FULLY RANDOMIZED PART IV Flashcards
1
Q
Early onset Alzheimer’s is inherited in an autosomal dominant fashion. Defects may occur in the following chromosomes and genes:Chromosome 1 (PSEN2)Chromosome 21 (APP)Chromosome 14 (PSEN1)Which inheritance of these defective genes is most commonly the cause of early onset Alzheimer’s?
A
PSEN1, on chromosome 14
2
Q
Comparing Crohn’s Disease and Ulcerative Colitis, which features remitting inflammation that is continuous?
A
Ulcerative Colitis
3
Q
True or false: most cases of acute HBV are self-limiting.
A
True.
4
Q
The CDC allows diagnosis of and treatment for Lyme disease based on their definition of EM and known exposure. Serological “two-tiered” testing is another way to try and diagnose this condition. Briefly describe two-tiered testing.
A
Start with an enzyme immunoassay (EIA) or an immunofluorescence assay (IFA). If negative, consider another diagnosis. If positive, continue to a Western Blot (for IgM and IgG if S/S less than 30 days, for IgG only if S/S for more than 30 days).
5
Q
The following are isoforms of the gene APOE on chromosome 19. Which of these isoforms is detrimental, and found in late onset Alzheimer’s? What does it cause?APOE-ε2APOE-ε3APOE-ε4
A
APOE-ε4. It increases beta-amyloid clumping, affects microtubule function, affects choline acetyltransferase activity in the hippocampus, and is associated with vascular disease.
6
Q
Wilson disease can present with liver, brain, and ocular symptoms. Name the liver symptoms.
A
Hepatitis, liver failure, cirrhosis
7
Q
True or false: the majority of patients infected with H. Pylori develop peptic ulcers.
A
False; only 10-15% of patients infected with H. Pylori develop peptic ulcers.
8
Q
Guidelines for starting ART are rated based on the recommendations and the evidence. What is the scale for rating recommendations?
A
A=strong recommendationB= moderate recommendationC=optional
9
Q
What would an EEG show in a patient with Creutzfeldt-Jakob disease?
A
Periodic sharp wave complexes
10
Q
Peripheral chemoreceptors would trigger increased respiration in resonse to what change in the blood?
A
Low O2 levels, high CO2 levels, or increased acidity.
11
Q
The National Dysphagia Diet consists of three levels, numbered 1-3, depending on the severity of the swallowing difficulty. Which level refers to a moderate to severe difficulty, in which the patient’s foods must have a pudding/puree-like consistency?
A
Level 1
12
Q
Treatment for specific cystic fibrosis mutations exists. Which two treatments were discussed in class, and what is their mechanism of action? What percentage of the cystic fibrosis population does each treatment reach?
A
Ivacaftor helps keep chloride channels open, but by itself is good for only 5% of the cystic fibrosis population.Adding lumacaftor (moves chloride channels) to ivacaftor (keeps channels open) increases the percentage to 25% of the cystic fibrosis population.
13
Q
What is the 5-year survival rate for hepatocellular carcinoma in the US?
A
10-12%
14
Q
What two conditions make up inflammatory bowel disease?
A
Crohn’s disease and ulcerative colitis.
15
Q
What are the symptoms of Zollinger-Ellison Syndrome?
A
Abdominal pain (from the ulcer), heartburn, diarrhea.
16
Q
What are the adverse effects of sulfa drugs?
A
SJS, aplastic anemia, hepatitis, ARF, pruritus, photosensitivity, hematuria, plus non-specific
17
Q
What are the signs and symptoms of pancreatic cancer?
A
Pain*, jaundice, weight loss, dark urine, pale stools, diarrhea, vomiting.
18
Q
Male patients with PPMS have the worst prognosis.
A
Free card.
19
Q
Which Cluster A personality disorder is characterized by suspicion without reason, and being unable to forgive?
A
Paranoid
20
Q
What ocular finding is a concern with interferon therapy?
A
Interferon retinopathy (CWS, superficial hemorrhages around ONH and posterior pole; also possible are subconj hemorrhages, BRAO, RD, ONH edema, and vitreous hemorrhages)
21
Q
What drugs for Huntington’s disease work by blocking dopamine receptors?
A
Risperidone, olanzapine, haloperidol.
