EYE/CREW Flashcards

Question

Pulmonary embolism treatment

Answer 1

1. Anticoagulation therapy is initiated; heparin is the anticoagulant of choice. Low-molecular-weight heparin or warfarin is continued after the acute phase 2. Duration of therapy depends on the clinical situation. A minimum of 3 months is advised 3. Vena cava interruption (filter) is helpful in patients at high risk of recurrence who are unable to tolerate anticoagulants

Answer 2

1. Treatment of primary pulmonary hypertension may include chronic oral anticoagulants (warfarin), CCBs to lower systemic arterial pressure, and prostacyclin (a potent pulmonary vasodilator). Despite these measures, heart-lung transplantation is usually required. 2. Treatment of secondary pulmonary HTN consists of treating the underlying disorder in addition to those treatments mentioned earlier.

Answer 3

1. Management is primarily supportive as no effective treatment is available. Supportive therapy includes oxygen, vaccinations (pneumococcal, influenza vaccine) and rehabilitation 2. Corticosteroids may relieve the chronic alveolitis in silicosis 3. Smoking cessation is especially important for patients with abestosis, because smoking interferes with short abestos fiber clearance from the lung. Smoking and abestos are synergistically linked to lung cancer, especially mesothelioma

Answer 4

Approximately 90% of cases are responsive to corticosteroids and can be controlled with modest maintenance doses

Answer 5

1. All patients require a CBC, blood type and cross-match, and coagulation parameters 2. Electrolytes, glucose, urinalysis, and serum creatinine will aid in determining the type of shock 3. Pulse oximetry or serial arterial blood gases are needed to monitor oxygenation 4. ECG and cardiac biomarkers (troponins, BNP, NT-proBNP) may be useful 5. Lactate levels can assist in identifying shock as well as monitoring treatment

Answer 6

1. The first step in treatment is attention to basic life support (airway, breathing, circulation) 2. Specific treatments depend on the cause of shock 3. The Trendelenberg or supine position with legs elevated may maximize blood flow to the brain 4. Oxygen and IV fluids are essential 5. Urine flow should be monitored via indwelling catheter and sustained at 0.5 mL/kg/hr or more 6. Continuous cardiac monitoring 7. Inotropes (i.e., dobutamine, dopamine, epinephrine) to increase CO 8. Pressors (i.e., dopamine, phenylephrine) improve pressure by increasing vascular tone

Answer 7

1. ACE-I or ARB 2. Beta blocker (Metoprolol ER, Carvedilol, Bisoprolol) 3. Spironolactone-for class 3 and class 4 HF 4. +/- Lasix (furosemide) for symptom relief 5. +/- nitrate, digoxin (doesn't decrease mortality) 6. CCB, preferably amlodipine, are used only to treat associated angina or HTN

Answer 8

Includes three or more of the following: - Abdominal obesity - Triglycerides greater than 150 mg/dL - HDL less than 40 mg/dL for men and less than 50 mg/dL for women - Fasting glucose greater than 110 mg/dL - HTN

Answer 9

1. Angina at rest 2. New onset of angina symptoms 3. Increasing pattern of pain in previously stable patients - UA is suspected when the pain is less responsive to NTG, lasts longer, and occurs at rest or with less exertion than previous episodes of angina

Answer 10

- ASA and clopidogrel should be given at once - Immediate (within 90 minutes) coronary angiography and primary PCI are superior to thrombolysis - Thrombolytic therapy (alteplase, reteplase, and tenecteplase) must be given within the first 3 hours

Answer 11

1. In the presence of hemodynamic compromise, pericardiocentesis is necessary to relieve fluid accumulation. Recurrent effusions may be treated surgically with a pericardial window 2. Strictly inflammatory conditions may be treated with steroids or NSAIDs 3. Infectious conditions require antibiotic therapy only if bacterial infection is suspected 4. Pericardectomy may be performed to relieve constrictive pericarditis

Answer 12

1. Empiric antibiotic treatment (gentamicin with ceftriaxone or vancomycin) 2. Antibiotic prophylaxis to prevent endocarditis is recommended before invasive dental work or surgical procedures in patients with prosthetic valves, previous IE, some congenital heart conditions, some acquired valve disorders, hypertrophic cardiomyopathy, and cardiac transplant recipients with valvulopathy. Amoxicillin is the usual DOC 3. Valve replacement may be needed 4. Anticoagulants are not beneficial with native valve infection and are controversial in patients with prosthetic valves

Answer 13

1. Strict bed rest is essential until the patient is stable 2. IM penicillin is used for documented streptococcal infection; in patients who are allergic to penicillin, erythromycin is appropriate 3. Salicylates reduce fever and relieve joint problems; corticosteroids relieve joint symptoms but do not prevent cardiac disease

Answer 14

1. Aggressive risk factor modification 2. BB, ACEI, statins, progressive exercise, and supervised exercise programs have been shown to be helpful at reducing symptoms of claudication 3. Antiplatelet therapy, with ASA and/or clopidogrel, should be used routinely in all patients without a contraindication. 4. Symptom relief can be achieved with the addition of cilostazol

Answer 15

1. It is usually treated with bed rest, local heat, elevation of the extremity, and NSAIDs 2. Antibiotics may be required if evidence of infection exists. 3. More serious disease may require surgical intervention

Answer 16

Anticoagulation with enoxaparin (LMW heparin) or unfractioned heparin followed by warfarin

Answer 17

1. General therapeutic measures include elevation of the legs, avoidance of extended sitting or standing, and compression hose 2. Stasis dermatitis should be treated with wet compresses and hydrocortisone cream; chronic dermatitis may require addition of zinc oxide with ichthammol and an antifungal cream 3. Ulcerations may be treated with wet compresses, compression boots or stockings, and occasionally skin grafting

