IM 2.0 Flashcards

Question

Criteria for resectability of hepatic metastases

Answer 1

Most patients with good performance status can be considered for surgical resection unless they have one of three conditions: tumor involvement of the common artery or portal vein or common bile duct; more than 70% liver involvement, more than six involved segments, or involvement of all three hepatic veins; and a predicted inadequate hepatic reserve after resection.

Answer 2

AP; assesses the metabolic activity of the disease

Answer 3

Adynamic bone disease can occur in patients with chronic kidney disease (CKD) or those on dialysis. It is typically associated with significant vascular calcifications. The gold standard for the diagnosis of adynamic bone disease is bone biopsy; however, this is rarely performed. Adynamic bone disease has no specific markers, but a constellation of findings may suggest this diagnosis. Patients with adynamic bone disease may present with fracture or bone pain. The latter has been attributed to the inability to repair microdamage because of low turnover. Serum calcium may be normal or elevated because the bone is unable to take up calcium. High PTH and alkaline phosphatase would exclude adynamic bone disease; in this disorder, both are typically normal. Treatment is targeted at factors that allow PTH secretion to rise. This includes avoiding calcium-based binders, conservative use of vitamin D, and decreasing the dialysate calcium concentration.

Answer 4

Osteitis fibrosa cystica is due to abnormally high bone turnover in secondary hyperparathyroidism and increases the risk of fracture. Patients can be asymptomatic, or they may have bone pain. Classic skeletal changes on radiograph include subperiosteal resorption of bone, most prominently at the phalanges of the hands, and radiolucent bone cysts of the long bones.

Answer 5

PML is a demyelinating disease of the central nervous system (CNS) caused by the JC polyomavirus. It occurs almost exclusively in severely immunocompromised patients, including those with advanced HIV infection/AIDS. Clinical findings of PML include dementia, hemiparesis or paralysis of one extremity, ataxia, hemianopia, and diplopia. The characteristic MRI appearance of these lesions is hyperintense (white) areas on T2-weighted images and fluid-attenuated inversion recovery sequences (FLAIR) and hypointense (dark) areas on T1-weighted images. There is usually no mass effect. In patients with advanced HIV infection/AIDS, the probability of PML exceeds 80% in those with white matter lesions with no mass effect. The finding of a positive JC virus nucleic acid amplification test in cerebrospinal fluid can also make the diagnosis. Treatment involves commencement of antiretroviral therapy to reverse the immunosuppression that interferes with the normal host response to the JC virus.

Answer 6

Impetigo is most commonly caused by Staphylococcus aureus or beta-hemolytic streptococci. Impetigo can be either nonbullous or bullous impetigo. - Bullous impetigo is a toxin-mediated process usually caused by production of an exfoliative toxin by S. aureus, which induces erythema and loss of the superficial layer of the epidermis. - Nonbullous impetigo is the more common type and often affects the face or extremities. It appears as erythematous papules or pustules that rupture and then progress to erosions with overlying honey-colored crust. The diagnosis of impetigo often can be made based on clinical presentation; however, culture of the honey-colored crust can confirm the pathologic organism and obtain sensitivity testing, which is important when treating extensive disease or staphylococcal scalded skin syndrome. Tx: Mupirocin is a topical antibiotic that inhibits bacterial protein synthesis and is used for localized infection; oral antibiotics required only for extensive lesions

Answer 7

Exercise echocardiography Explanation: Symptoms typically occur with exertion because exercise shortens diastolic filling time and increases the transvalvular flow and diastolic mitral gradient, leading to worsening of left atrial hypertension. Patients can also present with systemic embolization, atrial fibrillation, or, in severe cases, hemoptysis. Heart failure is the cause of death in approximately 60% of patients with mitral stenosis, and thromboembolism is the cause in most others. Symptoms typically are not present until the mitral valve area is less than 1.5 cm2. For patients with mitral stenosis, the valve gradient is heavily flow dependent and may become severely elevated only with exercise. Exercise and the accompanying increases in heart rate augment cardiac output and transvalvular flow and shorten the diastolic filling time in the left ventricle. These conditions can unmask mitral stenosis that does not appear to be echocardiographically severe at rest. With an increase in left atrial pressures during exercise, significant pulmonary hypertension also may become evident.

Answer 8

Asplenia is a major risk factor for fulminant Babesia infection, as is older age, HIV infection, or other immunocompromising conditions. Clinical manifestations are variable, with most relating to severe hemolytic anemia. Infection can be diagnosed by visualization of intraerythrocytic parasites, which appear as either ring forms or tetrads, with the latter often described as having the Maltese cross appearance shown. Complications, including acute respiratory distress syndrome, disseminated intravascular coagulation, heart failure, kidney failure, and coma, are associated with severe anemia (hematocrit level <30%) and parasitemia (exceeding 10%) and are indications for exchange transfusion.