22
Q
True or false: you should treat all patients with toxoplasmosis
A
False; immune competent, non-pregnant patients are usually not treated. If a patient is a newborn or immunocompromised, or if there is an ocular lesion threatening the macula, optic nerve, or papillomacular bundle, then treatment is usually pursued.
23
Q
What is the main possible complication for newborns with chlamydia?
A
Pneumonia; occurs 4-12 weeks after birth, no fever(FYI: otitis and vaginal or rectal infections also possible)
24
Q
What percentage of dementia are classified as Alzheimer’s?
A
60-80%
25
Cholelithiasis is another name for gallstones. 20% of gallstones are made of what?
Calcium bilirubinate
26
The diagnosis of dementia requires an acquired decline in one or more of several areas (learning/memory, language, executive function, etc.). What additional signs might be found in a patient with Alzheimer's Disease?
Loss of insight, sleep disturbances, seizures, olfactory changes.
27
Cerebrovascular disease is the fifth leading cause of death in the US, second worldwide. What percentage of these events are ischemic, and what percentage are hemorrhagic?
80% are ischemic; 20% are hemorrhagic
28
What lab tests are available for the diagnosis of gonorrhea? Which is preferred by the CDC, and what kinds of samples can be used for it?
Gram stain, culture, NAATNAAT is preferred by the CDC; can use urine or urethral or cervical swabs.
29
Which individuals are at higher risk for contracting TB?
Highest risk:-Close contact of patients suspected of having TB-Immune suppressed-Recent exposureLower risk-Health care workers serving high risk patients-Residents/employees of long-term care facilities, jails, homeless shelters, mycobateriology labs-Recent immigrants from high TB prevalence countries-Injectable drug users-Patients with chronic medical conditions-Children under 4 years old
30
What are the prodromal symptoms of HAV?
Fatigue, nausea, upper quadrant pain, anorexia, fever
31
Which GI condition leads to atrophy of esophageal smooth muscle and loss of LES tone?
Scleroderma esophagus.
32
True or false: at least 50% of people with antisocial disorder have depressive disorders, and at least 25% have anxiety disorder.
False; at least 50% of people with antisocial disorder have anxiety disorders, and at least 25% have depressive disorder.
33
True or false: with basilar migraine, it is possible for a patient to have weakness
False; there should be no evidence of weakness.
34
How would you treat a patient with Wilson Disease?
Detoxity with chelation, and prevent accumulation of copper by avoiding shellfish, liver, mushrooms, nuts, and chocolates. You can also have the patient take zinc to decrease copper absorption in the intestines.
35
What are the five "A's" of smoking cessation?
As a doctor, you need to -Ask patient about tobacco use-Advise them to quit-Assess their readiness to quit-Assist them to set goals and get help-Arrange a follow up
36
What is the definition of apnea?
Complete cessation of respiration for at least 10 seconds.
37
What are some of the chronic treatment options for cluster headaches?
Verapamil or prednisolone with taper
38
What is considered a normal respiratory rate for a newborn?
up to 44 cycles per minute
39
What is the typical transmission of Hepatitis A?
Fecal-oral
40
It is estimated that only 50% of individuals get recommended screening for STIs. What is the chlamydia screening recommendation for non-pregnant women?
Annual chlamydia screening if:-Sexually active AND-25 and underOR-Older AND-New or multiple sex partners
41
What are the 4 Cs of addiction?
Loss of Control (over drug use)Craving and Compulsive use of drugUse of drug despite adverse Consequences
42
What factors are taken into account when considering WNV as a diagnosis?
Symptoms consistent with the disease, having visited or lived in a high risk state.
43
Chronic traumatic encephalopathy is when repeated concussions cause cumulative neurologic defects, including an increase in risk for Alzheimer's.
Free card.
44
What is the survival rate of patients with bacterial meningitis?
25%
45
How would you treat symptomatic sarcoidosis?
Anti inflammatory meds (oral corticosteroids, steroid inhalers); immune modulating meds for severe cases (methotrexate, cyclosporine, hydroxychloroquine, azathioprine)
46
The cutaneous lesions of secondary syphilis are most obvious on the palms, hands, and soles of feet and DO NOT ITCH. Which other disease discussed in class features a maculopapular rash that SPARES the palms and soles? Which features a rash that DOES itch?
Acquired toxoplasmosis spares the palms and soles.HIV can feature an itchy rash.
