embolism are tr eated with either unfractionated

heparin or a low-molecular -weight heparin during the pregnancy

and for 6 weeks post par tum .

1 61 0. Silicosis with small n odules in th e lung s on r adiogr aphs is not

associated with sy m ptom s or phy siologic abnorm alities, but

continued exposure and development of progressive massive fibrosis

causes disabling symptoms.

1 61 1 . Screening for lun g cancer with chest radiogra phy or sputu m

cy tology does not lower lu ng cancer m ortality in the screened

popula tion and is not indicated.

1 61 2. The anti-Xa test is a sensitiv e mar ker for a nticoagu lant

activity of low-molecular-weight heparins and fondaparinux.

1 61 3. More tha n 90% of patients with sarcoidosis ha v e pulm onary inv olv ement that is manifest radiogra phically a s hilar a nd

mediastinal lymphadenopathy, with or without parenchymal

disease.

1 61 4. Treatm ent of sar coidosis is generally reserv ed for t hose with

disabling symptoms, ev idence for progressive lun g disease,

extrapulmonary disease, or complications such as hypercalcemia.

1 61 5. Patients with radiogr aphic stage 1 sar coidosis (hilar an d/or

mediastinal ly mphadenopathy without infiltrat es) and n o sy stemic

sy m ptom s hav e sponta neous remission ra tes of 50% to 90%.

1 61 6. Exposure to nerv e agents causes a cholinerg ic crisis by

inhibiting cholinesterase and causing muscarinic, nicotinic, and

central nerv ous sy stem effects.

1 61 7 . Pralidoxime (2 -PAM) reactiv ates acety lcholinesterase, an d

can r ev erse the muscle weakness, paraly sis, and respiratory

depression caused by exposure to nerve agents.

1618. Predictors of failure of noninvasive ventilation in patients



with an exacer bation of COPD include a respir ation rate m ore than

35/m in, APACHE score m ore tha n 2 9, pH less than 7 .25, and

Glasgow coma score less than 1 1 .

1 61 9. Patients with predominan t supine-dependent sleep apnea can

be m anaged init ia lly with a tria l of r estricting sleep to lateral

recumbency.

1 62 0. The adv anced car diac life support g uidelines stat e that asingle dose of v asopressin can be administered as a one-tim e

alternativ e to epinephr ine in patients with v entricular fibrillation

or pulseless v entricular tachy cardia.

1 62 1 . In patients with v entricular fibrillation or pulseless

v entr icula r tach y cardia , th e guidel ines for adv anced cardia c l ife

support recom mend th e followin g sequence of interv entions:

defibrilla tion, COTE [cardiopulm onary resuscitat ion, oxy gen, tu bes

(endotracheal and intr av enous), epinephrine (or v asopressin)], and

more defibrillation.

1622. D-dimer reflects the presence of thrombosis (or

inflam mation), but does not reflect th e activ ity of thr ombosis.

1 62 3. Hy pocapnia is the cause of centr al sleep apnea in patients

with Chey ne-Stokes respir ation.

1 62 4. A short course of ora l cort icosteroids may help restore asthma

contr ol in prev iously well-contr olled patients w ho hav e dev eloped

unstable disease as a result of a respiratory tract infection

1 62 5. Daily hemodialy sis has been shown to significantly reducein-hospital death s in patients with acute renal failur e in sur gical

and m edical intensiv e care un its.

1 62 6. Inhaled cort icosteroids with as-needed albuterol is the

corn erstone of therapy for persistent asthm a.

1 62 7 . In a patient with sev ere COPD and respirat ory failure with

sev ere carbon dioxide retention, inappropriately high r ate and tidal

v olume of m ech anical v entilation can ca use 1 ) excessiv ely rapid

reduction in PaCO2 potentially causing sev ere alkalemia a nd 2) the

induction of dy namic hy perin flation leading to a sev ere elev ation of

intrinsic positive end-expiratory pressure (auto-PEEP).

1 62 8. Helical CT scanning without contr ast enha ncement is not

sensitiv e for diagn osing pulm onary embolism.

1 62 9. In a patient presenting with likely adv anced m etastatic lung

can cer, a biopsy of an a ccessible site should be done to confirm the

diagnosis of metastatic disease with a m inim um of discomfort , r isk,

and expense.



1 63 0. Lung disease is the most comm on cause of morbidity and

mortality in sy stem ic sclerosis.

1631. In scleroderma, both interstitial lung disease and pulmonary

hy pertension can dev elop (both independently or together) and

hav e an adv erse effect on outcome.

1 63 2. Pulm onar y disease can be the initial clinical ma nifestation of

scleroderma.1 63 3. In a patient w ith potential smoke inhala tion injur y , the

presence of facial burn s, soot in the mouth, car bonaceous sputum , or

singed nasal hairs m ay corr elate with u pper airwa y injury and a

high risk of delay ed airwa y com promise from edema.

1 63 4. Approxima tely one fifth of adult patients with cy stic fibrosis

dev elop pneum othorax at some time in their liv es.

1 63 5. Tube thoracostomy is the preferred treatm ent for secondary

pneumothorax.

1 63 6. Patients with cy stic fibrosis hav e a high rate of recurrent

pneumothorax; therefore, parietal pleurectomy, pleural abrasion,

and th oracoscopy with t alc pleur odesis are reasonable interv entions

after initial m anag ement of the pneum othorax w ith tu be

thoracostomy.

1 63 7 . Placement of a pulmonary artery catheter in critically ill ICU

patients has not been shown to hav e a benefit on morta lity or other

outcomes.

1 63 8. The diagn osis of the acute respiratory distress sy ndrome(ARDS) requires a PaO2/FiO2 less than 200 in com bination with

bilateral infiltrates and the absence of other ev iden ce for congestiv e

heart failure.

1 63 9. The â€œlung protectiv e strategy â€� for intu bation in

patients with ARDS consists of the tidal v olum e at 6 mL/kg ideal

body weig ht and plateau pressure kept less than 30 cm H2 O.

1 64 0. Noctur nal pulse oxim etry can docum ent noctur nal

hy poxemia cau sing pulm onar y hy pertension in patients with

obstruct iv e lun g disease.

1 64 1 . Intr av enous heparin has imm ediate onset of action a nd has a

half-life of under an hour after discontin uation.

1 64 2. Low-molecular-weight heparins a nd fondaparinux hav e onset

of action w ithin about a half hour of subcutan eous admin istration,

and the effect lasts thr oughout m uch of the subsequent day .