Answer 18

Hemoglobin electrophoresis with quantification of HgbA2 and F (this will aid in the diagnosis of thalessemia)

Answer 19

1. Patients with mild disease should not receive iron if ferritin is normal because of the risk of iron overload 2. Persons with Hgb H disease (persons with one alpha-globin chain) need folic acid supplements and should avoid iron supplements and oxidative drugs 3. Treatment for beta-thalessemia major consists of transfusions 4. Allogeneic bone marrow transplantation also is used with increasing success; splenectomy may also be required 5. Genetic counseling

Answer 20

Parenteral deferoxamine or oral deferasirox

Answer 21

- Plasma ferritin level (will be decreased) - Serum iron (decreased) and TIBC (increased) - Transferrin saturation (decreased)

Answer 22

1. Ferrous sulfate, 325mg TID. Best absorbed on an empty stomach. Vitamin C may enhance absorption 2. Therapy should be continued for 6 months or longer 3. Iron supplementation during pregnancy and lactation is essential

Answer 23

1. Chelation therapy is needed for symptomatic lead toxicity | 2. Transfusion may also be required if the patient is symptomatic

Answer 24

1. Symptomatic treatment of pain episodes includes administration of analgesics, hypotonic fluids, and rest 2. Stroke, sequestration, acute chest syndrome, and multiorgan failure may require transfusion or exchange transfusion 3. Patients should receive low-dose daily penicillin from birth until age 6 years, pneumococcal vaccine (booster vaccine every 10 years), transcranial doppler (TCD) screening for stroke prevention, pulmonary function testing (PFT) for restrictive disease screening, and chronic folate supplementation 4. Daily lifelong oral hydroxyurea therapy should be considered for all SS and S beta 0 thalessemia patients as young as 1 year old to increase Hgb F production, prevent complications, and increase lifespan 5. Genetic counseling

Answer 25

1. In most cases, hemolytic episodes are self-limited as red cells are replaced as soon as the offending agent is stopped 2. Oxidative drugs and fava beans should be avoided

Answer 26

1 Phlebotomy is the treatment of choice 2. Myelosuppressive therapy with hydroxyurea may be indicated 3. Low-dose ASA reduces the risk of thrombosis

Answer 27

1. CBC reveals panocytopenia with circulating blasts 2. Bone marrow biopsy 3. Hyperuricemia may be present 4 Auer rods can be seen in AML 5. Terminal deoxynucleotidyl transferase is diagnostic for ALL 6. Cytogenic studies are the most powerful prognostic factors

Answer 28

1. Induction (remission-inducing) chemotherapy 2. Consolidation therapy 3. Allopurinol and diuretics to help prevent uric acid stones

Answer 29

1. Imatinib mesylate (Gleevec) is standard therapy. It is very effective during the chronic phase 2. Allogeneic bone marrow transplantation may be the initial treatment and is the only therapy proven to be curative. This is reserved for patients with severe disease, which progresses after the initial treatment

Answer 30

Treatment of CLL usually is palliative once the disease is advanced

Answer 31

Epstein-barr virus; Reed-Sternberg cells

Answer 32

Protein S, protein C, antithrombin III assay, factor V Leiden assay, fasting homocysteine level, anticardiolipin antibodies, prothrombin 20210 mutation test, fibrinogen level and HIT assay

Answer 33

1. Endoscopy in patients with CMV or HIV reveals large, deep ulcers. Infection with HSV is characterized by multiple shallow ulcers. Candidal infection shows white plaques 2. Cytology or culture from endoscopic brushings is needed for definitive diagnosis 3. Evaluate for underlying immunodeficiency

Answer 34

1. Treatment is specific to the type of infection 2. Fluconazole or ketoconazole for Candida sp. 3. Acyclovir for HSV 4. IV ganciclovir for CMV; foscarnet is indicated in cases of poor tolerability or poor response 5. Treatment of the underlying immunodeficiency, where possible, will aid in both resolution and prevention of esophageal infection. Consider HIV testing

Answer 35

1. Biphasic barium esophagram is the best initial test to visualize the lesion 2. Endoscopy with brushings is used for diagnosis 3. Endoscopic sonography and CT may be used for staging

Answer 36

1. Treatment of esophageal cancer is generally surgical. Radiotherapy and adjunctive chemotherapy have been used in various combinations with or without surgery

Answer 37

Duodenal ulcer; with a gastric ulcer, the pain typically worsens, which leads to anorexia and associated weight loss.

Answer 38

1. Combination therapy for H. pylori regimen should be taken for 2-4 weeks. Options include the following: a. PPI with clarithromycin and amoxicillin or clarithromycin and addition of metronidazole b. Bismuth subsalicylate plus tetracycline, metronidazole, and PPI

Answer 39

1. A fasting gastrin level greater than 150 pg/mL indicates hypergasrinemia 2. A secretin test is needed to confirm the presence of ZES (it will show levels greater than 200 pg/mL) 3. Endoscopy,CT, or MRI may help to localize the tumor

Answer 40

1. Use of PPIs controls gastrin secretion | 2. Surgical resection of the gastrinoma should be attempted when possible

Answer 41

1. Treatment include NPO, nasogastric suctioning, IV fluids, and monitoring 2. Partial obstruction in a hemodynamically stable patient may be managed with IV hydration and nasogastric decompression 3. Urgent surgical consultation is necessary when mechanical obstruction is suspected, especially of the large bowel 4. Pain management is necessary for patients with bowel obstruction

Answer 42

1. Endoscopic decompression is possible in many cases | 2. Surgical evaluation and treatment is required urgently if volvulus fails to quickly resolve by nonsurgical means

Answer 43

1. IgA antiendomysial (EMA) and antitissue transglutaminase (anti-tTG) antibodies are the serologic screening tests 2. Small bowel biopsy is needed to confirm the diagnosis

Answer 44

1. For acute attacks, oral corticosteroids (prednisone) are used with or without aminosalicylates (sulfasalazine). Metronidazole or cipro is added in perianal disease, fissures, or fistulae. Infliximab may be used in refractory cases 2. Elemental diet is nearly as effective as corticosteroids, but relapse is more likely 3. Mesalamine is generally the best option for maintenance therapy 4. Smoking cessation, supplements

Answer 45

1. Topical or oral aminosalicylates (mesalamine) and corticosteroids are the mainstays of medical treatment. Immunomodulators are indicated for refractory disease 2. Surgery can be curative in UC.

