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Usmle Students Notes
Th ur sday , Apri l 23, 23, 20 2009 09
tripleh tripleheli elix x n otes Notes by triplehelix triplehelix.. I did MKSAP MKSAP 1 1 4 qu estions estions and m ade notes based on the t he key point point s, and I plan to rev iew th is note bef befoore m y test. test. I thoug thoug ht to share th is notes notes with y ou gu y s. MKSAP MKSAP 1 4 neur ology logy notes: notes: 1 . A spinal spinal cord cord diso disorder should be consid considered ered in an y patient w ith bila bil a t er a l m otor a n d sensory sen sory dy sfun sfu n ct ion in t h e ex t r em ities it ies in i n th e absence absence of of signs signs or sy m ptom ptom s of of brain or brain stem stem dy sfun sfun ction. ction. 2 . Spinal Spina l cord com com pressio pression n due to epidur epidur al m etastasis etasta sis is a neur ologic logic emerg ency for for wh ich u rg ent MRI MRI of the entir e spine spine is appropriate. appropriate. 3. Vertebral ar tery dis dissectio ection ty pically pically presents presents with neck or or h ead pain, Horner's syndrome, dysarthria, dysphagia, decreased pain and temperatu temperatu re sensatio sensation, n, dy smetria, ataxia, and v ertigo. ertigo. 4. Magnetic r eso esonan ce ang iogr iogr aphy is a sensi sensitiv tiv e diagn diagn ostic test for for v er t ebr a l a r t ery er y dissect dissec t ion a s a ca u se of str oke. 5. Ju v enile my oclonic clonic epile epileps psyy is a primar y , genetic, generalized generalized epilep epilepsy sy t ha t ty pically m anifests anifests with m y oclonic clonic jerks fo followed llowed by by a generalized tonic–clonic seizure 6. Guillain–Barr Guillain–Barr é sy sy ndrome ndrome is char acterized acterized by by proxima proxima l an d dis distal wea w eakn kn ess, a u t onom ic sy m ptom pt oms, s, cr a n ia l n erv er v e in i n v olv em ent en t , a n d respi respiratory ratory failur failur e. 7 . Treatm ent of of Guillain–Barré Guillain–Barré sy sy ndrom ndrom e with either intrav enous enous imm un oglobulin globulin or plasm plasm apheresis is indicated indicated in patients wh o cannot walk independently or who have impaired respiratory function or or ra pidly pidly progr progr essi essivv e weakn ess. ess. 8. Sma ll, stable, asy asy m ptom ptom atic m eningiomas can be fo followed llowed with serial neur oima ging.
9. In larg e, sy sy m ptom ptom atic, or progres progresssiv e m eningioma eningioma s, surg ical resection offe offers rs an 80% ch an ce of of cur e. 1 0. Perso Personality nality chan ge, los lost initiativ e, and slowing slowing of though though t, w ith relat iv e prese preserv rv ation of of recent recent m emory , sug sug gest fronto frontotempo tempora ra l dementia. 1 1 . Fronto Frontotempo tempora ra l dem dem entia is usua usua lly asso associated with disproportionate atrophy of the anterior frontal and temporal lobes, a finding th at is usually clearly dem dem onstra ted on MRI MRI. 1 2 . Elev ation of of the cerebros cerebrospinal pinal fluid 1 4-3-3 protein protein in a patient wit w ith h r a pidly pidl y progr pr ogr essiv e dem ent en t ia a n d norm n orm a l str u ct u r a l im a g in g sugg ests ests Cr eutzf eut zfeldt–Ja eldt–Jako kob b disease. disease. 1 3 . Treat m ent w ith in terferon-b terferon-beta eta decreases decreases th e incidence incidence of of additional additional a tta cks in patients with m onosy nosy m ptom ptom atic dem dem y elinatio elination, n, including optic optic neuritis and my elopathy elopathy . 1 4. Propra ropra nolol nolol an d prim prim idone idone ar e firstfirst-line line drug s in in th e treatm ent of esse essentia ntia l tr emor (postura (postura l an d action tr emor). 1 5. The Th e diagn osis of Par Par kinso kin son's n's diseas diseasee requir r equir es the pr esence esence of at least two of the follo followin win g: trem or at rest, brady kinesia, rigidity , an d pos postur al reflex reflex abnorm abnorm ality . 1 6. Th e characteristics of migra ine headache headache with out a ur a include worsen w orsen in g of th e h eada ea dach ch e w ith it h m ov em ent en t , lim li m ita it a tion ti on of act a ct iv ities, it ies, and photo- and phonophobia 1 7 . Tran sv erse erse my elitis elitis is an acu te or or subacute demy demy elinativ elinativ e or or inflam m atory diso disorder of the spina spina l cord cord th at cau ses ses motor, motor, sensory ensory , and au tonomic tonomic dy sfun sfun ction ction below below a spinal spinal cord cord lev el. 18. High-dose intravenous corticosteroids are indicated for initial treatm ent of of acute transv erse erse my elitis elitis.. 19. Secondary prevention of cardioembolic stroke consists of wa w a r far fa r in w ith it h a t a r g et INR of 2.0 2 .0 t o 3. 3 . 0. 20 . Hepar Hepar in h as no establis established hed role in th e acut e treat m ent of stroke. stroke. 21 . Th e m anifestat anifestat ions ions of of partia l seizur seizur es dep depend end on on their neur oana tom tom ic location. location. 22 . Fronta Fronta l seiz seizur ur es ar e brief brief and ar e usually not asso associated ciated 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 fir st decade of of life. 24. Hereditary sensorimotor neuropathy is characterized by distal m uscle atr ophy , w eakness, eakness, an d senso sensory ry loss loss asso associated with hig h arch es (pes (pes cav us) and ham mert oes
9. In larg e, sy sy m ptom ptom atic, or progres progresssiv e m eningioma eningioma s, surg ical resection offe offers rs an 80% ch an ce of of cur e. 1 0. Perso Personality nality chan ge, los lost initiativ e, and slowing slowing of though though t, w ith relat iv e prese preserv rv ation of of recent recent m emory , sug sug gest fronto frontotempo tempora ra l dementia. 1 1 . Fronto Frontotempo tempora ra l dem dem entia is usua usua lly asso associated with disproportionate atrophy of the anterior frontal and temporal lobes, a finding th at is usually clearly dem dem onstra ted on MRI MRI. 1 2 . Elev ation of of the cerebros cerebrospinal pinal fluid 1 4-3-3 protein protein in a patient wit w ith h r a pidly pidl y progr pr ogr essiv e dem ent en t ia a n d norm n orm a l str u ct u r a l im a g in g sugg ests ests Cr eutzf eut zfeldt–Ja eldt–Jako kob b disease. disease. 1 3 . Treat m ent w ith in terferon-b terferon-beta eta decreases decreases th e incidence incidence of of additional additional a tta cks in patients with m onosy nosy m ptom ptom atic dem dem y elinatio elination, n, including optic optic neuritis and my elopathy elopathy . 1 4. Propra ropra nolol nolol an d prim prim idone idone ar e firstfirst-line line drug s in in th e treatm ent of esse essentia ntia l tr emor (postura (postura l an d action tr emor). 1 5. The Th e diagn osis of Par Par kinso kin son's n's diseas diseasee requir r equir es the pr esence esence of at least two of the follo followin win g: trem or at rest, brady kinesia, rigidity , an d pos postur al reflex reflex abnorm abnorm ality . 1 6. Th e characteristics of migra ine headache headache with out a ur a include worsen w orsen in g of th e h eada ea dach ch e w ith it h m ov em ent en t , lim li m ita it a tion ti on of act a ct iv ities, it ies, and photo- and phonophobia 1 7 . Tran sv erse erse my elitis elitis is an acu te or or subacute demy demy elinativ elinativ e or or inflam m atory diso disorder of the spina spina l cord cord th at cau ses ses motor, motor, sensory ensory , and au tonomic tonomic dy sfun sfun ction ction below below a spinal spinal cord cord lev el. 18. High-dose intravenous corticosteroids are indicated for initial treatm ent of of acute transv erse erse my elitis elitis.. 19. Secondary prevention of cardioembolic stroke consists of wa w a r far fa r in w ith it h a t a r g et INR of 2.0 2 .0 t o 3. 3 . 0. 20 . Hepar Hepar in h as no establis established hed role in th e acut e treat m ent of stroke. stroke. 21 . Th e m anifestat anifestat ions ions of of partia l seizur seizur es dep depend end on on their neur oana tom tom ic location. location. 22 . Fronta Fronta l seiz seizur ur es ar e brief brief and ar e usually not asso associated ciated 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 fir st decade of of life. 24. Hereditary sensorimotor neuropathy is characterized by distal m uscle atr ophy , w eakness, eakness, an d senso sensory ry loss loss asso associated with hig h arch es (pes (pes cav us) and ham mert oes
25. Cell Cell ty pe and tum or gr ade are th e mos most im portan portan t determin determin ants of sur v iv al in gliom gliom a. 26 . Higher-gra Higher-gra de glioma glioma s are m ore ag gress gressiv e than lower lower gra de. de. 27 . A lzheimer' lzheimer'ss dis diseas easee is char acterized acterized by by primar y dem dem entia with prom prom inent am nesia. nesia. 28. Dem Dem entia with Lewy bodi bodies es,, cha racterized racterized by fluctu fluctu ating cognit cognit ion, ion, parkin sonism, sonism, and/or and/or v isua isua l h allu cinat ions, ions, often often coexis coexists ts wit w ith h A lzh eim er's er 's disease. disea se. 29 . A ll patients wit h r elapsing elapsing m ult iple sclero sclerosi siss should should be consid considered ered for for im m un om odulat ory th erapy wit h either a form form of interferon-beta or glatiramer acetate. 30 . Adu lt-o lt-onset nset idiopathic idiopathic dy stonia stonia is usually focal focal or segm segm ental a nd does does not not g enera lize to oth er par ts of of th e body body . 31. Botulinum toxin injections can correct the abnormal posture and allev iate the pain asso associated with cerv ical dy stonia. tonia. 32 . Approxi Approxim m ately 20% of of patients patients with migr aine hav e headache headache wit w ith h a u r a , t h a t is, n eur eu r ologic ologi c pr p r oblem s such su ch a s v isu a l h a llu ll u cin ci n a tions ti ons or n um bness bness or or t inglin g befo before or or dur ing h eadache. 33 . Lherm itte's itte's sign, sign, an “electric shock”–like sensatio sensation n down down th e neck, back, or or extr emities occur occur rin g w ith n eck flexio flexion, n, is a helpful helpful historica historica l clu e to a cerv ical spinal cord diso disorder. rder. 34 . Cerv ical spondy spondy losi losiss is a ch ronic diso disorder of degenerativ degenerativ e and hypertrophic changes of the vertebrae, ligaments, and disks that ma y nar row row th e spi spinal nal cana l and cause cerv ical spi spinal nal cord cord compression. 35 . In In patients with stroke stroke not not eligible for for th romboly romboly tic th erapy , aspirin aspirin m odes destly reduces bo both the short-term short-term risk of of recur rent stroke stroke and t he long-term long-term risk of of str str oke-relat ke-relat ed death death and disability . 36 . In In patients with acute stroke, stroke, thromboly thromboly tic therapy mu st be star ted with in 3 hours of of the onset onset of of sy sy m ptom ptom s or or of the tim e the patient w as last known t o be well. 37 . Elderly Elderly patients patients may be particular ly sensitiv ensitiv e to the cognitiv cognitiv e, motor, and coordination side effects of phenytoin, even if the serum pheny pheny toin toin lev el is in the th erapeutic erapeutic ra nge. 38. Gabapentin, Gabapentin, lam otrigine, an d carbam azep azepine ine are equally effe effectiv ctiv e at controlling par tial onset seiz seizur ur es in th e elderly elderly , but gabapentin a nd lam otr igine ar e better better tolerat tolerat ed. ed. 39 . Peripheral Peripheral nerv ous sy sy stem v asculitis usually presents presents with asy m m etric w eakness and senso sensory ry loss loss in specif specific ic nerv e distributions.
40. In an elderly elderly patient wit h r ecur rent g lioblasto lioblastom m a an d po poor perfo perform rm ance stat us, r eferra eferra l for for hospice hospice care is prefera prefera ble to additio additional nal a ntitum or t reatm ent. 41 . The th ree spe specific cific crit eria for for dementia wit h Lewy bodie bodiess ar e fluctu fluctu ating encephalo encephalopathy pathy , parkinsonis parkinsonism m , an d v isual isual hallucinations. 42 . A centrally centrally acting anticholine anticholinessterase terase agent may allev allev iate the inattention, inattention, hallu cinations, cinations, and fluctu ating encephalo encephalopathy pathy of dem dem entia w ith Lewy Lewy bodie bodies. s. 43 . Wom Wom en taking imm unomodulato unomodulatory ry treatm ent fo for m ultiple sclerosis clerosis should should use effe effectiv ctiv e contr contr aception, aception, or if they wa nt to becom bec omee pr egn eg n a n t , stop th t h era er a py sev era er a l m onth ont h s before befor e at a t t em ptin pt in g t o conceive. 44 . Inv Inv olunta ry brief, brief, irregular , un predictable predictable mov ements flee fleeting ting from from one body body part t o another a re ha llm ar ks of of chorea. chorea. 45. Ch orea can occur as a hereditary and degenerativ e dis disease ease or secondar econdar y to dru dru gs, m etabolic etabolic diso disorders, infections, infections, im m un emediated diseases, and vascular lesions. 46 . Tensio Tension-ty pe headach e is disting disting uished from from m igr aine by th e fact th at pat ients with tension tension h eadache ar e not not disabled disabled an d can carr y out activ ities ities of daily daily liv ing in a norma l, exped expedie ient nt m ann er. 47 . Vita m in B1 2 deficiency deficiency can ca use dy sfun sfun ction ction of of the po posterior colum colum ns an d cort cort icosp icospinal inal tr acts of the spinal spinal cord, cord, ca using pares par esth th esias, esias, loss loss of of v ibra tion and an d positio position n sense, senso sensory ry atax at ax ia, wea w eakn kn ess, a n d u pper m otor n eur eu r on sig si g n s. 48. Neurolo Neurologic gic signs signs of of v itam in B1 2 defi deficie ciency ncy ma y m anifes anifest in th e absence absence of of hema tolo tologic gic signs of of v itam in B1 2 deficie deficiency ncy . 49 . In In a patient patient w ith a tran sient ient ischemic attack, car otid artery ult ra sonography sonography showin showin g a > 50% steno stenosi siss of of the intern al ca rotid artery m ay be an indication indication for for car otid endarterecto endarterectomy my . 50. A singl singl e antiepileptic antiepileptic dru g should be used in pregn an t w om en wit w ith h epilep epi lepsy sy ; m u lt iple ipl e dr u g th er a py in cr eases ea ses th t h e r isk for bir t h defects. 51 . Chronic Chronic inflamm inflamm atory atory demy demy elinating elinating poly poly neurop neuropathy , th e chr onic form form of Guillain–Bar ré sy ndrome, is char acter ized ized by proxim proxim al and distal w eakness, eakness, a reflexia, a nd distal distal senso sensory ry loss loss.. 52. Chronic inflamm atory atory dem dem y elinating elinating poly poly neuropathy neuropathy progresses progresses in a stepw stepw ise or or r elapsing c our se for for a t least lea st 8 w eeks an d can occur early in t he cour cour se of HIV HIV in fectio fection. n. 53 . In In a y oun g patient w ith totally resected resected low-gra low-gra de gliom gliom a,
posts postsur ur gical m an agem ent consists consists of obs observ erv ation w ith seria seria l neuroimaging. 54. V ascular ascular dem dem entia is sugg sugg ested ested by a h isto istory ry of v ascular ascular risk factors, factors, abru pt onset onset with subsequent subsequent im prov prov ement , periv periv entricular wh ite matter ischemia ischemia on imag ing, and focal focal neurologic findings. 55. Intr Intr av enous enous meth y lpredniso lprednisolone lone thera py follo followed wed by by an oral predniso prednisone ne taper spee speeds ds recov recov ery of v isua isua l acu ity in optic optic neur itis 56. The restless legs syndrome consists of abnormal sensations in the legs and restless restlessness ness reliev ed by by m ov ement. 57 . Patients are at r isk isk for for dev eloping eloping an alg esic esic ov ov eruse headache if they use prescriptio prescription n or ov er-th er-th e-co e-coun un ter m edication edication for for headach e more than 2 day s a week. 58. Pseudo seudotu tu m or cerebri is char acter ized ized by by papillede papilledem m a, postura postura l chang e with headache, v isual isual chan ges, ges, r ecent ecent report report of rapid weight weight gain , or or int roduct roduct ion ion of ora l contr contr aceptiv es or tetr acy cline. 59. Infar ction ction of the spina spina l cord cord ty pically presents presents as sudden sudden spinal spinal cord cord dy sfun sfun ction. ction. 60. Spinal cord infar ction ction usua lly affects affects the territory of the ant erior erior spinal ar tery , cau sing w eakness and pinprick loss loss of of sensation with sparing of vibration and position sense. 61 . CT scan scan m ay miss subara chnoid chnoid hemorr hemorr hag e, es especially pecially wh en there is a delay delay in presentatio presentation n a fter fter the initial h emorr emorr hag e. 62 . Focal Focal neur ologic logic sy mptoms mptoms 3 to 7 day s after after a subara chnoid chnoid hemorrha ge ma y be due due to va sospasm pasm with cerebral cerebral ischemia. ischemia. 63 . Patient Patient s wit h epileps epilepsyy wh o ar e most most likely likely to rem ain seizur seizur e free free after after m edicatio edication n w ithdraw al ar e thos those with no stru stru ctur al brain lesion, lesion, no epileptifo epileptiforr m or focal focal abno abn orm alit ies on on electroencephalogram, a sustained seizure-free period, and no abnorma lities on n eurologic eurologic exam inat ion. ion. 64 . Patients wit h epilep epilepsy sy wh o disco discontin ntin ue a ntiepileptic ntiepileptic m edication edication should sto stop p driv driv ing for for at least 3 m onth s an d preferably preferably 6 m onth s from from th e star star t of of the taper. 65. Cr itical illn ess ess poly poly neur opathy is a com com m on cau se of failu failu re to wea w ean n from fr om a v enti en tila la t or in i n a pat pa t ien t w ith it h a ssoci ssociaa t ed m u lt iorg ior g a n failu re a nd sepsis sepsis.. 66. Critical illness polyneuropathy is characterized by generalized or distal fla ccid par aly sis, sis, depresse depressed d or or a bsent bsent reflexes, an d distal distal sensory ensory loss loss wit h sparing of cran ial n erv e fun fun ction. ction. 67 . Patie Patients nts with primary central central n erv ous sy sy stem ly mphoma mphoma
should be be ev aluat ed fo for v itreal or or uv eal inv olv ement befo before th erapy is begun begun . 68. Aggr ess essiv e resectio resection n is not not r ecomm ecomm ended ended in in primar y central nerv ous sy sy stem ly m phom phom a; methotrexate methotrexate chemotherapy chemotherapy is primar y therapy. 69. Donepezil, an acetylcholinesterase inhibitor, may cause mild peripher peripher al ch olinerg ic side side effe effects, cts, inclu ding incr eased eased v ag al tone, wit w ith h br a dy ca r dia , a n d occa occ a siona sion a lly ll y a tr iov ent en t r icu ic u la r block. bl ock. 70. In at least 50% of patients with relapsing–remitting multiple sclerosis, disease will evolve to a secondary progressive course. 7 1 . In In a t least 50% of of patients patients with r elaps elapsing–remitting m ultiple sclerosis, disease will evolve to a secondary progressive course. 7 2 . Metoclo Metoclopram pram ide, ide, w hich blocks blocks do dopam ine receptors receptors both both in t he periphery periphery and inside inside the central nerv ous sy sy stem, ca n induce parkinsonism. 73. Prednisone is the most appropriate treatment for episodic cluster headache. 7 4. Acu te cerv ical spinal spinal cord com com pressi pressioon due to hy perexten perexten sion ion injury is co comm on in elderly elderly patients. patients. 7 5. Em ergent MR MRII of the cerv ical spinal cord cord is indicated in in a ny patient wit h qua driparesis driparesis after a fall. 7 6. The classic classic sy sy m ptom ptom s of cerebellar cerebellar stroke ar e headache, v ertigo, and ataxia. 7 7 . Patients with epilep epilepsy sy wh o fail to respo respond nd to thr ee trials of of ant iepilep iepileptic tic dru gs are un likely to ev er becom becom e seiz seizur ur e free free with drug therapy . 78. Treatment-resistant patients with epilepsy should be evaluated for for a sur gicall y rem ediable ediable epile epileps psyy sy ndrome. 7 9. My asthenia grav is is an autoimm une diseas diseasee caused caused by by ant ibodie ibodiess aga inst the acety lcholine recepto receptor, r, w hich results in impaired neuromuscular transmission. 80. My asthenia grav is is char char acterized acterized by fatigable weakness weakness with a predilection for ocular, bulbar, proximal-extremity, neck, and respiratory muscles. 81 . Lepto Leptom m eningeal spread spread of of sy sy stem stem ic car cinom cinom a m an ifests ifests as a cranial neuropathy neuropathy or spinal spinal poly poly radiculopathy radiculopathy , or or as encephalopathy, diffuse brain infiltration, or communicating hydrocephalus. 82 . Creut Cr eutzf zfeldt–Jak eldt–Jak ob disease disease is sugg ested ested by subacu te progressio progression n of dementia dementia wit h m y oclonu clonu s an d other other m otor tor signs and a norma l