1 64 3. The cha racteristic features of allergic bronchopulm onar y

aspergillosis include m odera te to sev ere persistent asthm a,



bronchiectasis and chest radiographic abnorm alities, elev ated

serum IgE, eosinophilia, and a positive skin test to Aspergillus

fumigatus.

1 64 4. Th e path ologic pattern n onspecific interstitial pneum onitis

(NSIP) can occur in v ar ious clinica l disorders, inclu ding in fections,

drug reactions, hy persensitiv ity pneum onitis, and connectiv e tissue

diseases.1 64 5. Patients in the intensiv e care unit generally require 25 to 30

nonprotein kcal/kg/d and 1 .0 to 1 .5 protein kca l/kg/d to m eet th e

energy expenditur es associated with critica l illness

1 64 6. In patients with adv anced neur om uscular disease,

inspiratory capacity is too small for an adequa te coug h, a nd cough

assistan ce may be requir ed in such patients with upper r espiratory

tract infection.

1 64 7 . Clinical findings of cocaine toxicity include tachy cardia,

hy pertension, hy perth ermia, my driasis, a gitation, and psy chosis.

1 64 8. Hy pertension in cocaine toxicity usually responds to contr ol of

agitation.

1 64 9. The Chur g-Strauss sy ndrome is a small-v essel v asculitis

ty pically associated with significant eosinophilia, pulm onary

infiltra tes in the setting of asthm a, the use of a leukotriene receptor

ant agonist, and with draw ing oral corticosteroids.

1 650. Extubation to noninv asiv e v entilation h as been shown to

improv e outcomes in ca refully selected intubated COPD patients who fail spontaneous breathin g tria ls.

1651. Exercise-induced asthma is confirmed by exercise challenge

(to more than 85% of ma xima l predicted heart rat e) with

post-exercise spirom etry showin g a 20% fall in FEV1 .

1 652 . Treatm ent with short -actin g inhaled Î²-agonists 5 to 1 0

minutes before exercise prev ents exercise-induced asthm a in >8 0%

of pat ients.

1 653 . Metabolic signs of salicy late toxicity include respiratory

alka losis, anion gap m etabolic acidosis, and hy perthermia; other

signs and symptoms inclu de depressed lev el of consciousness,

noncardiogenic pulm onary edema, prolonged prothrombin tim e,

hepatic toxicity , and hy pogly cemia.

1654. Management of salicylate toxicity includes alkalinization of

ur ine to enhance excretion of salicy lates and hem odialy sis for sev ere

toxicity.

1 655. Enoxapar in is cleared by the kidney , and if used in patients



with ch ronic kidney disea se, therapeutic drug m onitoring is

required for possible dosage adjustm ent.

1 656 . Malignan t pleural effusions are ty pically ly m phocy tic and

are usually exudativ e.

1 657 . Pleural fluid ery thr ocy te count s more than 1 00,000/Î¼L

(1 00 Ã— 109 /L), wh en not associated with trau m a or pulm onar y

infarction, ar e sugg estiv e of pleural m alignan cy .1 658. In patients with neuromuscular disease and chr onic

hy pov entilation, noninv asiv e mechanical v entilation is required to

ma intain v entilation dur ing sleep.

1 659 . Metastasectomy is indicated in patients with mu ltiple lung

metastases wh o ha v e a resectable prim ar y tumor, a low likelihood of

other metastases, a nd norm al pulm onar y function.

1 66 0. No m edical therapy has been shown to clearly alter the

nat ur al history of idiopathic pulm onar y fibrosis.

1 66 1 . Lung tran splantation ha s been shown t o improv e sur v iv al,

quality of life, and funct ional status in patients with end-stage

fibrotic lu ng disease.

1 66 2. A dministrat ion of ty pe A equine antitoxin w ithin 1 2 h our s of

diagnosis of wound botul ism may significant shorten the dur ation of

mechanical ventilation.

1 66 3. In a patient with acu te sev ere asthm a, prompt

adm inistr at ion of aerosolized bronchodilators is indicated after

sy stem ic cort icosteroid therapy is star ted.1 66 4. A pproxima tely 80% of effusions associated with pulm onary

emboli are exudativ e, usually sm all and un ilateral, and tend not to

be pr ogr essiv e or to persist bey ond 7 day s after form ation.

1 66 5. In m ost patients treated with heparin for pulmonar y

embolism, a substant ial portion of their perfusion defects resolv e

within the first week.

1 66 6. CT scanning to follow t he resolut ion of pulm onar y embolism is

not well standardized.

1667. No specific therapy is indicated for asymptomatic bronchial

hyperresponsiveness.

1 66 8. The co-presence of focal ar eas of fat and calcium ar e v irtua lly

pathognomonic of hamartoma.

1 66 9. Malignan t lu ng lesions tend to hav e a doubling tim e of

between 30 and 4 00 day s; ben ign lesions double in less th an 30 day s

or ov er v ery long periods of slow gr owth.

1 67 0. Patients with anaerobic bacterial infection inv olv ing the



#3

pleural space usually have subacute presentations with weight loss

and a history of alcoholism, un responsiv eness, possible aspirat ion,

and poor oral hy giene.

1 67 1 . Fibrinoly tic therapy m ay be considered in patients with

empy ema w ho are poor surgical ca ndidates.

1 67 2. Organizing pneum onia is a pathologic pattern of lung injur y

that can occur in various settings, including infections, connectivetissue diseases, and as a complication of treatments, such as

amiodarone or radiation therapy.

1673. Urinary Legionella pneumophila antigen test should be done

in pat ients with suspected Legionella pneum onia.

1 67 4. Early therapy with a zithromy cin plus ceftriaxone is

considered adequate initial cov erag e for a sever e com mun ity -

acquired pneumonia.

1 67 5. A h istory of orthopnea, abdom inal par adox, and a decrease in

forced v ital capacity more than 25% w hen th e patient goes from the

upright to supine position a re diagn ostic of diaphr agm para ly sis.

1 67 6. Patients with hy pov entilation secondary to diaphrag m

paralysis should be treated with nocturnal noninvasive positive

airw ay pressur e to aug ment their v entilation dur ing sleep.

1 67 7 . Clinical findings in hy drogen cy anide toxic


triplehelix - 01-12-09 23:56

1 67 7 . Clinical findings in hy drogen cy anide toxicity include coma ,

hy potension, cardiac irr itability , and profoun d anion ga p metabolic

acidosis in the setting of adequa te v olum e resuscitation an d oxy gen

administration.

