Fever, Body Weakness. Easy Fatigability, Pain, Headache, Weight loss, Dyspnea, Cough, Edema

Question 1

an unpleasant sensation localized to a part of the body. It is often described in terms of a penetrating or tissue-destructive process (e.g., stabbing, burning, twisting, tearing, squeezing) and/or of a bodily or emotional reaction (e.g., terrifying, nauseating, sickening)

Answer 1

Pain

Question 2

These properties illustrate the duality of pain

Answer 2

both sensation and emotion

Question 3

Peripheral nerve consists of the

axons of three different types of neurons:

Answer 3

primary sensory afferents, motor neurons, and sympathetic postganglionic neurons

Question 4

The cell bodies of primary sensory afferents

are located in

Answer 4

the dorsal root ganglia

within the vertebral foramina.

Question 5

The largest diameter afferent fibers, respond maximally to light touch and/or moving stimuli; they are
present primarily in nerves that innervate the skin

Answer 5

A-beta (Aβ)

Question 6

These fibers are present in nerves to the

skin and to deep somatic and visceral

Answer 6

A-delta (Aδ) and the unmyelinated (C) axons

primary afferent nociceptors (pain receptors)

Question 7

Innervated only by Aδ and C fiber afferents

Answer 7

Cornea

Question 8

When intense, repeated, or prolonged stimuli are applied to damaged or inflamed tissues, the threshold for activating primary afferent nociceptors is lowered, and the frequency of firing is higher for
all stimulus intensities

Answer 8

Sensitization

Question 9

Sensitization occurs at the level of the

Answer 9

peripheral nerve terminal (peripheral sensitization) as well as at the level of the dorsal horn of the spinal cord (central sensitization).

Question 10

occurs in damaged or inflamed tissues,
when inflammatory mediators activate intracellular signal transduction in nociceptors, prompting an increase in the production, transport, and membrane insertion of chemically gated and voltage-gated ion channels.

These changes increase the excitability of nociceptor
terminals and lower their threshold for activation by mechanical, thermal, and chemical stimuli

Answer 10

Peripheral sensitization

Question 11

occurs when activity, generated by nociceptors during inflammation, enhances the excitability of nerve cells in the dorsal horn of the spinal cord

Answer 11

Central sensitization

Question 12

Following injury and resultant sensitization, normally innocuous stimuli can produce pain

Answer 12

Allodynia

Question 13

increased pain intensity in response to the same noxious stimulus

Answer 13

hyperalgesia

Question 14

play a significant role in sensitization

Answer 14

Low pH, prostaglandins, leukotrienes

inflammatory mediators such as bradykinin

Question 15

is released from primary afferent nociceptors and
has multiple biologic activities. It is a potent vasodilator, degranulates mast cells, is a chemoattractant for leukocytes, and increases the production
and release of inflammatory mediators

Answer 15

Substance P

Question 16

When primary afferents are activated by noxious stimuli, they release neurotransmitters from their terminals that excite the spinal cord neurons. The major
neurotransmitter released is

Answer 16

glutamate

Question 17

The convergence of sensory inputs to a single spinal pain-transmission neuron is of great importance because it underlies the phenomenon of

Answer 17

referred pain

Question 18

Inflammation near the central diaphragm

is often reported as

Answer 18

shoulder discomfort.

Question 19

This spatial displacement of

pain sensation from the site of the injury that produces it is known as

Answer 19

referred pain

Question 20

causes vasodilation and neurogenic edema with further accumulation of bradykinin (BK).

also causes the release of histamine
(H) from mast cells and serotonin (5HT) from platelets

Answer 20

Substance P

Question 21

pathway is crucial for pain sensation in humans

Answer 21

The spinothalamic

Question 22

This projection mediates the purely sensory aspects of pain, i.e., its location, intensity, and quality

Answer 22

somatosensory cortex.

Question 23

According to this hypothesis, visceral afferent nociceptors converge on the same pain-projection neurons as the afferents from the somatic structures in which the pain is perceived. The brain has no way of knowing the actual source of input and mistakenly “projects” the sensation to the somatic structure

Answer 23

convergence-projection hypothesis of referred

pain

Question 24

The suggestion that pain will worsen following administration of an inert substance can increase its perceived intensity

Answer 24

(the nocebo effect)

Question 25

typically has an unusual burning, tingling, or

electric shock like quality and may be triggered by very light touch

Answer 25

Neuropathic pain

Question 26

a greatly exaggerated pain sensation to innocuous

Answer 26

Hyperpathia

Question 27

This constellation of spontaneous pain and signs of sympathetic dysfunction following injury has been termed

Answer 27

complex regional pain syndrome (CRPS)

Question 28

complex regional pain syndrome (CRPS) occurs after an identifiable nerve injury, it is termed

Answer 28

(CRPS) II also known as posttraumatic neuralgia

or, if severe, causalgia

Question 29

complex regional pain syndrome (CRPS) occurs without obvious nerve injury, it is termed

Answer 29

CRPS type I (also known as reflex sympathetic dystrophy)

Question 30

Effective for patients with postherpetic neuralgia who have prominent allodynia

Answer 30

topical preparation of 5% lidocaine in patch form

Question 31

The ideal treatment for any pain is to

Answer 31

remove the cause

Question 32

Gastric irritation is most severe

with this drug , which may cause erosion and ulceration of the gastric mucosa leading to bleeding or perforation

Answer 32

aspirin

Question 33

irreversibly acetylates platelet cyclooxygenase and thereby interferes with coagulation of the blood, gastrointestinal bleeding is a particular risk

Answer 33

aspirin

Question 34

two major classes of COX:

Answer 34

COX-1 is constitutively expressed, and COX-2 is induced in the inflammatory state.

Question 35

have similar analgesic potency and produce less gastric irritation than the nonselective COX inhibitors

Answer 35

COX-2– selective drugs

Question 36

COX-2 inhibitors, including celecoxib (Celebrex), are
associated with increased risk of ?

It appears that this is
a class effect of NSAIDs, excluding aspirin.

Answer 36

cardiovascular risk

These drugs are contraindicated in patients in the immediate period after coronary artery bypass surgery and should be used with caution in elderly patients and those with a history of or significant risk factors for cardiovascular disease.

Question 37

Side effects of opiods

Answer 37

Nausea, vomiting, pruritus, and constipation are the most frequent and bothersome side effects.

Respiratory depression is uncommon at standard analgesic doses, but can be life threatening.

Question 38

Opioid-related side effects can be reversed rapidly with the narcotic antagonist

Answer 38

naloxone

Question 39

Opioids produce analgesia by actions in

Answer 39

CNS. They activate pain-inhibitory neurons and directly inhibit pain-transmission neurons. Most of the commercially available opioid analgesics act at
the same opioid receptor (μ-receptor)

Question 40

metabolite of meperidine. At higher doses of meperidine, typically greater than 1 g/d, accumulation
of this drug can produce hyperexcitability and seizures that are not reversible with naloxone. accumulation is
increased in patients with renal failure

Answer 40

normeperidine

Question 41

The most common error made by physicians in managing severe pain with opioids is to?

Because many patients are reluctant to complain, this practice leads to needless suffering. In the absence of sedation at the expected time of peak effect

Answer 41

prescribe an inadequate dose

Question 42

Useful for the management of chronic

pain

Answer 42

The tricyclic antidepressants (TCAs), particularly nortriptyline and desipramin

TCAs potentiate opioid analgesia, so they may be useful adjuncts for the treatment of severe persistent pain such as occurs with malignant tumors

TCAs are of particular value in the management of neuropathic pain such as occurs in diabetic neuropathy and postherpetic neuralgia

Question 43

block both serotonin and norepinephrine reuptake, appear to retain most of the pain-relieving effect of TCAs with a side effect profile more like that of the selective serotonin reuptake inhibitors

These drugs may be particularly useful in patients who cannot tolerate the side effects of TCAs.