brain MRI. 83 . In th e setting of subacu tely progr essiv e dementia , th e presence of 1 4-3-3 pr otein in cerebrospinal fluid, or electroencepha logr aphy showing periodic shar p wa v es, ca n be diagn ostic of Creu tzfeldt–Ja kob disease. 84. Mitoxantrone therapy is of modest benefit in slowing progression of secondar y progr essiv e or sev ere relapsing–r emitt ing m ult iple sclerosis. 85. The prima ry concern a bout mitoxantrone therapy is the risk for cardiotoxicity. 86 . Progressiv e supra nu clear palsy is cha ra cterized 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 sy m ptom s of increased intra cra nial pressur e with out a m ass lesion on brain im agin g. 89 . In patients wit h possible idiopathic in tr acr ania l hy pert ension, a diagnostic and potentially therapeutic lumbar puncture is indicated after bra in im agin g exclu des a ma ss lesion. 90. Sev ere cerebral an oxia from cardiac arr est can cause sev ere diffuse cerebral hem ispheric cortical inju ry with relativ e preserv ation of brainstem function, leading to the dev elopment of a v egetativ e state. 91 . A v egetativ e stat e 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 epilepticu s, 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 stat us epilepticus. 96 . My asthenia grav is crisis is char acterized by dysphagia
requir ing n asogastr ic feeding a nd/or sev ere respiratory m uscle weakn ess necessitatin g 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 a nd is m ore com m on a fter whole-brain com pared with focal brain irr adiation. 1 00. Mild cogn itiv e impair m ent consists of isolated m ild am nesia with no im pair m ent of inter personal, 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, an d impotence, w ith gait -predom inan 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 paral y sis of horizonta l ey e mov ements and bulbar m uscles, an d can comm 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, usuall y 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 t he absence of chr onic hypertension or a lipid disorder. 1 08. Headache m ay be a lim iting factor in the use of the com bina tion of aspirin and exten ded-release dipy ridam ole for secondar y stroke prev ention. 1 09 . N onepileptic seizur es of psy chogenic orig in can be different iated from epilepsy by th eir longer du ra tion, n orm al electr oencepha logr am finding s, an d m aint enan ce of consciousness. 1 1 0. Nonepileptic psy chogenic seizur es are often associated w ith moaning, cry ing, and arrh y thm ic shaking of the body . 1 1 1 . A bsence 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 otr ophic latera l sclerosis usuall y begin s distally and asy m m etrically in the u pper 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 acc essible solitar y brain m etastasis in patients with lim ited or n o sy stem ic tum or. 1 1 6. Ch olinestera se inh ibitors 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 Alzh eim er's disease, but do not allev ia te cognitiv e or psy ch ia tric symptoms. 118. In patients with possible multiple sclerosis, new MRI whitem att er lesions or new gadoliniu m -enha ncing lesions on serial brain or spinal cord MRI at least 3 m onth s after a n in itial scan, indicate dissem inat ion of demy elination, ev en with out a n ew clinically ev ident attack. 1 1 9. Carbidopa-lev odopa is th e first-line t reat m ent for patients older tha n 7 0 y ears wit h new-onset Par kinson's disease. 120. Complications associated with the use of dopamine agonists, such as som nolence, 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 t he r isk of com plications 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 2 3 . Oxcar bazepine is effectiv e monoth erapy for par tial onset seizures. 1 2 4. Risk factors for r ecur rent seizur es inclu de m ult iple prev ious seizur es, a h istory of significan t head tr au m a, focal electroencephalogram abnorm alities, and stru ctur al abnorm ality on MRI. 1 2 5. Am y otr ophic later al sclerosis cau ses 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 2 6. N oninv asiv e positiv e-pressure v entilat ion should be start ed in patients with am y otr ophic lat eral sclerosis whose forced v ital capacity is less than 50% or w ho has sy m ptom s of noctu rn 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 stem ic cancer ar e most likely due to an im m un e-m ediated 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 cholinestera se inh ibitor th erapy . 1 2 9. Estrogen replacement in post-m enopausal women w ith Alzh eim er's dementia has not been shown to allev ia te cognitiv e sy m ptom s or delay disease progression. 1 3 0. Dr ug -indu ced psy chosis in Par kinson's disease consists primar ily of v isual h allucinat ions, ev olv ing at tim es into paran oid-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 3 2 . 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 uscle atrophy , an d cognitiv e dy sfunction. 1 34 . Cardiac disease resulting in ar rh y thm ias and respiratory failur e due to diaphr agm atic w eakness ar e com m on 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 3 6. Lam bert -Eaton m y asthenic sy ndrome is diagnosed by m otor nerv e conduct ion studies wit h r epetitiv e stim ula tion. 1 37 . Cognitive im pairment a ccompanied by fluctuating lethargy and inat tention, hal lucin ations, an d asterixis is likely th e result of a toxic encephalopathy. 1 3 8. Dru gs that block dopam ine receptors can induce acu te dy stonic reactions. 1 3 9. In acute ischemic stroke, tissue plasminogen activ ator is indicated if th erapy is star ted with in 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 crit eria are met. 1 40. A ll stat es require tha t an episode of loss of awar eness be report ed to gov ernm ent au th orit ies, either t o th e Depar tm ent of Health or t o th e Depart m ent of Motor Veh icles. 1 41 . Hypothy roid m y opathy is char acterized by m uscle pain, cra m ps, stiffness, fatigu e, a nd 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 m only associated with sm all-cell lu ng ca ncer. 1 44 . Par an eoplastic lim bic encephalitis is cha ra cterized by ra pidly progr essiv e decline in short-term m emory an d seizur es. 1 45. The m ost com m 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 h eritable form of Alzh eim er's disease is su spect ed. 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 th ere is penetr ation of th e dur a or loss of consciousness for m ore than 3 0 minutes. 1 49 . Critical illness my opathy is comm on in v entilator-dependent patients wh o ha v 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 par aly sis, mu scle atrophy , an d high cr eatine kinase lev els. 1 51 . Prim ar y im pairm ent of concentr ation and attention, as opposed to m emory , is likely th e result of depression r ath er th an a neur odegenera tiv 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 ptom s. 1 53 . Depression is a possible side effect of ma ny an tiepileptic dru gs, including phenobarbital, pheny toin, v alproate, lev etiracetam, a nd topiramate. 1 54. Selectiv e serotonin reupta ke inh ibitors, m oclobemide, v enla faxin e, and nefazodone do not in cr ease the seizur e threshold in
patients with epilepsy and th erefore ar e the preferr ed pharmacologic agents in depression. 1 55. Poly m y ositis is cha ra cterized 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 m otor un it potentia ls. 1 56. Result s of creatine kina se measur ement a nd needle electromy ography are inv ariably norm al in steroid my opathy but abnorm 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 th e preferred ant iplatelet ther apy for a spirinallerg ic patients with a h istory of str oke. My Cardiology Note: 1 60 . Righ t v entr icula r infar ction should be suspected in patients with in fer ior m y ocardia l in farct ion who present with hy poten sion, clear lu ng fields, an d elev ated jugu lar v enous pressur e. 1 61 . An echocar diogr am establishes th e diagn osis of right v entr icula r in farct ion by dem onstratin g rig ht 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, successful fibrinoly sis is sug gested by resolution of chest pain a nd 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 rh y 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 th an 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 wit h contra st is indicated to detect acu te aortic dissection. 1 69 . In patients at risk for r adiocontr ast nephr opathy an d contr aindication t o MRI, tr ansesophag eal 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 epicar dium is the most com m on location of metastatic car diac neoplasm. 1 7 2 . An A CE inh ibitor an d a β-blocker ar e indicated in all patients with sy stolic heart failure, in cludin g asy m ptomatic patients. 1 7 3 . Spironolactone and digoxin are not indicated in patients with asym 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 incr ease in left v entr icula r w all th ickness is a u seful diagnostic clue for cardiac amyloidosis. 1 7 6. Abdom inal fat aspira tion biopsy is a safe and reasona bly sensitiv e test for th e 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. Th e most sensitiv e sign on phy sical exam ination t o exclude the diagn osis of sev ere aortic stenosis is a phy siologicall y split S2 . 1 7 9. Most patients with peripheral v ascular disease hav e an A BI 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 is significant 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, r esistant infections, and lar ge mobile v egetations. 1 94 . Ev en if activ e bacter emia is still present or if the antibiotic tr eatm ent course is ong oing, sur gery for endocar ditis should n ot be delay ed if sur gical criteria a re m et. 1 95. Medical therapy for acute, r ecent m y ocardial infarction inclu des β-blockers, aspirin, ang iotensin-conv ertin g enzy m e inh ibitors, an d stat ins. 1 96 . Sm oking cessation is the single m ost effectiv e interv ention for patients with peripheral v ascular disease. 1 97 . β blockade does not prom ote clinica l cla udication. 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. 20 1 . 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 r equire aspirin a nd clopidogr el at discha rg e. 203 . Patients with ST-elev ation m y ocardial infarction treated without stents m ay be m anaged w ith aspir in alone or wit h warfarin if indicated for a tr ial fibrillation or a nter ior a kinesis or a neur y sm. 20 4. In low-risk patients with lone atr ial fibrilla tion, w ar farin 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 m itra l v alv e prolapse has a benign progn osis. 20 7 . An tibiotic prophy lax is for endocar ditis is indicated in mitr al v alv e pr olapse if there is m ore than m ild 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 anem ia, 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 wit h a tr ial fibrillation and risk factors for stroke require anticoagu lation with w arfarin. 21 1 . Risk factors for stroke in nonrh eum atic at ria l fibrilla tion inclu de prior em bolic ev ent or str oke, hy pert ension, 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 patient s who ar e acut ely decom pensated 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 ula r r egur gita tion does not pose a r isk of endocarditis and does not require antibiotic prophylaxis. 21 6. An tibiotic 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 for constrictiv 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 notic eable in the in fer ior leads. 21 9. Th e 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 par t of postinfarction medical therapy. 221. Angiotensin-converting enzyme inhibitors are indicated for all patients with sy stolic h eart failur e, rega rdless of ejection fr action or functional status, barring contraindications. 22 2 . Patients with STEMI should u ndergo coronar y reperfusion in the m ost expeditious m ann er. 22 3 . STEMI patients wh o cannot be reperfused by direct coronar y 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 pacema ker 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. Ech ocar diogr aphy is a useful diagn ostic m odality for th e delineation of pericar dial hem ody na m ics. 22 7 . • Papillar y m uscle dy sfun ction or r uptu re 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 ech ocar diogr am should be perform ed if papillar y m uscle 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 l eft 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 m ain and/or m ult iv essel corona ry artery disease. 23 3. Coronary artery bypass grafting improv es surv iv al in com parison t o percu tan eous interv ention in diabetic patients wit h mu 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 w av 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 m assage is u nsuccessful, adenosine is the dru g of choice for t he 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 h an dgripping exercises. 23 8. A scending 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 th e 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 . Noona n sy ndrome should alwa y 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 m atory m edication, 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 t o fibrinoly sis in patients w ith STEMI. 24 6. Rev ascular ization should proceed expeditiously with concomitan t m edical th erapy for h y pert ension 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 cardiom y 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 eaches 55 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 th ora x) a nd elev at ed but equal blood pressure in both upper extrem ities. 25 2 . A bicu spid aort ic v alv e is often seen in a ssociation with aortic coar ctat ion, presentin g w ith a ort ic regu rg itat ion or aort ic stenosis. 25 3 . Phy sical findings of m itr al regu rg itat ion inclu de holosy stolic mu rm ur at th e apex radiating to the axilla, w ithout r espirat ory v aria tion. 254 . In healthy adults, prema tur e v entricular contractions are com m on a nd ar e not a cau se for concern. 25 5. Suppression of prem atu re v entr icula r contra ctions is indicated only in patients with sev ere and disabling sy m ptom s. 256 . Smoking, hy pertension, adv anced age, and ma le sex are risk factors for abdom inal a ort ic aneur y sm. 257 . Most abdom inal aortic aneury sms are asy m ptom atic, but abdom inal pain is th e most comm on sy m ptom . 25 8. 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. 30 8. Prosth etic v alv e dehiscence or dy sfunct ion should be suspected in patients tha t dev elop sy m ptom s of cong estiv e heart failur e, particu lar ly if these sym ptom s occur in th e first 6 m onth s followin g surgery. 30 9. 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 in farction should be suspected as a ca use of hy potension w hen findings of righ t hear t failur e coincide with a n absence of evidence of pulmonary congestion. 31 1 . Im planta tion of a cardiov erter-defibrillat or is an import ant prophy lactic treatm ent in patients with h y pertr ophic cardiomyopathy and high risk for sudden death. 31 2 . Clinical featu res th at predict high r isk for sudden death in patients with h y pertr ophic cardiomy opathy include fam ily history of sudden death, sy ncope, ma rked left v entr icula r 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 recogn ized m echan ical com plications that occur ear ly after my ocardial infarction. 31 4. Both papillary mu scle rupture and v entricular septal defect present w ith 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 m ptom s and measur es of left v entr icula r size and sy stolic function. 31 7 . Classic featu res of Mar fan's sy ndrome inclu des tall statur e, high ar ched palate, joint h y perm obility , scoliosis, and positiv e “w rist sign.” 31 8. Patients with Mar fan'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 shockresistant v entricular fibrillation. 32 0. Th e risk of coronar y ar tery disease in diabetic patients is 2 to 4 tim es hig her th an in n ondiabetic patient s. 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 a nd interm ediate risk of coronar y ar tery 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 elect rocardiogram and a norm al exercise electr ocar diogr am can be discha rg ed wit hout coronar y angiography. 32 4. Although uncomm on, left atrial my xoma should be considered
in y oun g patients with embolic str oke. 32 5. Echocardiogra phy is an im portan t im aging modality for diagnosis of an intr aca rdiac tu m or. 32 6. Women wit h 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 pregna ncy . 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 th e QRS com plex. 32 9. • If atriov entricular nodal reentrant tachy cardia does not respond to v aga l m aneu v ers, adenosine is the tr eatm ent of choice 33 0. Contin uous effectiv e anticoagu lation is needed th rough out pregnancy in women with m echanical heart v alv es. 33 1 . Radiofrequency cath eter ablation is th e 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 inotr opic agen ts m ay be needed to au gm ent m y ocar dial contr actility and thu s cardiac output. 33 4. Exercise (or ph ar m acologic) stress testing is the m ost sensitiv e noninv asiv e meth od to establish th e diagnosis of coronar y ar tery disease. 33 5. Exercise (or pha rm acologic) stress car diac ima ging can be used to ev alu ate for coronar y ar tery disease if the resting electrocardiogram is abnormal. 33 6. The r ole of electr on-beam CT coronar y calciu m scores is not y et established in th e assessm ent of coronar y ar tery disease. 33 7 . Prolong ed imm obility followed by a stroke or t ra nsient ischem ic a tta ck should raise th e suspicion of a paradoxical embolism. 33 8. Tr ansesophag eal echocardiogr aphy is the test of choice to confirm th e diagnosis of a suspected patent fora m en ov ale 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. • Oth er cau ses of acu te my ocar dial infarction in y oun g persons inclu de coronar y spasm , em bolic corona ry 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 in clude those with a mitr al m echanical v alv e, atrial fibrillation, or prev ious embolism . 34 2 . Low risk patients do not requir e a h epar in br idge after stopping warfarin prior to sur gery and in clude pa tien ts wit h a bil eaflet aort ic v alv e and no other hig h 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 chr onic adjun ct in patients wh o m an ifest sy stem ic 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 a nd ar e associated with a sy stolic ejection click an d 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 acu te v olum e or pressur e ov erload. 34 7 . A denosine is the tr eatm ent of choice for n ar row-com plex tachycardia. 34 8. Neith er adenosine nor other atr iov entr icula r nodal blocking agent s should be giv en to patients with pr eexcited 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 un stable ang ina or non-ST-elev ation my ocar dial 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. 35 2 . Spinal stenosis is char acter ized by pain w ith stan ding or walkin g th at is r eliev ed by sittin g or bendin g forw ard and is further support ed 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. 35 4. The u se of angiotensin-conv erting enzy m e inhibitors should be av oided during pregnancy . 35 5. Hy drala zine and nitr ates are th e v asodilators of choice to tr eat heart failure during pregnancy . 35 6. Induction of mild hy poth erm ia im prov es out com es in comat ose 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 inclu de 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 is indicated for patients refractory to m edical th erapy ; a larg e 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 diogr aphic finding in digitalis toxicity . 363. The first-line treatment for life-threatening digitalis toxicity is admin istr ation of digoxin-specific a ntibody frag m ents. 36 4. Iron deficiency is a comm on ca use for dy spnea an d fatig ue in patients with cy anotic heart disease. 36 5. Th e most com m on ca use of iron deficiency in patients with cy anotic heart disease is recu rr 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 dim ension > 45 m m , a n end-diastolic dim ension >6 0 m m , an d an ejection fra ction 5 m m of indura tion is considered a positiv e test. 654 . Dengu e fev er is cha ra cterized by th e 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 th e dev elopment of Pseudom ona s 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 tr an splant recipients. 65 8. Person-to-person t ra nsm ission of menin gococcal orga nism s occurs by the r espiratory route. 659 . Prophy laxis of health car e workers exposed to a patient wit h a m eningococcal in fection 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 pr ocedur es of choice in t he diagn osis of patient s with suspected osteom y elitis. 66 1 . The m ost appropria te empiric th erapy for Str eptococcus pneum oniae m eningitis is v ancom y cin plus ceftriax one and dexamethasone. 66 2 . Africa n tick bite fev er is th e most com m on 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 ptom s 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 sy m ptom s. 66 5. Th e cour se of Creut zfeldt–Jak ob disease is rapid and progr essiv e; 90% of patients die within 1 y ear of diagnosis. 66 6. Th e most appropriate th erapy 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 m ust be used if the probability of resistance to isonia zid is great er than 4%. 66 8. Th e recomm ended empiric therapy for a patient w ith com m un ity -acquir ed pneum onia w ho is hospitalized on a g eneral medical floor is either m onotherapy with an intra v enous fluoroquinolone or combination therapy with an intravenous β-lacta m plus either a n int ra v enous or oral m acr olide or doxycycline. 66 9. The recomm ended empiric therapy for a patient w ith com m un ity -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 m acr 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 sy philis in th e fetu s. 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 . Im m un osuppressed tr ansplant r ecipients are at hig h r isk for dev elopment of bacterial in fections durin g th e first m onth after surgery.