Answer 46

1. Occult blood in the stool and mild to moderate leukocytosis may occur with diverticulitis 2. Plain-film radiography should be done to r/o free air 3. CT is warranted if patients do not respond to therapy 4. Barium enema should be avoided during an acute episode

Answer 47

1. Low-residue diet and broad-spectrum antibiotics (Cipro + Flagyl) are appropriate for patients with mild diverticulitis 2. Hospitalization for IV administration of antibiotics, bowel rest, and analgesics often is required. A nasogastric tube is inserted if ileus develops 3. Surgical management may be necessary in severe cases, including peritonitis, large abscesses, fistulae, or obstruction 4. Patients with diverticulosis should maintain a high-fiber diet to prevent diverticulitis. Evidence has negated the need to recommend avoidance of nuts, seeds, and popcorn

Answer 48

1. Plain-film radiography and CT are performed to rule out other causes of abdominal pain or to show areas of dilation or edema 2. All patients should have duplex ultrasound of the mesenteric arteries, which may be confirmed by angiography

Answer 49

Surgical revascularization. Hydration is also a critical factor

Answer 50

1. Decompression of the colon is required. In some cases, colostomy or even complete colonic resection may be required 2. Careful attention must be paid to fluid and electrolyte balance

Answer 51

1. RUQ U/S will generally show biliary dilation or stones and is a good initial test 2. Leukocytosis with left shift along with increased bilirubin and mildly increased transaminase levels support the diagnosis 3. ERCP is the optimal procedure for both diagnosis and treatment but, unless urgent decompression is necessary, should not be done until the patient is stable

Answer 52

1. Antibiotics (Ceftriaxone + Metronidazole), fluid and electrolyte replacement, and analgesia are the initial treatment 2. ERCP can be done once the patient is stable. Percutaneous biliary drainage or surgical biliary drainage may be required 3. Cholecystectomy should be performed after the acute syndrome is resolved

Answer 53

1. Localized strictures may be relieved with balloon dilation and stent placement. Long-term stenting increases risk of cholangitis 2. Liver transplant is the only treatment with a known survival benefit

Answer 54

1. First detectable marker 2. Hallmark of active infection 3. HBsAg >6 months =chronic infection

Answer 55

1. Synonymous with HBsAb | 2. Signifies recover and immunity (either by past infection or vaccination)

Answer 56

1. IgM anti-HBc: Indicates acute or recent infection | 2. IgG anti-HBc: Indicates prior or resolving infection; persists indefinitely

Answer 57

Used as an index of infectivity

Answer 58

1. Indicates lower levels of HBV DNA

Answer 59

Tenofovir with either emtricitabine or lamivudine

Answer 60

Cefotaxime

Answer 61

1. Antistreptolysin-O titer is increased and should be considered if there is a possibility of a recent streptococcal infection 2. UA reveals hematuria, RBC casts, and proteinuria 3. Serum complement (C3) levels are often decreased 4. Renal biopsy may be done to determine the exact diagnosis or severity of disease

Answer 62

1. Steroids and immunosuppressive drugs (cyclophosphamide) may be used to control the inflammatory response, which is responsible for the damage. These are usually not needed in PSGN 2. Dietary management: Salt and fluid intake should be decreased 3. Dialysis should be performed if symptomatic azotemia is present 4. Medical therapy: ACEI in chronic GN

Answer 63

1. Neurogenic or central DI is best treated with parenteral or intrasnasal desmopressin 2. Diuretics, chlorpropamide, or carbamazepine can be used in patients with mild disease 3. Nephrogenic diabetes can be treated with HCTZ or amiloride diuretics or indomethacin. Adequate water intake is essential to prevent dehydration 4. Dietary measures, such as limiting salt and protein intake, can be helpful in nephrogenic DI

Answer 64

1. CBC and blood chemistry should be done to evaluate for infection and renal function 2. Cystoscopy is the definitive diagnostic procedure. Biopsy confirms the pathologic diagnosis 3. Radiologic procedures include IV urogram, pelvic and abdominal CT, chest radiography, bone scan, and retrograde pyelography for renal pelvic or ureteral tumors and staging

Answer 65

1. CBC, urinalysis, lipid profile, thyroid function tests, serum testosterone, glucose, and prolactin screening should be done, depending on the suspected cause 2. Measurement of FSH and LH may be required for patients with abnormalities of testosterone or prolactin 3. Nocturnal penile tumescence testing 4. Direct injections of vasoactive substances

Answer 66

1. First line test is beta-hCG for pregnancy, TSH, and prolactin 2. Serum FSH, estrogen, LH, and testosterone levels 3. Progesterone challenge test 4. Other tests: thyroid studies, MRI or CT of the hypothalamus and pituitary or pelvis, genetic testing, and pelvic and transvaginal ultrasonography

Answer 67

1. Tests include daily charting of symptoms, the specific constellation of symptoms is less important than their cyclical pattern of occurrence 2. Thyroid studies and CBC are used to r/o thyroid disease and anemia