Answer 43

nontricyclic antidepressants (SNRI)
venlafaxine (Effexor) and duloxetine (Cymbalta),

Question 44

The most common causes of abdominal pain on admission are

Answer 44

acute appendicitis, nonspecific abdominal pain, pain of urologic origin, and intestinal obstruction.

Question 45

Pain is steady and aching in character and is located directly over the inflamed area, its exact reference being possible because it is transmitted by somatic nerves

Answer 45

The pain of parietal peritoneal

inflammation

Question 46

Exposure of blood and urine to the peritoneal cavity may go unnoticed unless it is sudden and massive

Answer 46

Blood is normally only a mild irritant and the response to urine can be bland

Question 47

Invariably accentuated by pressure or changes in tension of the peritoneum, whether produced by palpation or by movement such as with coughing or sneezing

Characteristically lies quietly in bed, preferring
to avoid motion, in contrast to the patient with colic, who may be thrashing in discomfort

tonic reflex spasm of the abdominal musculature, localized to the involved body segment

Answer 47

The pain of peritoneal inflammation

Question 48

Classically elicits intermittent or colicky abdominal pain that is not as well localized as the pain of parietal peritoneal irritation.

Answer 48

Intraluminal obstruction

Question 49

often presents as poorly localized, intermittent
periumbilical or supraumbilical pain. As the intestine progressively dilates and loses muscular tone, the colicky nature of the pain may diminish. With superimposed strangulating obstruction, pain
may spread to the lower lumbar region if there is traction on the root of the mesentery.

Answer 49

Small-bowel obstruction

colicky pain of colonic obstruction is of lesser
intensity, is commonly located in the infraumbilical area, and may often radiate to the lumbar region

Question 50

usually causes pain in the right upper quadrant with radiation to the right posterior region of the thorax or to the tip of the right scapula, but it is also not uncommonly found near
the midline.

Answer 50

Acute distention of the gallbladder

Question 51

Often causes epigastric pain that may radiate to the upper lumbar region.

Answer 51

Distention of the common bile duct

Question 52

Abdominal pain with radiation to the sacral region,

flank, or genitalia should always signal the possible presence of a

Answer 52

rupturing

abdominal aortic aneurysm.

Question 53

Often accompanied by splinting
of the involved hemithorax with respiratory lag and decrease in excursion more marked than that seen in the presence of intraabdominaldisease.

Answer 53

Referred pain of thoracic origin

Question 54

Hallmark of familial Mediterranean fever

Answer 54

Abdominal pain

Question 55

associated with angioneurotic edema is often associated with episodes of severe abdominal pain.

Answer 55

C1 esterase deficiency

Question 56

Should also be considered, especially when evaluating

patients with left upper quadrant or left flank pain.

Answer 56

Splenic abscesses due to Candida or

Salmonella infection

Question 57

Clinically important weight loss is defined as the loss of

Answer 57

10 pounds (4.5 kg) or >5% of one’s body weight over a period of 6–12 months

Question 58

IWL is encountered in up to

Answer 58

8% of all adult outpatients and

27% of frail persons age 65 years and older.

Question 59

Significant weight loss is associated with increased mortality, which can range

Answer 59

from 9% to as high as 38% within 1 to 2.5 years in the absence of clinical awareness and attention

Question 60

Among healthy aging people, total body weight peaks in the

Answer 60

sixth decade of life and generally remains

stable until the ninth decade, after which it gradually falls

Question 61

lean body mass (fat-free mass) begins to decline at a rate of

Answer 61

0.3 kg per year in the third decade, and the rate of decline increases further beginning at age 60 in men and age 65 in women.

Question 62

These changes in lean body mass largely reflect the age-dependent decline in growth hormone secretion and, consequently, circulating levels of

Answer 62

insulin-like growth factor type I (IGF-I) that occur with normal aging.

Question 63

In the healthy elderly, an increase in fat tissue balances the loss in lean body mass until

Answer 63

very old age, when loss of both fat and skeletal muscle occurs

Question 64

Between ages 20 and 80, mean energy intake is reduced by

Answer 64

up to 1200 kcal/d in men and 800 kcal/d in women

Question 65

Half of all patients with cancer lose some body weight;

Answer 65

one-third lose more than 5% of their original body weight, and up to 20% of all cancer deaths are caused directly by cachexia (through immobility and/or cardiac/respiratory failure).

Question 66

The greatest incidence of weight loss

is seen among patients with

Answer 66

solid tumors

Question 67

Hyperthyroidism in the elderly may have less prominent sympathomimetic, features and may present as

Answer 67

“apathetic hyperthyroidism” or T3 toxicosis

Question 68

may be one of the earliest manifestations

of Alzheimer’s dementia.

Answer 68

Involuntary weight loss

Question 69

The four major manifestations of IWL are

Answer 69

(1) anorexia (loss of appetite),
(2) sarcopenia (loss of muscle mass)
(3) cachexia (a syndrome that combines weight loss, loss of muscle and adipose tissue, anorexia, and weakness), and
4) dehydration

Question 70

Assessment and Testing for Involuntar y Weight Loss

Answer 70

5% weight loss in 30 d= Complete blood count

10% weight loss in 180 d =Comprehensive electrolyte andmetabolic panel, including liver and
renal function tests

Body mass index <21 =Thyroid function tests

25% of food left uneaten after 7 d =ESR

Change in fit of clothing= CRP

Change in appetite, smell, or taste =Ferritin

Question 71

The first priority in managing weight loss

Answer 71

to identify and treat the underlying causes systematically. Treatment of underlying metabolic, psychiatric, infectious, or other systemic disorders may
be sufficient to restore weight and functional status gradually.

Question 72

Refers to an inherently subjective human experience of physical and mental weariness, sluggishness, and exhaustion.

In the context of clinical medicine, it is
most typically and practically defined as difficulty initiating or maintaining voluntary mental or physical activity

Answer 72

Fatigue

Question 73

is a cardinal manifestation of some neuromuscular disorders such as myasthenia gravis and can be
distinguished from fatigue by finding clinically apparent diminution of the amount of force that a muscle generates upon repeated contraction

Answer 73

Fatigability of muscle power

Question 74

On confrontational testing, they are able
to generate full power for only a brief period before suddenly giving way to the examiner. This type of weakness is often referred to as

Answer 74

breakaway weakness

Question 75

is a reduction in the power that can be exerted by one or more muscles.

Answer 75

Weakness

It must be distinguished from increased fatigability (i.e., the inability to sustain the performance of an activity that should be normal for a person of the same age, sex, and size), limitation in function due to pain or articular stiffness, or impaired motor activity because severe proprioceptive sensory
loss prevents adequate feedback information about the direction and power of movements

also distinct from bradykinesia (in which increased time is required for full power to be exerted) and apraxia,
a disorder of planning and initiating a skilled or learned movement unrelated to a significant motor or sensory deficit

Question 76

or the suffix “-plegia” indicates weakness so severe that a muscle cannot be contracted at all, whereas paresis refers to less severe weakness.

Answer 76

Paralysis

Question 77

Weakness from involvement of

occurs particularly in the extensors and abductors of the upper limb and the flexors of the lower limb.

Answer 77

upper motor neurons

Question 78

weakness depends on whether
involvement is at the level of the anterior horn cells, nerve root, limb plexus, or peripheral nerve—only muscles supplied by the affected structure are weak

Answer 78

Lower motor neuron

Question 79

is generally most marked in

proximal muscles

Answer 79

Myopathic weakness

Question 80

is the resistance of a muscle to passive stretch

Answer 80

Tone

Question 81

is the increase in tone associated with
disease of upper motor neurons. It is velocity-dependent, has a sudden release after reaching a maximum (the “clasp-knife” phenomenon), and predominantly affects the antigravity muscles (i.e., upper-limb flexors and lower-limb extensors).