67 4. In pat ients with a contigu ous foot u lcer a nd possible osteom y elitis, bone biopsy wit h cult ur es and h istopathologic exam inat ion should be perform ed before init iatin g a ntim icrobial therapy. 67 5. Intr av ascular cath eter–associated bloodstr eam in fections are preventable if proper insertion procedures are used. 676. Chlorhexidine is superior to povidone-iodine for cleaning a cath 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. 68 0. No cur rent ly av ailable test can differentia te tru e-positiv e from false-positiv e tu bercu lin skin test r eactions in a person wh o prev iously receiv ed bacille Calmette–Guérin v accine. 68 1 . The r ecom m ended treatm ent for la tent t ubercu 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. 68 3 . Conta cts of patients w ith possible sma llpox should r eceiv e sm 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 tr an splan t 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 sy m ptom s or a bnorm al laboratory studies an d cultur e results. 687 . The m ost appropriate empiric th erapy for a patient w ith purulent m eningitis following neurosur gery is v ancomy cin plus cefepime. 68 8. Th e finding of 14 -3 -3 protein in cerebrospinal fluid has a specificity and sensitiv ity of greater t ha n 9 0% for diagn osing
spora dic Creu tzfeldt–Ja kob disease. 689 . Liv e attenuated influenza v accine is contr aindicated in an imm un osuppressed patient. 69 0. All fam ily m embers of an im m un osuppressed patient should be imm un ized again st influenza to decrease the patient's risk of exposure to this v iru s. 69 1 . Doxy cy cline in a single dose is high ly effectiv e for preventing ery th ema m igr an s in patients from ar eas endem ic for Ly m e disease who present with an em bedded, engorg ed tick. 692. Contact isolation is most effective for reducing spread of Clostridiu m difficile in hospitals. 69 3. The treatm ent of choice for patients with sy m ptom atic babesiosis is atov aqu one plu s azithromy cin. 694. A positive Western blot analysis confirms the diagnosis of HIV infection; a negat iv e test r ules out th is 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 an tibodies. 69 6. Sta ined specimens of v agin al discha rg e from patients with candidal v agin itis show pseudohy phae and budding y east. 69 7 . Stained specim ens of v agin al discha rg e from patients with bact eria l v agin osis show gram -neg ativ e ba cilli a ttach ed to squam ous epithelial cells (clue cells). 69 8. In patients w ith cath eter-associated bloodstr eam 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 ha v e three different sput um smears tha t ar e negativ e for acid-fast bacilli. 7 01 . Bra in a bscesses that result from contigu ous spread of head and neck infections may contain multiple organisms. 7 02 . Ceftriax one plus m etronidazole is the m ost appropria te empiric ant imicr obial ther apy for a bra in abscess resulting fr om 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 sy ndrome. 7 04 . Gra m -positiv e bacter ia (staphy lococci and streptococci) are th e
most common causes of nongonococcal septic arthritis in adults. 7 05. Because am ant adine is excreted by th e kidney s, dosage adjustment is requir ed in patients with rena l com prom ise. 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 hich must be administered at least 2 weeks before a potential exposure. 7 08. Patients takin g an ti–tum or n ecrosis factor-α inh ibitors are at incr eased risk for dev eloping l atent tu berculosis. 7 09. Patients about to begin therapy with anti–tum or necrosis factor-α inh ibitors should u ndergo tubercu lin skin test screening. 7 1 0. Tra nsplan t recipients are at r isk for dev elopment of opport un istic in fections such as fung al pneum onia. 7 1 1 . Alm ost all patients with am ebic abscesses will ha v e high lev els of an tibodies directed again st Entam oeba h istoly tica. 7 1 2 . In a patient w ith sickle cell disease an d osteom y elitis, potentia l cau sativ e org anism s are staphy lococci, streptococci, an d Salmonella species. 7 1 3. Penicillin is the only antim icrobial agent a pprov ed for tr eatm ent of neur osy philis. 7 1 4. Patients wh o are allergic to penicillin but for w hom alternativ e ant imicr obial a gents ca nn ot 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 sy stem ic sy m ptom s. 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 com m on com plication of operations, especially coronar y artery by pass graft surgery . 7 1 9. Th e appropria te dose, tim ing, a nd dur ation of prophy lactic perioperativ e an tibiotics help decrease the r isk of surg ical site infections. 7 2 0. Deep fung al in fections such as histoplasm osis are a risk to tr av elers to endem ic areas. 7 21 . Reactiv ation of hum an h erpesv iruses 6 an d 7 is being incr easingl y recognized in im m un osuppressed patient s.
7 22 . Reactiv ation of hum an h erpesv iruses 6 and 7 may cause hepatitis and m eningoencepha litis. 7 2 3 . Treat m ent of latent tu berculosis is indicated for a ny person with a kn own tuber cu lin skin test conv ersion, regardless of th e person's age. 724. Most cases of toxic shock syndrome are caused by Staphylococcus aureus or Streptococcus pyogenes. 7 2 5. Ceftr iaxone prov ides effectiv e em piric thera py for patients with possible dissem in ated g onococcal in fection. 7 26 . Health car e workers in contact with a patient with possible sm allpox r equir e gown , g lov es, a nd a persona l r espirator for protection. 7 27 . A qualitativ e assay for h epatitis C v irus RNA v iral load is the most sensitive test for diagnosing hepatitis C infection. 7 2 8. Penicillin r esistan 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 h igh -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 un iform ly sensitiv e to v ancom y cin and lin ezolid 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 nsitiona l cells is highly indicativ e of poly om av iru s BK. 7 3 2 . 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 3 4. In contra st to patients with spora dic, genetic, or ia tr ogenic Creutzfeldt–Jakob disease, patients w ith th e 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 th e disease, m ore prom inent sensory finding s, and MRI abnorma lities in pulv inar ar ea of th e thala m us 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 th e 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 ther apy for a patient w ith a n epidura l abscess and a history of injection dr ug use. 7 3 8. Th e dev elopment of focal ly m phadenitis in a patient w ith HIV infection is most com m only cau sed by m y cobacteria, Streptococcus species, or Staph y lococcu s species. 7 3 9. Cry ptococcal in fection in t ra nsplan t r ecipients is associated with hig h m orbidity and m ort ality . 7 40 . Flucy tosine plus a lipid form ula tion of am photericin B is usuall y effectiv e for tr eating cr y ptococcal infections in tran splan t recipients. 7 41 . Em piric antibiotic therapy w hile awaiting cultu re results is requir ed for patient s with a n infected clench ed-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” tha t cha ra cterize botu lism ar e diplopia, dysphonia, dy sart hr ia, and dysphag ia. 7 44 . Fatal familia l insom nia is the ra rest of the prion diseases. 7 45. • Fatal familial insom nia is char acterized by sev ere insomn ia, confusion, oth er signs of dem entia, an d aut onomic n erv ous sy stem instability 7 46 . An aplasmosis (form erly hu m an g ran ulocy tic ehrlichiosis) is cha ra cterized by fev er, flu-like sy m ptom s, 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 th e treatm ent of choice for an aplasmosis. 748. A patient with suspected herpes simplex virus encephalitis requir es poly m erase chain reaction of the cerebrospinal fluid and MRI of th e brain t o confirm th e diagn osis. 7 49 . Acy clov ir is the preferred initial therapy for a patient with herpes sim plex v iru s encephalitis. 7 50. Keeping m echanically v entilated patients semi-recum bent (at a 4 5-degr ee angle) helps prev ent dev elopment of v entilat orassociated pneumonia. 7 51 . Thr om bocy topenia m ay occur in patients wh o take linezolid for 2 or m ore w eeks. 7 52 . The decision about wh ether a dmission to an intensiv e care un it is needed for patients with com m un ity -acquir ed pneum onia is based on th e presence of specific m ajor an d m inor cr iteria. 7 53 . Because Legionella pneum onia is of par ticul ar 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 an d Kaposi's sar com a, th e sar com a frequently regr esses and som etimes resolv es com pletely 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 acu te py elonephrit is wh o can eat a nd drin k. 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 wit h pr ogr essiv e ma ssiv e fibrosis ar e at in creased risk for developing tuberculosis. 759. The most appropriate diagnostic studies for suspected tubercu losis are tu berculin skin t esting and sputum for acid-fast stain an d culture. 7 60 . Staphy lococcus aur eus and Pseudom onas aeru ginosa ar e the m ost likely cau ses of septic ar th ritis in a n in jection dru g u ser. 7 61 . Enterotoxigenic Escherich ia coli is th e most comm on ca use of diarr hea 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 illn ess. 7 63 . West Nile v iru s encepha litis is m ost likely to occur in patients 65 y ears of age an d 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 ch ang es, a nd possibly seizur es. 7 65. Th e need for isolat ion precau tions is based on the r out e of tr ansm ission of th e suspected path ogen or th e clinica l sy m ptom s of the patient. 7 66 . Because Francisella tu lar ensis is not tr an sm itted from person to person, only stan dard precaut ions, ra th er 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 cau sed 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. A dministra 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 requir ed for household conta cts of patients with an in v asiv e streptococca l in fection. 7 7 3 . If two or m ore ca ses of inv asiv e streptococcal disease occur in postpar tu m or postsurg ical patient s hospitalized with in 6 m onth s in the sam e institution, an epidem iologic in v estiga tion is required to determ ine if a hospital w orker is a car rier. 7 7 4. Im m un osuppressed patient s are at incr eased risk for developing nosocomial pneumonia even when mechanical v entila tion is not r equ ir ed. 7 7 5. A “ halo sign” (a nodular lesion w ith a sur rounding gr oun d-gla ss appear anc e) on chest ra diogr aphs is char acter istic of Aspergillu s pneum onia. 7 7 6. Bactericidal agents such a s daptomy cin are m andatory for tr eatm ent of endocar ditis. 7 7 7 . Emergence of resistance to daptom y cin is rare, an d daptom y cin is not correlat ed with cross-resistan ce to any oth er dru g class. 7 7 8. Cu rr ent r ecom m endations do not support use of tubercul in skin testing as a screening test in otherw ise health y persons with no persona l or occu pational exposure to persons wit h t uber culosis. 7 7 9. Pneum ococcal strains are becom ing incr easingly resistant to penicillins an d m acr olides. 7 80. Most expert s and g uidelines support th e use of a t hir dgenera tion cepha losporin plus a m acr olide for tr eatm 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 wit h bloodborn e exposures in health car e workers are HIV, h epatitis B, and hepatitis C. 7 84. • Two or th ree antiretrov iral a gents are recomm ended wh en 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 th e palm s an d soles, is cha ra cteristic of dissem inat ed (secondar y ) sy philis. 7 87 . A patient w ith possible neur osy philis should receiv e intrav enous aqueous cry stal penicillin G for 1 4 day s. 7 88. Patient s with osteom y elitis and an epidura l abscess wh o do not ha v e focal neu rologic deficits can u sually be tr eated wit h antim icrobial therapy alone, but m ust be monitored carefully . 7 89 . A spira tion a nd cul tur e of joint flu id is th e most appropria te test for determ ining wh ether a prosth etic joint is infected. 7 90. Patients with pneumonic plague ty pically present with h igh fev er, headache, my algias, dy spnea, h emopty 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 2 4 h our s of dev elopmen t 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 car e worker s. 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 t an ks. 7 97 . Th e most a ppropria te diagnostic study is biopsy of a n odule for histopathologic exam inat ion, a cid-fast stain, and cu ltu re. 798. Trimethoprim–sulfamethoxazole is the preferred antimicrobial ther apy for a pat ient wit h a br ain a bscess cau sed by Nocar dia species. 7 99 . Patients with a presumptiv e diagn osis of Rocky Moun tain spotted fev er should receiv e treatm ent wit h doxy cy cline ev en before th e diagn osis is confirm ed. 800. Cam py lobacter jejun i is th e most comm on cau se of bacteria l diarr heal disease in th e United Stat es. 801 . C. jejuni often ca uses disease by cross-contam ina tion of cooking ut ensils or sur faces suc h a s coun tertops.
802 . A complete history of antir etrov ira l dru g u se is essential for a patient w ith HIV infection w ho has been on m an y drug s and is not benefit in g from the current treatm ent regim en. 803 . A spergillosis is the m ost com m on pulm ona ry m old infection in immunosuppressed patients in the United States. 804 . A spergillu s infection can not be disting uished from infection cau sed by Pseudallescheria before cult ur e result s ar e av ailable 805. 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 com m un ity -acquir ed pneum onia in an outpatient w ithout additional r isk factors include an adv anc edgenera tion m acr olide or a ketolide or doxy cy cline. 808. Treatm ent of an outpatient with comm unity -acquired pneum onia should be start ed wit hout w aitin g 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 significan tly allev iate acu te pain in patients wit h her pes zoster (shingles). 81 1 . Cort icosteroids are contra indicated in patients w ith poorly cont rolled plasma glu cose lev els, osteoporosis, or hy pertension. 81 2. Hos http://www.doctok.com/archived/my-notes-a-small-gift-for-you/21146
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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 e multifocal leukoencephalopathy will survive the latter disease if highly active antiretroviral therapy is administered. 81 6. Poly m erase 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 un usua l path ogens, such a s Cry ptococcus neoform an s. 81 8. A dministra tion of zidov udine to a pregna nt patient w ith HIV infection is believed to reduce the risk of maternal-to-child tr an smission of HIV. 81 9. Efav irenz is contr aindicated in a pregnant patient with HIV infection. 820. Cyclosporiasis is associated with positive acid-fast–stained stool specimens and copious diarrhea without fever. 82 1 . The tr eatm ent of choice for cy closporia sis is tr im ethoprim – sulfamethoxazole. 82 2 . The in cidence of fluoroquinolone-resistan t N. gonorr hoeae h as been in cr easing, especia lly on t he West Coast of th e United St ates and in Hawaii. 823 . Th e most a ppropriate treatm ent for concur rent g onorr hea an d a chl am y dial infection is a single dose of intra m uscula r 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 tr act infections. 82 5. Risk factors for aspira tion pneum onia inclu de difficult y swallowing , episodes of depressed consciousness, an d m echa nica l factors such a s esophageal obstr uction. 826 . Clindamy cin prov ides effectiv e treatm ent for anaerobic aspira tion pneum onia. 827 . Necrotizing fasciitis in an injection dru g u ser m ay be due to ma ny different orga nisms. 82 8. Th e most effectiv e initial empiric a ntibiotic regim en for necrotizing fasciitis in an in jection dru g user is v anc om y cin plus
piperacillin–ta zobactam plus clindamy cin. 82 9. The m ost successful th erapy for t reat ing in fected prosth etic joints in v olv es rem ov al of th e pr osthesis a nd a 6-week course of ant imicr obial ther apy followed by reim planta tion of a new prosthesis. 83 0. Aztreona m ca n be used safely in patients who ar e allergic to penicillin. 83 1 . Th e 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 h em orr hagic fev er ; and Boliv ia n hem orr hagic fev er as m ost likely to be used as biochemical w eapons. 83 2 . Influenza v iru s resistan ce dev elops ra pidly followin g exposure to riman tadine. 83 3 . If one family m ember dev elops 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 becom e 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 ereas ulcer ativ e colitis occur s more often in form er smokers an d nonsmokers. 84 0. Colonoscopic findings in Crohn's disease include deep ulcer ations separ ated by ar eas of norm al m ucosa (skip lesions) an d rectal sparing . 84 1 . Colonoscopic findings in ulcer ativ e colitis inclu de contin uous inflamm ation, ty pically including the rectum, but w ithout deep ulcera tions or skip lesions. 842 . A pproxim 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 tow ard norm al.
84 5. Patients with hepatitis C and cirr hosis are at incr eased risk for dev elopment of hepatocellular car cinoma. 846 . The finding of a new ma ss with v ascular enhancem ent in a patient wit h h epatit is C and cirrh osis alm ost cert ainly indicates hepatocellular carcinoma. 84 7 . Th e most comm on cau se of ody nopha gia (pain on swall owin g) is pill-induced esophagit is. 84 8. Gastroparesis is a w ell-recogn ized com plicat ion of diabetes mellitus. 84 9. Patient s with gastr oparesis should be started on sm all, frequent feedings of a diet low in fiber, fat, and refined sugar. 850. Patients with choledocholithiasis typically have moderate to sev ere epigastric or righ t u pper quadran t abdomina l pain th at is usually intermittent, inconsistently associated with nausea or v omitin g, 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 sma ll bowel biopsies is the definit iv e test to confir m or ex clu de a diagn osis of celiac spru e. 853 . An tim itochondrial an tibody titers of more or equal t o 1 :40 occur in approximately 90% of patients with primar y biliary cirrhosis. 854 . Mar ked v olum e depletion is a poor progn ostic sign in a patient with acu te pancr eatitis. 855. Vigorous hy dration is critical in a patient w ith acu te pancr eatitis and ma rked v olum e depletion in order to ma xim ize pancr eatic perfusion and reduce subsequent com plications. 856 . Patients wh o ha v e had pancolitis for 1 0 or m ore y ears should un derg o colonoscopy wit h 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 a ntibody to hepatitis C v iru s (an ti-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 a ntibody 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 olum e bleeding. 86 0. Proton pum p inhibitors are m ost effectiv e for t reatin g a n
active nonsteroidal anti-inflammatory drug (NSAID)–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 . 86 2 . A v ideofluoroscopy stu dy is the m ost appropria te initia l test in patients with suspected oropharyngeal dysphagia. 863. Gastrointestinal bleeding, fever, abdominal pain, and leukocy tosis in a patient w ith a n abdom inal prosth etic v ascular graft should raise suspicion for an aortoenteric fistula. 86 4. Upper endoscopy is the initia l diagn ostic study for ev alu ation of a possible aort oenter ic fistula. 86 5. If upper endoscopy is norm al despite a str ong clin ical suspicion for an aortoenteric fistula, a contr ast-enha nced CT scan of the abdom en should be done n ext. 866 . Patients with sev ere cholangitis generally present with fev er, jaundice, and alt ered m enta l st atu s; abdomin al pain is u sually , but not inv ariably , present. 86 7 . Patients with cholangit is requir e endoscopic retrograde cholangiopan creat ogr aphy to determ ine th e presence of com m on bile du ct stones and pr ov ide endoscopic t herapy , if indicated. 868. Endoscopic ultrasonography is the most sensitive test for diagnosing an insulinoma of the pancr eas. 86 9. In patients with chr onic ulcer ativ 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. Patient s wit h ch ronic 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 pioglita zone m ay be indicated for patients wit h nonalcoholic steatohepatit is and featu res of th e m etabolic sy ndrome in order to prev ent pr ogr ession of th e liv er disease. 87 3 . Intr aoperat iv e endoscopy m ay be needed for a pat ient wit h unexplained severe recurrent gastrointestinal bleeding that cannot be diagnosed by less inv asiv e studies. 87 4. Patient s with short bowel sy ndrome associated with less than 1 1 5 cm of sm all in testine in th e 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 a nta gonist m ay help reduce excessiv e gastr ic secretions and stom al 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 pert ension, obstr uct iv e sleep apnea, an d hy perlipidem ia. 87 7 . â €¢ Dev elopment of gallstones is a comm on complication following bariatric surgery 87 8. Th e incidental finding of indirect (un conju gat ed) hy perbilirubinemia in an asy mptoma tic patient with a norm al hem oglobin lev el and oth erw ise norm al liv er tests is indicativ e of Gilbert's syndrome. 87 9. Tenesm us (a sensation of incom plete ev acu ation of the bowels) indicates the presence of proctitis. 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 . Patient s wit h diabetes m ellitus 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 secondar y lactose intolera nce 884 . Patients with acu te gastrointestina l bleeding associated with decreased 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 r etrograde ch olang iopancr eatogr aphy is indicated prior to laparoscopic cholecy stectom y only for patients with gallstones and possible concom itant com m on bile du ct stones. 886 . Patients wit h a h igh -risk poly poid lesion detected and rem ov ed durin g screening colonoscopy should u ndergo sur v eillance colonoscopy in 3 y ears. 887 . Sy m ptom s of noncardiac ch est pain frequently m imic th ose of car diac chest pain. 888. The diagn osis of nonca rdiac ch est pain ca n only be made after a thoroug h ev alu ation has ru led out ca rdiac cau ses for th e pain. 889 . Low-dose ant idepressan ts ma y be helpful in tr eating patients with noncardia c chest pain . 890. Antinu clear an tibody and an ti–smooth m uscle antibody
titers m ore or equal to 1 :80 support a diag nosis of aut oim m un e hepatitis. 89 1 . Ant im itochondrial ant ibody is th e serologic m ar ker for primary biliary cirrhosis. 89 2 . Gastrinoma (Zolling er-Ellison sy ndrome) and gastric distention related to gastric outlet obstruction are causes of hypergastrinemia. 89 3 . A helical CT scan of the abdom en is a reasonable initia l test when ev alu atin g a patien t for a possibl e gastr in oma. 89 4. Patient s who hav e had tw o or m ore episodes of div erticu litis are more likely to develop complications such as abscesses, strictures, and perforation. 89 5. Patients wh o ha v e had t wo or m ore episodes of div erticu litis should undergo surgical resection of the affected intestine. 896 . A n a sy m ptoma tic patient with a single positiv e fecal occult blood test on r out in e scr een in g requ ir es follow-up w it h colonoscopy . 89 7 . Can didiasis is the m ost c om m on esophageal disorder in patients with HIV in fection. 89 8. Patients with HIV infection associated with dy spha gia a nd ody nopha gia should r eceiv e an empiric t ria l of fluconazole. 89 9. Nonu lcer dy spepsia is th e m ost com m 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 e serologic t est for Helicobacter py lori. 901 . Chr onic int estina l pseudo-obstr uct ion m ay be associated with a paran eoplastic sy ndrome. 902 . Th e hallm ar k of mesenter ic ischem ia is the presence of pain tha t is out of proport ion t o th e phy sical exa m inat ion findings. 903 . Th e most comm on ca use of mesenter ic ischem ia is a proth rombotic state due to an inh erited or acquir ed coagu lation disorder or ma lignancy . 904 . CT an giogr aphy is usua lly done to establish t he diagn osis 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 with out 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 th e v ascular space rat her th an to contin uin g bleeding. 91 0. Ultr asonographic findings of gallstones, a th ickened gallbladder wall, per icholecy stic fl uid, and a positiv e sonographic Murphy 's sign ar e hig hly specific for a diagnosis of acu te ch olecy stitis. 91 1 . Initial m anag ement of a patient with acute cholecystitis inclu des pain m edication, broad-spectru m an tibiotics, and sur gical consulta tion 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. An al fissures may occur after a period of constipation. 91 5. Nu tcr acker 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 ga stroesophageal reflu x disease. 91 7 . A person wh o ha s 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 a ge 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 h av e jaundice. 92 1 . A Mallory -Weiss tear is a lacera tion near the ga stroesophag eal ju nct ion that often result s from forceful retch in g. 92 2 . Bleeding from a Mallory -Weiss tear stops sponta neously in m ore th an 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 com m on 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 or pancreas div isum . 927. Fever, alcoholism, findings consistent with chronic liver disease, an d a serum aspar tat e am inotr ansfera se to seru m a lan ine am inotran sferase ratio (AST:ALT) m ore th an 2 ar e associated with alcoholic hepatitis. 92 8. Self-lim ited hem atochezia is a com m on cau se of ischem ic colitis in elderly patients. 92 9. Diagnostic studies, oth er t ha n colonoscopy or flexible sigm oidoscopy , 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 ch ronic hepatitis C v irus infection w ho ha v e oth er comorbid illnesses m ay not be can didates for tr eatm ent of hepat itis. 93 2 . Th e age of a patient w ith obscur e gastrointestinal bleeding helps gu ide the ch oice 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 wit h obscur e gastrointestinal bleeding should undergo studies for angiectasias. 93 5. A n intr a-abdom inal infection should be exclu ded before begin nin g im m unosuppr essiv e agents in a patien t wit h 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 a denomas should be r esected whenev er possible because of th eir poten tia l for becom in g m alignant and their risk for bleeding. 93 8. Cam eron's erosions ar e m ost often foun d in patients w ith lar ge hiatal hernias and iron deficiency anemia.