Answer 68

1. Pyridoxine (vitamin B6) and evening primrose oil show no benefit but do relieve breast tenderness and depression in some women 2. +/- OCP 3. Diuretics (e.g., spironolactone) may be useful for fluid retention symptoms; bromocriptine may help relieve mastalgia 4. NSAIDs for pain 5. SSRIs have proven to be beneficial in some patients

Answer 69

FSH > 30 mIU/mL

Answer 70

1. Urinary beta-hCG levels 2. CBC, possibly iron studies, PT and PTT, documentation of ovulation, TSH, serum progesterone levels, LFTs, and prolactin and serum FSH levels are needed

Answer 71

1. Observation is recommended in most cases of leiomyomata 2. Symptomatic patients may undergo myomectomy, hysterectomy, or D&C 3. GnRH agonists (depot leuprolide) and mifepristone may reduce tumor size; in women with small leiomyomata, GnRH agonists may restore fertility. Treatment is limited to 6 months 4. Use of uterine arterial embolization or endometrial ablation as a treatment for fibroid is increasing for women who have no desire of future fertility 5. Hysterectomy is the final step

Answer 72

1. Women with postmenopausal bleeding should have a Pap smear, endocervical curettage, and endometrial biopsy 2. Other tests include fractional D&C and transvaginal ultrasonography

Answer 73

1. Total hysterectomy combined with bilateral salpingo-oophorectomy is the basis of treatment and staging 2. Radiotherapy may be indicated. Chemotherapy is used at advanced stages 3. Recurrence is treated with high-dose progestins or antiestrogens

Answer 74

Ultrasonography and laparoscopy

Answer 75

1. It is based on the severity of symptoms, location and severity of disease, and desire for childbearing 2. In women with few symptoms, expectant management may suffice 3. NSAIDs and prostaglandin synthetase inhibitors may relieve discomfort 4. Combined OCPs or progestins (SQ DMPA) may relieve symptoms 5. Surgery may be conservative or definitive; large endometriomas must be resected 6. Treatment with danazol or GnRH agonist around surgery improves fertility

Answer 76

1. Pelvic ultrasonography must detect adenomyosis 2. Pregnancy should be ruled out 3. Endometrial biopsy, fractional D&C, or hysteroscopy in a patient with suspected adenomyosis will r/o endometrial cancer

Answer 77

1. May be treated with D&C, a GnRH agonist (Leuprorelin), or mifepristone; hysterectomy is the definitive therapy 2. Hormonal therapy has not been successful

Answer 78

1. Nonsurgical approaches include weight reduction, smoking cessation, pelvic muscle exercises, and use of a vaginal pessary 2. Surgical treatment relieves symptoms, restores normal anatomic relationships and visceral function, and allows coitus

Answer 79

Pelvic ultrasound

Answer 80

1. Follow for one or two cycles in premenopausal women with cysts smaller than 8 cm 2. Large or persistent cysts require laparoscopic evaluation 3. Cysts in postmenopausal women are presumed to be malignant until proven otherwise 4. OCPs have not been proven in treating functional cysts

Answer 81

1. U/S may demonstrate a characteristic "string of pearls" or "oyster ovaries" appearance within the ovaries 2. Labs reveal mildly elevated serum androgen levels, increased LH/FSH ratio, lipid abnormalities, and insulin resistance

Answer 82

1. Weight reduction improves hirsutism, lipid and glucose parameters, and infertility 2. Hirsutism is treated with androgen-lowering agents, including OCPs 3. Infertility is usually treated with clomiphene citrate 4. Lipid abnormalities and insulin resistance should be managed medically. Adding metformin increases ovulation and pregnancy rates

Answer 83

1. The BRCA1 gene testing; CA-125 may be used to follow treatment, particularly in postmenopausal women 2. An association exists with mutations in the P53 tumor suppression gene 3. Transvaginal or abdominal U/S is useful in distinguishing benigns from potentially malignant masses

Answer 84

1. Mild lesions may resolve spontaneously 2. Preinvasive neoplasia may be treated with electrocautery or cryocautery, laser therapy, conization, large loop excision of transitional zonem or LEEP 3. Hysterectomy and pelvic lymphadenectomy or radiation therapy is indicated for more severe abnormalities

Answer 85

1. Application of acetic acid or staining with toluidine blue may help to direct biopsies of suspicious vulvar lesions 2. Vaginal biopsy for suspected vaginal invasive neoplasm should be directed by colposcopy or Lugol staining 3. Clear cell adenocarcinoma is diagnosed by careful inspection and palpation of the vagina and cervix

Answer 86

1. Local excision, topical 5-FU, and laser therapy are used for early vulvar lesions 2. Surgical excision is required for most vaginal neoplasms; primary vaginal cancer is treated with radiotherapy 3. For clear cell lesions, radical hysterectomy and vaginectomy or radiation therapy is effective

Answer 87

1. Antibiotics (cloxacillin, dicloxacillin, or nafcillin) or a cephalosporin and hot compresses. Breast-feeding may continue because the source is likely to be infant's oropharynx 2. Surgical treatment may be required for abscesses or duct ectasia

Answer 88

1. Many types of fibrocystic breast problems need no treatment other than a supportive bra 2. Some patients respond to low-salt diet, vitamin E supplementation, or HCTZ premenstrually

Answer 89

1. DNA probes for gonorrhea and chlamydia (most common cause of PID) have largely replaced Gram staining and culture of any discharge 2. Transvaginal ultrasonography is helpful in differentiating acute and chronic inflammation or the presence of adnexal masses 3. Diagnostic culdocentesis or laparoscopy may be required

Answer 90

1. Women with mild disease can be treated as outpatients with antibiotics, analgesics, and bed rest. If present, an IUD should be removed 2. Women with severe disease should be hospitalized for IV antibiotic therapy and possible surgery 3. Sex partners should be evaluated and treated