47
True or false: the diaphragm is dome shaped with contraction, and returns to a flat shape upon relaxation.
False; it is dome-shaped at rest. When it contracts, it flattens and moves downward, to put negative pressure on the lungs during inspiration.
48
What are the symptoms of jaundice, besides the yellowing of skin, conjunctiva, and mucous membranes?
Pale stools*, dark urine*, itching, ever, chills, abdominal pain, and weight loss.
49
Though most (80%) patients with diverticula are asymptomatic, what symptoms are experienced by the other 20%?
Caused by inflammation or infection of the diverticula: acute lower abdominal pain (intermittent or constant), N&V, anorexia, and diarrhea or constipation.
50
When would a seizure indicate that you call 911?
If it lasts more than 5 minutes, if the patient stops breathing, if there are multiple seizures in a short period of time, if the patient is injured from the seizure, or if this is their first seizure. Also if any of the following are involved: diabetes, drain infection, heat exhaustion, poisoning, high fever, head injury, or pregnancy.
51
What are some viral causes of aspectic meningitis?
Enterovirus, herpes simplex, HIV, WNV, herpes zoster, mumps
52
Comparing intracerebral hemorrhage with subarachnoid hemorrhage, which has the more sudden onset?
Subarachnoid hemorrhage
53
Trigeminal autonomic cephalgias (TACs) are headache disorders with _____________ (unilateral/bilateral) trigeminal pain with _____________ (ipsilateral/contralateral) cranial autonomic features. Which headache disorders fit into this category?
UnilateralIpsilateralCluster headaches, paroxysmal hemicrania, and short-lasting unilateral neuralgiform headaches with conjunctival injection and tearing (SUNCT)
54
True or false: narcotics and opioids are good treatment options for acute migraines.
False; they are not recommended.
55
Prevention of migraines can be done with antidepressants like _________ and __________.
Amitriptyline and venlafaxine
56
Gastric glands in the stomach have surface mucus cells, mucus neck cells, parietal cells, chief cells, and endocrine cells. What do mucus neck cells secrete?
Mucus
57
Comparing Crohn's Disease and Ulcerative Colitis, which features lower left abdominal pain?
Ulcerative Colitis
58
What are the symptoms of gastric cancer?
Poor appetite, weight loss, abdominal pain, sense of fullness after small meals, heartburn, nausea, vomiting, swelling or fluid buildup in abdomen, anemia.
59
What is ophthalmia neonatorum prophylaxis?
Prophylactic instillation of erythromycin 0.5% ointment in neonate eyes immediately after deliver for potential gonorrheal conjunctivitis.
60
Which drugs are broad spectrum anti-epileptic drugs?
Lamotrigine, topiramate, valproate
61
What can you do if a patient faints in your chair?
Position them in a supine position and elevate their legs, and administer an ammonia inhalant.
62
What is the major cause of chronic pancreatitis? What are some other causes?
Alcohol abuse is the main cause. Ductal obstruction, tropical location, systemic diseases, autoimmune diseases are some other causes.
63
True or false: hypotension is a risk factor for trigeminal neuralgia.
False; hypertension is a risk factor for trigeminal neuralgia. (Thought to be due to compression on the nerve by an artery or a vein.)
64
What is expedited partner therapy? For which conditions discussed in class can it be done (depending on the state where you are practicing)?
It means you can write a prescription for your patient's sexual partner without ever having examined that person. It can only be done for chlamydia.
65
Fill in the blank: viral load is measured in log units (3.0 log units is 1000 RNA units/mm3) and is used to monitor ____________.
Response to antiretroviral therapy.
66
Stimulants increase alertness, attention, and energy. Which stimulants were asterisked in the presentation?
Methylphenidate, cocaine, and amphetamine derivatives.
67
Which blood gas can be used to determine if acidosis is due to a respiratory problem or a metabolic problem?
CO2--in a respiratory problem, it will be high. In a metabolic problem, it will be normal.
68
Which Cluster A personality disorder is characterized by unusual perceptual experiences and odd beliefs or magical thinking?
Schizotypal
69
In terms of reducing risk of disease progression, what guidelines are in place for when to start ART? How are these guidelines rated?
Based on CD4 cell count:Less than 350 cells per mm3, AI350-500 cells per mm3, AIIMore than 500 cells per mm3, BIII
70
True or false: absence seizures (petite mal) are convulsive seizures.