1678. The treatment for cyanide poisoning is intravenous sodium

thiosulfate.

1 67 9. In patients with sev ere sepsis, early goal-directed therapy within the first 6 hour s to m aintain a central v enous oxy gen

satu ration of m ore than 7 0% and to resolv e lactic acidosis improv es

sur v iv al over m ore delay ed resuscitation a ttempts.

1 68 0. Acute m oun tain sickness is cha racterized by poor sleep,

anorexia, fatigue, nau sea, and v om iting.

1 68 1 . Acetazolam ide taken for 2 day s before ascent to high al titu de

is effectiv e prophy lax is for acute m oun tain sickness.



1 682 . Diffuse alv eolar hemorrha ge is char acterized by dy spnea an d

diffuse alv eolar infiltra tes; it can be the initia l m anifestat ion of

primar y or secondary pulmonar y v asculitis, drug r eactions,

coagulation disorders, and infection.

1 68 3. The diagnosis of diffuse alv eolar hem orr hage is m ade with

bronchoalv eolar la v age, with seria l sa mplings showing a

persistently bloody fluid.1 684 . Malignan t hy perth ermia is a life-thr eatening inherited

skeletal muscle disorder cha ra cterized by a hy perm etabolic state

precipitated by exposure to v olatile inh alat ional a nesthetics and

depolar izing m uscle relaxa nts.

1685. Heparin, low-molecular-weight heparins, and fondaparinux

all cat aly ze antith rom bin to neutralize clotting enzy m es, a nd these

drug s can be assay ed by incu bation of the patient 's plasma with

activ ated factor Xa.

1 686 . The reactiv e airway dy sfunction sy ndrome follows a single,

accidental inhalat ion of high lev els of a n onspecific r espiratory

irritan t in patients wh o ty pically do not ha v e a history of asthm a.

1 687 . The diagnosis of the reactiv e airwa y s dy sfunction sy ndrome is

based on h istory and confirm ed by positiv e m ethach olin e challenge.

1 688 . The m ost com mon causes of chy lothorax ar e cancer and

trau ma ; other causes are pulm onar y tuberculosis, ch ronic

mediastinal infections, sarcoidosis, ly m phangioleiomy omatosis, and

ra diation fibrosis.1 689 . In a competent, severely ill patient in the ICU with a tr eatable

condition but a clearly expressed preference for comfort measures

rath er tha n m ore agg ressiv e interv ention, com fort measures to

prov ide good end-of-life care should be provided

1 69 0. Although a fixed therapeutic dose of subcut aneous heparin

may be appropriate for treatm ent of deep v enous thrombosis and

pulm onar y embolism, aPTT monitorin g an d dose adjustment ar e

required for patients at h igh risk of bleeding.

1 69 1 . Renal ultra sound with renal ar tery Doppler examinat ion

prov ides anatom ic and fun ctional assessment of the renal arteries,

and has a sensitiv ity of 7 2% to 92% for r enov ascular h y pertension.

1 69 2. Idiopathic pulm onar y fibrosis (IPF) is the m ost common of the

idiopathic int erstitial pneumonias, and by far more comm on than

other m embers of the group.

1 69 3. Sarcoidosis, the m ost com mon in terstitial lu ng disease, is a

sy stem ic disorder a nd its radiogr aphic presentation is generally



dom inated by mediastinal an d hilar a denopathy with or w ithout

parenchy mal changes.

1694. For ventilator-associated pneumonia manifesting clinical

resolution of sy m ptom s and signs of infection, r adiologic

improv ement, a nd requirement for less v entilatory support with

improv ing oxy genat ion, cour ses of no more th an 8 day s of antibiotic

therapy are associated with as good outcomes as longer courses.1 69 5. Activ ated protein C has anticoagu lant properties, an d

ev idence of activ e bleeding is a contr aindication to its use in patient s

with sepsis.

1 69 6. Patients with COPD may experience a fall in PaO2 of as much

as 25 to 30 m m Hg during air t rav el, and pre-flight assessment is

useful to determ ine the need for in-flight oxy gen supplementat ion

with the goal of maintaining PaO2 either at equ al or m ore than 50

mm Hg or, in high risk patients, at t he PaO2 w ith w hich th e patient

is clinically stable at sea lev el.

1 69 7 . The neuroleptic m alignan t sy ndrom e is a rar e, but

potentia lly fatal, complication of the administrat ion of neuroleptic

(ant ipsy chotic) drug s such as ha loperidol.

1 69 8. Acu te hy poxemia a nd sy stemic hy potension in combination

with an incr ease in peak air way pressure and asy mm etric ch est

wall expansion are cardinal featu res of an acu te tension

pneumothorax

1 69 9. In patients taking th eophy lline as part of asthm a therapy ,concomitan t ciprofloxacin t herapy can decrease theophy lline

clearance in the liver, increasing theophylline blood levels and

leading to potentia l theophy lline toxicity .

1 7 00. Theophy lline cleara nce is decreased by v arious drugs as well

as in the elderly and patients with congestiv e heart failure.

1 7 01 . Insertion of an inferior v ena cav a filter reduces the short-term

incidence of pulm onar y embolism in patients being anticoagulated

for deep v enous thrombosis.

1 7 02. Lung tra nsplant-related bronchiolitis obliterans, w hich is

probably a form of chronic rejection, occurs in up to 50% of

long-term survivors of transplantation.

1 7 03. The ty pical findings of lung tra nsplant-related bronchiolitis

obliterans include cough , dy spnea, early inspirat ory crackles, a nd

sev ere a irflow obstruct ion.

1 7 04. Obstru ctiv e sleep apnea can exacerbate noctur nal asthm a;

CPAP therapy for sleep apnea can im prov e asthm a control.



1 7 05. Prompt int ubation is indicated in patients with sev ere

pneumonia wh ose condition is deteriorating on conv entional

therapy.

1 7 06. Intubation r ates are high in non-COPD patients with severe

comm unity -acquired pneum onia treated with n oninv asiv e

v enti la tion.

1 7 07 . Hypergly cemia should be treated in critically ill patients with aggressiv e insulin th erapy to maintain tight gly cemic control.

1708. Intermittent bolus dosing of sedatives titrated via a validated

sedation scale is consistent with the gu idelines for the use of sedation

in critically ill patients.