Answer 91

1. Serum levels of hCG normally double every 48 hours. If serial increases of hCG are less than expected, ectopic gestation should be suspected until the diagnosis has been definitively excluded 2. Transvaginal ultrasonography is diagnostic in 90% of cases of ectopic gestation 3. Women with hCG titer of greater than 1500 mU/mL should show evidence of a developing intrauterine gestation on transvaginal ultrasound. If no such evidence is found, ectopic pregnancy is the clinical diagnosis

Answer 92

1. Medical treatment with methotrexate can be used to treat up to 80% of ectopic gestations when diagnosed early. 2. Surgical treatment involves removal of the ectopic gestation most commonly via laparoscopy. Laparotomy usually is reserved for patients with known significant abdominal adhesions or those who are clinically unstable 3. F/up testing using serum hCG levels or pelvic examination is crucial to exclude any remaining evidence of pregnancy

Answer 93

1. Serum hCG titer of less than 5000 mU | 2. Ectopic mass

Answer 94

1. With complete molar pregnancy, the hCG level is often greater than 100,000 mU/mL.Persistently elevated levels of hCG may indicate gestational trophoblastic tumor 2. U/S of a complete hydatidiform mole shows a characteristic "grapelike vesicles" or "snowstorm" appearance consistent with the swelling of the chorionic villi. It may also aid in the diagnosis of a partial mole pregnancy

Answer 95

1. Treatment depends on tumor classification. Benign tumors and low-risk metastatic tumors can be treated with chemotherapy. Metastatic high-risk tumors require a combination of chemotherapy with or without adjuvant radiation and surgery 2. Surgical treatment includes suction curettage and hysterectomy 3. After evacuation, patients must be monitored with serial hCG to assure return to baseline and to diagnose and manage sequelae properly. Contraception is recommended for 6-12 months after remission

Answer 96

1. Screening consists of administering a nonfasting 50 g glucose challenge test, followed by a serum glucose test 1 hour later. If the one hour serum glucose value is greater than 130 mg/dL, a 3 hour glucose tolerance test is performed 2. The 3 hour glucose tolerance test consists of a 100 g glucose load in the morning after an overnight fast . Serum glucose levels are taken at fasting and then at 1, 2, and 3 hours after the glucose load. If two or more of the values are abnormal then the patient is diagnosed with gestational diabetes (see pg. 170 for values)

Answer 97

1. Synovial fluid should be collected | 2. Radiographs usually only show soft-tissue swelling

Answer 98

1. Aggressive treatment with IV antibiotics for 2 weeks is required. Ceftriaxone is recommended for empiric treatment 2. Athrotomy and arthrocentesis often are required 3. Oral antibiotics should follow the IV antibiotics for up to an additional 4 week

Answer 99

1. ESR is elevated; nomocytic nomochromic anemia is seen 2. Hyperuricemia may occur when skin involvement is severe 3. RF is normal 4. "Pencil in cup" deformities of the proximal phalanx are demonstrated on radiography

Answer 100

NSAIDs for mild cases; methotrexate

Answer 101

1. HLA-B27 2. Synovial fluid is usually culture negative 3. Evidence of permanent and progressive joint disease may be present on radiography

Answer 102

1. Physical therapy and NSAIDs are the mainstay of treatment 2. Antibiotics given at the time of infection will reduce the chance of developing the disorder but do not alleviate the symptoms of the reactive arthritis

Answer 103

1. CBC, CMP, urinalysis, ESR, and serum complement (C3 or C4) 2. Antibodies to smith antigen, double stranded DNA, or depressed levels of serum complement may be used as markers for progression of the disease 3. ANA is present

Answer 104

1. Regular exercise and sun protection are important for all patients 2. NSAIDs are often used for musculoskeletal complaints 3. Antimalarials (hydroxychloroquine) may be used for musculoskeletal complaints and cutaneous manifestations 4. Corticosteroids 5. Methotrexate is used at low doses

Answer 105

1. Creatinine phosphokinase (CPK) and aldolase will be elevated 2. Muscle biopsy should be performed

Answer 106

1. Treated with high dose steroids, methotrexate, or azathioprine until symptoms resolve

Answer 107

1. Patients respond quickly to low-dose corticosteroid therapy, which may be required for up to 2 years and slowly tapered 2. Higher doses are required if giant cell arteritis is present; treatment should not be delayed while awaiting biopsy

Answer 108

1. The diagnosis is usually established by vessel biopsy or angiography 2. Elevated ESR and CRP and proteinuria may be present as well as a positive hepatitis B surface antigen (HBsAg) 4. Presence of ANCA is suggestive but not diagnostic

Answer 109

1. Initial treatment is with high doses of corticosteroids 2. Cytotoxic drugs and immunotherapy (azathioprine or methotrexate) also may be used. Concomitant treatment of hepatitis B may be required. 3. HTN should be treated if present

Answer 110

1. ANA is present in 90% of patients with diffuse scleroderma 2. Anticentromere antibody is associated with CREST syndrome and anti-SCL-70 antibody is associated with diffuse disease 3. Patients should be monitored for the development of HTN, heralding kidney involvement

Answer 111

1. There is no cure 2. Treatment is aimed at organ-specific disease processes (i.e., PPIs for reflux disease, ACEI for renal disease, avoidance of triggers and CCBs for Raynaud, and immunosuppressive drugs for pulmonary HTN)

Answer 112

1. RF, ANA, anti-Ro antibodies, and anti-La antibodies | 2. Schirmer test (evaluates tear secretions by the lacrimal glands. Wetting of

Answer 113

1. Mainly symptomatic. This can be achieved by using artificial tears and saliva, increased oral fluid intake, and ocular and vaginal lubricants 2. Pilocarpine may increase saliva flow 3. Cyclosporine may improve ocular symptoms