False; they are non-convulsive.
71
What is the most common symptom of acquired toxoplasmosis?
Non-tender cervical lymphadenopathy
72
The average age of death for patients with Huntington's disease is 51-57; most survive 10-25 years after onset.
Free card.
73
In terms of pharmacologic treatment for hemorrhagic stroke, you want the patient off any anticoagulants and antiplatelets. You would also initiate anti-HTN meds, and possible anti-epileptic drugs if the patient is having seizures. What specific drug can be used for subarachnoid hemorrhage?
Nimodipine.
74
True or false: asbestosis increases the risk for bronchogenic carcinoma
True. Malignanat mesothelioma of the pleura and peritoneum is also associated with asbestos exposure.
75
Which short acting bronchodilator is the most commonly used?
Albuterol.
76
Early congenital syphilis has manifestations prior to age two. What manifestations can occur?
Mucocutaneous lesions like those in secondary syphilis, as well as a bilateral rash with vesicles on the palms and feet, and inflammation of cartilage and bone (very painful, child may not move much).
77
Oropharyngeal dysphagia causes difficulty in initiating a swallow, and ___________ (solids/liquids) are more problematic.
Liquids.
78
What sorts of ocular opportunistic infections can occur with an HIV infection?
CMV, herpes (zoster or simplex), varicella-zoster, M. tubuerculosis, histoplasmosis, candidiasis, toxoplasmosis, molluscum contagiosum.
79
Where do the most common metastatic tumors arise from?
Lung cancer, breast cancer
80
About how long after infection does late neurosyphilis tend to occur?
10-30 years
81
True or false: major depressive disorder is more common among females and in the 20's
True.
82
What ethnic group, though only 12% of the US population, makes up 44% of new HIV infections in the US?
African American
83
The initial stage HIV infection occurs 2-4 weeks after infection, and usually consists only of mild flu-like symptoms. An skin rash can occur as well.
Free card.FYI: compare the itchy rash of early HIV infection to the non-itchy rash of secondary syphilis.
84
Combination medications are available for HIV treatment. What are the main advantages and disadvantages of combo meds?
Advantage: decreases the complexity of medication regimenDisadvantages: more expensive, and decreases overall effectiveness of the individual medications regimen (if it were perfectly followed)
85
True or false: 1/3 of patients with Bipolar I and 1/3 of patients with Bipolar II have a history of suicide attempt.
True.
86
What are the symptoms of cirrhosis?
Weight loss, weakness, jaundice, upper GI bleed, spider angioa, gynecomastia, ascites, splenomegaly, palmar erythema, digital clubbing, asterixis, hepatic encephalopathy, absent/irregular menstruation, erectile dysfunction, infertility in men, hepatomegaly.
87
What medications can be used for treatment of asthma?
Anti-inflammatory meds (steroids, LT inhibitors, mast cell stabilizers, monoclonal antibodies), adrenergic agonists (to reduce bronchospasm, mucous production, and mast cell degranulation), anticholinergics (prevent smooth muscle contraction), glucocorticoids (decrease inflammatory response), and monoclonal antibodies (decreases inflammatory response by binding with IgE).
88
The motor aura that occurs in hemiplegic migraines contrasts with the aura of basilar migraines in that the hemiplegic migraine auras last how long?
1 to 24 hours
89
All of the combo medications for HIV involve three medications. What is the one exception, and for what is it used?
Truvada contains only two nukes, and is used for pre-exposure prophylaxis.
90
True or false: you can treat a histoplasmosis patient with systemic corticosteroids without anti-fungals.
False; systemic corticosteroids are always given with anti-fungals.
91
True or false: as soon as the bronchi enter the lungs, air exchange begins to take place.
False; there is no air exchange through the first 18 bifurcations.
92
Which part of the basal ganglia is damaged in Parkinson's disease? What is the name for the abnormal protein clumps you might find there?
Substantia nigra; Lewy bodies.
93
There are lots of possible triggers for migraines. Which three were bolded on the list in class?
Emotional stress, hormones in women, not eating/hunger.
94
What is the name of the disease caused by a defect in the ATP7B gene? Is this an autosomal dominant or recessive condition? Transport of what substance is decreased in this condition.
Wilson Disease; autosomal recessive. Copper transport is decreased.