Answer 81

Spasticity

Question 82

is hypertonia that is present throughout the range of motion (a “lead pipe” or “plastic” stiffness)
and affects flexors and extensors equally; it sometimes has a cogwheel quality that is enhanced by voluntary movement of the contralateral limb (reinforcement)

Answer 82

Rigidity

Question 83

is increased tone that varies irregularly in a manner seemingly related to the degree of relaxation, is present throughout the range of motion, and affects flexors and extensors equally; it usually results from disease of the frontal lobes

Answer 83

Paratonia (or gegenhalten)

Question 84

Weakness with decreased tone (flaccidity) or normal

tone occurs with disorders of motor units. A motor unit consists of

Answer 84

a single lower motor neuron and all the muscle fibers that it innervates

Question 85

Generally is not affected by upper motor neuron lesions, although mild disuse atrophy eventually may occur.

Answer 85

Muscle bulk

By contrast, atrophy is often conspicuous when a lower motor neuron lesion is responsible for weakness and also may occur with advanced muscle disease

Question 86

are usually increased with upper motor neuron lesions, but may be decreased or absent for a variable period immediately after onset of an acute lesion

Answer 86

Muscle stretch (tendon) reflexes

Question 87

The muscle stretch reflexes are

depressed with

Answer 87

lower motor neuron lesions directly involving specific
reflex arcs. They generally are preserved in patients with myopathic weakness except in advanced stages, when they sometimes are attenuated.

In disorders of the neuromuscular junction, reflex responses may be affected by preceding voluntary activity of affected muscles; such activity may lead to enhancement of initially depressed reflexes in
Lambert-Eaton myasthenic syndrome

and, conversely, to depression of initially normal reflexes in myasthenia gravis

Lambert–Eaton myasthenic syndrome is caused by autoantibodies to the presynaptic membrane. Myasthenia gravis is caused by autoantibodies to the postsynaptic acetylcholine receptors

Question 88

distal weakness is likely to be

Answer 88

neuropathic,

and symmetric proximal weakness
myopathic

Question 89

distal muscle groups are affected more severely than proximal ones, and axial movements are spared unless the lesion is severe and bilateral.

Spasticity is typical but may not be present acutely. Rapid repetitive movements are slowed and coarse, but normal rhythmicity is maintained.

Answer 89

Upper motor neuron lesion

(EMG) shows that with weakness of the upper motor neuron type, motor units have a diminished maximal
discharge frequency.

Question 90

Bilateral corticobulbar lesions produce a

Answer 90

pseudobulbar palsy: dysarthria, dysphagia, dysphonia, and emotional lability accompany bilateral facial weakness and a brisk jaw jerk

Question 91

disorders brainstem motor nuclei and the anterior
horn of the spinal cord or from dysfunction of the axons of these neurons as they pass to skeletal muscle

Weakness is due to a
decrease in the number of muscle fibers that can be activated through a loss of α motor neurons or disruption of their connections to muscle. Loss of γ motor neurons does not cause weakness but decreases tension on the muscle spindles, which decreases muscle tone and attenuates
the stretch reflexes

Answer 91

Lower Motor Neuron lesion

Question 92

When a motor unit becomes diseased, especially in anterior horn cell diseases, it may discharge spontaneously, producing

Answer 92

fasciculations

Question 93

Atrophy
Fasciculations
Tone Decreased
Distal/segmental Distribution of weakness
Hypoactive/absent Muscle stretch reflexes
Absent Babinski

Answer 93

Lower Motor Neuron

Question 94

Tone Spastic
Atrophy Absent
Fasciculations Absent
Hyperactive
Babinski sign Present

Answer 94

Upper Motor Neuronn

Question 95

The bulbospinal system sometimes is referred to as the

Answer 95

extrapyramidal upper motor neuron system

Question 96

The larger α motor neurons are more numerous and innervate the extrafusal muscle fibers of the motor unit.

Loss of α motor neurons or disruption of their axons produces

Answer 96

Lower motor neuron weakness

Question 97

The smaller, less numerous γ motor neurons innervate the _

and contribute to normal tone and stretch reflexes

Answer 97

intrafusal muscle fibers of the muscle spindle

Question 98

is produced by a decrease

in the number or contractile force of muscle fibers activated within motor units

Answer 98

Myopathic weakness

On EMG, the size of each motor
unit action potential is decreased, and motor units must be recruited more rapidly than normal to produce the desired power.

Some myopathies produce weakness through loss of contractile force of muscle fibers or through relatively selective involvement of type II (fast)

Question 99

Weakness may occur without a recognizable
organic basis. It tends to be variable, inconsistent, and with a pattern
of distribution that cannot be explained on a neuroanatomic basis

Answer 99

Psychogenic Weakness

Question 100

Causes of Episodic Generalized Weakness

Answer 100

1. Electrolyte disturbances, e.g., hypokalemia, hyperkalemia, hypercalcemia,
   hypernatremia, hyponatremia, hypophosphatemia, hypermagnesemia
2. Muscle disorders
   a. Channelopathies (periodic paralyses)
   b. Metabolic defects of muscle (impaired carbohydrate or fatty acid utilization;
   abnormal mitochondrial function)
3. Neuromuscular junction disorders
   a. Myasthenia gravis
   b. Lambert-Eaton myasthenic syndrome
4. Central nervous system disorders
   a. Transient ischemic attacks of the brainstem
   b. Transient global cerebral ischemia
   c. Multiple sclerosis
5. Lack of voluntary effort
   a. Anxiety
   b. Pain or discomfort
   c. Somatization disorder

Question 101

results from an upper motor neuron lesion

above the midcervical spinal cord; most such lesions are above the foramen magnum.

Answer 101

Hemiparesis

Question 102

reflect either a cortical or a subcortical hemispheric lesion.

Answer 102

Homonymous visual field defects

Question 103

produce “crossed paralyses,” consisting of ipsilateral cranial nerve signs and contralateral hemiparesis

Answer 103

brainstem lesions

Question 104

The absence of cranial nerve signs or facial weakness suggests that a hemiparesis is due to a lesion in the high cervical spinal cord, especially if associated with the

Answer 104

Brown-Séquard syndrome

Question 105

usually results from focal structural lesions, particularly rapidly expanding lesions, or an inflammatory
process

Answer 105

Acute or episodic hemiparesis

Question 106

that evolves over days or weeks may relate to subdural hematoma, infectious or inflammatory disorders (e.g., cerebral abscess, fungal granuloma or meningitis, parasitic infection, multiple sclerosis, sarcoidosis), or primary and metastatic
neoplasms.

Answer 106

Subacute hemiparesis

Question 107

that evolves over months usually is due to a neoplasm

or vascular malformation, a chronic subdural hematoma, or a degenerative disease

Answer 107

Chronic hemiparesis

Question 108

If weakness is predominantly distal and of upper

motor neuron type and is not associated with sensory impairment or pain, focal cortical ischemia is likely

Answer 108

Acute monoparesis 

Question 109

often produces symmetric weakness

of the pelvic or shoulder girdle muscles

Answer 109

Myopathy

Question 110

may present with symmetric proximal weakness often associated with ptosis, diplopia, or bulbar weakness and fluctuating in severity during the day

Answer 110

Diseases of the neuromuscular junction, such as myasthenia gravis

Question 111

proximal weakness is usually

asymmetric, but it may be symmetric if familial

Answer 111

anterior horn cell disease

Question 112

suggests Guillain-Barré syndrome

Answer 112

Bilateral facial palsy with areflexia

Question 113

Body temperature is controlled by the

Answer 113

hypothalamus

Neurons in both the preoptic anterior hypothalamus and the posterior hypothalamus receive two kinds of signals: one from peripheral nerves that transmit
information from warmth/cold receptors in the skin and the other from the temperature of the blood bathing the region

Question 114

In a neutral temperature environment, the human metabolic rate produces more heat than is necessary to maintain the core body temperature in the range of

Answer 114

36.5–37.5°C (97.7–99.5°F)

Question 115

According to studies of healthy individuals 18–40 years of age, the mean oral temperature is

Answer 115

36.8° ± 0.4°C (98.2° ± 0.7°F), with

low levels at 6 a.m. and higher levels at 4–6 p.m.