Answer 114

1. It is recognized by the typical pattern of pain and other symptoms as well as by the exclusion of contributory or underlying diseases such as hypothyroidism, hepatitis C, and vitamin D deficiency 2. There are no routine lab markers; it is often a diagnosis of exclusion

Answer 115

1. SSRIs, SNRIs, and TCAs (amitriptyline) are helpful; NSAIDs are not 2. Pregabalin (Lyrica) is the only drug that is FDA-approved for the treatment of fibromyalgia. Side effects include fatigue, trouble concentrating, sleepiness, and edema 3. Aerobic exercise improves conditioning and has been shown to improve functioning as long as overtraining is avoided 4. Patient education, stress reduction, sleep assistance, and treatment of psychological problems may alleviate some of the symptoms

Answer 116

1. Ice, rest, stretching may help to alleviate inflammation 2. NSAIDs may alleviate pain but do not penetrate the tendon circulation adequately. An injection with corticosteroids combined with anesthesia and administered alongside the tendon may be beneficial

Answer 117

Prevention of precipitating factors, rest, NSAIDs, and steroid injections

Answer 118

1. CBC, CRP, and ESR 2. Identification of the infectious organism by blood culture or bone biopsy is best 3. Radiographic evidence of osteomyelitis lags behind symptoms and pathologic changes by 7-10 days. U/S can be useful for early detection of acute osteomyelitis 4. MRI shows the changes before plain-film radiography or bone scan

Answer 119

1. Acute osteomyelitis is treated with a 6- to 8-week course of IV antibiotics (vancomycin + cipro) 2. Chronic osteomyelitis is treated with a minimum of 4 weeks to 24 months of IV and po antibiotics 3. Immobilization and surgical drainage may be indicated 4. Surgical debridement may be required

Answer 120

1. AP and lateral films 2. Radionucleotide bone scanning shows increased uptake at the site of an occult fracture or stress fracture 3. CT is a better diagnostic method than plain-film radiography or bone scans 4. MRI is the study of choice to diagnose an occult hip fracture

Answer 121

Analgesics, immobilization, and emergent referral to an orthopaedist

Answer 122

1. Any bleeding fracture should be considered an open fracture until proven otherwise 2. Ideally, they must be debrided and irrigated within 4-8 hrs of injury 3. IV antibiotics (gentamicin) should be administered for 48 hours after fracture and for 48 hours after surgical procedures 4. Immobilization and fixation should be performed to preserve function

Answer 123

1. Open treatment may be indicated to restore and maintain articular congruity 2. When stable, consider active ROM

Answer 124

1. Treat femoral neck fractures with percutaneous screws or hemiarthroplasty, femoral shift fractures with intramedullary rods or plates, and intertrochanteric fractures with sliding hip screw fixation or a long gamma nail 3. There is significant potential for hemorrhage with fractures of the femur

Answer 125

1. Fractures of the tibia and fibula are associated with ligamental, meniscal, and vascular injuries 2. For simple fractures, closed reduction with cast placement is appropriate; for more complicated or unstable fractures, ORIF is required

Answer 126

1. After assessment of the neurovascular status, most dislocations are treated with closed reduction 2. Dislocations that reduce spontaneously require immobilizations for 2-4 weeks, followed by ROM activity and return to normal activity 3. If associated fractures or interposed soft tissues are present, the patient needs to undergo ORIF 4. It is imperative to assess the neurovascular status pre- and postreduction as well as get postreduction radiographs to ensure adequate reduction

Answer 127

Both strains and sprains require supportive therapy: rest, ice, compression, elevation, and support/bracing (RICES)

Answer 128

1. Suggestion of conservative lifestyle changes and behavior modification can be helpful

Answer 129

1. Conservative treatment involves the use of a cervical collar, traction, physical therapy, and analgesics 2. In advanced disease, cervical fusion or diskectomy may be necessary

Answer 130

1. Radiographs are useful in ruling out calcific tendinitis, glenohumeral or acromioclavicular arthrosis, and bone tumors 2. Arthrography or MRI can be used to diagnose tears

Answer 131

1. Aggravating factors must be avoided 2. NSAIDs may help to alleviate inflammation and pain 3. Local steroid injections may be considered 4. PT may provide relief

Answer 132

1. AP view of the shoulder as well as a transthoracic "Y" view 2. Possible MRI

Answer 133

1. Reduction and immobilization 2. Postreduction films should be obtained and neurovascular status should be assessed 3. Immobilization by sling and swath (Velpeau sling) is recommended for all 4. Therapy begins after 3 weeks for those younger than 40 and in one week for those after 40 years of age.

Answer 134

Arthrography (may show decreased volume of the joint capsule and capsular contraction)

Answer 135

NSAIDs, passive ROM, and occasionally, manipulation under anesthesia

Answer 136

An AP view generally will visualize the fracture

Answer 137

1. In children, the figure-of-eight sling is used for 4-6 weeks 2. In adults, a sling for 6 weeks is generally enough to treat the fracture

Answer 138

1. An AP view of both shoulders usually is necessary 2. Mild separations may require stress films that are obtained while the patient holds a weighted object to reveal the separation

Answer 139

1. Conservative management is possible for mild to moderate injuries because they can be managed with a sling and analgesia 2. More severe injuries usually will require operative repair

Answer 140

1. AP, lateral, and "Y" views typically are diagnostic

Answer 141

1. Closed reduction with the application of a sling and swath (Velpeau sling) can treat most nondisplaced fractures. Early mobilization with pendulum exercises is indicated to prevent frozen shoulder 2. ORIF is reserved for the management of displaced fractures

Answer 142

AP and lateral views that include the elbow and shoulder should be performed.