95
What techniques or treatments can be used to help clear the airways of a patient with cystic fibrosis?
Percussion/postural drainage, dornase alpha (makes sputum less viscous), hypertonic saline (to draw water out of cells, decrease viscosity of mucous).
96
Trigeminal neuralgia episodes last how long? Which branches of the trigeminal nerve are most commonly affected?
Episodes last a few seconds to 2 minutes*; V2 and/or V3 are most commonly affected*
97
What are the features of Parkinson's disease?
Bradykinesia, (resting) tremor, rigidity, and postural instability.
98
What type of headache is commonly misdiagnosed as due to sinusitis?
Migraine
99
With 35 million international infections (1.2 million in the US), what disease is the leading infectious killer?
HIV/AIDS
100
What are the non-ocular signs and symptoms of secondary syphilis?
Cutaneous lesions (rash on trunk/extremeties), mucous membrane lesions (small superficial ulcerated areas), condylomata lata (moist, wart-like papules in warm intertriginous [skin-on-skin] areas), alopecia (including eyebrows, eyelashes, and facial hair), and flu-like symptoms.
101
True or false: the symptoms of Barret's esophagus are the same as GERD.
True.
102
What is the #1 cause of COPD in the U.S.?
Smoking
103
Which of the anxiety disorders is more common in males? In females?
Males: none. Females: separation anxiety, specific phobia, panic disorder, panic attack specifier, agoraphobia, generalized anxiety disorder
104
The chronic stage of HIV infection lasts for months to years and exhibits only mild constitutional changes (if any). What two markers are used to manage and monitor the disease?
The viral load (HIV RNA in the blood) and CD4 T-cell count.
105
Bell's Palsy is the most common cranial nerve palsy and is most common in what kind of patient?
Pregnant women.
106
True or false: Barret's esophagus that invovles high-grade dysplasia has an 80% risk of cancer development.
False; it's a 30% risk of cancer development.
107
Comparing psychotherapy, sociotherapy, and pharmacotherapy, which is best to treat obsessive compulsive disorder?
Psychotherapy
108
What is the drug of choice to treat general seizures? What pregnancy category does this drug fall into?
Valproate; Category D. Note: valproate can also be used for anti-convulsion in MS.
109
HIV transmission can occur through exposure to any bodily fluids except _______.
SweatFYI: there hasn't yet been a documented case of transmission through tears, but it's still on the list.
110
List the treatment for neurosyphilis, or syphilis with ophthalmic involvement.
Penicillin G aqeous, 18-24 million U IV for 10-14 days (divided into q4h)ORProcaine penicillin 2.4 million U IM qd with probenicid 500 mg po qid for 10-14 daysORIf allergic to penicillin and not pregnant-Ceftriaxone 2 g qd IM or IV for 10-14 days
111
What are some potential complications of HBV?
Cirrhosis, hepatocellular carcinoma, hepatic failure, and serum sickness
112
What other treatment options, besides drugs and surgery, may be used to help with seizures?
Vagus nerve stimulation, and NeuroPace (brain implant that interrupts seizures automatically)
113
What percent of patients with MG have an abnormality of the thymus? What percent have a thymoma?
60-70% = abnormal thymus; 10-12% have a thymoma.
114
Some medications can be used to manage the symptoms of MS. Which medication helps improve walking speed?
Dalfamiridine
115
Which Cluster B personality disorder is characterized by a need to be the center of attention, inappropriate provacative behavior, and use of physical appearance to draw attention?
Histrionic
116
What percent of untreated patients with MS develop significant disability in 20-25 years?
30%
117
Hiatal hernia predisposes a patient to develop which esophageal disorder? GERD, achalasia, or inability to form a bolus?
GERD.
118
What is the name for the postictal paresis that can sometimes occur in a patient after a tonic-clonic seizure?
Todd's paralysis; it typically lasts less than 48 hours
119
Testing for serum bilirubin (both conjugated and unconjugated) is one way to test for liver function. Which, conjugated or unconjugated, is found in small amounts in the serum of healthy patients?
Unconjugated
120
How would you evaluate a patient for sarcoidosis?
Chest x-ray, pulmonary function tests; lab tests for ACE (released by pulmonary granulomas), creatnine, calcium, and liver enzymes; TB test (to rule it out); and Kveim test.