Question 116

The maximal normal oral temperature is

Answer 116

37.2°C (98.9°F) at 6 a.m. and 37.7°C (99.9°F) at 4 p.m

Question 117

what would define a fever.

Answer 117

an a.m. temperature of >37.2°C (>98.9°F) or a

p.m. temperature of >37.7°C (>99.9°F)

Question 118

The normal daily temperature variation is typically

Answer 118

0.5°C (0.9°F)

in some individuals recovering from a febrile illness, this daily variation can be as great as 1.0°C.

Question 119

Rectal temperatures are generally

Answer 119

0.4°C (0.7°F) higher than oral readings

Question 120

that unadjusted-mode tympanic membrane values are

Answer 120

0.8°C (1.6°F) lower than rectal temperatures

Question 121

In women who menstruate, the a.m. temperature is generally lower in the 2 weeks before ovulation; it then rises by

Answer 121

∼0.6°C (1°F) with ovulation and remains at that level until menses occur

Question 122

is an elevation of body temperature that exceeds the normal daily variation and occurs in conjunction with an increase in the hypothalamic set point

Answer 122

Fever

Question 123

A fever of >41.5°C (>106.7°F) is called

Answer 123

hyperpyrexia

extraordinarily high fever can develop in patients with severe infections but most commonly occurs in patients with central nervous system (CNS) hemorrhages

The term hypothalamic fever is sometimes used to describe elevated temperature caused by abnormal hypothalamic function. However, most patients with hypothalamic damage have subnormal, not supranormal, body temperatures

Question 124

is characterized by an uncontrolled increase in body temperature that exceeds the body’s ability to lose heat.

Answer 124

Hyperthermia

The setting of the hypothalamic thermoregulatory
center is unchanged

In contrast to fever in infections, hyperthermia does not involve pyrogenic molecules. Exogenous heat exposure and endogenous heat production are two mechanisms by which hyperthermia can result in dangerously high internal temperatures

Hyperthermia is often diagnosed on the basis of the
events immediately preceding the elevation of core temperature— e.g., heat exposure or treatment with drugs that interfere with thermoregulation

Antipyretics do not reduce the elevated temperature in hyperthermia, whereas in fever—and even in hyperpyrexia—adequate doses of either aspirin or acetaminophen usually result in some decrease in body temperature

Question 125

is used to describe any substance

that causes fever.

Answer 125

pyrogen (Greek pyro, “fire”)

Exogenous pyrogens are derived from outside the patient; most are microbial products, microbial toxins, or whole microorganisms (including viruses).

The classic example of an exogenous pyrogen is the lipopolysaccharide (endotoxin) produced by all gram-negative bacteria.

Pyrogenic products of gram-positive organisms include the enterotoxins of Staphylococcus aureus and the groups A and B streptococcal toxins, also called superantigens

Question 126

are small proteins (molecular mass, 10,000–20,000 Da) that regulate immune, inflammatory, and hematopoietic processes.

Answer 126

Cytokines

Question 127

the elevated leukocytosis seen in several infections with an absolute neutrophilia is attributable to the cytokines

Answer 127

interleukin (IL) 1 and IL-6

Some cytokines also cause fever; formerly referred to as endogenous pyrogens, they are now called pyrogenic cytokines

Question 128

The pyrogenic cytokines include

Answer 128

IL-1, IL-6, tumor necrosis factor (TNF), and ciliary neurotropic factor, a member of the IL-6 family

Question 129

Interferons (IFNs), particularly , also are pyrogenic cytokines

Answer 129

IFN-α

fever is a prominent side effect of IFN-α

Question 130

During fever, levels of prostaglandin are elevated in hypothalamic tissue and the third cerebral ventricle

Answer 130

E2 (PGE2

Question 131

cells are the primary cell types that produce pyrogenic cytokines. Pyrogenic cytokines such as IL-1, IL-6, and TNF are released from these cells and enter the systemic circulation

Answer 131

Myeloid and endothelial

Question 132

PGE2 in the periphery accounts for

Answer 132

the nonspecific myalgias and arthralgias that often accompany fever. It is thought that some systemic PGE2 escapes destruction by the lung and gains access to the hypothalamus via the internal carotid. However, it is the elevation of PGE2 in the brain that starts the process of raising the hypothalamic set point for core temperature

Cytokines produced in the brain may account for the hyperpyrexia of CNS hemorrhage, trauma, or infection

Question 133

There are four receptors for PGE2, and each signals the cell in different ways. Of the four receptors,

Answer 133

the third (EP-3) is essential for fever

Question 134

PGE2 is not a neurotransmitter

the release of PGE2 from the brain side of the hypothalamic endothelium triggers the PGE2 receptor
on glial cells, and this stimulation results in the rapid release of

Answer 134

cyclic adenosine 5′-monophosphate (cAMP), which is a neurotransmitter

Question 135

The elevation of _ is thought to account for changes

in the hypothalamic set point either directly or indirectly (by inducing the release of neurotransmitters)

Answer 135

cAMP

Question 136

The workup should include a complete blood count; a differential count should be performed manually or with an instrument sensitive to the identification of juvenile or band forms, toxic granulations, and Döhle bodies, which are suggestive

Answer 136

bacterial infection

Question 137

in patients with low-grade fevers or possible disease, the most valuable measurements are

Answer 137

the C-reactive protein level and the erythrocyte sedimentation rate

Question 138

Measurement of circulating IL-6 is useful because

IL-6 induces

Answer 138

C-reactive protein

Question 139

Even when the results of tests for latent Mycobacterium

tuberculosis infection are negative, active tuberculosis can develop in patients receiving

Answer 139

anti-TNF therapy

Question 140

Temperature-pulse dissociation (relative bradycardia) occurs in

Answer 140

typhoid fever, brucellosis, leptospirosis, some drug-induced fevers, and factitious fever.

Question 141

fever may not be present despite infection in the ff conditions

Answer 141

in newborns, elderly patients, patients with chronic liver or kidney failure, and patients taking glucocorticoids,

Question 142

relapsing fever is related

Answer 142

to Borrelia infection, with days of fever followed by a several-day afebrile period and then a relapse into additional days of fever

Question 143

fever lasting 3–10 days is followed by afebrile periods of 3–10 days; this pattern can be classic for Hodgkin’s disease and other lymphomas.

Answer 143

Pel-Ebstein pattern

Question 144

fevers occur every 21 days and accompany the neutropenia

Answer 144

cyclic neutropenia

Question 145

The reduction of fever by lowering of the elevated hypothalamic set point is a direct function of reduction of the PGE2 level in the thermoregulatory center. The synthesis of PGE2 depends on the constitutively expressed enzyme

Answer 145

cyclooxygenase.

Question 146

this release is the rate-limiting step in the synthesis of PGE2.