93 9. Barr ett's esophag us is a r isk factor for th e dev elopment of esophageal adenocar cinom a. 94 0. Patients with Barr ett's esophag us with out dy splasia should un derg o sur v eillance u pper endoscopy wit h 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 th e presence of m icr oscopic colitis. 94 2 . Biopsies of the colonic m ucosa at t he tim e of flexible sigm oidoscopy or colonoscopy ar e the definitiv e stu dy for diagn osing m icr oscopic colitis. 94 3. Cav ernous hema ngiom as are benign lesions that are found in 2% of th e genera l population. 94 4. Cav ernous hemang iom as are usually found incidentally wh en patients hav e ima ging studies for other in dications. 94 5. Patients wh o 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 th e 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 patien t w ith suspected peptic ulcer disease an d 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 cholangiopan creat ogr aphy . 950. Cholangitis is the most common cause of liver abscesses. 951 . Percut aneous aspiration is helpful for both diagnosis and tr eatm ent of py ogenic liv er a bscesses. 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 ch olang iocar cinoma. 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 elem ental diet and either ora l or topical cort icosteroids. 956 . A patient w ith suspected AIDS cholan giopathy should un derg o endoscopic retrograde cholangiopancreatography (ERCP) to confirm th e diagn osis. 957. A patient with AIDS cholangiopathy associated with extra hepatic bile duct obstr uct ion should u ndergo ERCP with sphincterotomy. 958 . Hepatic ischem ia is cha ra cterized by m ar ked 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. Com m on v ar iable imm un odeficiency should be suspected in a patient wit h r ecurr ent ga str ointestinal 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 ach ala sia w ho do not respond to pneum atic dilation m ay require my otomy . 96 3 . Patients wit h cirr hosis should un derg o upper endoscopy to determ ine th e presence of esophageal v ar ices. 964. Patients with large esophageal varices should receive a nonselectiv e β-blocker for prophy laxis ag ainst v ar iceal bleeding. 965. Certain medications, including antidepressant agents and calciu m ch ann el blockers, increase colonic tr ansit tim e and may cause constipation. 96 6. Tr iple th erapy (a proton pum p inh ibitor an d tw o an tibiotics) is the m ost effectiv e regim en for eradication of Helicobacter py lori. 96 7 . Tr iple th erapy for er adication 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 , fatig ue, and im poten ce. 96 9. • The m ost appropria te initial diag nostic study for a patient with suspect ed h eredit ary hem ochromatosis is determ in 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 Cr ohn 's disease bu t with a norm al colonoscopic examination. 97 2 . Persons with one or m ore adenom atous colorecta l poly ps ha v e an incr eased risk for dev eloping colorecta l ca ncer. 97 3 . Persons wit h one or m ore a denomat ous colorecta l poly ps should un dergo periodic colonoscopic surv eillan ce to detect colorectal cancer. 97 4. In patients wit h ch ronic hepatitis B and cir rh osis, one of the ora l a gents is preferr ed to pegy lated int erferon because interferon m ay be associated with m ore serious com plications, such as hepatic decom pensation and infection. 97 5. Patients wit h cir rh osis and ga strointestinal 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 an d 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 tr eatm ent of choice for a pat ient wit h th e HELLP sy ndrome (hem oly sis, elev ated liv er enzy m es, low platelets) is prom pt deliv ery of the in fant. 98 0. Adm inistrat ion of ora l pancreat ic enzy m e supplements mu st be spaced out durin g a m eal (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. 98 1 . Either azath ioprine or 6 -m ercaptopur ine prov ides effectiv e m aint enan ce th erapy 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. 98 3 . New-onset obstr uct iv e jaundice in an elderly patient is most often due to pancr eatic or biliar y tr act can cer. 98 4. Pseudoach alasia m ay be associated wit h th e presence of a malignant disorder. 98 5. Elderly patients with a cha lasia should undergo upper endoscopy to rul e out pseudoach ala sia. 98 6. The sy m ptom s of pseudoach alasia m ay m im ic those of idiopathic (benign ) acha lasia.
98 7 . The most com m on cau ses of serum am inotran sferase v alu es m ore tha n 5000 U/L ar e acetam inophen hepatotoxicity , hepatic ischem ia, an d hepatitis due to un usual v iru ses. 98 8. Persons with alcoholism ca n dev elop acetam inophen hepatotoxicity wh en tak ing lower doses of acetam inophen th an th ose necessary to cau se liv er dam age in persons with out alcoholism . 989. Endoscopic treatment of pancreatic duct strictures may reduce abdom inal pain. 99 0. Radiation colitis ty pically occur s 9 m onth s to 4 y ears after ra diation th erapy for prostat e, gy necologic, or oth er 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 istr ation of nar cotics. 99 3 . Th e ma jor com plicat 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 m ore t ha n 5 y ears should undergo screening for Barrett's esophagus. 99 5. Upper en doscopy 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 dru g of choice for t rea tin g a Cr ohn 's disease flare tha t is lim ited to th e ileum . 99 7 . Colorectal can cer screening for av erag e-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 agin g stu dies th at show a “strin g of beads†� pattern in the biliary tree. 1 001 . Pan creat icoduodenectom y (Whipple procedure) offers th e best cha nce of cure for a patient w ith cancer of the head of the pancr eas. 1 002 . For im m un 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 in ducing prolonged remissions in patients with collagenous colitis. 1 004 . The 1 4C-urea breath test is th e 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 past exposure to th e org an ism ; 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 (a nti-HCV ) a re consist ent wit h 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 wh ere in the gastrointestinal tr act a nd m ay be bey ond th e reach of stan dard upper endoscopes and colonoscopes. 1 009 . A h elical CT scan of th e abdom en is the most sensitiv e and specific initial im agin g study for a patient w ith possible pan creatic 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 m ellitus, and electroly te abnorma lities. 1 01 1 . Sponta neous bacteria l peritonitis is an ascitic fluid infection tha t is a com m 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 . Th e choice of diagn ostic stu dies for a patient w ith obscur e gastrointestina l bleeding should ta ke into accoun t t he patient's age an d the presence of significant comorbid conditions. 1 01 4. Dru g–drug interactions are comm on in patients taking tacr olim us or cy closporin e plus oth er m edications. 1 01 5. Calcium ch annel blockers ma y interfere with t he metabolism of ta crolimu s. 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 an d exter na l ana l sphin cter 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 h ernia a re postpra ndial fulln ess, pain, and v om iting . 1 01 9. A paraesophageal hernia m ay be associated with gastric ischem ia a s a result of torsion of th e stoma ch. 1 020. The recomm ended treatm ent for a sy m ptom atic paraesophag eal hern ia is ur gent r epair of th e hernia. 1 02 1 . Era dication of Helicobacter py lori is associated with a significan t decrease in th e risk of dev eloping a r ecurr ent u lcer. 1 02 2 . Era dication of H. py lori does not r educe t he r isk of dev eloping gastric cancer. 1 02 3 . Becau se patients with celiac sprue ar e at incr eased risk for osteoporosis and osteomalacia, monitoring of serum vitamin D and calciu m lev els is requir ed. 1 024 . The most appropriate treatm ent for prim ary biliary cirrh osis is ursodeoxycholic acid. 1 02 5. Approxim ately 3 % to 5% of patient s foun d to ha v e one colorecta l cancer w ill ha v e one or m ore sy nch ronous cancers in oth er areas of the colon. 1026. A patient diagnosed with colorectal cancer requires ev alu ation of the entire colon either preopera tiv 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. • Proctocolectomy should be considered for patients with ulcer ativ e colitis associated w ith colonic dy splasia 1029. The overall risk of maternal–fetal transmission of hepatitis C is approxim ately 5%. 1 03 0. Moth ers infected wit h both h epatitis C and HIV h av e an incr eased risk of tra nsmitt ing hepatitis C to th eir new born s. 1 031 . To determ ine the occurr ence of matern al–fetal tr an smission of hepat itis C, th e newborn shoul d 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 abdomin al pain , nausea, fev er, and m ild hyperbilirubinemia. 1 03 3 . â €¢ Postcholecy stectom y bile leaks can be identified by endoscopic retr ogr ade cholangiopan creat ogr aphy 1 034 . The presence of a hy perv ascular hepatic mass in a patient with cirrhosis an d a hig h serum α-fetoprotein lev el is diagnostic of
hepatocellular carcinoma. 1 035. Patients with adv anced liv er disease and h epatocellular 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 pancr eatic 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 port al h y pert ension. 1 03 9. Port al h y pert ension is m ost often due to cirrh osis. 1 04 0. Fun doplication should be considered for a patient wit h sev ere iron deficiency anem ia associated w ith Cam eron's erosions w ho 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 04 2 . A patient wh o ha s undergone resection for colorecta l can cer requir es surv eillance colonoscopy 3 y ears postoperat iv ely to detect the possible presence of metachronous lesions. 1 04 4. Pill-induced esophagit is is cha ra cterized by th e acu te onset of painful swallowing (odynophagia) shortly after a patient begins taking a drug. 1 04 5. Tr eatm ent of pill-induced esophag itis inv olv es discontin uin g the causativ e drug. 1046. Wilson's disease should be considered in a young patient with abnorm al liv er chemistry studies, cognitiv e changes, and hemolysis. 1 047 . A low seru m ceruloplasmin v alue ( less tha n 2 0 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 div erticu litis are admin istr ation 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 om y cin should be considered for patients with gastropar esis wh o cann ot tolerat e 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 ucin ous cy stic neoplasm of the pancr eas is often asy m ptom atic a nd is detected as an incidental finding dur ing abdom inal im agin g studies for other cau ses. 1 055. Because of its m align an t potential , a m ucin 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 wit h 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 rin g a t t he tim e of the endoscopic examination. 1 06 0. A proton pum p inhibitor is the ag ent of choice for h ealing a nonsteroidal anti-inflammatory drug (NSAID)–induced gastric ulcer after t he N SAID ha s 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 06 3 . Th e diagnosis of chr onic m esenteric ischem ia is established by the clin ical h istory and findings of com prom ised mesenteric v essels on im ag ing stu dies. 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 06 6. Manifestat ions of sy stem ic 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 th e knee, hip, distal an d proxima l interpha lan geal, an d first carpometacarpal. 1 068. Osteoarth ritis is char acterized by pain th at worsens with activ ity and m ornin g joint stiffness that lasts less than 30 min utes. 1 06 9. Postmenopau sal wom en wh o use diuretics hav e an incr eased risk for tophaceous gout of the distal interphalangeal joints. 1 07 0. Patients with diffuse cut an eous sy stem ic sclerosis ar e at incr eased risk for dev eloping in terstitial lun g disease. 1 07 1 . A nti–Scl-7 0 an tibodies are m ost frequently associated with diffuse cut an eous sy stemic scler osis an d 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. Th e 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 , an d oth er 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 ar teries in a w om an 1 8 m onth s of m inocy cline exposure. 1 095. Liv er inv olv ement in minocy cline-induced lupus often mim ics autoimm une h epatitis. 1 09 6. Th e clinical presentat ion of adult contact s of children wit h 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 onth s, and u sually responds to nonsteroidal a nti-inflamm atory drug s. 1 098. Poly m y algia rh euma tica is char acterized by pain or m ornin g stiffness in the n eck or t orso, shoulders and u pper a rm s, or h ips an d thigh s 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 aspira tion is indicated for patients with a cut e olecran on bursitis to gu ide ther apy . 1 1 02. Patients with fibromy algia h av e widespread mu sculoskeletal pain a nd stiffness, par esth esias, nonrestora tiv e sleep, fatigu e, 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 l ong h istory of Ray nau d's phenom enon an d diffuse or lim ited cuta neous scleroderm a a re a t r isk for pulm ona ry v ascu la r disea se. 1 1 05. High-dose cort icosteroid therapy in t he setting of scleroderm a m ay be associated with n orm otensiv e renal cr isis. 1106. Invasive diagnostic studies or empirical treatment is not indicated in asy m ptom atic patients with a n isolated elev ated creatine kinase level. 1 1 07 . Ant i–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 it h rheum atoid fact or measurement. 1 1 08. Patients taking prednisone, equal or m ore th an 5 m g/d, for more than 3 months ma y benefit from calcium and v itam in D supplement s and a bisphosphonate. 1 1 09. Allopur inol is equally effectiv e in the setting of inefficient excretion a nd ov erproduct ion of ura te. 1 1 1 0. All opurin ol at a dose of more th an 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 picillin–sulbactam and others with broad-spect rum cov erage, are indicated for anim al bites. 1 1 1 2 . There is no tr eatm ent for scleroderm a th at 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 patient s with scleroderm a, h igh -dose cort icosteroid therapy m ay be associated with n orm otensiv e renal cr isis. 1 1 1 5. Estrogen th erapy is contr aindicated in women w ith an tiphospholipid an tibodies. 1 1 1 6. An unexplained prolonged activ ated part ial th rom boplastin time raises suspicion for the antiphospholipid antibody syndrome. 1 1 1 7 . Rheum atoid ar th ritis predisposes patients to secondar y
osteoarthritis. 1 1 1 8. Im m ediate prednisone thera py is indicated for patients with clinical suspicion for gian t cell a rt eritis before tem pora l ar tery biopsy to decr ease the r isk for v isu al l oss. 1 1 1 9. Low-dose aspirin m ay decrease v isua l loss an d cerebrov ascular 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; or subdiaphrag 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 diarr hea in patients with scleroderm a an d is tr eated wit h interm ittent broad-spectru m ant ibiotics. 1 1 23 . Opioid antidiarrh eal thera py is not indicated for patients with scleroderm a because it ma y worsen int estina l m otility disorders. 1 1 24 . Psoriatic a rth ritis 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 m y ositis and in in clusion body m y ositis. 1 1 26 . • 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 anti–tum or necrosis factor a gents is th e most likely regim en to im prov e function, lim it furt her dam age, an d contr ol disease in sev ere rh euma toid arth ritis. 1 1 28 . Im m un 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 th an 1 5 m g/d, or a ny oth er imm unosuppressiv e agent and wh o hav e equal or m ore than 5 m m of indura tion on tu berculin skin testing . 1 1 30 . Urate lev els in patients with tophaceous gout should be reduced to 6.0 m g/dL (0.36 m m ol/L) to dissolv e tophi and other ur ate depositions in t he tissue. 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 th e ur ate lev el stabilizes. 1 1 32 . A cetaminophen is an effectiv e, safe, an d inexpensiv e tr eatm ent for osteoar th ritis.
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 th erapy with acetaminophen, often w ithout com prom ising pain contr ol. 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 il infection is exclu ded. 1 1 36 . Alv eolar hemorrhage may dev elop in systemic lupus ery thema tosus even without h emopty 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 rheu m atoid ar thr itis. 1138. Rheumatoid arthritis–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 tr an sitiona l cell ca rcin om a of the bladder. 1 1 40. Lifelong screening for bladder can cer is indicated for pat ients tr eated wit h cy clophospham ide. 1 1 41 . Adequate draina ge and intrav enous antibiotics are standard treatment for a “closed-space†� joint infection. 1 1 42 . The m alar rash of sy stemic lupus ery thema tosus is often photosensitiv e and spar es th e nasolabia l folds an d areas below t he nar es an d lower lip. 1 1 43 . Rosacea is an inflam ma tory derm atitis characterized by ery th ema , telan giectasias, papules, pustules, and sebaceous hyperplasia that affects the central face, including the nasolabial folds. 1 1 44 . A nti–tu mor necrosis factor-α therapy is contr aindicated in patients with infection. 1 1 45. Corticosteroid-induced my opathy is cha ra cterized by continued or worsening proximal muscle weakness, particularly in the lower extr emities, after a decrease in or n orm alization of m uscle enzy m e levels. 1 1 46 . Tr am adol is as effective a s ibuprofen in allev iating pain in osteoar th rit is of the hip an d knee in patients in w hom nonsteroidal ant i-inflam m atory 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 m ediate MRI scannin g is indicated in patient s wit h rh euma toid arth ritis 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 th e immune response to inactivated influenza vaccine. 1 1 51 . Intra nasal triv alent liv e-attenua ted influenza v accination is contr aindicated in im m un 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 inh ibitors of CYP3A4 and P-gly coprotein, w hich m etabolize and tr an sport this ag ent, respectiv ely , m ay incr ease th e 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, an d 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 wit hout a history of tr au m a 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 m ay 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 rh euma toid arth ritis. 1 1 61 . Combination th erapy with methotrexate and anti–tum or necr osis fact or-α ag ents 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 tr acts and kidney s. 1 1 63 . Löfgr en's syn drom e, a v ar iant of sarcoidosis, is cha ra cterized 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 ha nds is less sensitiv e an d specific for sy m ptom atic ha nd osteoarthritis. 1165. The most characteristic radiographic finding of osteoarthritis is osteophytes with joint-space narrowing. 1166. The most characteristic radiographic finding of psoriatic ar th ritis is the coexistence of erosiv e cha ng es and n ew bone form ation in the distal joints. 1 1 67 . Methotrexate is metabolized by the liv er and excreted by the kidney s and should be r educed 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 m ixed neur opathic an d my opathic findings on electromyography. 1 1 69 . Muscle biopsy is the diagnostic study of choice for m y ositis. 1170. Characteristic radiographic changes of the hands associated with rheum atoid arthritis include juxta-ar ticula r osteoporosis and m ar gina l erosions in the m etacar pophala ng eal joints. 1 1 7 1 . Propy lthiour acil use is strongly associated with the dev elopment of an tineut rophil cy toplasm ic a ntibodies directed aga inst m y eloperoxidase an d associated v asculitis. 1 1 7 2. An tineutrophil cy toplasm ic antibodyâ €“positiv e drug -induced v asculitis ma y contin ue to progress after discontin ua tion of the in citing m edication. 1 1 7 3. Whipple's disease is a ch ronic 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 h our s. 1 1 7 5. The mean duration of therapy for poly my algia rheumatica is 2. 4 y ears at an a v erag e 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 th ema tosus or a nother 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 an d ev entua lly lead to ossification of th e out er fibers of the an nu lus fibrosis and th e dev elopmen t of syndesmophytes. 1 1 80. Cry oglobulinemic v asculitis is char acterized by palpable purpura, a rth ritis, weakness, neuropath y , and a membranoproliferative glomerulonephritis. 1 1 81 . Laborat ory findings in cry oglobulinemic v asculitis include circulating 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 com m on 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 th e disease cour se of this infection a nd m ay m imic rh euma toid arth ritis. 1 1 84. Ev en in th e absence of arth ritis, patients with h epatitis 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 dam agin g dig it al ischem ia. 1 1 86. Th e 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 arth ritis is a sy stemic inflamm atory disorder tr iggered by a m ucosal infection in th e ureth ra or the bowel an d is m anifested by a n onseptic oligoarticu lar ar thritis; enth esitis; and, occasionally, eye, skin, or mucosal inflammation. 1 1 90. Sjögren's sy ndrom e is char acterized by oral and ocular dry ness and ant i-Ro/SSA and/or an ti-La/SSB antibody positiv ity in women between 40 and 6 0 y ears of ag e. 1 1 91 . Sjögren's sy ndrome is associated with an in creased risk for non-Hodgkin's ly m phom a and other ly m phoprolifera tiv e conditions. 1 1 92 . A com plete response to appropriate a ntibiotic th erapy for disseminated gonorr hea m ay take up to 7 2 hour s. 1 1 93 . Patients with n ongonococcal septic arth ritis ma y hav e positive blood cultures and extra-articular sites of infection. 1 1 94 . Hemorrh ag ic cy stitis is a possible com plication of
cyclophosphamide therapy. 1 1 95. Mononeuritis mu ltiplex is a com m on presenting featu re of polyarteritis nodosa. 1 1 96 . Extr a-art icular m anifestations of anky losing spondy litis inclu de aortitis with aortic insufficiency , upper-lobe pulm ona ry fibrocystic disease, amyloidosis, cardiac conduction disease, and recurrent uveitis. 1 1 97 . Relapsing poly chondritis is chara cterized by inflamm ation and destr uct ion of car tilag inous struct ur es. 1 1 98 . The most com m on 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 th ritis; enthesitis inv olv ing tendon in sert ion sites; and extr aarticu lar ma nifestations, including uv eitis. 1 2 00. Reactiv e arth ritis is tr igger ed 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 2 02 . In th e setting of septic art hr itis, a decrease of fluid v olum e and leukocy te an d neutr ophil coun ts in seria l samples sug gests adequa te needle draina ge, w her eas persistence of inflamm atory fluid after 7 day s of therapy sugg ests treatment failure. 1 2 03 . Ant i–t um or necr osis factor-α th erapy incr eases the risk for reactivation tuberculosis. 1 2 04 . 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 2 06 . Periphera l joint disease in psoria tic a rt hr itis responds to m ethotrexate an d sulfasalazine, wh ereas related spinal inflam m ation does not. 1 2 07 . Psoria tic spinal inflam m ation responds to ant i–t um or necrosis factor t hera py . 1 2 08. Behà §et's disease is cha ra cterized by recur rent aphth ous ora l ulcer s and at least tw o or m ore of the followin g featur es: recur rent genita l u lcerat ion, ey e or cut aneous 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 2 000/µL (2 × 109/L).