1 7 09. Ant ipsy chotic agents may cause torsades de pointes in

patients with prolonged QTc interv als.

1 7 1 0. Patients with ev idence of a phy siologically sev ere and

progressive fibrosing lung disease should be referred early for

ev aluat ion for lu ng t ran splantation.

1 7 1 1 . In patients with acute lung injury /ARDS on m echanical

v enti la tion w ith a lu ng protectiv e strategy , PEEP should be

increased in 2- to 3-cm H2O incr ements to lower FiO2 to 60%, if

possible, and to m aintain a n ar terial oxy gen satur ation of â‰¥88%

and â‰¤ 95%

1 7 1 2. V ocal cord dy sfunction m imics asthm a, but un like asthma , it

begins and ends abruptly , does not respond t o Î²-agonists, and

airflow limitation is mainly during inspirat ion.1 7 1 3. The ultrasound ma y be abnorm al for sev eral months after a

deep v enous thrombosis, and the v enous wall does not return to

norma l compressibility at a ll in some patients.

1 7 1 4. Th e most common form of delirium in the ICU is hy poactiv e or

â€œquietâ€� delirium .

1 7 1 5. Delirium is a form of acute brain dy sfunction th at occurs in

50% to 80% of ventilated patients in the intensiv e care unit; it is

associated with high er m ortality rates, longer hospital and ICU stay ,

high er costs, and chr onic cognitiv e deficits.

1 7 1 6. Th e cardinal features of delirium are 1 ) acute onset or

fluctu ations in m ental status ov er a 24 hour period, 2) inattention,

3) disorg anization of thinkin g, a nd 4) a n al tered lev el of

consciousness at th e tim e of the ev alu ation.

1 7 1 7 . Patients with potential healthcar e-acquired pneum onia

(HCAP) require initial cov erage for r esistan t org anisms inclu ding

methicillin-resistan t Staphy lococcus aur eus and Pseudomonas.



1 7 1 8. Segmental perfusion defects in patients with right heart

failur e and right v entricular hy pertr ophy strongly suggests the

diagnosis of chr onic thr omboembolic pulm onar y hy pertension

(CTEPH).

1 7 1 9. Surgical pulmonary thromboendarterectomy can improv e

cardiac output, reduce mortality , an d enhance quality of life in

patients with thr omboembolic pulm onar y hy pertension (CTEPH)1 7 20. Cry togenic orga nizing pneum onia is an idiopathic interstitial

pneum onia th at clinically resembles a flulike sy ndrom e, and is

chara cterized by cra ckles and patchy persistent infiltr ates on chest

radiogr aph, an d restr ictiv e lung defect with decrease in car bon

monoxide diffusing capacity .

1 7 21 . Inability to protect the airw ay because of impaired

swa llowin g or coug h fun ction is a contra indication to the u se

noninvasive positive pressure ventilation.

1 7 22 . In a neur omu scular disease patient wh o cannot mana ge

airw ay secretions, sev ere restriction w ith a v ital capacity of less

tha n 1 5-20 m L/kg is an indicator of the need for intubation.

1 7 23. No drug is FDA-approv ed for th e treatm ent of delirium , but

clinical practice guidelines recommend antipsy chotic agents, such

as haloperidol.

1 7 24 . All antipsy chotics, and especially â€œty picalâ€� agents,

pose a r isk of torsades de pointes and extrapy ram idal side-effects as

well a s the m ore rare neuroleptic malignant sy ndrome.1 7 25. Patient educat ion and encouragement in the use of CPAP and

mana gement of associated adv erse effects improves compliance with

CPAP in sev ere sleep apnea .

1 7 26 . A highly elevated peak pulmonary artery pressure is

consistent w ith pulmonar y hy pertension, but n ot n ecessary to

confirm the diagnosis and may be inaccur ate for ev alua ting

severity.

1 7 27 . In patients in status asthma ticus, pulse oximetry is a good

monitoring tool but is not a substitute for determ ining actu al

oxy genat ion by m easur ing arterial blood gases.

1 7 28 . The char acteristic clinical features of interstitial lu ng disease

are progressiv e dy spnea, diffuse radiogr aphic pulm onary infiltra tes,

restrictiv e pulm onar y phy siology , and oxy gen desatu ration with

exertion.

1 7 29 . In th e corr ect clinical setting, bronchoscopy with

bronchoalv eolar la v age can prov ide a specific diagnosis in



interstitial lun g disease.

1 7 30. Epoprostenol is first-line therapy for patients with sev ere

pulm onar y hy pertension, an d m ay be life-sav ing for patients in cor

pulmonale.

1 7 31 . Bosentan causes pulmonar y artery v asodilation and is

associated with a reduction in mortality in patients with pulm onar y

artery hypertension1 7 32. Intu bated patients should receiv e a tra cheostomy as soon as it

is deemed unlikely that they will wean from mechan ical v entilation

within 21 day s.

1 7 33 . In patients with asthm a who hav e increased noctur nal

sy m ptom s despite adequate day tim e contr ol, a t ria l of gastric acid

suppression th erapy is wa rr ant ed.

1 7 34. In selected imm un osuppressed patients with respiratory

failure, noninv asiv e positiv e pressur e v entilat ion is associated with

a lower mortality rate than conv entional oxy gen therapy an d

intubation.

1 7 35. Hereditar y hemorrha gic telangiectasia (HHT) is diagnosed

clinically by the presence of three of the followin g four criter ia: (1 )

recurr ent epistaxis; (2) telangiectasias in th e lips, oral cav ity ,

fingers, or nose; (3) v isceral lesions such as gastrointestinal

telangiectasias, or ar teriov enous m alform ations in th e lung , liv er,

or bra in; and (4) first-degree relat iv es with th e sy ndrome.

1 7 36. Th e propofol infusion sy ndrome in adults occur s primar ily inpatients with acu te neurologic or acu te inflamm atory diseases

complicated by sev ere infection or sepsis, a nd r eceiv ing

catecholam ines an d/or cort icosteroids in a ddition to propofol.

1 7 37 . The m ain features of the propofol infusion sy ndrome are

cardiac failure, rhabdomy oly sis, sev ere meta bolic acidosis, an d

renal failure associated with hy perkalemia.

1 7 38 . Noninv asiv e positiv e pressur e v entilation can r ev erse

hy pov entilation a nd allev iate cor pulmonale in patients with

obesity hypoventilation syndrome.

1 7 39 . Metha choline challenge testing is most useful in ev alua ting

patients with suspected asthma but wh o ha s episodic sy mptoms and

normal baseline spirometry.