Answer 146

The substrate for cyclooxygenase is arachidonic acid released from the cell membrane

Therefore, inhibitors of cyclooxygenase are potent antipyretics

Question 147

is a poor cyclooxygenase inhibitor in peripheral tissue and lacks noteworthy anti-inflammatory activity; in the brain, however, acetaminophen is oxidized by the p450 cytochrome system, and the oxidized form inhibits cyclooxygenase activity. Moreover, in the brain, the inhibition of another enzyme, COX-3, by acetaminophen may account for the antipyretic effect of this agent.

Answer 147

Acetaminophen

However, COX-3 is not found outside the CNS.

Question 148

PGE2 appears to play no role in

Answer 148

normal thermoregulation

Question 149

glucocorticoids act at two levels

Answer 149

First, similar to the cyclooxygenase inhibitors, glucocorticoids reduce PGE2 synthesis by inhibiting the activity of phospholipase A2, which is needed to release arachidonic acid from the cell membrane

Second, glucocorticoids block the transcription of
the mRNA for the pyrogenic cytokines

Question 150

ibuprofen and COX-2 inhibitors reduce

Answer 150

IL-1- induced IL-6 production and may contribute to the antipyretic activity of NSAIDs

Question 151

In children, acetaminophen or oral ibuprofen must be used because aspirin increases the risk of

Answer 151

Reye’s syndrome

Question 152

Fever increases the demand for oxygen (i.e., for every increase of 1°C over 37°C, there is a

Answer 152

13% increase in oxygen consumption

Question 153

are flat lesions defined by an area of changed

color (i.e., a blanchable erythema).

Answer 153

Macules

Question 154

are raised, solid lesions <5 mm in diameter; plaques are lesions >5 mm in diameter with a flat, plateau-like surface;

Answer 154

Papules

Question 155

are lesions >5 mm in diameter with a more rounded configuration

Answer 155

Nodules

Question 156

are papules or plaques that are pale pink and may appear annular (ringlike) as they enlarge;

Answer 156

Wheals (urticaria, hives)

classic (nonvasculitic) wheals are transient, lasting only 24 h in any defined area.

Question 157

are circumscribed, elevated lesions containing fluid

Answer 157

Vesicles (<5 mm) and bullae (>5 mm)

Question 158

is a flat lesion that is due to bleeding into the skin

Answer 158

<3 mm in diameter, the purpuric lesions are

termed petechiae; if >3 mm, they are termed ecchymoses.

Question 159

an illness of >3 weeks’ duration with fever of ≥38.3°C (101°F) on two occasions and an uncertain diagnosis despite 1 week of inpatient evaluation

Answer 159

FUO

1. Fever >38.3°C (101°F) on at least two occasions
2. Illness duration of ≥3 weeks
3. No known immunocompromised state
4. Diagnosis that remains uncertain after a thorough history-taking, physical examination, and the following obligatory investigations:

determination of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level; platelet count; leukocyte count and differential; measurement of levels of hemoglobin, electrolytes, creatinine, total protein, alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, lactate dehydrogenase, creatine kinase, ferritin, antinuclear antibodies, and rheumatoid factor;protein electrophoresis; urinalysis; blood cultures (n = 3); urine culture; chest x-ray; abdominal ultrasonography; and tuberculin skin test (TST).

Question 160

In general, what accounts for about 20–25% of cases of FUO in Western countries

Answer 160

infection

next in frequency are neoplasms and noninfectious inflammatory diseases (NIIDs), the latter including “collagen or rheumatic diseases,” vasculitis syndromes, and granulomatous disorders

In geographic areas outside the West, infections are a much more common cause of FUO (43% vs 22%), while the proportions of cases due to NIIDs and neoplasms are similar. Up to 50% of cases caused by infections in
patients with FUO outside Western nations are due to tuberculosis

Question 161

(defined as repeated episodes of fever interspersed with fever-free intervals of at least 2 weeks and apparent remission of the underlying disease), the chance of attaining an etiologic diagnosis is <50%.

Answer 161

recurrent fever

Question 162

is often accompanied by eosinophilia and also by lymphadenopathy, which can be extensive

Answer 162

Drug-induced fever, including DRESS (drug reaction with eosinophilia and systemic symptoms

Question 163

More common causes of drug induced

fever are

Answer 163

allopurinol, carbamazepine, lamotrigine, phenytoin,
sulfasalazine, furosemide, antimicrobial drugs (especially sulfonamides, minocycline, vancomycin, β-lactam antibiotics, and isoniazid), some cardiovascular drugs

Question 164

is characterized by an elevated body temperature that is associated with moderate to strenuous exercise lasting from half an hour up to several hours without an increase in CRP level or ESR; typically these patients sweat during the temperature elevation

Answer 164

Exercise-induced hyperthermia

Question 165

(fever artificially induced by the patient—for example, by IV injection of contaminated water) should be considered in all patients but is more common among young women in health care professions

Answer 165

Factitious fever

Question 166

the patient is normothermic but manipulates the thermometer

Answer 166

fraudulent fever

Another clue to fraudulent fever is a dissociation between pulse rate and temperature.

Question 167

Tuberculosis is the most common infectious

disease associated with FUO in elderly patients, occurring much more often than in younger patients.

Answer 167

Tuberculosis

Question 168

the CSF typically has elevated

protein and lowered glucose concentrations, with a mononuclear pleocytosis. C

Answer 168

CNS tuberculosis

SF protein levels range from 100 to 500 mg/dL in most
patients, the CSF glucose concentration is <45 mg/dL in 80% of cases, and the usual CSF cell count is between 100 and 500 cells/μL.

Question 169

should be avoided in FUO except when a patient’s condition is rapidly deteriorating after the aforementioned diagnostic tests have failed to provide a definite diagnosis

Answer 169

Empirical therapeutic trials with antibiotics, glucocorticoids, or antituberculous agents

Question 170

is highly effective in preventing attacks of familial

Mediterranean fever but is not always effective once an attack is well under way.

Answer 170

Colchicine

Question 171

a recombinant form of the naturally occurring IL-1 receptor antagonist (IL-1Ra), blocks the activity of both IL-1α and IL-1β.

Answer 171

Anakinra

Question 172

are those in which headache

and its associated features are the disorder in itself,

Answer 172

Primary headaches

whereas secondary headaches are those caused by exogenous disorders (HeadacheClassification Committee of the International Headache Society, 2013)

Question 173

Most Common Primary Headache

Answer 173

Tension-type 69%
Migraine 16%
Idiopathic stabbing 2%

Question 174

Most Common Secondary Headache

Answer 174

Systemic infection 63%

Head injury 4%

Question 175

Most common pain-producing structures in head

Answer 175

the scalp, middle meningeal artery, dural sinuses, falx cerebri, and proximal segments of the large pial arteries.

Question 176

NOT pain-producing structures in head

Answer 176

The ventricular ependyma, choroid plexus, pial veins, and much of the brain parenchyma

Question 177

Cranial autonomic symptoms

Answer 177

lacrimation, conjunctival injection, nasal congestion, rhinorrhea, periorbital swelling, aural fullness,
and ptosis, are prominent in the trigeminal autonomic cephalalgia

including cluster headache and paroxysmal hemicrania, and may also be seen in migraine, even in children.

Question 178

Headache Symptoms That Suggest a Serious Underlying Disorder

Answer 178

Sudden-onset headache
First severe headache
“Worst” headache ever
Vomiting that precedes headache
Subacute worsening over days or weeks
Pain induced by bending, lifting, cough
Pain that disturbs sleep or presents immediately upon awakening
Known systemic illness
Onset after age 55
Fever or unexplained systemic signs
Abnormal neurologic examination
Pain associated with local tenderness, e.g., region of temporal artery

Question 179

Acute, severe headache with stiff neck and fever suggests

Often there is striking accentuation of pain with eye movement

Answer 179

Meningitis.