1 2 1 0. Gout a nd pseudogout a re associated with in flamm atory sy nov ial fluid with a leukocy te count between 2000/µ L (2 × 1 09/L) and 50,000/µL (50 × 1 09/L) but ma y be high er. 1 21 1 . Sy nov ial fluid in septic arthr itis is generally high ly inflamm atory with a leukocy te count between 1 0,000/µL (1 0 × 1 09 /L) and 50,000/µ L (50 × 1 09 /L) and is often high er. 1 21 2. Patients with th e clinical triad of asthm a, na sal poly ps, and aspirin 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 2 1 4. A nter oposterior plain radiogr aphy of th e pelv is is th e initia l im ag ing test of choice for suspected sacr oiliitis. 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 wit h early sacroiliitis and enth esitis. Here is the Hem atology Oncology notes: 1 21 1 . Patients with acut e v enous thromboembolism and metastatic cancer a re at h igh er risk for r ecur rent v enous thr om bosis tha n th ose without m alignancy . 1 21 2. Chronic low-molecular-weight heparin at therapeutic doses reduces the r isk for t hr om botic r ecurr ence com pared with stan dardintensity war farin in patients with v enous thr om boembolism and cancer. 1 2 1 3 . Hemat ologic findings in iron-deficiency anem ia consist of m icrocy tic, h y pochr om ic red blood cells; abnorm alities in ery th rocy te size and shape; an d occasiona l 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 ma ss, a norma l blood oxy gen satu ra tion, a nd the presence of splenomegaly. 1 2 1 7 . Low-dose aspirin reduces the r isk of thrombotic complications in poly cy themia v era. 1 2 1 8. Th e electrophoretic gel in patients with hem oglobin SC disease is cha ra cterized by tw o bands of equal intensity th at ar e
slow-migrating. 1 2 1 9. Monoclonal g am m opathy of unknown significance (MGUS) is cha ra cterized by th e 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 th an 3 .5 g/dL (3 5 g/L), and less th an 1 0% plasma cy tosis in the bone marrow. 1 2 2 0. Man agem ent of MGUS requir es rout ine follow-up to identify signs of progression to mu ltiple m y elom a a nd periodic m easur 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 h ema tocrit h igh er th an the blood lost during sur gery an d has none of the clerica l r isks associated with blood ba nking. 1 2 2 2 . Periphera l neur opathy is a com m on side effect of bort ezom ib 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 om bocy topenia (HIT). 1 22 4. In patients with HIT, heparin t herapy mu st stopped and alternativ e anticoagula tion w ith a direct th rombin inh ibitor instituted imm ediately . 1 2 2 5. Estrogen-conta ining ora l contr aceptiv es confer a four fold incr eased relativ e risk for v enous th romboembolism in w om en of childbearing a ge with out h eritable thr om bophilia an d a 35-fold incr eased risk in w om en w ho are h eterozy gous for t he factor V Leiden m uta tion. 1 22 6. Oral progestin-only –containing contr aceptiv es appear to confer litt le, if any , inc reased risk for v enous th rombosis. 1 22 7 . No other interv ention is required in han dling a delay ed hem oly tic tr an sfusion r eaction except for a v oidance of the incompatible antigen. 1 2 2 8. Sign s sug gestiv e of disease tr an sform ation from m y elody splastic sy ndrome to acu te my eloid leukem ia (AML) include sev ere pancy topenia an d circu latin g m y eloid blasts on peripheral blood sm ear. 1 2 2 9. Patients with t ra nsform ed v ersus de nov o AML ha v e poorer response rat es and disease-free sur v iv al, despite receiv ing th e sam e chemotherapeutic r egimen. 1 23 0. Patients with the α-thalassemia t rait hav e a tw o-gene defect
([α,--]/[α,--]) in t he α-globin gen e cha in of chromosom e 1 6. 1 23 1 . Patients wh o hav e α-thalassemia trait ha v e mild m icrocy tic anem ia w ith promin ent tar get cells on peripheral blood sm ear. 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 e factor V Leiden m uta tion is not gr eater th an t ha t in th ose wit hout an underly ing thr om bophilic abnorm ality . 1 23 4. Patients at high risk for recurr ent th rom bosis should receiv e long-term anticoagu lation therapy with w arfarin. 1 2 3 5. Patient s wit h delay ed-onset hepar in-induced thr om bocy topenia (HIT) can present w ith ty pical m anifestat ions of HIT as late as 3 to 4 weeks after heparin exposure. 1 2 3 6. 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, short ness of breath, hy poxia, an d a chest infiltrat e in a patient with a sicklin g disorder. 1 23 8. Patients with ACS require ery thr ocy te transfusion to achiev e a ta rg et hem oglobin of 1 0 g/dL (1 00 g/L). 1 23 9. Ery thr opoietin th erapy has been shown to improv e anemia and r educe tr ansfusion r equirem ents in som e patient s with tr ansfusion-dependent m y elody splastic sy ndrome. 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 com plement activ ation on direct antibody testing . 1 24 1 . Factor V Leiden and prothrombin G202 1 0A m utat ions are the m ost com m on m uta tions predisposing t o 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 2 43 . Bone m ar row aspira te and biopsy should be perform ed in patients with suspected idiopathic t hr om bocy topenic pur pura wh o do not r espond to prednisone ther apy . 1244. Immunosuppressive therapy with antithymocyte globulin and cy closporin e is effectiv e in r educin g tr an sfusion 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
seru m iron concentr ation, r educed seru m total iron-binding capacity , and serum ferr itin th at is not decreased. 1 24 6. Hy percalcemia, bone pain, an emia, an d clusters of large plasm a cells on bone ma rr ow aspira te smear ar e 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 h eter ozy gous for the fact or V Leiden m utation is low. 1 2 48 . Com plete hem atologic r emission r ates for pat ients with CML who receiv ed im atinib m esy la te compared w ith in terfer on 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 icroangiopath ic hemoly tic anem ia, an d renal insufficiency. 1 2 50. Th e treatm ent of choice for TTP is emerg ent plasma exch ang 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 tr ansfusion, 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 2 53 . Patients whose first th rombotic ev ents are associated with tr ansient risk factors are at r elativ ely low r isk for a sponta neous recur 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/μL (7 0× 1 09/L). 1 2 56. Drug -induced agra nu locy tosis is th e most likely diagnosis in patients with sepsis, sev ere neutr openia, a nd relativ ely well-pr eserv ed h em atocrit and platelet counts a fter in gestion of trimethoprim–sulfamethoxazole 1 257 . A history of mu cosal bleeding and a mildly prolonged activ ated partia l th romboplastin tim e is consistent w ith a diagnosis of v on Willebran d's disease. 1 2 58. Factor V Leiden m ut ation is associated with v enous, not ar terial , 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 th erapy , n ot blood tr ansfusion. 1 2 62 . Prim ar y (AL) am y loidosis should be suspected in patients with neph rotic-range pr oteinuria in the pr esence of monoclonal gam ma globulin in serum or ur ine. 1 2 63 . A diag nosis of prim ar y (AL) am y 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 postpar tu m settin g m ay be sug gestiv e of an acqu ired factor VIII inhibitor. 1 2 65. Fondaparin ux a dministered for 2 8 day s results in a low frequency of v enous thr om boembolism after hip-fractu re repair a nd is FDA approved for extended thromboprophylaxis following this procedure. 1 26 6. Patients with h ereditary spherocy tosis hav e predomina ntly spher ocy tic r ed cells on th e peripheral blood sm ear ; a m ild, Coom b'snegativ 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 with sickle cell disease who ha v e adv erse tran sfusion react ions. 1 2 68 . Patients with sickle cell disease m ay experience infusionrelated reactions that ar e man ifested by lower, r ather than high er, reticulocyte counts. 1 26 9. Fatigue, weight loss, m assiv e splenom egaly , a nd teardropsha ped ery thr ocy tes on periphera l blood ar e consistent wit h myelofibrosis. 1 27 0. Chronic tra nsfusion th erapy is an appropriate mana gement option for som e patients wit h m y elofibrosis. 1 27 1 . Isolated thrombocy topenia in an otherw ise-healthy y oung patient is m ost comm only due to idiopathic th rombocy topenic purpur a (ITP). 1 2 7 2 . Patients with ITP an d low risk for bleeding as demonstra ted by a platelet coun t > 40, 000 r equire 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 t hrombotic ev ents in association wit h ant iphospholipid an tibody sy ndrome. 1 27 5. Patients with asy m ptom atic inflam ma tory anemia do not requir e 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 2 7 7 . Stopping th e blood tran sfusion is th e only inter v ention required in the management of nonhemolytic transfusion reactions and should result in qu ick sy m ptom atic r esolut ion. 1 2 7 8. A disease-free and ov erall sur v iv al benefit is observ ed in patients receiv ing hig h-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) usuall y resolv es wit hin sev eral day s after deliv ery of the fetu s. 1 2 80. An inh erited thr om bocy topenic disorder should be suspected in otherwise-healthy patients with a low platelet count, giant platelets on peripheral blood sm ear, a fam ily history of thr om bocy topenia, and w ho are r efra ctory 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 e incr 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 m ental status. 1 28 3. Patients with pulmonary hemorrha ge and those undergoing m ost ty pes of ma jor surger y need sustain ed platelet counts of 40, 000 (4 0 × 1 09/L) to 50,000 /μL (50 × 10 9/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 soun ds, dia phoresis, hy per reflexia , clonu s, and changes in mental statu s. 1 2 85. 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 sy ndrome. 1 28 6. Patients with th alassemia m ay experience secondary iron overload due to increased iron absorption from the gut.
1 28 7 . Deferoxam ine is a parenteral iron chelator that is used to decrease the tissue ir on in patients with tha lassemia. 1288. Leukoreduced blood should be used in pregnant patients in whom the cy tomegalov ir us in fection sta tus is n ot known . 1 28 9. Ima tinib mesyla te can cause a mild, maculopapular ra sh tha t is most promin ent ov er th e extremities and tr unk, and ty pically resolv es wit hin a w eek of interru ption of therapy . 1 2 90 . For m ost patient s wh o experience an im atin ib-induced rash, the dru g can be re-institut ed after th e rash resolv es, wit hout recurrence. 1291. Consumptive coagulopathy is often accompanied by thr om bocy topenia and a prolonged proth rombin tim e. 1 2 92 . All stages of Hodgkin's ly m phom a now are tr eated wit h sy stemic chem otherapy and no longer r equire inv asiv e testing to identify the extent of disease. 1 2 93 . Mort ality in patients with stage III colon can cer tr eated wit h 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 aria n ca ncer com pared w ith the general population. 1 29 5. Patients with a family history sugg estiv e of germ linesusceptibility can cer should be referr ed for genetic counseling. 1 2 96 . Gonadotr opin-releasing h orm one ag onists such as leuprolide m ay result in bone loss in th e lum bar spine in patient s wit h prostat e cancer. 1 2 97 . β-Carotene is associated with an incr eased risk for l un g cancer in patie Re: My NOTES: a sm a ll gi ft for y ou ...
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1 2 97 . β-Carotene is associated with an incr eased risk for l un g cancer in pat ients wh o alr eady ha v e an elev ated risk for th is disease because of smokin g history . 1 2 98 . Serum α-fetoprotein h as 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 ar ian ca ncer in 9 0% of cases. 1 300. Ly mphadenopathy in the supraclav icular r egion alm ost
alw ay s indicates an in fectious or n eoplastic ca use and requir es an imm ediate diagnostic procedur e. 1 3 01 . A com plete ly m ph node excision is alw ay s preferred ov er a percu taneous 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 ch emotherapy . 1 3 03 . Additiona l diagnostic testing for extr ah epatic m etastases is necessary only wh en surg ical r esection of hepatic m etastases is a consideration. 1 3 04 . A diet high in fruit s and v egetables is associated with a lower risk for car diov ascular disease but n ot for can cer. 1305. Hyperviscosity syndrome must be considered in patients who have lymphoplasmacytic lymphoma (Waldenström'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 m ptom s, 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 3 08. Patients wit h r ecently diagnosed prostate cancer an d a prostate-specific ant igen concentr ation less than 1 0 ng /mL (1 0 μg/L) h av e a low incidence of bony m etastasis. 1 309 . Only w omen w ho are at high risk for ov arian ca ncer should consider prophy lactic bilatera l oophorectomy . 1 3 1 0. Lung ca ncer screening does not decrease m ort ality and is not support ed 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 3 1 2 . Gemcita bine is Food and Drug Adm inistrat ion a pprov 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 ra diation h av 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 wh o hav e
bulky Burkitt's ly m phoma and sy m ptoms of v omitin g and dehydration. 1 31 5. Patients with sy mptomatic bulky ly mphoma require hy dration, ur inary alkalinization, an d administration of a xanth ine oxidase inh ibitor before chem oth erapy to prev ent tu m or ly sis syndrome. 1 31 6. Breast-conserv ing surgery results in similar and sometim es superior sur v iv al in patients with early -stage breast cancer rega rdless of patient a ge com pared with m astectom y . 1 3 1 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 3 2 0. Selenium ha s been associated with an in creased risk for nonmelan om atous skin ca ncer 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 sphin cter-preserv ing sur gery in patients with distal rectal tumors. 1 3 2 3 . Gastric m ucosa-associated ly m phoid tissue (MALT) ly m phom a is alm ost alway s associated with Helicobacter py lori infection. 1 3 2 4. Disease in m ost patients with MALT ly m phom a r egresses after treatm ent w ith a ntibiotics alone with in sev eral m onths. 1 3 2 5. Most patient s wit h sma ll-cell lung ca ncer r espond drama tically to combination chemotherapy and w hole-brain radiation therapy . 1 3 2 6. Bisphosphonates such as pam idrona te or zolendronat e help reduce skeletal-relat ed ev ents in patient s wit h 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-nega tiv e result s most likely in w om en w ith 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 μg/L) rar ely ha v e metastatic disease and don't need extensiv e staging 1 3 3 0. Ov ar ian ca ncer screening does not result in decreased m ort ality in genera l or h igh -risk populat ions. 1 33 1 . The infrequency of ov arian can cer occurr ence and inv asiv eness of th e associated diagn ostic procedur es make routine ov arian cancer screening ina ppropriate. 1 3 3 2 . The risks of chemotherapy in bedboun d 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 sh ould be treated for sta ge II br east c ancer . 1 33 4. Watchful w aiting is appropriate for patients with adv anced-stage follicula r ly m phom a un less the disease progr esses ra pidly or poses an im m inent t hr eat to well-being . 1 33 5. Alth ough 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 ha v e an elev ated risk for this disease. 1 33 7 . Tam oxifen is the only Food and Dru g Adm in istrationâ €“ approv ed m edication for use in decreasing br east cancer r isk. 1 3 3 8. Infection w ith hepatitis B or C is associated with an incr eased risk for h epatocellula 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 3 40 . In th e Gleason h istologic scorin g sy stem , gr ade 1 represents the m ost well-differentiat ed tum ors, a nd gr ade 5 r epresents th e m ost poorly different iated t um ors. 1 3 41 . Gleason scores consist of two scores deriv ed from t he m ost prev alent a nd second most prev alent differentiat ed tu m ors, wh ich result s in a combined score. 1 3 42 . Th e first of the tw o report ed Gleason scores in th e com bined score m ay be most pr edictiv e of outc om e. 1343. Mixed seminomatous and nonseminomatous germ cell tumors
should be man aged as though th ey wer e nonseminomat ous tum ors. 1 34 4. Chem otherapy is indicated in th e treatment of mixed semin om atous and nonseminomat ous germ cell tum ors. 1 3 45. Flow cy tom etry of the peripheral blood is th e best and least inv asiv e way to establish a diagn osis in patients wit h suspicious lymphocytosis. 1 3 46 . Sma ll-cell lung can cer is presum ed to be a sy stem ic disease with m icrometasta ses, ev en when it appears to be isola ted 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 sm all sur v iv al benefit ov er sequential use of these m odalities or ch emotherapy alone. 1 34 9. Finasteride reduces prostate cancer preva lence by 25%. 1 3 50. Finasteride is associated with hig her-gra de tum ors and more sexua l side effects but fewer sy m ptom s of ur inar y obstr uct ion com pared w ith 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 anc ed 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 3 53 . Marg inal-zone B-cell ly m phom a h as been associated with hepatitis C v iru s in som e patient s; 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 m it oxantrone plu s prednisone. 1 3 56. Most patients becom e azoosperm ic short ly after ch emotherapy for testicular germ cell cancer, but th ey ma y regain normalized sperm count s with in 2 y ears; howev er, ma ny rema in infertile or subfertile. 1 3 57 . Sperm stora ge is offered to m en with testicu lar canc er before they undergo chemotherapy.
1 3 58. 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 non–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 3 61 . Ritux im ab and CHOP (cy clophospha m ide, doxorubicin, v in cr istin e, and pr ednisone), with or wit hout radia tion therapy , is cur ativ e for m ost patients with diffuse lar ge B-cell ly m phom a. 1 3 62 . Follow-up ev alu ation of postmenopau sal w om en wit h br east cancer wh o un derg o successful t reat m ent consists of ann ua l mammography. 1 3 63 . 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 th erapy wit h 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 shown to increase the risk for breast can cer. 1 3 67 . Follow-up exam inat ions for patients with successfully tr eated testicu lar can cer should inclu de stu dies focused only on new sy m ptom s rath er than an ar bitrary schedule of ima ging or workups. 1 3 68 . Patients with a poor perform an ce stat us and widely m etastatic n onâ €“smal l-cell lun g 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 t ha n th at of the av erag e population. 1 37 0. Ova rian can cer metastasizes comm only to the pleura an d perit oneum , ra rely to bone or liv er, an d alm ost nev er to breast. 1 37 1 . Breast cancer m etastasizes comm only to the pleur a, perit oneum , liv er and bone.