121
What are the signs and symptoms of chronic pancreatitis?
Epigastric abdominal pain, jaundice, and inability to digest complex foods.
122
What are the ocular manifestations of cannabis use?
Conjunctival hyperemia, decreased IOP, decreased tear production, slightly dilated pupil.
123
True or false: 1/3 of patients with schizophreniform recover within 6 months, and 2/3 develop schizophrenia or schizoaffective disorder.
True.
124
There are four categories of histoplasmosis. Which is uncommonly diagnosed and found usually in infants and children? How is the prognosis?
Primary acute. Resolves to the benign form in 1-3 months without treatment
125
What is the cause of most cases of encephalitis?
Viral (usually herpes simplex)
126
What would a brain biopsy show in a patient with Creutzfeldt-Jakob disease?
Spongiform degeneration (pockets left by misfolded proteins)
127
In terms of preventing disease transmission, what guidelines are in place for when to start ART? How are these guidelines rated?
Based on transmission risks:-Perinatal, AI-Heterosexual, AI-Other, AIII
128
True or false: internuclear ophthalmoplegia is one of the symptoms of MS.
True.
129
Which Cluster C personality disorder is characterized by preoccupation with details, perfectionism, devotion to the point of exclusion of lesure, and reluctance to delegate tasks or work with others?
Obsessive compulsive
130
True or false: toxocara canis is transferred to puppies through their mother.
True.
131
What medications can be given to treat GERD?
Antacids, H2 blocking agents, and proton pump inhibitors.
132
What are the typical symptoms of GERD?
Heartburn, regurgitation, and dysphagia
133
Workup for Zollinger-Ellison Syndrome involves endoscopy (for diagnosis of the ulcer), imaging to locate the gastrinoma, and testing of serum gastrin level. What level of serum gastrin is indicative of a gastrinoma?
More than 1000 pg/mL
134
In 75% of patients with Gardner's Syndrome, there are multiple, bilateral familiar CHRPEs (sometimes called pigmented ocular fundus lesions of FAP, or POFLs)
Free card.
135
How long does it take for inhaled cocaine to reach the brain? How long is its effect?
Reaches brain in 3-5 minutes, lasts 60-90 minutes
136
Which type of TBI is the most severe?
Diffuse axonal injury
137
The DEA has established drug schedules to classify drugs according to the acceptable medical uses and the drug's abuse or dependency potential. The schedule runs from I to V. Which schedule has the highest potential for abuse, and which has the lowest?
Schedule I = highest potential for abuse. Schedule V = lowest potential for abuse.
138
Encephalitis has more severe brain function abnormalities than meningitis.
Free card.
139
What are the symptoms of acute HCV?
Fatigue, myalgias, right upper quadrant pain, N&V, poor appetite. (Remember that most acute HCV is asymptomatic, though.)
140
True or false: the tuberculin skin test is injected perpendicular to the long axis of the arm, and measured parallel to the long axis of the arm.
False; it is injected parallel to the long axis and measured perpendicular to the long axis.
141
Epilepsy is characterized by decreased amounts of which neurotransmitter? And increased activation of which receptors?
Decreased GABA (decreased inhibition) and increased NMDA activation (increased excitation)
142
There is an incubation period typically of 2-6 days for West Nile Virus before symptoms start to appear. What type of non-ocular symptoms are there? How many people infected with WNV experience these symptoms?
Only 20%; it's known as West Nile Fever at this stage. Early symptoms include flu-like symptoms, rash on trunk.
143
There are four categories of histoplasmosis. Which is the most common form? Which syndrome might we as optometrists identify in these patients?
Benign is the most common. We could identify presumed ocular histoplasmosis syndrome (POHS). This syndrome involves circumpapillary choroiditis, atrophic chorioretinal scars (histo spots), and exudative maculopathy. Choroidal neovascularization can occur.
144
During alcohol withdrawal, many symptoms can occur (anxiety, irritability, insomnia, tremor, tachycardia, hypertension, hyperthermia, N&V, seizures, hallucinations, etc). What type of medication can reduce the tremors, seizures, hallucinations, anxiety?
Benzodiazepines.
145
Post-treatment Lyme disease is a very serious condition that features continuing pain, sleep disturbance, and cognitive dysfunction. It occurs in 10-20% of patients with Lyme disease.
Free card.