Answer 143

1. Initial treatment usually is the application of a coaptation splint 2. The coaptation splint can be followed by a hanging cast, Sarmiento brace, or operative repair

Answer 144

1. AP and lateral views generally are sufficient to make the diagnosis 2. In children, always obtain comparative views

Answer 145

1. Treatment involves closed reduction in the OR with posterior splint application for displaced fractures in children 2. Adults should have ORIF

Answer 146

Nerve conduction studies and EMG

Answer 147

1. Activity modification, volar wrist splint, and NSAIDs (except in pregnancy) 2. Steroid injections may be used 3. Surgical interventions may be needed

Answer 148

Fractures with 25-30 degrees of angulation should be reduced with the application of an ulnar splint with f/up in 1-2 weeks

Answer 149

Cast immobilization is adequate after reduction in most cases

Answer 150

Surgical repair is indicated for a complete rupture, a partial rupture may be treated by immobilization with a thumb spica cast

Answer 151

1. AP and lateral views of the elbow may demonstrate osteophytes overlying the lateral epicondyle 2. MRI is useful in demonstrating tendon disruption

Answer 152

a. Cessation of the provocative activity for at least 6 weeks is probably the most important component in the treatment. b. Counterbalance braces (tennis elbow braces) are beneficial. c. Instruct the patient to pick up objects with the extremity in supination. d. Physical and occupational therapy e. Steroid injections may give short-term relief but do not offer long-term treatment. f. NSAIDs frequently are used g. Surgery is reserved for those patients who fail at least 6 months of conservative management.

Answer 153

MRI is typically not indicated but is useful for assessing the ulnar nerve

Answer 154

a. Conservative management, including cessation of precipitating activity, NSAIDs, and physical and occupational therapy, most commonly is used. b. A medial counterforce brace frequently is applied.

Answer 155

a. Avoid continued trauma to elbow and use ace wrap for compression. Aspiration of the bursa is not recommended unless infection is suspected. b. NSAIDs and warm compresses are used for their analgesic properties.

Answer 156

AP and lateral films of the elbow usually are sufficient to establish the diagnosis. CT is useful in determining the degree of comminution

Answer 157

1. AP, lateral, and scaphoid views should be ordered. If negative initially, films may be repeated after 2-3 weeks, at which time the fracture may become apparent 2. Bone scan or MRI can be used to make the diagnosis at the time of injury

Answer 158

1. A delay in diagnosis should be avoided. If it is suspected, it should be treated as a fracture in a long-arm thumb spica cast until bone scan or MRI can be done 2. There should also be a referral to an orthopaedic surgeon 3. For displaced: Long arm thumb spica cast. For nondisplaced: referral to an orthopaedic specialist 4. Displacement of 1 mm or greater requires ORIF

Answer 159

1. Conservative treatment for at least one month using a thumb spica splint, NSAIDs, and physical/occupational therapy is required

Answer 160

Fever, weight loss, morning stiffness, history of IV or steroid use, trauma, history of CA, saddle anesthesia, loss of anal sphincter tone, or major motor weakness

Answer 161

1. Short-term relative rest (maximum of 2 days) with support under the knees and neck and administration of NSAIDs or analgesics are the first components of treatment 2. Progressive ambulation to normal activity may follow 3. A fitness program should be implemented for back rehab 4. If no improvement occurs after 6 weeks, perform further evaluation with bone scan, MRI, CT, or EMG and a medical workup to rule out spinal tumor or infection

Answer 162

1. Elevated levels of ESR and CRP are seen. Also HLA-B27 positive 2. Sacroiliitis is an early radiographic finding. "Bamboo appearance" 3. Generalized osteopenia of the spine may be seen

Answer 163

1. PT with emphasis on posture, extension exercises, and breathing exercises. Swimming is considered the best overall exercise 2. NSAIDs are the first-line treatment. If there is resistance to NSAIDs, TNF inhibitors have been used with great success 3. Spine fractures need intervention and stabilization

Answer 164

This is a surgical emergency requiring immediate referral

Answer 165

1. MRI is the study of choice 2. Radiography may be normal in the beginning 3. Bone scans are useful but less sensitive than MRI

Answer 166

1. Protected weight bearing for early stage disease is considered a temporary treatment. Alendronate has been used to prevent early collapse 2. Surgical options range from core decompression to total hip replacement

Answer 167

1. Initial treatment consists of activity modification, NSAIDs, quadriceps strengthening exercises and time 2. Indications for arthroscopy includes persistent symptoms unresponsive to conservative treatment or irreducible locking

Answer 168

1. Maintenance therapy includes oral calcium (1-2 g/day) and vitamin D preparations. Calcitrol is also used. Magnesium supplementation may also be required 2. Phenothiazines and furosemide should be avoided

Answer 169

1. T3 and free T4 levels (will be elevated) 2. TSH levels (will be low) 3. Peroxidase antibodies and thyroglobulin antibodies (+ in Graves disease but not in toxic multinodular goiter) 4. Radioactive iodine uptake 5. MRI or CT scan of the orbits is performed for severe or unilateral ocular signs or when causation may be other than Graves

Answer 170

1. Beta blockers (primarily propanolol) for symptoms 2. PTU (for preggers) or MMI 3. Ophthalmopathy respond best to IV methylprednisolone but may respond to high dose, tapered prednisone treatment, particularly in nonsmokers 4. For atrial fibrillation, it is not likely to convert electrically. a. Digoxin may be used in large doses and beta blockers with caution (especially in the presence of cardiomyopathy or heart failure) b. Anticoagulation with warfarin is recommended

Answer 171

Arthritis, lupus, aplastic anemia, thrombocytopenia, and hepatic necrosis

Answer 172

1. Less risk of hepatic necrosis | 2. Serum sickness, cholestatic jaundice, alopecia, nephrotic syndrome, and hypoglycemia

Answer 173

1. Levothyroxine. Remember to adjust dosage after 4-6 weeks | 2. Assess patients for adrenal insufficiency and angina prior to initiating treatment

Answer 174

1. Fine-needle aspiration (FNA) with Gram stain and culture is required

Answer 175

Medications for the underlying cause (i.e., dicloxacillin) and surgical drainage with fluctuation

Answer 176

1. It is the most common cause of a painful thyroid gland | 2. It is believed to be the result of a preceding viral illness

Answer 177

1. Thyrotoxicosis initially presents, followed by a period of hypothryoidism with resumption of euthyroid within 12 months 2. The ESR is markedly elevated and antithyroid antibody titers are low

Answer 178

1. Treatment of choice is ASA 2. Steroids have proven no additional benefit 3. Symptoms may be lessened with beta blockers and iodinated contrast products. Antithyroid medication is usually of no benefit.