Endocrin ology an d m etabolism 1 37 2. The insulin sensitizing drug s metform in and the thia zolidinediones are contr aindicat ed in patient s with adv anced heart failure. 1 37 3. Thy roid horm one increases the metabolism of war farin but incr eases th e tur nov er of clottin g proteins ev en more, resulting in a decreased dose requirem ent 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, th e 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 m orn 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 m easur ement of ur ine free cort isol, th e ov ernig ht dexam ethasone suppression t est, a nd th e 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 3 80. Mult iple endocrin e neoplasia ty pe 2 A is char acterized by pheochr omocy toma , medullary thy roid carcinom a, and hy perparat hy roidism due to parathy roid hy perplasia. 1 3 81 . Th e goal of preopera tiv e blood pressure control in patients with pheoch romocy tom a is less than 1 40/90 m m Hg. 1382. α-Adrenergic blockade is used to reduce preoperative blood pressure in patients with pheochr om ocy tom a. 1 38 3. No pharm acologic thera py is m ore effectiv e than diet and exercise in prev enting th e progr ession t o 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 th an 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 th er comprom ised by extension of th e arm s ov er th e head, resulting in compression of th e great v eins of the neck a nd th e m ar ked facial plethora known as Pemberton's sign. 1 38 7 . Pituitar y apoplexy is the sudden onset of headache, v isual distu rban ces, opthalm oplegia, an d menta l status cha ng es cau sed 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 distu rban ces and/or m ental statu s cha ng es. 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 demonstr ate acu te hemorrh age in th e region of the sella tu rcica. 1 3 90 . In a patient w ith an drogen-dependent hir sutism w ho does not wish to becom e pr egnant, antia ndrogen and ov aria n 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 it am in D and is m easured as the in itia 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 m ellitus 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 an gina 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 th eir LDL cholesterol concentr ations when tr eated with lev oth y roxine. 1 39 6. Hy pom agnesemia in th e patient with a lcoholism can m imic hy poparath y roidism , including sev ere hy pocalcemia and hyperphosphatemia. 1 39 7 . New-onset hirsutism w ith v irilization, particularly in an older w om an , 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 3 98 . Excision of a cortisol-producing adrena l a denoma results in ra pid cleara nce of cort isol with in th e first 24 hours after sur gery and subsequent acu te adrena l in sufficiency ; cort icosteroid replacement is th e appropria te ther apy 1 39 9. Growth hormone stim ulation t esting is more sensitiv e and specific for determin ing g rowth h orm one deficiency th an m easur ing basal horm one lev els. 1 40 0. 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 adm inistered wh en any ra diogr aphic procedur e using an intr av enous contr ast agent is perform ed. 1 40 1 . Inh ibition of the r enin-angiotensin axis reduces proteinur ia and preserv es rena l funct ion in pat ients with diabetes m ellitus. 1 40 2 . A dom inan t th y roid nodule shown to be benign by fine-needle aspiration biopsy should be followed by serial monitoring with ultr asoun d to assess size sta bility . 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 str ong pretest probability for Cushing 's sy ndrome, t he combined dexam ethasone - CRH stim ula tion t est m ay disting uish Cushin g's syndrome from pseudo-Cushing's syndrome. 1 40 5. Th e th erapy of choice for un com plicated Paget's disease is an ora l bisphosphonate. 1 40 6. In m en, excessiv e production of glu cocort icoids causes hy pogonadotropic hy pogonadism w ith dimin ished libido an d 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 diam eter, un ilater al, homogenous in consistency , a nd less than 1 0 Houn sfield units in density. 1 40 8. Th e serum TSH can not be used to m onitor thy roid horm one replacement th erapy in patients with centr al hy pothy roidism 1 409 . On patients with centr al hy pothy roidism, the goal of thy roid horm one r eplacem ent is to titr ate t he dose to norm alize the free T4 (or t otal T4 and free thy roxine index) not to norm alize th e TSH.
1 41 0. Patients with ty pe 2 diabetes taking m onotherapy often requir e mu ltidru g th erapy as the durat ion of disease incr eases an d beta-cell destruct ion progr esses. 1 41 1 . The addition of one class of dru g to anoth er is the cur rent fav ored approach in th e patient w ith t y pe 2 diabetes and progr essiv e hy pergly cemia despite monotherapy . 1 41 2 . Measurem ent of TSH-receptor au toan tibodies, which ar e present in m ore th an 90 % of patients wit h Gr av es' disease but ar e not present in postpar tu m t hy roiditis, can disting uish between the tw o disorders in a patient w ith postpregn an cy th y 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 iona l diabetes. 1 41 4. Non–parat hy roid horm one–mediated hy percalcemia is cha ra 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 horm one–r elated peptide, which sha res significan t homology wit h m any of the meta bolic actions of parathy roid horm one. 1 41 6. A gra dual decline in strength, cognitiv e and sexual function, and an hedonia in a n elderly m ale 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 th e aldosterone system is still functional. 1 41 8. Multiple endocrin e neoplasia (MEN) ty pe 2 A is an au tosom al dom inant sy ndrome in wh ich 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 an ification ch ar acter ized by congenit al sensorin eura l hear ing loss com bined with goiter. 1 42 0. Osteom alac ia is a m etabolic bone disease wit h failu re of the org an ic m atr ix (osteoid) of bone to miner alize norm ally in adu lts. 1 42 1 . Looser's zones or Milkm an s' fractu res (pseudofractu res) on ra diogr aphy ar e pathognom onic of osteom ala cia. 1 42 2 . In patients with t y pe 1 diabetes and suboptima l glu cose contr ol, m ore complex regim ens with m ore frequent injections of both short /r apid and long /in term edia te act in g in sulins usually provide more effective control.
1 42 3. The ADA r ecomm ended goals for ma nagem ent of adults with diabetes ar e hemoglobin A1 C less tha n 7 .0%, preprandial plasma glu cose 90 -1 3 0 mg /dL (5-7 .2 2 m m ol/L), peak (2 h our ) postpra ndial plasm a g lucose less than 1 80 m g/dL (9. 99 m m ol/L), blood pressur e less than 1 30/80 m m Hg, tr igly cerides less tha n 1 50 mg /dL (1 .69 m m ol/L), HDL cholesterol more th an 4 0 m g/dL (1 .03 m m ol/L), an d LDL cholesterol less tha n 1 00 m g/dL (2 .59 m m ol/L). 1 42 4. Benign adrenal adenoma s generally hav e sm ooth borders, att enua tion v alu es less th an 1 0 Houn sfield un its, and are homogenous in consistency. 1 42 5. Th e size of an adr enal lesion is predictiv e of mal igna nt potentia l; 25% of lesions more tha n 6 cm ar e carc inom as. 1 42 6. In patients with ma lignancy -associated hy percalcemia, therapy with zoledronate, a long-acting intr av enous nitr ogencontaining bisphosphonate, induces rapid and long-lasting hy pocalcem ic response. 1 42 7 . Multiple endocrin e neoplasia (MEN) 2 a 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 int ra v enous insulin. 1429. The differential diagnosis in patients with apparently inappropriate TSH secretion incl udes a TSH-producing pituitar y adenom a an d cong enital th y roid horm one resistan ce. 1 43 0. h e Am erican Diabetes Association crit eria for t he diagn osis of diabetes m ellitus are a fasting plasm a gl ucose more or equa l 1 2 6 m g/dL (6. 99 m m ol/L), a 2 -hour plasma glu cose m ore or equal 2 00 m g/dL (1 1 .1 m m ol/L) after a 7 5-g ora l glu cose load, or a r andom glu cose m ore or equal 2 00 m g/dL (1 1 .1 m m ol/L) plus sy m ptom s of diabetes. 1 43 1 . Thiazide diuretics stimu late renal tubular calcium reabsorption a nd in som e patients lead to a mild h y perca lcemia , which usually resolv es w hen th e diuretic therapy is discontin ued. 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 Cushin g's sy ndrome can be
disting uished by the dexam ethasone 8-mg (h igh-dose) ov ernig ht suppression t est 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 wh o does not hav e coexisting insulin resistan ce requir es a t otal daily dose of about 0.4 to 0.5 un its of insulin per kg of body weigh t. 1 43 6. In the wat er depriv ation test, im paired ability to concentrate ur ine is consistent w ith either n ephr 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 a dmin istr ation of desmopressin is indicativ e of centr al diabetes insipidus; no such incr ease occur s in n ephr ogenic diabetes insipidus. 1 43 8. Hy pocalcemia frequently occurs after r emov al of a hy perfun ctioning para th y roid adenom a because of deficient secretion of parathyroid hormone by the remaining previously suppressed parathyroid tissue. 1 43 9. Perma nent hy poparath y roidism after an initial neck explorat ion for prim ary hy perparat hy roidism is rar e, but t he incidence is gr eatly incr eased 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 , th erapy with thy roid horm one could increase my 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 m acr 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 impr ov es v isua l fields an d pituita ry 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 µm ol/L) or in women w ith creatinine lev els greater than 1 .4 m g/dL (1 23 .7 9 µm ol/L).
1445. A thiazolidinedione should not be used in patients with class III congestiv e heart failu re an d will often cause worsening edem a ev en in patients with less sev ere cong estiv 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 hig h-norm al TSH. 1 44 7 . Osteoporosis is diagnosed by the presence of fragility fract ur es or by a bone min eral density v alue less than −2. 5 in patients who hav 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 cau se of hy perprolactinem ia. 1 450 . Secondar y diabetes m ellitus may be the direct result of such underlying disease states as other endocrinopathies, islet cell neoplasm s, and disorders of the exocrin e pancr eas such a s pancr eatitis, panc reatic m align anc ies, and cy stic fibrosis. 1 451 . Localizing th e ectopic sour ce of ACTH in a patient wit h ev idence of ACTH-dependent Cushing 's sy ndrome m ay requir e com bina tion CT/MRI/octr eotide imag ing of chest/abdom en/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 stim ula tes expansion of TSH-pr oducin g pit uitary cells, 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 th at ha s been shown to significa ntly parathy roid horm one lev els in patien ts with ch ronic kidney disea se and u ncontrolled seconda ry hyperparathyroidism. 1 456 . The classic presenta tion of hereditar y hem ochr om atosis inclu des hy pogonadism , diabetes m ellitus, 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 th e pituitar y gland, pancreas, liv er, and heart. 1 458 . Postpra ndial 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. Th e absence of menses for sev eral m onth s after dilation and cur reta ge ra ises th e possibility of endom etrial dam age or form ation of scar tissue cau sing an out flow tr act obstr uct ion (A sherm an '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 oug h t he adrena ls is th e preferred initial localizing stu dy for pheochromocytoma. 1 46 3 . Patients with Hashim oto's thy roiditis are at r isk for other au toim m un 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 sy m ptom s of renal osteody str ophy ar e v agu e bone pain localized to th e lower back, hips, or leg s; m uscle weakn ess often occur s with n orm al m uscle enzy m es 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 ha nds, neck of fem ur , an d clav icle. 1 46 6. Th e presence of three or m ore pituita ry horm one deficiencies ha s a positiv e predictiv e v alu e for g rowth horm one deficiency of 95%. 1 46 7 . Replacem ent of gr owt h h orm one in horm one-deficient adu lts ha s been shown to improv e body com position, lipid par am eters, and bone m in eral density . 1 46 8. Th erapy with an angiotensin II receptor blocker delay s the progr ession of nephr opathy in diabetic patients wit h hy pert ension, ma croalbum inur ia, and renal insufficiency .
1 46 9. β-Blocker th erapy to reduce thy rotoxic sy m ptom s is th e 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 diabetes mellitus. 1 47 2. Growth hormone replacement is star ted at a low dose and titr ated up based on t he patient's insulin-like growt h fact or 1 lev el, sy m ptom contr ol, a nd side effects of ther apy . 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 supplement ation. 1 47 6. In men with bilateral adrenal hy perplasia in whom spironolactone th erapy cau ses painfu l 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 tu rn ov er, disru ption of th e norm al a rchit ectu re of bone, a nd som etim es to gross deform ities of bone (enla rgem ent of th e skull, bowin g of th e fem ur or tibia). 1 47 8. Osteoma lacia usually presents with an elev ation of alkaline phospha tase 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 excessiv e hepatic gl ucose production, ar e contr olled m ainly by th e basal in sulin dose. 1 48 1 . Patient s on basal bolus insulin th erapy often take 40% to 50% of their t otal daily dose as basal in sulin (gl ar gine) a nd 50% to 60% as m eal 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-tr eated diabetes m ellitus, is an adaptiv e centr al nerv ous sy stem r esponse and is exacerbat ed by recu rr ent episodes of hy pogly cem ia. 1 484 . In patients with ty pe 1 diabetes mellitus and hy pogly cemic un aw ar eness, insulin dose should be reduced and treat m ent g oals relaxed. 1 48 5. Th e classic tr iad of sy m ptom s for pheochr om ocy tom a consists of headach es, palpita tion an d diaphoresis. 1486. The sensitivity of fractionated plasma metanephrines for catecholam ine-producing tum ors is nearly 97 %; howev er, th e specificity is 85%. 1 487 . The first step in the ev alua tion of a th y roid nodule is m easur ement of serum TSH; if TSH is norm al, th e nodule is m ost likely nonfun ctionin g or “cold�; if TSH is low, the n odule is m ore likely to be hy perfun ctioning or “hot.†� 1 48 8. Measur ement of seru m th y 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 m align ant nodules. 1 489 . Very high levels of hum an ch orionic gonadotropin (hCG) are sufficient to stim ula te the t hy roid glan d to release excess thy roid hormone. 1 490. Risk fact ors for osteoporosis in m en in clu de a BMI less th an 1 8, a h istory of sm oking or excessiv e alcohol consum ption, family history of osteoporotic fractures, hypogonadism, history of cort icosteroid use, v itam in D deficiency , an d medications causing osteom ala cia or hy pogonadism . 1 49 1 . Hy pogonadism increases the skeletal sensitiv ity to parat hy roid horm one an d decreases intestina l calciu m absorption, predisposing to osteoporosis. 1 49 2. Th e objectives in ev aluat ing pituitary incidentaloma s are to determ ine whether th ey are secreting pituitary horm ones, causing deficiencies of pituit ar y horm ones, and gr owin g. 1 49 3 . Close observ ation of the tum or to detect growth and pituita ry horm one deficiency is th e treatm ent choice for clin ically silent sma ll adenomas. 1 49 4. DEXA scann ing ha s the best correlat ion of procedures for m easur ing bone loss wit h fra ctu re risk, requir es a short scann ing tim e, and m easures the bone m inera 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 sy ndrome include a precipitous drop in seru m 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 ar e likely adaptiv e, as a m eans of protecting th e body from cata bolic illness; th y roid horm one thera py in patients with euth y 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 com plications 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 com plicat ions of Pag et's disease of the bone inclu de osteogenic sar com a in affected bone, h y perca lcemia , h igh -out put congestiv e hear t failur e, deafness, and excessiv e bleeding durin g sur gery as a result of hy perv ascular bone. 1 500. Non-tu m or ca uses of elev ated prolactin lev els ar e ty pically associated with lev els less th an 1 00 ng /dL (1 00 m g/L). 1501. • Psychotropic medications may raise serum prolactin levels modestly ; patients with hy perprolactinemia and sev ere psychiatric illnesses requiring continued therapy with psychotropic agent s can be treated w ith estr ogen- and progesterone-conta ining ora 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 , acr om egaly , pheochr om ocy tom a, an d Cushing 's syndrome. 1 505. During a norm al pregnancy , thy roid horm one production m ust be incr eased to prov ide thy roid horm one to the dev eloping fetu s; m ost wom en wh o ar e taking th y roid horm one replacement requir e a 3 0% to 50% incr ease in th eir th y roid horm one dose durin g their pregnancy . 1 506 . Risk factors for gestat iona l diabetes m ellitus inclu de obesity , a family history of ty pe 2 diabetes, and a h istory of gestat iona l
diabetes in prev ious pregn ancies. 1 507 . The diagnosis of gestat iona l diabetes m ellitus requires any tw o of the followin g four v alu es in a 3 -h, 1 00-g oral g lucose toleran ce test: fasting equal or m ore th an 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 gestationa l diabetes m ellitus consists of restricted diet, with insulin if gly cemic target v alues are not achiev ed. 1509. In hypercalcemia secondary to production of parathyroid horm one-relat ed peptide by a car cinoid, the seru m 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 recom m ended in osteoporosis secondar y to prim ar 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-horm one binding globulin concentr ation. 1 51 4. Orth ostatic hy potension is a com m on m an ifestat ion of diabetic au tonomic n europath y , r eflecting loss of norm al v asoconstrictor tone, w ith dera ng ed com pensation t o uprig ht posture. 1 51 5. Fludrocortisone th erapy expands the plasma v olum e, thereby ra ising blood pressur e and im prov ing sy m ptom s in diabetic autonomic n europathy . 1516. After biochemical confirmation of primary aldosteronism, localization procedures differen tia te a ldosterone-producing adenom as from bilatera l adrena l hy perplasia; aldosteronism producing adenomas are amenable to laparoscopic resection, wher eas bil ateral a drenal hy perpla sia is m edica lly treated. 1 51 7 . Radiogra phic ima ging rar ely differentiates aldosteroneproducing a denomas from bilatera l adrenal h y 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 eu thy roid. 1 52 0. Exogenous testosterone suppresses sperm production, resulting in in fertility . 1 52 1 . Tr eatm ent w ith exogenous testosterone at n orm al doses does not norm ally cau se perm anent in fert ility , but restora tion of sperm production requir es gonadotropins. 1 522 . Silent th y roiditis is an autoimmu ne disorder cha racterized by high lev els of an tith y 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 r etur n to euth y roidism in m ost patients. 1 52 3. Most patient s wit h int erferon alfaâ €“associated thy roid dy sfun ction r ecov er after t he dru g is discontin ued. 1 52 4. Hy popituita rism is a frequent outcome of patient s tr eated with ir radia tion of th e thy roid gla nd. 1 525. In a patient w ith h y popituitar ism , docum entation an d therapy of adrenal insufficiency takes priority over other anterior pituitary hormonal deficiencies. 1 52 6. Infection is a com m on precipitan t of my xedem a com a, an d pan-culture and empiric antibiotic therapy with broad-spectrum an tibiotics is recomm ended for a ll affected patient s. 1 52 7 . Signs of androgen excess (incr eased muscle mass, irr itability , and pustula r a cne) wit h sm all testes and low seru m testosterone and gona dotr opins in a y oun g m ale sugg est a ndrogenic ana bolic steroid abuse. 1 528. In patients with m acroprolactinom a a nd norm al v isual fields, dopam ine agonist thera py effectiv ely reduces prolactin secretion and t um 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 lt erations in the androgen /estrogen ra tio—eith er a ndrogen deficiency or estr ogen 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 l calcium 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 supplem entat ion, a DEXA scan at th e initiat ion of thera py , a nd bisphosphonates in patients taking prednisone equal or m ore th an 5 m g/d (or it s equiv alent) for m ore than 3 m onth s. 1 53 6. A s m an y as 3% of patient s wit h poorly contr olled diabetes mellitus (hemoglobin A1 c m ore th an 8 .0%) hav e Cushing's syndrome. 1 537 . The tr eatment of choice for a nonfunctioning pituitar y adenom a is tra nssphenoidal tu m or resection. 1 53 8. Benign adrena l adenomas are homogenous and ha v e sm ooth borders and attenuation v alu es of less than 1 0 Hounsfield u nits 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 roiditis a nd a rapidly expandin g thy roid ma ss. 1 540 . Latent a ut oim m un e diabetes of adulth ood (LADA) occurs in lean patients with in itially apparent ty pe 2 diabetes wh o becom e insulin-dependent la ter in life and exh ibit the labile gly cemic tendencies and m an y of th e autoimm un e mar kers of patient s wit h ty pe 1 diabetes. 1 541 . Latent au toim m un e diabetes of adulth ood (LADA) is cha ra cterized by slowly progr essiv e loss of beta-cell fun ction, leading to sev ere insulin deficiency and labile gly cemic control. 1 542 . Patient s wit h lat ent au toim m un e diabetes of adult hood (LADA) becom e refract ory to ora l a gents an d as insulin-dependent and ketosis-prone as patients with type 1 diabetes. 1 543 . Pericar dial effusion is a consequence of m odera te to sev ere hy pothy roidism and is indicated by diminished heart soun ds, low v oltage on elect rocardiography , and an enla rged cardia c silhouett e. 1 544. The “hy pothy roid heart†� r efers to decreased
contr actility an d pulse ra te—both contribu ting t o 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 fact or 1 and g rowth horm one lev els, MRI of the head is indicated to identify and cha ra cterize th e causativ e pituitary tum or. 1 546 . Multiple endocrin e neoplasia ty pe 1 is cha ra 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 ½ para thy roid glands are removed. 1 548. Chemotherapy w ith alky lating agents often induces irr ev ersible dam age to sperm pr oduction in y oun g m en. 1 549 . Subacu te thy roiditis is cha ra cterized by a prodrom e of arth ralg ias, m alaise, an d anorexia followed by pain in th e thy roid bed a nd thy rotoxicosis. 1 550. Teriparatide (recombinant h um an parath y roid horm one [1 -3 4]) stimu lates osteoblastic bone form ation; it sign ificantly incr eases bone m ass in patients wit h osteoporosis and can decrease the incidence of both v ertebral an d nonv ertebral fra ctu res. 1551. Kallman's syndrome is X-linked hypothalamic hypogonadism accompanied by anosmia. 1 552 . In patients with diabetes an d sev erely im paired beta-cell secretory capacity , basal insulin is effectiv e on fasting g lucose but cann ot adequa tely 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 m etabolism, or a n in creased occupan cy of binding proteins 1 555. Most a drenal nodules are hormonally silent and ha v e no ma lignant potential. 1 556 . Patient s wit h an in cidenta lly detected adrena l ma ss should be screened for pheochromocy tom a, Cu shing's sy ndrome, an d prim ar y 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 percoagu lable stat e 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 un recogn ized initiall y ; as th y roxine deficiency is corr ected, th e patient dev elops clinical a drenal insufficiency , requir ing glucocorticoid supplementation. 1 559 . Testosterone thera py 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 1 2 m onth s after t he start of therapy . 1 561 . Vita m in D deficiency m ust be corr ected before startin g oth er activ e osteoporosis thera py because the r esponse to the th erapy will be im pair ed by the defect iv e m in eralizat ion associated w ith v itam in D deficiency an d osteom ala cia. 1 562 . Prediabetes gly cemic stat es consist of im paired glu cose toleran ce, defined as a 2 -hour g lucose lev el of 1 40 -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 th e 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 m ost likely diagnosis. 1566. High-risk patients with obesity and metabolic syndrome can m ost effectiv ely reduce th eir 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 h y perth y roidism a re a TSH-producing adenom a a nd th e resistan ce to thy roid horm one syndrome. 1 568 . The tw o cau ses of centr al hy pert hy roidism, TSH-producing adenom a an d the resistan ce to th y roid horm one sy ndrome, can be disting uished by m easur ing TSH α subun it. 1 569 . Testosterone stim ula tes product ion of ery thr opoietin, a nd th e hema tocrit an d ery thr ocy te indices rise significantly during testosterone replacement th erapy .