1 7 40. The diagnosis of cough -v arian t asthm a is sugg ested by the

presence of airw ay hy perr esponsiv eness and confirm ed wh en coug h

resolv es with a sthm a therapy .

1 7 41 . A t rial of inhaled albuterol can h elp contr ol sym ptoms and



confirm the diagn osis of cough-v ariant a sthm a.

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 t o medications.

1 7 43 . All patients with COPD who hav e interm ittent sy mptoms

should receiv e a short-acting bronchodilator.

1 7 44 . For patients with stage 3 COPD, especially those with frequentexacerbations, inhaled corticosteroids should be part of their regular

therapy.

1 7 45. In the staging of patients with dy spnea for th erapy , the

post-bronchodilator FEV1 is most relevant finding.

1 7 46 . A postbronchodilator FEV1 /FVC ra tio greater th an 7 0%

indicates stage 0 (at r isk) chr onic obstruct iv e pulm onary disease.

1 7 47 . Chronic obstruct iv e pulm onar y disease is cort icosteroid-

insensitiv e, an d inhaled cort icosteroids do not cha nge t he r ate of

FEV1 decline in affected patients.

1 7 48 . In patients with COPD, cor pulm onale usua lly occur s in GOLD

stage 3 or 4 in patients with an FEV1 equal or less than 1 L.

1 7 49 . In patients with end-stage chr onic obstru ctiv e pulmonar y

disease, pulm onar y reha bilitation improves sy m ptom s, exercise

endura nce, and quality of life.

1 7 50. Patients with GOLD stage 4 chr onic obstru ctiv e pulmonar y

disease wh o hav e an a cute exacerbation should be treated like

patients with comm unity -acquired pneum onia.

Last part of the notes, now it is COMPLETE !!

Nephrology:

1 7 51 . Sleep apnea is associated with resistan t hy pertension an d is

particularly preva lent in obese patients.

1 7 52. Hy pertension associated with sleep apnea m ay be related to

insulin r esistance, incr eased activity of the sy mpathetic nerv ous

sy stem , an d increased sodium retent ion.

1 7 53. Referr al to a nephrologist for educat ion an d ev alu ation for

consideration of preemptiv e kidney transplanta tion is indicated for

patients with chronic kidney disease when the glomerular filtration

rate reaches the 30 m L/min ra nge

1 7 54. Minim al change disease is the most comm on cau se of the



nephr otic sy ndrome in children a nd y oung adults.

1 7 55. The presence of num erous ov al fat bodies on u rin aly sis is a

hallmark of a proteinuric state.

1 7 56. Decreased thresholds for arginine v asopressin in norm al

pregnan cy cause relativ ely lower sodium levels.

1757. Increased vasodilation in pregnancy is associated with a

decreased blood pressure m easurem ent and an incr eased heart ra te.1 7 58. In normal pregnan cy , increases in the glom erular filtrat ion

rate and renal blood flow result in decreased creatinine and blood

ur ea nitrogen lev els.

1 7 59. The sudden dev elopment of hy perkalemia in a patient on

dialysis may be a sign of tissue necrosis.

1 7 60. Abdomina l pain, h ematochezia, an d lactic acidosis are

sug gestiv e of bowel infarct ion.

1 7 61 . Henochâ€“SchÃ¶nlein pur pura is a renalâ€“derm al

v ascu litis sy ndrome that m ay present with interm ittent episodes of

mild abdom inal pain.

1762. Patients with chronic kidney disease have increased risk for

acute rena l failur e becau se of their use of osm otic agents such as

dextr an 4 0, m ann itol, an d sucr ose-conta ining preparat ions of

intrav enous immu ne globulin.

1 7 63 . Reduction in blood pressur e has been shown to influence the

progression of renal disease and the development of cardiovascular

disease in patients with diabetes.1 7 64 . Dialy sis should be considered ear ly in th e cour se of tum or

ly sis sy ndrome in patients with oliguric acute r enal failure.

1 7 65. Measur ement of urine m icroalbum in is the screening test of

choice for diabetic n ephr opathy .

1 7 66 . A 2 4-hour ur ine collection is no longer recomm ended to assess

kidney function or quant ify proteinuria.

1767. Combination therapy with angiotensin-converting enzyme

inhibitors and angiotensin r eceptor blockers may be more

renoprotective th an single-agent th erapy with either dru g in

patients with diabetic nephropathy.

1 7 68. An antiâ€“glomerular basement m embrane antibody assay is

indicated to diagnose Goodpastur e's syndrome.

1 7 69 . In selected patients, am bulatory blood pressur e monitorin g

should be used to diagn ose whit e coat h y pertension.

1 7 7 0. The sy ndrome of inappropriate an tidiuretic horm one

secretion (SIADH) is defined as hy potonic h y ponatremia with a



ur ine osmolality m ore tha n 1 00 mosm/kg H2O in the absence of

v olume depletion, adrenal insufficien cy , congestiv e heart failure,

hy pothy roidism , cir rhosis, and/or renal impairm ent.

1 7 7 1 . The classical triad of acute interstitial nephritis (fev er, skin

rash, an d arthralg ias) in th e setting of acute or subacute renal

failure is present in only a m inority of affected patients.

1772. The presence of a slowly progressive nephrotic syndromesuggests the possibility of solid tumorâ€“associated membranous

nephropathy

1 7 7 3. Nonsteroidal anti-inflamm atory drugs can cause acute

interstitial nephritis as well as prerenal acut e renal failure th rough

chang es in local glom erular hemody nam ics.

1 7 7 4. Abdomina l CT or ultr asonogra phy are the recom mended

ima ging m odalities for ur ic acid stones.

1 7 7 5. Patients with progressiv e chronic kidney disease should be

referred for cr eation of a perm anent v ascular dialy sis access wh en

the glomeru lar filtrat ion ra te decreases below 3 0 mL/min .

1776. Blood pressure measurements in elderly patients who tolerate

medication poorly ma y be higher in the office than at home.

1 7 7 7 . In selected patients, ambulatory blood pressure monitorin g

can exclu de wh ite coat hy pertension.

1 7 7 8. Ambulat ory blood pressur e monitoring can detect sy mptoms

that may be related to excessive reduction of blood pressure.

1 7 7 9. Elev ated blood pressur e in early pregnancy is most likely caused by a ch ronic condition.