Answer 9

(Polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes). POEMS syndrome is characterized by the presence of a monoclonal plasma cell disorder, peripheral neuropathy, and one or more of the following: osteosclerotic myeloma, Castleman disease (angiofollicular lymph node hyperplasia), elevated serum vascular endothelial growth factor, organomegaly, endocrinopathy, edema, typical skin changes, and papilledema. It is indicative of an underlying malignancy

Answer 10

-The most common cause of primary amenorrhea is gonadal dysgenesis caused by chromosomal abnormalities, most commonly those associated with Turner syndrome (TS). TS is caused by loss of part or all of an X chromosome (45,X0) occurring in 1 in 2500 live female births. In some studies, more than 20% of patients are diagnosed after 12 years of age; primary amenorrhea may be the presenting sign. -The most consistent physical finding is short stature, as seen in this patient. Other findings may include neck webbing, hearing loss, aortic coarctation, and bicuspid aortic valve. Primary amenorrhea is seen in approximately 90% of women with TS. TS should be considered in women with primary or secondary amenorrhea, particularly those of short stature. -Diagnosis is made by karyotype analysis.

Answer 11

Low dose prednisone therapy -Can also use low-dose colchicine or NSAIDs if there are no other comorbidities in the patient

Answer 12

Hypoechoic material distending the dorsal joint capsule suggests synovial hypertrophy due to rheumatoid arthritis. Erosion can be noted over the metacarpal head. Ultrasonography is more sensitive than plain radiography for the detection of mild rheumatoid arthritis changes, which include joint fluid, synovial tissue thickening, early erosions, and increased vascularity.

Answer 13

Ascitic-fluid total protein level less than 1.5 g/dL (15 g/L) in conjunction with any of the following: -sodium level less than or equal to 130 mEq/L -creatinine level greater than or equal to 1.2 mg/dL -blood urea nitrogen level greater than or equal to 25 mg/dL -bilirubin level greater than or equal to 3 mg/dL (51.3 µmol/L) -Child-Turcotte-Pugh class B or C cirrhosis. -Prior episode of SBP (regardless of ascitic fluid protein level) -7 day course indicated with episode of variceal bleeding

Answer 14

Needs two doses; 3 if there is a current outbreak

Answer 15

Basophilic stippling is associated with megaloblastic anemias (such as cobalamin deficiency), thalassemia, sickle cell anemia, sideroblastic anemia, alcohol abuse, and lead poisoning -Basophilic stippling itself is leftover ribosomal fragments that have yet to be degraded

Answer 16

Superficial, saucer-shaped ulcers with overlying crusts are the classic findings of classic ecthyma, which is a variant of impetigo. They almost always occur on the legs or feet and are usually caused by streptococci.

Answer 17

Lupus pneumonitis is a rare but severe presentation of SLE characterized by shortness of breath, hypoxia, and diffuse pulmonary infiltrates. Other major entities in the differential diagnosis include infection and diffuse alveolar hemorrhage. Signs pointing to this are: evidence of active SLE with polyarthritis, a high erythrocyte sedimentation rate, hypocomplementemia, and diffuse pulmonary infiltrates on radiologic studies, as well as lymphocytic predominance on bronchoalveolar lavage. It usually requires rapid and aggressive therapy with glucocorticoids and/or immunosuppressive agents.

Answer 18

"Discoid" lupus consists of ongoing, slowly progressive, scaly infiltrative papules and plaques or atrophic red plaques (also known as discoid lupus erythematosus) on sun-exposed skin surfaces. Other chronic lesions may be hypertrophic or verrucous appearing. Most patients with chronic cutaneous lupus erythematosus, particularly those whose lesions are only on the head and neck, do not have systemic disease. Approximately 10% of patients with CCLE develop systemic lupus erythematosus (SLE).

Answer 19

Administer tPA When performed twice daily for 3 days, intrapleural administration of tPA-DNase has been shown to decrease the radiographic pleural opacity, lower the rate of surgical intervention, and decrease hospital stay of patients with empyema (MIST-2 trial). It should be noted that the tPA-DNase has not been shown to decrease mortality. In addition, video-assisted thorascopic surgery has also been shown to effectively manage empyema in greater than 90% of cases, and a delay in surgery increases the risk of open thoracotomy.