1 57 0. The som atostat in an alogue, octr eotide, reduces growt h horm one production an d shr inks tum or in patients with a cromegaly and is first-line th erapy for patient s not cu red by surger y alone or sur gery combined with radiation 1 57 1 . The hu moral mediator of hy percalcemia of ma lignancy in m ost cases, especially in lun g can cer, is para thy roid horm one–r elated peptide (PTHrp), w hich is secreted by th e tumor. 1572. In gonadotropinoma, the gonadotropins are often detected on imm unostaining of the surgical specim en but a re ra rely secreted into the bloodstr eam in m eaning ful am oun ts.
Pulm onology and cr itical car e 1 57 3. In a patient t aking hig h-dose inh aled cort icosteroids as par t 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 th era py related side effects. 1 57 4. High-resolut ion computed tom ogr aphic scann ing (HRCT) is m ore 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 h epatic hy drothorax, un derly ing cirr hosis results in usuall y rig ht-sided pleur al effusion th at is tra nsudativ e as a r esult of hy poalbum inem ia an d reduced serum oncotic pressur e. 1 57 6. In patient s wit h sev ere sepsis from nosocom ial pneum onia, the v entila tor should be adju sted by using a “pr otectiv e lung strategy†� with 6 m L/kg of ideal body weigh t an d a plateau pressure less than 3 0 cm H2O. 1 57 7 . Low-dose dopam ine h as 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 odera te to high risk for v enous thr om bosis in wh om heparin and low-molecular-weight heparin are contraindicated. 1 57 9. Ina dequat e am oun t of sleep is the m ost com m on c au se of day tim e som nolence in y oun g adult s; impr ov ed sleep hy giene and incr eased amount of sleep ar e the initial m ana gem ent. 1 580. Noninv asiv e positiv e pressur e v entilat ion in selected patients with m oderate r espir atory distress has been shown to im prov e h eart
and respira tion r ates, gas exch ang e; an d to reduce morbidity an d m ort ality ra tes, th e need for int ubat ion, a nd the length of hospital stay. 1581. Contraindications to noninvasive positive pressure ventilation in patients w ith m odera te respira tory distr ess include excessive secretions, u ncoopera tiv eness, and a cut e ischem ic ch ang es on electrocardiography. 1 582 . Th e diagnosis of rh abdom y oly sis is based on c linical findings and a history of a predisposing factor(s) an d confirm ed by th e presence of my oglobinu ria , an in creased seru m creat ine kinase, and hyperkalemia. 1 583. Early aggr essiv e fluid therapy is essential in rh abdom y oly sis to coun tera ct flu id loss from sequestr ation int o 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 m onitored periodically to detect signs of growth com patible wit h lung cancer. 1 586. The clinical presentation of hy persensitiv ity pneum onitis is ty pically recur rent a cut e episodes of fev er, coug h, a nd dy spnea th at begin 4 to 6 hour s after antig en exposur e and r esolv e spont aneously 24 to 48 h our s after antigen a v oidance. 1 587 . Rev ersible airflow obstr uct ion is a n onspecific finding th at can occur with asthma , postinfectious bronchial hy perr eactiv ity , endotoxin inhalation, or hypersensitivity pneumonitis 1 588. In patient s wit h persistent asthm a not adequately contr olled with daily low - or m oderate-dose in haled corticosteroids, addin g a long -actin g β-agonist im prov es asthm a contr ol an d quality of life. 1 589 . In idiopathic pulm onar y fibrosis, a ch ar acter istic HRCT pattern is seen in approxim ately 50% of patient s and the extent of disease on HRCT is a predictor of sur v iv al. 1 590 . Patients with sev ere sepsis and refract ory shock despite adequa te fluid r esuscitation should be t reated w ith replacement -dose corticosteroids. 1 591 . High-dose cort icosteroid th erapy is ineffectiv e and ma y 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 usua lly associated with a lymphocytic pleocytosis.
1 593 . Tu bercu lous pleura l effusion m ost often dev elops from a cell-mediated immune response to tuberculosis antigens. 1 594 . In patients with potentia lly opera ble non-sm all-cell lun g cancer , pulm onar y funct ion tests ar e indicated to assess pulm onar y reserve. 1 595 . Brain scan a nd bone scan a re needed in patients with potentia lly opera ble non-sm all-cell lu ng cancer . 1596. Unfractionated and low-molecular-weight heparins reduce the r isk of clinically im port ant v enous thr om boembolism in critically ill patients by up to 60%. 1 597 . Aspirin h as 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 entila tion (NPPV) m ore 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 standar d of pra ctice to determ ine the optima l contin uous positiv e airw ay pressure lev el to m ana ge obstr uct iv e sleep apnea is an at tended labora tory poly som nography wit h CPAP pressur e titration. 1 60 0. Th e goal of th erapy for h y pert ensiv e crisis is not to decrease the blood pressure to norm al l ev els but to prev ent fur th er end-org an dam ag e; precipitous r eduction of blood pressur e incr eases th e risk for cerebral, car diac, an d renal ischemia. 1 60 1 . In prospectiv ely ev alu ation by HRCT, up to 60 % of patients with rheum atoid arthritis h av e r adiographic abnorm alities consistent w ith interstitial lun g disease. 1 60 2 . In dru g-induced interstitial lu ng disease, ther e are not specific pathologic patt erns th at 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 durin g in spiration. 1 604 . Treatm ent of hepatic hy drothorax is directed to m anag ement of cirrh osis and ascites wit h salt r estr iction a nd 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 wh ich dev elop within 3 0 min ut es to 1 hour after th e offending ant igen is injected or up to 2 h our s after t he an tigen is ingested. 1 606 . Patients with m oderate to sev ere anaphy laxis should be
m onitored for at least 1 2 hours for a possible late r ecur rence (biphasic a naphy laxis) 1 607 . Risk factors for n oninv asiv e v entilatory failur e include the acu te respiratory distr ess sy ndrome (ARDS) or sever e com m un 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 a patient in th e intensiv e care unit for delirium , takes less th an a minu te and is recom mended for a ll mechan ically v entilated patients. 1 60 9. Pregna nt w om en with deep v enous thr om boembolism 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 sm all n odules in th e lung s on r adiogr aphs is not associated wit h sy m ptom s or phy siologic a bnorm alities, but continued exposure and development of progressive massive fibrosis cau ses disabling sy m ptom s. 1 61 1 . Screening for lun g cancer with chest radiogra phy or sputu m cy tology does not lower lu ng ca ncer m ort ality in th e screened popula tion an d 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 9 0% of patients with sarcoidosis ha v e pulm ona ry 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 sy m ptom s, ev idence for progr essiv e lun g disease, extrapulmonary disease, or complications such as hypercalcemia. 1 61 5. Patient s with ra diogr aphic stage 1 sar coidosis (hila r an d/or mediastinal ly mphadenopathy with out infiltrat es) and n o sy stemic sy m ptom s hav e sponta neous r emission ra tes of 50% to 90%. 1 61 6. Exposure to nerv e agents causes a ch olinerg ic crisis by inhibiting cholinesterase and causing muscarinic, nicotinic, and centr al ner v ous sy stem effects. 1 61 7 . Pralidoxime (2 -PAM) reactiv ates acety lcholinesterase, an d can r ev erse th e muscle weakness, paraly sis, and respira tory 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. Patient s with pr edom inan t supine-dependent sleep apnea can be m anaged init ially with a tria l of r estrictin g sleep to lateral recumbency. 1 62 0. The adv an ced car diac life support g uidelines stat e that a single dose of v asopressin can be administer ed 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 ca rdia , th e guidel in es for adv anced cardia c life support recom m end th e followin g sequence of interv entions: defibrilla tion, COTE [car diopulm ona ry resuscitat ion, oxy gen, tu bes (endotr ach eal and intr av enous), epinephrin e (or v asopressin)], a nd more defibrillation. 1622. D-dimer reflects the presence of thrombosis (or inflam m ation), but does not reflect th e activ ity of thr om bosis. 1 62 3 . Hy pocapnia is the cause of centr al sleep apnea in patients with Ch ey ne-Stokes respir ation. 1 62 4. A short course of ora l cort icosteroids may help restore asth m a contr ol in prev iously well-contr olled patients w ho hav e dev eloped un stable disease as a result of a respira tory tr act infection 1 62 5. Daily hemodialy sis has been shown to significantly reduce in-hospital death s in patients with a cut e renal failur e in sur gical and m edical intensiv e care un its. 1 62 6. Inh aled cort icosteroids with as-needed albuterol is the corn erstone of th erapy for persistent asthm a. 1 62 7 . In a patient with sev ere COPD and respirat ory failure with sev ere carbon dioxide retention, in appropriately hig h r ate an d tidal v olum e of m ech anical v entilation ca n ca use 1 ) excessiv ely rapid reduction in PaCO2 potentially causing sev ere alkalemia a nd 2 ) th e induction of dy na m ic hy perin flation leading to a sev ere elev ation of intrinsic positive end-expiratory pressure (auto-PEEP). 1 62 8. Helical CT scanning with out contr ast enha ncement is not sensitiv e for diagn osing pulm ona ry 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 confir m th e diagnosis of m etastatic disease with a m inim um of discom fort , r isk, an d expense.
1 63 0. Lung disease is th e most com m on ca use of morbidity and m ort ality in sy stem ic sclerosis. 1631. In scleroderma, both interstitial lung disease and pulmonary hy pert ension can dev elop (both independently or t ogeth er) an d ha v e an adv erse effect on out com e. 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 bu rn s, soot in the m out h, car bona ceous sput um , or singed nasal hairs m ay corr elate with u pper airwa y injury and a high risk of delay ed air wa y com prom ise from edem a. 1 63 4. A pproxima tely one fifth of adult patient s wit h cy stic fibrosis dev elop pneum oth ora x at som e time in th eir liv es. 1 63 5. Tube thoracostomy is th e preferred treatm ent for secondar y pneumothorax. 1 63 6. Patients with cy stic fibrosis hav e a high rate of recurrent pneumothorax; therefore, parietal pleurectomy, pleural abrasion, and th ora coscopy wit h t alc pleur odesis are reasonable int erv 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. Th e diagn osis of the acu te respira tory distr ess sy ndrome (ARDS) requires a PaO2 /FiO2 less th an 2 00 in com bination with bilater al in filtrates and the absence of other ev iden ce for congestiv e heart failure. 1 63 9. The “lung protectiv e strategy †� for intu bation in patients with ARDS consists of the tidal v olum e at 6 m L/kg ideal body weig ht and plateau pressure kept less t han 3 0 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 obstr uct iv e lun g disease. 1 64 1 . Intr av enous heparin has imm ediate onset of action a nd has a ha lf-life of un der an hour after discontin ua tion. 1 64 2. Low-molecular-weight heparins a nd fondaparinux hav e onset of action w ithin about a h alf hour of subcutan eous admin istr ation, and th e effect lasts thr oug hout 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, inspira tory capacity is too small for an adequa te coug h, a nd coug h 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 perten sion in c ocaine toxicity usua lly 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 sign ificant eosinophilia, pulm ona ry infiltra tes in th e setting of asthm a, th e use of a leukotriene r eceptor ant agonist, a nd with draw ing oral corticosteroids. 1 650. Extubation to noninv asiv e v entilation h as been shown to impr ov e outc om es in ca refully selected intubat ed 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 2 0% fall in FEV1 . 1 652 . Treatm ent wit h short -actin g inh aled β-agonists 5 to 1 0 m inu tes before exercise prev ents exercise-induced asthm a in >8 0% of patients. 1 653 . Metabolic signs of salicy late toxicity inclu de respira tory alka losis, anion gap m etabolic acidosis, and hy pert her m ia; other signs an d sy m ptom s inclu de depressed lev el of consciousness, noncardiogenic pulm ona ry edema , prolonged proth rombin tim e, hepatic toxicity , and hy pogly cemia. 1654. Management of salicylate toxicity includes alkalinization of ur ine to enh an ce excretion of salicy lates and hem odialy sis for sev ere toxicity. 1 655 . Enoxapar in is cleared by th e 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/μL (1 00 × 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 m etastases wh o ha v e a resectable prim ar y tu m or, 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 h istory 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 m ay significant shorten t he 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 bronch odilators is indicated after sy stem ic cort icosteroid therapy is star ted. 1 66 4. A pproxima tely 80% of effusions associated with pulm ona ry 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 scan ning 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. Th e co-presence of focal ar eas of fat a nd calcium ar e v irt ua lly pathognomonic of hamartoma. 1 66 9. Malignan t lu ng lesions tend to hav e a doubling tim e of between 3 0 and 4 00 day s; ben ig n lesions double in less th an 30 day s or ov er v ery long periods of slow gr owt h. 1 67 0. Patients with anaerobic bacterial infection inv olv ing th e
pleural space usually have subacute presentations with weight loss an d a history of alcoholism, un responsiv eness, possible aspirat ion, and poor oral h y giene. 1 67 1 . Fibrinoly tic therapy m ay be considered in patients with empy ema w ho are poor sur gical ca ndidates. 1 67 2. Organizing pneum onia is a path ologic pattern of lung injur y that can occur in various settings, including infections, connective tissue diseases, and as a complication of treatments, such as amiodarone or radiation therapy. 1673. Urinary Legionella pneumophila antigen test should be done in pat ients with suspected Legionella pneum onia. 1 67 4. Early therapy with a zithromy cin plus ceftriaxone is considered adequa te initial cov erag e for a sever e com m un ity acquired pneumonia. 1 67 5. A h istory of ort hopnea, a bdom inal par adox, a nd a decrease in forced v ital capacity more than 25% w hen th e patient goes from the uprig ht 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 Re: My NOTES: a sm a ll gi ft for y ou ...
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triplehelix - 01-12-09 23:56
1 67 7 . Clinical findings in hy drogen cy anide toxicity include coma , hy potension, ca rdiac irr itability , and profoun d anion ga p metabolic acidosis in t he 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 patient s wit h sev ere sepsis, early goal-directed therapy within the first 6 hour s to m ain tain a central v enous oxy gen satu ra tion of m ore th an 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. Ac ute m oun tain sickness is cha ra cterized 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 acu te 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 ha ge is m ade with bronchoalv eolar la v age, wit h seria l sa m plings showing a persistently bloody fluid. 1 684 . Malignan t hy perth ermia is a life-thr eatening inherited skeletal m uscle disorder cha ra cterized by a h y perm etabolic stat e precipitated by exposure to v olatile inh alat ional a nesthetics an d 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 th e patient 's plasma wit h activ ated factor Xa. 1 686 . The reactiv e airway dy sfunction sy ndrome follows a single, accidental inh alat 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 m ediastinal infections, sar coidosis, ly m phan gioleiom y om atosis, an d ra diation fibr osis. 1 689 . In a competent, severely ill patient in the ICU with a tr eatable condition but a cl early expressed preference for com fort m easures rath er tha n m ore agg ressiv e interv ention, com fort measures to prov ide good end-of-life care should be prov ided 1 69 0. Al th oug h a fixed th erapeutic dose of subcut aneous heparin m ay be appropria te for tr eatm ent of deep v enous th rombosis and pulm onar y embolism, aPTT monitorin g an d dose adjustm ent ar e requir ed for patients at h igh risk of bleeding. 1 69 1 . Renal ultra sound with renal ar tery Doppler examinat ion prov ides anat om ic an d fun ctiona l assessment of th e renal ar teries, 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 c om m on of the idiopathic int erstitial pneum onias, and by far m ore com m on th an oth er m embers of the g roup. 1 69 3 . Sar coidosis, the m ost com m on in terstitial lu ng disease, is a sy stem ic disorder a nd its ra diogr 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 impr ov ing oxy genat ion, cour ses of no m ore th an 8 day s of antibiotic therapy are associated with as good outcomes as longer courses. 1 69 5. Activ ated protein C h as 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 th e need for in-fligh t oxy gen supplementat ion with the goal of main tain in g PaO2 eit her 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 clinicall y stable at sea lev el. 1 69 7 . The neuroleptic m alignan t sy ndrom e is a rar e, but potentia lly fatal, com plication of the adm inistrat 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 in cr ease in peak air way pressure and asy m m etric ch est wall expansion are cardin al featu res of an acu te tension pneumothorax 1 69 9. In patients taking th eophy lline as part of asthm a th erapy , concomitan t ciprofloxacin t her apy can decrease th eophy 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 th e short-term incidence of pulm onar y embolism in patients being a nticoagu lated for deep v enous th rombosis. 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 obstr uct ion. 1 7 04. Obstru ctiv e sleep apnea can exacerbate noctur nal asthm a; CPAP thera py for sleep apnea can im prov e asthm a control.
1 7 05. Prompt int ubation is indicated in patients with sev ere pneum onia wh ose condition is deterioratin g on conv entiona l 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 entila tion. 1 7 07 . Hypergly cemia should be treated in critically ill patients with aggressiv e insulin th er apy to main tain tig ht gly cem ic control. 1708. Intermittent bolus dosing of sedatives titrated via a validated sedation scale is consistent with th e gu idelines for th e use of sedation in critically ill patients. 1 7 09 . Ant ipsy chotic agents may cau se torsades de pointes in patients with prolong ed 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 entila tion w ith a lu ng protectiv e strategy , PEEP should be incr eased in 2 - to 3-cm H2O incr ements to lower FiO2 to 60%, if possible, and to m aint ain a n ar terial oxy gen satur ation of ≥88% and ≤ 95% 1 7 1 2. V ocal cord dy sfunction m imics asthm a, but un like asthma , it begin s and en ds abr uptly , does not respond t o β-ag onists, and airflow limitation is mainly during inspirat ion. 1 7 1 3. Th e ultrasound ma y be abnorm al for sev eral months after a deep v enous th rombosis, a nd th e v enous w all does not retu rn to norma l com pressibility at a ll in som e patient s. 1 7 1 4. Th e most com m on form of delirium in th e ICU is hy poactiv e or “quiet†� delirium . 1 7 1 5. Delirium is a form of acute brain dy sfunction th at occurs in 50% to 80% of v entilat ed patients in the intensiv e care un it; it is associated with high er m ort ality ra tes, long er hospital and ICU stay , high er costs, an d 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) requir e initial cov erag e for r esistan t org anism s inclu ding m ethicillin-resistan t Staphy lococcus a ur eus an d Pseudom ona s.