1 7 80. Glom erulonephr itis, not preeclampsia, is the most likely

diagnosis in patients with elevated creatinin e lev els and proteinur ia

early in pregnancy .

1 7 81 . Patients with mem branous nephr opathy are at incr eased risk

for r enal v ein thrombosis.

1 7 82 . CT, MRI, or v enogr aphy is indicated to definitiv ely diagnose

renal v ein thr om bosis.

1 7 83 . Hy pertonic saline is not indicated for asym ptoma tic

hyponatremia.

1 7 84 . Focal segment al g lom erulosclerosis is the m ost comm on ca use

of the nephrotic sy ndrome in black patients, part icula rly those of

y oun ger age.

1 7 85. An tiretrov iral th erapy and plasma pheresis are indicated for

patients with HIV in fection a nd thrombotic th rombocy topenic

purpura.



1 7 86. Listeria is a comm on ca use of meningitis in renal tra nsplant

recipients.

1 7 87 . Increasing dietary calcium intake to 1 g/d to 4 g /d decreases

the r isk for r ecurr ent calciu m oxalate stones.

1 7 88. High-protein and -sodium diets can w orsen kidney stone

disease by causing hy percalciur ia and hy peru ricosur ia.

1 7 89. A decrease in the bicarbonate lev el accom panied by anelev ated anion gap is consistent w ith a prim ary m etabolic acidosis.

1 7 90. In a patient w ith a primar y m etabolic acidosis, a PCO2 that is

much higher than would be expected based on th e degr ee of

acidemia in dicates a condition that is secondary to inadequate

v enti la tion.

1 7 91 . Compar ed with h emodialy sis therapy , renal tran splantation

offers a sur v iv al adv antag e in patients with diabetic nephropathy

and end-stage r enal disease.

1 7 92 . Renal tr ansplantat ion is most beneficial in y oun g people and

in patients with diabetes mellitus.

1 7 93 . Hy pera ldosteronism should be considered in patients with

difficult-to-contr ol h y pertension and hy pokalem ia in the absence of

diuretic u se.

1 7 94 . Hy pera ldosteronism should be considered in patients with

difficult-to-control hypertension even in the absence of

hypokalemia.

1 7 95. The aldosteroneâ€“renin ra tio is a reasonable screening study for primar y hy peraldosteronism .

1 7 96 . Rha bdomy oly sis-associated acute renal failure presents with

dipstick-positiv e hematur ia but no inta ct ery throcy tes on

microscopic ana ly sis of the ur ine sediment.

1 7 97 . Heparin therapy inhibits aldosterone sy nthesis and therefore

may cause hy perkalemia.

1 7 98 . The dev elopment of the nephrotic sy ndrome in the setting of

ur inary reflux is most likely caused by focal segm ental

glomerulosclerosis.

1 7 99 . The fractional excretion of sodium ma y be more than 4 % in

patients with prerena l acut e renal failur e who use diuretics.

1 800. Patients with the nephrotic sy ndrome ar e predisposed to

dev elop deep v enous an d renal v ein th rombosis.

1 801 . Stagh orn ca lculi form as a result of chr onic infections with

ur ease-splitt ing org anisms such a s Proteus or Klebsiella.

1 802 . Stone rem ov al in struv ite stone disease often is indicated to



prev ent recurrence of infection an d stone gr owth.

1 803 . An giotensin-conv erting enzym e inhibitor therapy has been

shown to prevent the development of microalbuminuria in patients

who ha v e diabetes and norm oalbuminuria .

1 804 . Microalbum inuria is the first clinical sign of diabetic

nephropath y and a ma jor r isk factor for the development of clinical

proteinuria , chronic kidney disease progr ession, and ca rdiov asculardeath.

1 805. The most comm on cau ses of prim ar y hy pera ldosteronism a re

aldosterone-producing adenoma (Conn's syndrome) and bilateral

adrenal hy perplasia.

1 806 . Hy potonic flu ids should n ot be u sed postoperativ ely .

1 807 . Norm al saline (0.9%) is the m ost appropriate intrav enous

fluid when flu id therapy is indicated in the postopera tiv e setting.

1 808. SjÃ¶gren's syndrome is a comm on cau se of interstitial

nephritis.

1 809 . A collapsing form of focal segm ental glomeru losclerosis is the

most likely diagnosis in black patients with HIV infection w ho hav e

the nephrotic syndrome.

1 81 0. Postinfectious glomeru lonephrit is associated wit h hepatitis C

ty pically presents with hema tur ia, proteinuria, an d low C3 and C4

levels.

1 81 1 . A lbumin infusions decrease the r isk for acute r enal failure in

patients undergoing par acentesis with m ore than 5 L of volum erem ov ed and in patients with sponta neous bacterial peritonitis.

1 81 2. Octogenarian s with poor functional statu s are unlikely to

experience im prov ement or benefit from dialy sis.

1 81 3. Increasing calcium intake decreases the r isk for calcium

oxalat e stones because calcium binds to gastrointestina l sour ces of

oxala te an d therefore prev ents absorption.

1 81 4. Dietary m odifications such as decreasing anim al protein

intake, decreasing sodium intake, and increasing citrate can reduce

the r isk for r ecurr ent kidney stones without additional medical

therapy.

1815. Clinical manifestations of autosomal dominant polycystic

kidney disease inclu de rena l, hepatic, an d pancr eatic cy sts;

intracr anial, th oracic, and abdomina l aortic aneur y sm s; and

colonic div erticu lae.

1816. Certain manifestations of autosomal dominant polycystic

kidney disease, such as intracranial aneurysms, tend to cluster in



families.

1 81 7 . Patients with pheochromocy toma should receiv e an

Î±-blocker 2 weeks before surgery.

1 81 8. Î²-Blockade in the absence of Î±-blockade is contraindicated in

patients with pheochr omocy toma and m ay lead to hy pertensiv e

crisis.

1819. The combination of upper and/or lower respiratory tractdisease and proteinase-3 antinu clear cy toplasmic ant ibody

positiv ity at the tim e of diagnosis is associated with the h ighest

likelihood of relapsing disease in a ntin uclear cy toplasmic

ant ibody â€“a ssociated sma ll-v essel v asculitis.

1 820. Hy drochlorothiazide can ca use sev ere hy ponatr emia.

1 821 . Cry oglobulinemia is char acterized by Ray nau d's

phenom enon, a pur puric rash, abnorm al findings on liv er function

studies, and the presence of glomerulonephritis.