LP is mandatory

Meningitis can be easily mistaken for migraine in that the cardinal symptoms of pounding headache, photophobia, nausea, and vomiting are frequently present, perhaps reflecting the underlying biology of some of the patients

Question 180

Acute, severe headache with stiff neck but without fever suggests

Answer 180

Subarachnoid hemorrhage

A ruptured aneurysm, arteriovenous malformation,
or intraparenchymal hemorrhage may also present with
headache alone. Rarely, if the hemorrhage is small or below the foramen magnum, the head CT scan can be normal.

Therefore, LP may be required to definitively diagnose subarachnoid hemorrhage

Question 181

Approximately 30% of patients with brain tumors consider headache to be their chief complaint.

Answer 181

The head pain is usually nondescript—an
intermittent deep, dull aching of moderate intensity, which may worsen with exertion or change in position and may be associated with nausea and vomiting.

Question 182

Vomiting that precedes the appearance of headache by weeks is highly characteristic of

Answer 182

posterior fossa brain tumors.

Question 183

A history of amenorrhea or galactorrhea should lead one to question

Answer 183

whether a prolactin-secreting pituitary adenoma (or the polycystic ovary syndrome) is the source of headache

Question 184

is an inflammatory disorder of arteries that frequently involves the extracranial carotid circulation. It is a common disorder of the elderly

Answer 184

Temporal (giant cell) arteritis

The average age of onset is 70 years, and women account for 65% of cases

About half of patients with untreated temporal arteritis develop blindness due to involvement of the ophthalmic artery and its branches; indeed, the ischemic optic neuropathy induced by giant cell arteritis is the major cause of rapidly developing bilateral blindness in patients >60 years

glucocorticoids is effective

Typical presenting symptoms include headache, polymyalgia rheumatica, jaw claudication, fever, and weight loss. Headache is the dominant symptom and often appears in association with malaise and muscle aches. Head pain may be unilateral or bilateral
and is located temporally in 50% of patients but may involve any and all aspects of the cranium.
Pain usually appears gradually over a few hours before peak intensity is reached; occasionally, it is explosive
in onset. The quality of pain is only seldom throbbing; it is almost invariably described as dull and boring, with superimposed episodic stabbing pains similar to the sharp pains that appear in migraine.

Most patients can recognize that the origin of their head pain is superficial, external to the skull, rather than originating deep within the cranium (the pain site for migraineurs). Scalp tenderness is present, often to a marked degree; brushing the hair or resting the head on a pillow may be impossible because of pain. Headache is usually worse at night and often aggravated by exposure to cold

reddened, tender nodules or red streaking of the skin overlying the temporal arteries, and tenderness of the temporal or, less commonly, the occipital arteries

The erythrocyte sedimentation rate (ESR) is often, although not always, elevated

Question 185

Diagnosis and Tx of Temporal Arteritis

Answer 185

A temporal artery biopsy followed by immediate treatment with prednisone 80 mg daily for the first 4–6 weeks should be initiated when clinical suspicion is high.

Question 186

may present with a prostrating headache associated with nausea and vomiting. The headache often starts with severe eye pain

On physical examination, the eye is often red with a fixed, moderately
dilated pupil.

Answer 186

Glaucoma

Question 187

Classiification of Chronic Daily Headache

Answer 187

> 4 h Daily
Chronic migraine Headace

<4 h Daily
Chronic cluster headache

Question 188

when a patient experiences headache on 15 days or more per month.

Answer 188

chronic daily headache (CDH)

Question 189

are also useful in migraine

Answer 189

Tricyclics are started in low doses (10–25 mg) daily and may be given 12 h before the expected time of awakening in order to avoid excess morning sleepiness. Anticonvulsants, such as topiramate,
valproate, flunarizine (not available in the United States), and candesartan

Question 190

(SUNA), (SUNCT)

Answer 190

short-lasting unilateral neuralgiform
headache attacks with cranial autonomic symptoms

short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing

Question 191

Overuse of analgesic medication for headache can aggravate headache frequency, markedly impair the effect of preventive medicines, and induce a state of refractory daily or near-daily headache called

Answer 191

medication-overuse headache

One approach is to reduce the medication dose
by 10% every 1–2 weeks. Immediate cessation of analgesic use is possible for some patients, provided there is no contraindication

small dose of a nonsteroidal anti-inflammatory drug (NSAID) such as naproxen, 500 mg bid

Question 192

is used for opioid withdrawal symptoms

Answer 192

clonidine

Question 193

Tx for substance withdrawal causing headache

Answer 193

Three to 5 days into the admission, as the effect of the withdrawn substance wears off, a course of IV dihydroergotamine (DHE) can be used. DHE, administered every 8 h for 5 consecutive days, can
induce a significant remission that allows a preventive treatment to be established

Question 194

presents with headache on most if not all days, and the patient can clearly, and often vividly, recall the moment of onset. The headache usually begins abruptly, but onset may be more gradual; evolution over 3 days has been proposed as the upper limit for this syndrome.

Answer 194

NDPH New Daily Persistent Headache

Question 195

head pain is positional: it begins when the patient sits or stands upright and resolves upon reclining.

The pain, which is occipitofrontal, is usually a dull ache but may be throbbing.

Patients typically present with a history of headache from one day to the next that is generally not present
on waking but worsens during the day.

Recumbency usually improves the headache within minutes, and it can take only minutes to an hour for the pain to return when the patient resumes an upright position

Answer 195

Low CSF Volume Headache

Question 196

The most common cause of headache due to persistent low CSF volume is

Answer 196

CSF leak following LP

Question 197

Post-LP headache usually begins within

Answer 197

48 h but may be delayed for up to 12 days

Beverages with caffeine may provide temporary
relief. Besides LP, index events may include epidural injection or a vigorous Valsalva maneuver, such as from lifting, straining, coughing, clearing the eustachian tubes in an airplane, or multiple orgasms.

Symptoms appear to result from low volume rather than low pressure: although low CSF pressures, typically 0–50 mmH2O, are usually identified, a pressure as high as 140 mmH2O has been noted with a documented leak

Postural orthostatic tachycardia syndrome (POTS) can present with orthostatic headache similar to low CSF volume headache and is a diagnosis that needs consideration in this setting

Question 198

Initial treatment for low CSF volume headache is

Answer 198

bed rest.

For patients with persistent pain, IV caffeine (500 mg in 500 mL of saline administered over 2 h) can be very effective

An electrocardiogram (ECG) to screen for arrhythmia should be performed before administration

It is reasonable to administer at least two infusions of caffeine before embarking on additional tests to identify the source of the CSF leak

If unsuccessful, an abdominal binder may be helpful. If a leak can be identified, an autologous blood patch is usually curative. A blood patch is also effective for post-LP headache; in this setting, the location is empirically determined to be the site of the LP.

In patients with intractable pain, oral theophylline is a useful alternative; however, its effect is less rapid than caffeine

Question 199

increased ICP

Answer 199

Initial treatment is with acetazolamide (250–500 mg bid); the headache may improve within weeks. If ineffective, topiramate is the next treatment of choice

Question 200

as a “subjective experience

of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity.

Answer 200

dyspnea

Question 201

in the carotid bodies and medulla
are activated by hypoxemia, acute hypercapnia, and acidemia. Stimulation of these receptors and of others that lead to an increase in ventilation produce a sensation of “air hunger

Answer 201

Chemoreceptors

Question 202

chest radiograph in cardiogenic pulmonary edema typically

shows

Answer 202

an enlarged cardiac silhouette, vascular redistribution, interstitial thickening, and perihilar alveolar infiltrates; pleural effusions are common.