1 7 1 8. Segmental perfusion defects in patients with righ t h eart failur e and right v entricular h y pertr ophy strongly suggests the diagnosis of chr onic t hr om boembolic pulm onar y hy pert ension (CTEPH). 1 7 1 9. Surgical pulmonary thromboendarterectomy can improv e cardiac output, reduce mortality , an d enhance quality of life in patients with t hr om boembolic pulm onar y hy pert ension (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 cha ra cterized by cra ckles and patch y persistent infiltr ates on ch est ra diogr aph, an d restr ictiv e lung defect with decrease in car bon m onoxide diffusing capacit y . 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 5-2 0 m L/kg is an indicator of the need for in tu bation. 1 7 2 3 . No drug is FDA-approv ed for th e treatm ent of delirium , but clinical pra ctice guidelines recom m end antipsy chotic agents, such as h aloperidol. 1 7 24 . All antipsy chotics, and especially “ty pical†� agents, pose a r isk of torsades de point es and ext rapy ram idal side-effects as well a s the m ore rare neuroleptic m alignant sy ndrome. 1 7 2 5. Patient educat ion an d encoura gem ent in th e use of CPAP and m ana gem ent of associated adv erse effects improv es com pliance w ith 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 m onitoring tool but is not a substitut e for determ ining actu al oxy genat ion by m easur ing a rt erial blood gases. 1 7 28 . Th e char acteristic clinical features of interstitial lu ng disease ar e progressiv e dy spnea, diffuse radiogr aphic pulm ona ry 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 dia gnosis in
interstitial lun g disease. 1 7 3 0. Epoprostenol is first-line th erapy for patient s with sev ere pulm onar y hy pert ension, 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 hypertension 1 7 3 2 . Intu bated patients should receiv e a tra cheostom y as soon as it is deemed unlikely that they will wean from mechan ical v entilation within 2 1 day s. 1 7 33 . In patients with asthm a wh o 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 3 4. In selected imm un osuppressed patients with respira tory failur e, 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 th e presence of thr ee 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 gastr ointestinal telangiectasias, or ar teriov enous m alform ations in th e lung , liv er, or bra in; and (4) first-degr ee relat iv es wit h th e sy ndrome. 1 7 3 6. Th e propofol infusion sy ndrome in adults occur s prim ar ily in patients with acu te neurologic or acu te inflamm atory diseases com plicated by sev ere infection or sepsis, a nd r eceiv ing cat echolam ines an d/or cort icosteroids in a ddition to propofol. 1 7 3 7 . The m ain featu res of the propofol infusion sy ndrome are car diac failur e, rh abdom y 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 asth m a but wh o ha s episodic sy m ptom s 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 th e diagn osis of coug h-v ar iant 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 wh o hav e interm ittent sy mptoms should receiv e a short-acting bronch odilator. 1 7 44 . For patients with stage 3 COPD, especially those with frequent exacerbations, inhaled corticosteroids should be part of their regular therapy. 1 7 45. In the staging of patients with dy spnea for th erapy , th e post-bronch odilator FEV1 is m ost r elev ant 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 ona ry disease. 1 7 47 . Chronic obstr uct iv e pulm onar y disease is cort icosteroidinsensitiv e, an d inh aled 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 u sua 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 improv es 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 ha v e an a cut e exacerbation should be tr eated 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 pert ension an d is particularly preva lent in obese patients. 1 7 52 . Hy pert ension associated with sleep apnea m ay be relat ed to insulin r esistance, incr eased activity of the sy mpath etic 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 tr ansplanta 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 ch an ge disease is th e most com m on cau se of the
nephr otic sy ndrome in children a nd y oung adults. 1 7 55. Th e presence of num erous ov al fat bodies on u rin aly sis is a hallmark of a proteinuric state. 1 7 56. Decreased th resholds for a rg inine 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 a nd 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 . Henoch–Schönlein pur pura is a renal–derm al v ascu litis sy ndrome that m ay present with in term ittent episodes of m ild abdom inal pain. 1762. Patients with chronic kidney disease have increased risk for acu te rena l failur e becau se of their use of osm otic a gents 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 long er recomm ended to assess kidney function or quant ify proteinuria. 1767. Combination therapy with angiotensin-converting enzyme inh ibitors an d angiotensin r eceptor blockers m ay be more renoprotective th an single-agent th erapy with either dru g in patients with diabetic nephropathy. 1 7 68. An anti–glomerular basement m embrane antibody assay is indicated to diagnose Goodpastur e's sy ndr om e. 1 7 69 . In selected patients, am bulat ory 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 h orm one secretion (SIADH) is defined as hy potonic h y pona tr emia wit h a
ur ine osmolality m ore tha n 1 00 m osm/kg H2O in the absence of v olum e depletion, adrenal in sufficien cy , congestiv e h eart failure, hy pothy roidism , cir rh osis, and/or renal impairm ent. 1 7 7 1 . The classical triad of acute interstitial nephritis (fev er, skin rash, an d arth ralg ias) in th e setting of acute or subacute renal failur e is present in only a m inority of affected patients. 1772. The presence of a slowly progressive nephrotic syndrome suggests the possibility of solid tumor–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. A bdomina l CT or ultr asonogra phy are the recom mended ima ging m odalities for ur ic acid stones. 1 7 7 5. Patient s wit h 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 m L/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, am bulat ory blood pressure monitorin g can exclu de wh ite coat h y pert ension. 1 7 7 8. A mbulat 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 cau sed by a ch ronic condition. 1 7 80. Glom erulonephr itis, not preeclam psia, is the most likely diagnosis in patients with elev ated 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 th rombosis. 1 7 82 . CT, MRI, or v enogr aphy is indicated to definitiv ely diagnose rena l 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 erul osclerosis is the m ost com m on ca use of the nephrotic sy ndrome in black patients, part icula rly th ose 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 th rombotic 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 oxala te stones. 1 7 88. High-protein and -sodium diets can w orsen kidney stone disease by causing hy percalciur ia and h y peru ricosur ia. 1 7 89. A decrease in the bicarbonate lev el accom panied by an elev ated anion gap is consistent w ith a prim ar y m etabolic acidosis. 1 7 90. In a patient w ith a primar y m etabolic acidosis, a PCO2 th at is m uch hig her th an would be expected based on th e degr ee of acidemia in dicates a condition t ha t is secondar y to ina dequate v entila 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 an d end-stage r enal disease. 1 7 92 . Renal tr an splan tat ion is m ost beneficial in y oun g people and in patients with diabetes m ellitus. 1 7 93 . Hy pera ldosteronism should be considered in patients with difficult-to-contr ol h y pert ension an d 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 aldosterone–renin ra tio is a reasona ble screening study for primar y hy peraldosteronism . 1 7 96 . Rha bdom y oly sis-associated acute rena l failure presents with dipstick-positiv e hema tur ia but no inta ct ery th rocy tes on m icroscopic ana ly sis of the ur ine sediment. 1 7 97 . Heparin therapy inhibits aldosterone sy nth esis 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 w ith th e nephrotic sy ndrome ar e predisposed to dev elop deep v enous an d rena l v ein th rombosis. 1 801 . Stagh orn ca lculi form as a result of chr onic infections with ur ease-splitt ing org an isms such a s Proteus or Klebsiella. 1 802 . Stone rem ov al in struv ite stone disease often is indicated to
prev ent r ecur rence of infection an d stone gr owt h. 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 oalbu m in uria . 1 804 . Microalbum inu ria is the first clinical sign of diabetic nephropath y an d a ma jor r isk factor for t he dev elopment of clinical proteinu ria , ch ronic kidney disease progr ession, and ca rdiov ascular death. 1 805. Th e most com m 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 postopera tiv ely . 1 807 . Norm al saline (0.9%) is the m ost appropriate intrav enous fluid when flu id thera py is indicated in the postopera tiv e setting . 1 808. Sjögren's sy ndrome is a comm on cau se of interstitial nephritis. 1 809 . A collapsing form of focal segm ental glomeru losclerosis is the m ost likely diagnosis in black patient s with HIV in fection 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 wit h m ore th an 5 L of v olum e rem ov ed and in patients wit h sponta neous bacterial perit onitis. 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 oxa lat e stones because calciu m binds to ga strointestina l sour ces of oxala te an d th erefore pr ev 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 m edical 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 Patients with pheochromo pheochromocy cy toma toma should hould receiv receiv e an α-blocker 2 weeks before surgery. 1 81 8. β-Blo β-Blocka ckade de in th e absence absence of α -blocka blockade de is contr ain dicated dicat ed in patients patients with pheo pheochr omocy toma toma and m ay lead to hy pertensi pertensivv e crisis. 1819. The combination of upper and/or lower respiratory tract disease disease and proteinaseproteinase-33 an tinu clear cy toplasmic toplasmic ant ibody ibody positiv positiv ity at th e tim e of of diagnosis diagnosis is asso associated wit h the h ighest likelihoo likelihood of of relapsing disease disease in a ntin uclear cy toplasmic toplasmic ant ibody ibody –a ssociated sociated sma ll-v ll-v esse essell v asculitis. 1 82 0. Hy drochlo drochloro rothiazid thiazidee can ca use sev sev ere hy ponatr ponatr emia. 1 82 1 . Cry oglobulinemia globulinemia is char acterized acterized by Ray nau d's d's phenom phenom enon, enon, a pur puric r ash, abnorm al findings on liv er function studies, and the presence of glomerulonephritis. 1 82 2. Cry oglobulinemia globulinemia ty pically pically decreas decreases es the C4 lev lev el, which indicates activ ation of of the classical classical path wa y of com com plem plem ent activ ation, ation, m ore than th e C3 level. 1 82 3 . Renal Renal biops biopsyy is indicated fo for patients with acu te glomeru lonephrit lonephrit is of of unkn own cau se. se. 1 82 4. Pulmonar Pulmonar y hemorrha ge ass associated with acu te glomeru lonephrit lonephrit is is asso associated ciated with substan substan tial m orbidity and mortality. 1 82 5. A theroembo theroembolic lic diseas diseasee can m imic v asculitis asculitis. 1 82 6. The presence presence of of liv edo edo reticu lar is, is, Hollenhorst Hollenhorst plaque, cy anotic toe, toe, low C3 lev els, els, a nd peripheral eosi eosinop nophilia hilia suggests a diagnosis of atheroembolic disease. 1 82 7 . A ther oembolic embolic disease disease should should be suspe suspected cted in patient s with erosi erosivv e ath eroscle eroscleros rosis is presenting presenting wit h a cute r enal failu re. 1 82 8. Asym ptom ptom atic hy percalcemia percalcemia in a patient patient with a h isto istory ry of calcium stones tones war ran ts ev ev alua tion tion for for prim ary hyperparathyroidism. 1 82 9. Para th y roidecto roidectom m y should should be consid considered ered for for patients with calciu m -conta conta ining stones stones seco secondar ndar y to prim ar y hyperparathyroidism. 1 83 0. A lport lport 's sy sy ndrome cau ses ses persis persistent tent m icrosco icroscopic pic hema tu ria , progr progr essi essivv e nephritis wit h pr oteinur ia, a nd progr progr essi essivv e decline decline in renal function to end-stage renal disease. 1 83 1 . A lport's lport's sy ndrome ndrome is an inherited conditio condition n t hat m ay present present wit w ith h h ig h -frequ -fre quen ency cy sensori sen sorin n eur eu r a l h ear ea r in g loss an a n d/or ocula ocu la r
abnormalities. 1 83 2 . Iso Isotonic tonic saline is preferred preferred ov ov er bicar bonat bonat e-co e-conta nta ining solutions for resuscitation of patients with rhabdomyolysis. 1 83 3. In th e absence absence of of renal failure or flash flash pulmonary edema, edema, m edical edical ra th er tha n inv asiv e therapy is preferr preferr ed for for bloo blood press pressur ur e contr contr ol, ev en wh en renov ascular hy pert pert ensio ension is suspe suspected. cted. 1 83 4. Solut Solut e diur diur esis esis seco secondar ndar y to a high ur ea load load is a comm on cause of of hy perna perna trem ia in th e critical care setting. setting. 1 83 5. Simple cy sts disco discovv ered on rena l ima ging studies studies requir e no therapy. 1836. Complex renal cysts on ultrasonography require follow-up ima ging wit h CT or MRI MRI. 1 83 7 . Kidney Kidney biops biopsyy is contr contr aindicat ed in patients with complex rena l m asses asses suspicio suspicious us for for m align ancy . 1 83 8. A parapr otein asso associated with sy stem ic am y loido loidosi siss or or m ult iple m y elom elom a is a likely cau se of of th e nephr nephr otic sy ndrome in older patients. pat ients. 1 83 9. An giotens giotensinin-co conv nv erting enzy enzy me inhibitor inhibitor th erapy is wa w a r r a n t ed in i n pati pa tien entt s wit w ith h sta g e III III an d sta st a g e IV ch r onic oni c kidn ki dney ey disease disease un less less the cr eatinin e lev el rises >3 0% after in itiation of of therapy. 1 84 0. Once-daily Once-daily dosi dosing ng of ang iotensiniotensin-co conv nv erting enzy enzy m e inh ibitors ibitors can decrease th e risk risk for for h y perka perka lemia. 1 84 1 . Sar coido coidosi siss may cau se nephrolithiasis, nephrolithiasis, nephr ocalcin osis, sis, an d interstitial nephritis. 1842. Angiotensin-converting enzyme inhibitors or angiotensin receptor receptor blockers blockers ar e th e agent s of of choice fo for th e tr eatm ent of hy pert pert ensio ension in chr onic kidney disease disease.. 1 84 3 . An a nion gap metabolic metabolic acidosi acidosiss m ay be present present in a patient wit w ith h sev er e h y poalbu poal bum m in em ia a n d a â €œn orm a lâ € � anion gap. 1 844 . Renal Renal ultr asono asonogra gra phy can be norm norm al early in the cour cour se of of acute urina ry tra ct obs obstru tru ction. ction. 1 84 5. Urinar y tr act obstruct obstruct ion ion should should be suspe suspected cted in elderly elderly m en wit w ith h a cu t e r ena en a l fa f a ilu il u r e. 1846. IgA glomerulonephritis is manifested by the nephritic syndrome and is associated with dysmorphic erythrocytes and ery thr ocy te casts casts.. 1 84 7 . Diabetic ketoacido ketoacidosis sis can lead to an anion ga p metabolic acidosis and metabolic alkalosis simultaneously. 1 84 8. Iatr Iatr ogenic respira respira tory tory alka losis losis m ay dev dev elop elop after after initia tion tion of of
mechanical ventilation. 1849. Antihypertensive agents such as diuretics and β-blockers ha v e been been asso associated with an incr eased eased risk fo for t y pe 2 diabetes diabetes mellitus, whereas angiotensin-converting enzyme inhibitors and angiotensin receptor blockers may improve insulin sensitivity. 1 850. Risk isk factors fo for contr ast nephropath nephropath y inclu de diabetic diabetic nephr nephr opathy , dehy dehy dration, dration, heart failure, age more more than 7 0 y ears, impair ed kidney funct ion, ion, a nd concu concu rr ent use of of nephr nephr otoxic toxic dru gs and high-osmolar or high doses of radiocontrast medium. 1 851 . Prev ention ention of contr contr ast nephr nephr opathy in patients at incr eased eased risk for for th is conditio condition n inv olv es dis disco contin ntin uin g nephrotoxic nephrotoxic dr ug s, using th e lowest poss possible ible dose dose of of low low -osmolality smolalit y contr ast m edium for for the study study , and adm adm inistering inistering intr av enous enous therapy w ith 0.9% saline saline at 1 mL/kg/h mL/kg/h for for 24 hour hour s beginning beginning 1 2 hour hour s bef befoore administration administration of contr contr ast m edium edium . 1852. Myeloma-related kidney disorders should be suspected in patients patients with a nemia, a low low serum anion anion ga p, and renal failure. 1 853. A low low seru seru m a nion nion gap war ran ts ev aluat ion ion for for m y eloma eloma due to an inc rease in un m easured cations cations such such as calcium an d immunoglobulins. 1 854. My eloma eloma kidney kidney is ass associated with a dis discrepancy crepancy in proteinu proteinu ria detectio detection n betw een th e dipstick dipstick ur inal y sis and a spo spot ur ine collection. collection. 1 855. Math ema tical equat ions ions such such as Co Cockcr oft–Gau lt or or Modification Modification of Diet in Renal Disease Disease are ar e recomm ended fo for th e asses assesssment of glomeru glomeru lar filtration filtration rate r ather than 24 -hour hour ur ine collections or radioimaging studies. 1 856. Indiv iduals iduals with uncontrolled uncontrolled hy pertensi pertensioon a nd recur rent episo episodes of flash pu lm ona r y edem edem a sho sh oul d be scr scr eened for for renov ascular disease disease.. 1 857 . In In patients with suspe suspected cted renov renov ascular disease disease an d a glomeru glomeru lar filtration filtration ra te more more than 6 0 mL/min, ma gnetic resonan resonan ce angiograph y is th e imag ing study of choice choice to av oid the risk for for c ontr ast-induced ast-induced acut e renal failur e. 1 858. A low low glomeru glomeru lar filtration filtration rate is the ma in cau se of of phosp phospha ha te retention and hy perphos perphosphatem phatem ia in patients with chr onic kidney diseas disease. e. 1 859. Diur Diur etics etics are effe effectiv ctiv e antihy pertensive pertensive ag ents in in elderly elderly patients patients but m ay cause electro electroly ly te abnorm abnorm alities. alities. 1 86 0. Th e presentat presentat ion ion of anion anion g ap m etabolic etabolic acidosi acidosiss and
respira tory alka losis suggests salicy late toxicity . 1 86 1 . Im m obilization in the exagger ated lithotom y position can result in rh abdom y oly sis. 1 862 . An extremely elev ated creatine kinase lev el and eleva ted ur ine my oglobin lev el sug gest a diagn osis of pigm ent nephr opathy . 1 863 . Com bination thera py with an an giotensin-conv erting enzy m e inh ibitor and a n an giotensin r eceptor blocker is associated with decreasing proteinuria in patien ts wit h 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 th rocy tes on m icroscopic an aly sis of the urin e and no ev idence of proteinu ria . 1865. Patients with ethylene glycol poisoning presenting with both an incr eased anion and osm olar gap m etabolic a cidosis require dialy sis in a ddition t o eith er fom epizole or ethan ol. 1 86 6. Am y loidosis is a com m on ca use 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 out com es after treatm ent with angiotensin-conv ertin g enzy m e inhibitor th erapy com pared with am lodipine or β-blockers. 1 86 9. In pregn anc y , la betalol is preferable to pur e β-blockers, which m ay be a ssociated w it h 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 durin g m etabolic acidosis. 1 87 2 . Alport 's sy ndrome is associated with a glomeru lonephrit is with dy smorph ic ery throcy tes, m ild pr oteinuria , and a high-frequency hearing loss. 1 87 3. Wegener's gran ulom atosis is char acterized by upper an d lower air wa y disease, gl om erul onephrit is, an d positiv e findings on a proteinase-3 a ntin 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 sug gests m ult iple myeloma. 1 87 5. Microscopic poly ang iitis is a nongr anu lom atous or sma ll-
v essel v ascu litis occasiona lly accompanied by m ediu m -sized v essel inv olv ement that causes a pulm onar y –renal syn drome. 1 87 6. Renal tr ansplant recipients who are Epstein–Barr v ir us–negativ e are at in cr eased risk for post-tr anspla nt lymphoproliferative disorder, especially after receiving an organ from an Epstein–Bar r v iru s–positiv e donor. 1 87 7 . One of the m ost im porta nt initial steps in th e eva luation of m icroscopic hemat ur ia is urine m icroscopy to assess ery th rocy 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. Lower ing blood pressure to appropria te tar gets is par ticu lar ly import ant in patients wit h diabetes wh o ha v e increased risk for cardiovascular and renal complications. 1 881 . Diuretics potentia te th e blood pressur e–lower ing effects of ang iotensin-conv erting enzy m e inh ibitors a nd β-blockers. 1 882 . Postinfectious glom erulonephr itis may present 3 weeks after onset of the in citing infection and is associated w ith low C3 lev els and norm al C4 lev els. 1 883 . Respiratory alka losis com m only dev elops in end-stage liv er disease. 1 884 . The r efeeding sy ndrome is a potentia l com plication in m aln our ished patients wh o suddenly receiv e a larg e calorie load. 1 885. Rha bdom y oly sis is a potentia lly sev ere com plication of the refeeding sy ndrome. 1 886 . The an tiphospholipid antibody sy ndrome is cha ra cterized by thr om bosis in association wit h a lu pus anticoagu lant or persistently elevated levels of anticardiolipin antibodies. 1 887 . A peritoneal fluid cell count more than 1 00 total nu cleated cells/µ L is abnorm al and consistent wit h th e diagnosis of peritonitis. 1 888. An tibiotic therapy covering both gr am -negativ e and gr am -positiv e path ogens should be start ed im m ediately in a pat ient with suspect ed per itonea l dia ly sis– related per itonitis. 1 889 . Acu te tubul ar n ecrosis is th e most com m on cau se of acute rena l 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 ar m s to preserv e v eins for fut ur e creation of
ar teriov enous fistul as. 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 ar teriov enous 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 non–an ion g ap m etabolic acidosis. 1 89 6. In addition to cort icosteroids, t he m ost a ppropria te tr eatm ent for lupus nephritis is intravenous cyclophosphamide followed by m aint enan ce my cophenolate m ofetil once rem ission is achiev ed. 1 89 7 . Infusion of norm al saline before a nd after exposure to ra diocontr ast 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 ceou s nodul es on t he trunk, proxim al extr em ities, 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 adult s 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 ur ine sedim ent. 1901. Hospitalization and delivery are indicated for women with preeclampsia at term. 1 90 2 . Th e ma nifestat ions of the HELLP sy ndrome (hem oly sis, elev ated liv er enzy m es, an d low plat elets) ar e featur es of sev ere preeclampsia. Posted by dokidok at 2:1 0 PM Labels: step 3
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