Answer 179

1. Follicular adenoma is the most common type 2. Papillary adenomas are very rare 3. Hurtle cell has eosinophilic staining and has malignant potential

Answer 180

1. If the TSH is low, the patient should be assessed for hyperthyroidism and undergo radionuclide thyroid scan. Cold nodules (no uptake) are hypofunctioning and require surgery. Hot nodules (increased uptake) are functional, and therefore, carry a lower risk of malignancy 2. High-resolution U/S is the test of choice 3. Malignancy is suspected in the presence of irregular or indistinct margins, heterogenous echogenicity, intranodular vascular margins, microcalcifications, complex cyst patters, or size greater than 1 cm. 4. Lesions suspicious for malignancy should undergo U/S guided FNA

Answer 181

1. First, determine cortisol excess using overnight dexamthasone suppression test. Additional testing includes a 24-hour urine collection for free cortisol and creatinine. Late night salivary cortisol assays may also be useful 2. Plasma or serum ACTH of less than 20 pg/mL suggests an adrenal tumor; higher levels suggest pituitary or ectopic production 3. MRI is preferred to identify pituitary tumors.

Answer 182

1. Transsphenoidal selective resection of the pituitary tumor cures 75-90% 2. Irradiation for non-resectable tumors 3. Medical therapy before surgery can inhibit glucorticoid synthesis. Mitotane, metyrapone, or ketoconazole may suppress hypercortisolism. Parenteral octreotide suppresses ACTH in one third of cases

Answer 183

1. CBC, CMP | 2. Low (

Answer 184

1. Primary disease is treated with a combination of corticosteroids and mineralcorticoids. These include oral hydrocortisone or prednisone and fludrocortisone acetate for its sodium-retaining effect 2. DHEA may be give 3. Patients must be fully informed about their condition

Answer 185

Aphasia, apraxia, hemiparesis, hemisensory losses, and/or visual field defects

Answer 186

Coma, drop attacks, vertigo, nausea, vomiting, and/or ataxia

Answer 187

1. CBC, ESR, platelet count, PT, PTT, lipid panel, and blood glucose level 2. Additional tests: VDRL test for syphilis, HIV antibody, Lyme disease antibody, antinuclear antibodies, and antiphospholipid antibodies depending on patient risk factors 3. Blood cultures should be considered if endocarditis is suspected 4. Non-contrast CT is recommended during the acute phase 5. Cardiac monitoring 6. Lumbar puncture and angiography should be reserved for patients with suspected hemorrhage or vascular malformations

Answer 188

1. Thrombolytic therapy (recombinant tissue plasminogen factor) is given to reduce the extent of deficit; it is most effective if given within 3 hours of symptoms but can be attempted up to 4.5 hours after the onset of symptoms 2. Antiplatelet therapy is initiated for ischemic stroke and TIA, whereas anticoagulant therapy is indicated in the setting of cardiac emboli 3. Endarterectomy may be indicated if greater than 70% stenosis of the common or internal carotid artery is present 4. Hemorrhagic stroke is treated with conservative and supportive measures, including management of hypertension and antiedema therapy (mannitol and corticosteroids). Endovascular repair and surgical clipping or coil embolization are options available for some patients with specific anatomic foci 5. Long-term supportive therapy, follow-up physical therapy, and social supports are important

Answer 189

Contralateral hand-arm weakness with sensory loss, ipsilateral visual symptoms or aphasia, and/or amaurosis fugax. Carotid bruit may be present, but with a high-grade stenosis, it may be absent

Answer 190

Diplopia, ataxia, vertigo, dysarthria, crania nerve palsies, lower extremity weakness, dimness or blurring of vision, perioral numbness, and/or drop attacks

Answer 191

1. Noninvasive transcranial Doppler and duplex ultrasound. CT angiography or MRI are other options (minimally invasive) to evaluate the patient; conventional angiography remains the definitive study but is invasive and associated with a small risk of stroke 2. Head CT or MRI will exclude a possible small cerebral hemorrhage 3. Cardiac workup should be done to exclude arrhythmia and new murmurs 4. Hematologic workup (ESR, CBC, lipid panel, PT, PTT, and antiphospholipids)

Answer 192

1. Prophylactic antiplatelet therapy is initiated with the TIA is not cardiogenic. This therapy might include aspirin, clopidogrel, ticlopidine, or ASA/extended-release dipyrimadole 2. Cardiogenic TIA requires anticoagulation initially with IV heparin for those who are admitted to the hospital and with warfarin for long-term therapy 3. Carotid endarterectomy may be indicated in patients with anterior circulation TIAs and moderate to high-grade carotid stenosis on the side appropriate to account for the symptoms 4. Adjunctive therapies include control of BP, cholesterol, glucose, and afib.

Answer 193

1. Noncontrast CT is the initial imaging study for suspected SAH 2. Lumbar puncture with evaluation of CSF 3. Cerebral angiography 4. Electroencephalography