In noncardiogenic pulmonary edema, heart size is normal, alveolar infiltrates are distributed more uniformly throughout the lungs, and pleural effusions are uncommon

Question 203

The American Thoracic Society defines__ as a “subjective experience of breathing discomfort that consists of qualitatively distinct
sensations that vary in intensity

Answer 203

dyspnea

Question 204

Chemoreceptors in the__
are activated by hypoxemia, acute hypercapnia, and acidemia. Stimulation of these receptors and of others that lead to an increase in ventilation produce a sensation of “air hunger.”

Answer 204

carotid bodies and medulla

Question 205

__ in the lungs, when stimulated by bronchospasm, lead to a sensation of chest tightness.

Answer 205

Mechanoreceptors

Question 206

__which are sensitive to interstitial edema,
and pulmonary vascular receptors, which are activated by acute changes in pulmonary artery pressure, appear to contribute to air hunger.

Answer 206

J-receptors

Question 207

should be considered when the patient complains of platypnea—i.e., dyspnea in the upright position with relief in the supine position

Answer 207

Left atrial myxoma or hepatopulmonary syndrome

Question 208

Clubbing of

the digits may be an indication

Answer 208

interstitial pulmonary fibrosis

Question 209

___is useful in patients with intermittent symptoms suggestive of asthma but normal physical examination
and lung function

Answer 209

Bronchoprovocation testing

Question 210

Supplemental O2 should be administered if the resting O2 saturation is

Answer 210

≤89% or if the patient’s saturation drops to these levels

with activity.

Question 211

Early signs of pulmonary edema

Answer 211

include exertional dyspnea and

orthopnea.

Question 212

Chest radiographs of pulmonary edema

Answer 212

peribronchial thickening,
prominent vascular markings in the upper lung zones, and Kerley B lines.
As the pulmonary edema worsens, alveoli fill with fluid

the chest radiograph shows patchy alveolar filling, typically in a perihilar distribution, which then progresses to diffuse alveolar infiltrates. Increasing airway edema is associated with rhonchi and wheezes

Question 213

in cardiogenic pulmonary edema typically shows

Answer 213

an enlarged cardiac silhouette, vascular redistribution, interstitial thickening, and perihilar alveolar infiltrates; pleural effusions are common

hypoxemia of
cardiogenic pulmonary edema is due largely to V /Q to mismatch and responds to the administration of supplemental oxygen

Question 214

The chest radiograph In noncardiogenic pulmonary edema

Answer 214

heart size is normal, alveolar infiltrates are distributed more uniformly throughout the lungs, and pleural effusions are uncommon

hypoxemia in noncardiogenic pulmonary edema is due primarily to intrapulmonary shunting and typically persists despite high concentrations of inhaled oxygen

Question 215

Spontaneous cough is triggered by stimulation of sensory nerve endings that are thought to be

Answer 215

primarily rapidly adapting receptors and C fibers

Question 216

Afferent nerve endings richly innervate the pharynx, larynx, and airways to the level of the terminal bronchioles and extend into the lung parenchyma. They may also be located in the external auditory meatus

AKA

Answer 216

(the auricular branch of the vagus nerve, or the Arnold nerve) and in the esophagus

Question 217

in cough
Sensory signals travel via the vagus and superior laryngeal nerves to a region of the brainstem in the nucleus tractus solitarius vaguely identified as the

Answer 217

“cough center.”

Question 218

Acute cough is most commonly due to a respiratory tract infection, aspiration, or inhalation of noxious chemicals or smoke.

duration?

Answer 218

(<3 weeks)

Question 219

Subacute cough is a common residuum of
tracheobronchitis, as in pertussis or “postviral tussive syndrome

duration?

Answer 219

(3–8 weeks in duration)

Question 220

Chronic cough

duration?

Answer 220

(>8 weeks

Question 221

ACE inhibitor–induced cough occurs in__% of
patients taking these agents and is not dose dependent. ACE metabolizes
bradykinin and other tachykinins, such as substance P

Answer 221

5–30%

The mechanism of ACE inhibitor–associated cough may involve sensitization of sensory nerve endings due to accumulation of bradykinin.

Question 222

Cough due to asthma in the absence

of wheezing, shortness of breath, and chest tightness is referred to as

Answer 222

“cough-variant asthma

Cough-variant asthma typically responds well to inhaled glucocorticoids and intermittent use of inhaled β-agonist bronchodilators

Question 223

causes chronic cough with a normal chest radiograph.

This condition is characterized by sputum eosinophilia in excess of 3% without airflow obstruction or bronchial
hyperresponsiveness and is successfully treated with inhaled glucocorticoids

Answer 223

Chronic eosinophilic bronchitis

Question 224

also called cough hypersensitivity syndrome,
is distressingly common. It is often experienced as a tickle or sensitivity in the throat, occurs more often in women, and is typically “dry” or at most productive of scant amounts of mucoid sputum

Answer 224

Chronic idiopathic cough

Most effective are narcotic cough suppressants, such as codeine or hydrocodone, which are thought to act in the “cough center” in the brainstem

Case series have reported benefit
from off-label use of gabapentin or amitriptyline for chronic idiopathic
cough.

Question 225

is an over-the-counter, centrally acting

cough suppressant with fewer side effects and less efficacy than the narcotic cough suppressants

Answer 225

Dextromethorphan

Dextromethorphan is thought to have
a different site of action than narcotic cough suppressants and can be
used in combination with them if necessary

Question 226

the expectoration of blood from the respiratory tract, can arise at any location from the alveoli to the glottis.

Answer 226

Hemoptysis

It is important to distinguish hemoptysis from epistaxis (bleeding from the nasopharynx) and hematemesis (bleeding from the upper gastrointestinal tract)

Worldwide, the most common cause of hemoptysis is infection with Mycobacterium tuberculosis, presumably because of the high prevalence of tuberculosis and its predilection for cavity formation.

Question 227

Diffuse bleeding in the alveolar space, often referred to as may present as hemoptysis.

Answer 227

diffuse alveolar hemorrhage (DAH)

Causes of DAH can be inflammatory or noninflammatory. Inflammatory DAH is due to smallvessel vasculitis/capillaritis from a variety of diseases, including granulomatosis with polyangiitis and microscopic polyangiitis

Antibodies to the alveolar basement membrane, as are seen in Goodpasture’s disease, can also result in alveolar hemorrhage

DAH should be suspected in patients with sudden onset dyspnea and hypoxemia in the first 100 days after bone marrow transplantation

Question 228

organisms such as___ can also result in hemoptysis

Answer 228

Streptococcus pneumoniae, Haemophilus influenzae,

or Moraxella catarrhalis

Question 229

(a permanent dilation of the airways with loss of

mucosal integrity)

Answer 229

bronchiectasis

One common presentation of
patients with advanced cystic fibrosis—the prototypical bronchiectatic lung disease—is hemoptysis, which can be life-threatening.

Question 230

(the dilation of a pulmonary artery in a cavity formed by previous tuberculous infection) remains
a source of massive, life-threatening hemoptysis in the developing world.

Answer 230

Rasmussen’s aneurysm

Question 231

has been reported secondary to ingestion of crayfish or small crabs

Answer 231

pulmonary paragonimiasis

Question 232

Malignancies that commonly

metastasize to the lungs include

Answer 232

renal cell, breast, colon, testicular, and thyroid cancers as well as melanoma. While hemoptysis is not a common manifestation of pulmonary metastases, the combination of multiple pulmonary nodules and hemoptysis should raise suspicion of this etiology

Question 233

Patients with a__ can
present with an upper-lobe opacity on chest radiography together with hemoptysis. This finding is thought to be due to focal increases in pulmonary capillary pressure due to the regurgitant jet.

Pulmonary
arteriovenous malformations are prone to bleeding

Answer 233

focal jet of mitral regurgitation

Question 234

Monthly hemoptysis in a woman suggests

Answer 234

catamenial hemoptysis from pulmonary endometriosis

Question 235

Large-volume hemoptysis, referred to as massive

hemoptysis, is variably defined as hemoptysis of

Answer 235

> 200–600 mL in 24 h.