1 822. Cry oglobulinemia ty pically decreases the C4 lev el, which

indicates activ ation of the classical pathwa y of complem ent

activ ation, m ore than th e C3 level.

1 82 3. Renal biopsy is indicated for patients with acute

glomerulonephrit is of unkn own cau se.

1 824. Pulmonar y hemorrha ge associated with acu te

glomerulonephrit is is associated with substan tial m orbidity and

mortality.

1 825. Atheroembolic disease can m imic v asculitis.1 82 6. The presence of liv edo reticu lar is, Hollenhorst plaque,

cy anotic toe, low C3 lev els, and peripheral eosinophilia suggests a

diagnosis of atheroembolic disease.

1 82 7 . A ther oembolic disease should be suspected in patient s with

erosiv e atherosclerosis presenting with a cute r enal failure.

1 828. Asym ptom atic hy percalcemia in a patient with a h istory of

calcium stones war ran ts ev alua tion for prim ary


1 82 9. Para thy roidectom y should be considered for patients with

calcium -conta ining stones secondary to prim ar y


1 83 0. Alport 's sy ndrome causes persistent m icroscopic hematuria ,

progr essiv e nephritis with proteinur ia, a nd progr essiv e decline in

renal function to end-stage renal disease.

1 83 1 . A lport's sy ndrome is an inherited condition t hat m ay present

with high-frequency sensorineural hearing loss and/or ocula r



abnormalities.

1 83 2. Isotonic saline is preferred ov er bicar bonat e-conta ining

solutions for resuscitation of patients with rhabdomyolysis.

1 83 3. In th e absence of renal failure or flash pulmonary edema,

medical ra ther tha n inv asiv e therapy is preferred for blood pressur e

contr ol, ev en wh en renovascular hy pertension is suspected.

1 83 4. Solute diur esis secondary to a high ur ea load is a comm oncause of hy perna trem ia in th e critical care setting.

1 83 5. Simple cy sts discov ered on rena l imaging studies requir e no

therapy.

1836. Complex renal cysts on ultrasonography require follow-up

ima ging with CT or MRI.

1 83 7 . Kidney biopsy is contr aindicated in patients with complex

renal m asses suspicious for m align ancy .

1 83 8. A paraprotein associated with systemic am y loidosis or

mult iple my eloma is a likely cau se of the nephr otic syndrome in

older pat ients.

1 83 9. An giotensin-conv erting enzy me inhibitor therapy is

warranted in patients with sta ge III and stage IV ch ronic kidney

disease un less the cr eatinine lev el rises >3 0% after in itiation of

therapy.

1 84 0. Once-daily dosing of ang iotensin-conv erting enzy me

inhibitors can decrease the risk for hy perka lemia.

1 84 1 . Sarcoidosis may cause nephrolithiasis, nephrocalcinosis, an dinterstitial nephritis.

1842. Angiotensin-converting enzyme inhibitors or angiotensin

receptor blockers ar e the agent s of choice for the treatm ent of

hy pertension in chr onic kidney disease.

1 84 3. An anion gap metabolic acidosis may be present in a patient

with sev ere hy poalbumin em ia and a â€œn orm alâ €� anion gap.

1 844 . Renal ultr asonogra phy can be norm al early in the cour se of

acute urina ry tra ct obstru ction.

1 84 5. Urinar y tract obstruct ion should be suspected in elderly men

with acu te renal failure.

1846. IgA glomerulonephritis is manifested by the nephritic

syndrome and is associated with dysmorphic erythrocytes and

ery thr ocy te casts.

1 84 7 . Diabetic ketoacidosis can lead to an anion gap metabolic

acidosis and metabolic alkalosis simultaneously.

1 84 8. Iatr ogenic respira tory alka losis may dev elop after initia tion of



mechanical ventilation.

1849. Antihypertensive agents such as diuretics and Î²-blockers

hav e been associated with an increased risk for t y pe 2 diabetes

mellitus, whereas angiotensin-converting enzyme inhibitors and

angiotensin receptor blockers may improve insulin sensitivity.

1 850. Risk factors for contrast nephropath y inclu de diabetic

nephr opathy , dehy dration, heart failure, age more than 7 0 y ears,impair ed kidney funct ion, and concu rr ent use of nephr otoxic drugs

and high-osmolar or high doses of radiocontrast medium.

1 851 . Prev ention of contr ast nephr opathy in patients at incr eased

risk for this condition inv olv es discontin uing nephrotoxic drug s,

using the lowest possible dose of low-osmolality contrast m edium for

the study , and adm inistering intr av enous therapy w ith 0.9% saline

at 1 mL/kg/h for 24 hour s beginning 1 2 hour s before administration

of contr ast medium .

1852. Myeloma-related kidney disorders should be suspected in

patients with a nemia, a low serum anion ga p, and renal failure.

1 853. A low seru m a nion gap war ran ts ev aluat ion for m y eloma due

to an increase in un measured cations such as calcium and

immunoglobulins.

1 854. My eloma kidney is associated with a discrepancy in

proteinuria detection between the dipstick ur inaly sis and a spot

ur ine collection.

1 855. Mathematical equat ions such as Cockcroftâ€“Gau lt orModification of Diet in Renal Disease are recomm ended for the

assessment of glomeru lar filtration rate r ather than 24 -hour ur ine

collections or radioimaging studies.

1 856. Indiv iduals with uncontrolled hy pertension a nd recur rent

episodes of flash pulm onary edem a should be screened for

renov ascular disease.

1 857 . In patients with suspected renov ascular disease and a

glomeru lar filtration ra te more than 6 0 mL/min, ma gnetic

resonan ce angiography is the imag ing study of choice to av oid the

risk for contr ast-induced acut e renal failur e.

1 858. A low glomeru lar filtration rate is the ma in cau se of

phosphate retention and hy perphosphatem ia in patients with

chr onic kidney disease.

1 859. Diur etics are effectiv e antihy pertensive ag ents in elderly

patients but m ay cause electroly te abnorm alities.

1 86 0. Th e presentat ion of anion g ap m etabolic acidosis and



respiratory alka losis suggests salicy late toxicity .

1 86 1 . Im mobilization in the exagger ated lithotomy position can

result in rhabdom y oly sis.

1 862 . An extremely elev ated creatine kinase lev el and eleva ted

ur ine my oglobin lev el suggest a diagn osis of pigm ent nephropathy .