Question 236

About one-third of total-body water is confined to the extracellular space. Approximately __% of the latter is interstitial fluid, and the remainder is the plasma

Answer 236

75

The forces that regulate the disposition of fluid between these two components of the extracellular compartment frequently are referred to as the Starling forces

Question 237

is defined as a clinically apparent increase in the interstitial fluid volume, which develops when Starling forces are altered so that there is increased flow of fluid from the vascular system into the interstitium.

Answer 237

Edema

Question 238

___characteristic of states in which the effective arterial blood volume is reduced is translated by the renal juxtaglomerular cells (specialized myoepithelial cells surrounding the afferent arteriole) into a signal for increased renin release

Answer 238

The diminished renal blood flow

Question 239

is an enzyme with a molecular mass of about 40,000 Da that acts on its substrate, angiotensinogen, an α2-globulin synthesized by the liver, to release angiotensin I, a decapeptide, which in turn is converted to angiotensin II (AII), an octapeptide.

Answer 239

Renin

Question 240

has generalized vasoconstrictor
properties, particularly on the renal efferent arterioles.

This action reduces the hydrostatic pressure in the peritubular capillaries, whereas the increased filtration fraction raises the colloid osmotic pressure in
these vessels, thereby enhancing salt and water reabsorption in the proximal tubule as well as in the ascending limb of the loop of Henle.

Answer 240

Angiotensin 2

Question 241

operates as both a hormonal and paracrine system. Its activation causes sodium and water retention and thereby contributes to edema formation.

Blockade of the conversion of angiotensin I to AII and blockade of the AII receptor enhance sodium and water excretion and reduce many forms
of edema.

Answer 241

The renin-angiotensin-aldosterone system (RAAS)

Question 242

Angiotensin 2 enters the systemic circulation stimulates the production of ___ by the zona glomerulosa of the adrenal cortex.

Answer 242

aldosterone

Aldosterone in turn enhances sodium reabsorption (and potassium excretion) by the collecting tubule, further favoring edema formation

Question 243

In patients with___, not only is aldosterone secretion elevated
but the biologic half-life of the hormone is prolonged secondary to the depression of hepatic blood flow, which reduces its hepatic catabolism and increases further the plasma level of the hormone

Answer 243

heart failure

Question 244

Blockade of the action of aldosterone by spironolactone or eplerenone

Answer 244

(aldosterone antagonists) or by

amiloride (a blocker of epithelial sodium channels

Question 245

The secretion of __

occurs in response to increased intracellular osmolar concentration, and, by stimulating V2 receptors,

Answer 245

arginine vasopressin (AVP)

AVP increases the reabsorption of free water in the distal tubules and collecting ducts of the kidneys,
thereby increasing total-body water

Circulating AVP is elevated in many patients with heart failure secondary to a nonosmotic stimulus associated with decreased effective arterial volume and reduced compliance of the left atrium. Such patients fail to show the normal reduction of AVP with a reduction of osmolality, contributing to edema formation and hyponatremia

Question 246

This potent peptide vasoconstrictor is released by endothelial cells. Its concentration in the plasma is elevated in patients with severe heart failure and contributes to renal vasoconstriction, sodium retention,
and edema

Answer 246

ENDOTHELIN-1

Question 247

Atrial distention causes release into the circulation of__, a polypeptide; a high-molecular-weight precursor of

Answer 247

atrial natriuretic peptide (ANP)

ANP is stored in secretory granules within atrial myocytes

Question 248

___ is stored primarily in ventricular myocytes and is released when ventricular diastolic pressure rises

Answer 248

brain natriuretic peptide (pre-prohormone

BNP)

Question 249

Released ANP and BNP (which is derived from its precursor) bind to the natriuretic receptor-A, which
causes:

Answer 249

(1) excretion of sodium and water by augmenting glomerular filtration rate, inhibiting sodium reabsorption in the proximal tubule, and inhibiting release of renin and aldosterone; and
(2) dilation of arterioles and venules by antagonizing the vasoconstrictor actions of AII, AVP, and sympathetic stimulation.

Thus, elevated levels of natriuretic peptides have the capacity to oppose sodium retention in hypervolemic and edematous states

Although circulating levels of ANP and BNP are elevated in heart failure and in cirrhosis with ascites, the natriuretic peptides are not sufficiently potent to prevent edema
formation.

Question 250

Systems ___are responsible for a majority of patients

with generalized edema.

Answer 250

Cardiac, renal, hepatic, or nutritional disorders

Question 251

acts as a stimulus for renal sodium retention

and causes a reduction of effective arterial blood volume.

Answer 251

Intrahepatic hypertension

These alterations are frequently complicated by hypoalbuminemia secondary to reduced hepatic synthesis of albumin, as well as peripheral
arterial vasodilation.

Question 252

Patients with edema due to acute renal failure commonly have arterial hypertension as well as pulmonary congestion on chest roentgenogram,
often without considerable cardiac enlargement, but they may not develop orthopnea.

Answer 252

Patients with chronic renal failure may also

develop edema due to primary renal retention of sodium and water.

Question 253

This condition is characterized in part by hepatic venous outflow blockade, which in turn expands
the splanchnic blood volume and increases hepatic lymph formation.

Answer 253

Hepatic Cirrhosis

Intrahepatic hypertension acts as a stimulus for renal sodium retention and causes a reduction of effective arterial blood volume. These alterations are frequently complicated by hypoalbuminemia secondary to reduced hepatic synthesis of albumin, as well as peripheral arterial vasodilation.

These effects reduce the effective arterial blood volume further, leading to activation of the RAAS and renal sympathetic nerves and to release of AVP, endothelin, and other sodium and water-retaining mechanisms

The concentration of circulating aldosterone often is elevated by the failure of the liver to metabolize this hormone.

Question 254

The excess production of prostaglandins in cirrhosis

attenuates renal sodium retention.

Answer 254

(PGE2 and PGI2)

Question 255

DRugS ASSoCiATED wiTH EDEMA foRMATion

Answer 255

Nonsteroidal anti-inflammatory drugs
Antihypertensive agents

Direct arterial/arteriolar vasodilators
Hydralazine
Clonidine
Methyldopa
Guanethidine
Minoxidil
Calcium channel antagonists
α-Adrenergic antagonists

Thiazolidinediones
Steroid hormones
Glucocorticoids
Anabolic steroids

Estrogens
Progestins
Cyclosporine
Growth hormone
Immunotherapies
Interleukin 2
OKT3 monoclonal antibody

Question 256

The ingestion of more food may increase the quantity of sodium ingested, which is then retained along with water.

So-called___
also may be linked to increased release of insulin, which directly increases tubular sodium reabsorption

Answer 256

refeeding

edema

Question 257

These causes include hypothyroidism and hyperthyrodism

Answer 257

hypothyroidism (myxedema) and hyperthyroidism (pretibial myxedema secondary to Graves’ disease), the edema in which is typically non-pitting and due to deposition of hyaluronic acid and, in Graves’ disease, lymphocytic infiltration and inflammation;

Question 258

Severe heart failure may cause ascites that may be distinguished from the ascites caused
by hepatic cirrhosis by the

Answer 258

jugular venous pressure, which is usually

elevated in heart failure and normal in cirrhosis

Question 259

Edema resulting from hypoproteinemia, as occurs in the nephrotic syndrome, characteristically is generalized, but it is especially evident in the very soft tissues of the

Answer 259

eyelids and face and tends to be most pronounced in the morning owing to the recumbent posture assumed
during the night.

Question 260

hypoalbuminemia

Answer 260

serum albumin <25 g/L