1 863 . Com bination thera py with an an giotensin-conv erting

enzy m e inhibitor and a n angiotensin receptor blocker is associated with decreasing proteinuria in patien ts with nondiabetic renal

disease.

1 864 . Thin basement m embrane disease (benign familial

hema tur ia) is char acterized by glomerular h ematu ria with

dy smorphic ery throcy tes on m icroscopic analy sis of the urine and

no ev idence of proteinu ria .

1865. Patients with ethylene glycol poisoning presenting with both

an incr eased anion and osmolar gap m etabolic acidosis require

dialy sis in addition to either fomepizole or ethanol.

1 86 6. Am y loidosis is a com mon cause of the nephrotic sy ndrome in

nondiabetic patients >50 y ears of age.

1 867 . Phosphate binders ma y help to treat h y perphosphatemia in

patients with chr onic kidney disease.

1 868 . Black patients with kidney disease and hy pertension h av e

better renal outcomes after treatm ent with angiotensin-conv erting

enzy m e inhibitor th erapy com pared with am lodipine or Î²-blockers.

1 86 9. In pregn ancy , labetalol is preferable to pur e Î²-blockers, which may be associated w ith low bir thweig ht.

1 87 0. A ngiotensin-conv erting enzy me inhibitors an d angiotensin

receptor blockers are contr aindicated in pregnan cy .

1 87 1 . A h ighly negativ e urine anion gap suggests that the kidney is

appropriately excreting acid during m etabolic acidosis.

1 87 2. Alport 's syndrome is associated with a glomeru lonephrit is

with dy smorph ic ery throcy tes, mild proteinuria , and a

high-frequency hearing loss.

1 87 3. Wegener's gran ulom atosis is char acterized by upper an d

lower airwa y disease, glomerulonephrit is, an d positiv e findings on a

proteinase-3 antin eutr ophil cy toplasmic ant ibody assay .

1 87 4. A disparity between the dipstick protein lev el and quantified

ur inary protein excretion, a low anion ga p, and an incr ease in the

globulin fraction of the total protein lev el suggests mult iple

myeloma.

1 87 5. Microscopic poly ang iitis is a nongranu lomatous or sma ll-



v essel v ascu litis occasiona lly accompanied by mediu m-sized v essel

inv olv ement that causes a pulm onar y â€“renal syn drome.

1 87 6. Renal tr ansplant recipients who are Epsteinâ€“Barr

v ir usâ€“negativ e are at in cr eased risk for post-tr anspla nt

lymphoproliferative disorder, especially after receiving an organ

from an Epsteinâ€“Bar r v iru sâ€“positiv e donor.

1 87 7 . One of the m ost im porta nt initial steps in th e eva luation of microscopic hemat ur ia is urine m icroscopy to assess ery throcy te

morphology.

1 87 8. Glom erular hema tur ia is associated with dy smorphic

ery thr ocy tes and ery thr ocy te casts on ur inaly sis.

1 87 9. Obesity m ay lead to proteinuria and chr onic kidney disease.

1 880. Lowering blood pressure to appropriate tar gets is particular ly

important in patients with diabetes wh o hav e increased risk for

cardiovascular and renal complications.

1 881 . Diuretics potentia te th e blood pressur eâ€“lowering effects of

ang iotensin-conv erting enzy me inh ibitors a nd Î²-blockers.

1 882 . Postinfectious glom erulonephr itis may present 3 weeks after

onset of the in citing infection and is associated with low C3 lev els

and norm al C4 lev els.

1 883 . Respiratory alka losis com monly dev elops in end-stage liv er

disease.

1 884 . The r efeeding sy ndrome is a potentia l complication in

malnour ished patients wh o suddenly receiv e a larg e calorie load.1 885. Rhabdomy oly sis is a potentia lly sev ere complication of the

refeeding sy ndrome.

1 886 . The an tiphospholipid antibody syndrome is cha ra cterized by

thr ombosis in association with a lu pus anticoagulant or persistently

elevated levels of anticardiolipin antibodies.

1 887 . A peritoneal fluid cell count more than 1 00 total nu cleated

cells/ÂµL is abnorm al and consistent with the diagnosis of

peritonitis.

1 888. An tibiotic therapy covering both gr am -negativ e and

gram -positiv e path ogens should be started imm ediately in a pat ient

with suspect ed per itonea l dia ly sisâ€“related per itonitis.

1 889 . Acu te tubular n ecrosis is the most com mon cau se of acute

renal failur e after acetam inophen poisoning .

1 89 0. Patients with chr onic kidney disease should be educa ted to

av oid v enipunctu re and intrav enous catheters in v eins abov e the

lev el of the wr ist in both arm s to preserv e v eins for futur e creation of



arteriovenous fistulas.

1 891 . Subclav ian v ein lines should be strictly av oided in patients

with ch ronic kidney disea se.

1 89 2. Creat ion of an arteriovenous fistu la is indicated months before

initiation of dialysis.

1 893 . Patients m ore tha n 50 y ears of age with persistent hema tur ia

should be ev aluat ed for genitour inary tract m alignan cy .1 894 . Nonsteroidal a nti-inflamm atory drug use is a com mon cause

of resistance to antihypertensive therapy.

1 895. Acetazolam ide ma y cause nonâ€“an ion g ap m etabolic

acidosis.

1 89 6. In addition to cort icosteroids, t he m ost a ppropriate tr eatm ent

for lupus nephritis is intravenous cyclophosphamide followed by

maintenance my cophenolate m ofetil once rem ission is achiev ed.

1 89 7 . Infusion of norm al saline before and after exposure to

ra diocontrast is the m ost effectiv e method to decrease the r isk for

radiocontrast nephropathy.

1 898 . Calcific urem ic arteriolopathy ty pically presents with painful

v iola ceous nodules on t he trunk, proximal extr em it ies, and bu ttocks

in patients with chr onic kidney disease.

1 899 . Quantification of urinar y protein in upright an d recumbent

positions to ev alu ate for orthostatic proteinur ia is indicat ed for

y oun g adults with proteinuria and no other ev iden ce of kidney

disease.1 900. A cute glomeru lonephr itis is uncomm on w ithout h ematu ria

and a bland urine sediment.

1901. Hospitalization and delivery are indicated for women with

preeclampsia at term.

1 902. The ma nifestat ions of the HELLP sy ndrome (hem oly sis,

elev ated liv er enzym es, an d low platelets) are featur es of sev ere

preeclampsia.Posted by dokidok at 2:1 0 PM Labels: step 3

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