Answer 20

Alveolar PO2 = 150 − (1.25 × arterial PCO2) Alveolar-arterial oxygen difference = Alveolar PO2 – arterial PO2

Answer 21

Evidence of right atrial enlargement Right axis deviation or indeterminate axis Incomplete right bundle branch block (or an rSr’ in lead V1) Low voltage Persistent precordial S waves Right ventricular strain pattern Tall R wave in lead V1

Answer 22

Posthypoxic myoclonus (Lance-Adams syndrome) occurs in patients with a history of hypoxic brain injury (suggested in this patient by his previous cardiopulmonary arrest) and is characterized by prominent action-induced myoclonus that impairs ambulation because of a combination of positive (rapid jerky movements) and negative (lapses in muscle tone) myoclonus.

Answer 23

Topical erythromycin To reduce the incidence of bacterial resistance, topical erythromycin can be combined with topical benzoyl peroxide

Answer 24

Aeromonas infections of the skin and soft tissue and of the bloodstream are more likely to occur in patients with underlying immunocompromising conditions, such as cirrhosis and cancer, and are more common in men. Necrotizing fasciitis caused by this gram-negative bacillus requires surgery, supportive care, and antibiotics. Pending culture data, empiric therapy for necrotizing skin infections typically consists of broad-spectrum antibiotics such as vancomycin plus piperacillin-tazobactam. When the diagnosis of A. hydrophila infection is established, doxycycline plus ciprofloxacin or ceftriaxone is recommended

Answer 25

Vocal cord dysfunction is caused by paradoxical adduction of the vocal cords during inspiration. The diagnosis is suggested by dysphonia midchest or throat tightness with exposure to particular triggers such as strong irritants or emotions; difficulty breathing in; and symptoms that only partially respond to asthma medications. Patients may also experience midchest tightness, dyspnea, cough, and dysphonia, and stridor may be detected as inspiratory monophonic wheezing. Vocal cord dysfunction is commonly misdiagnosed as asthma, leading to excessive health care use. Diagnosis is ideally made by visualization of the abnormal vocal cord adduction during laryngoscopy. It may also be diagnosed if spirometry happens to capture a flat inspiratory limb on the flow-volume loop. However, if patients are unable to tolerate laryngoscopy while symptomatic, empiric therapy should be started if there is a high clinical suspicion of vocal cord dysfunction. Treatment consists of speech therapy utilizing cognitive behavioral techniques.

Answer 26

Phenoxybenzamine is started approximately 10 to 14 days prior to surgery, and the dose progressively increased to achieve a desired blood pressure of 130/80 mm Hg or lower when seated, and systolic pressure of 90 mm Hg or higher when standing. Because phenoxybenzamine causes vasodilation, an expected consequence of therapy is postural hypotension. To counteract this and allow appropriate dose escalation of phenoxybenzamine, patients are advised to drink plenty of fluids, eat high salt-containing foods, and to make liberal use of the salt shaker at meal times. If blood pressure is not adequately controlled with an α-receptor blockade (or prohibitive side effects occur with required higher doses), a calcium-channel blocker such as amlodipine can be added. A short-acting, selective α-blocker such as prazosin, doxazosin, or terazosin, can be considered alternatives to phenoxybenzamine, based on decreased cost and limited data suggesting similar patient outcomes.

Answer 27

Acute glomerulonephritis (GN) and rapidly progressive GN are kidney diseases characterized by immune-mediated damage to the glomerular basement membrane, mesangium, and capillary endothelium that presents as acute kidney injury (AKI). GN can be present at the time of infection (rather than after a delay of at least 1 week after the infection); the term “infection-related” GN is, therefore, is more appropriate. Diabetes mellitus is a major risk factor for staphylococcal-associated GN, with methicillin-resistant strains more common in patients with diabetes. A urinary sediment of dysmorphic erythrocytes and proteinuria is consistent with GN as well as decreased complement levels in the blood The pathogenesis is thought to involve glomerular deposition of preformed circulating immune complexes. The antigen in the immune complex is derived from the infectious agent. After depositing in the subepithelial area, complement activation and subsequent recruitment of inflammatory cells lead to a proliferative GN.

Answer 28

Hard exudates, microaneurysms, and minor hemorrhages, Nonproliferative diabetic retinopathy is not typically associated with decline in visual acuity but is a marker for future development of more significant abnormalities that can lead to vision loss.

Answer 29

Mismatch repair protein; this will examine for Lynch Syndrome Loss of expression of mismatch repair proteins would be expected in approximately 15% of patients with colorectal cancer. Of these 15% with mismatch repair protein deficiency, approximately one in five will have a germline mismatch repair deficiency, which is known as Lynch syndrome. Patients with Lynch syndrome require more extensive surveillance for additional colorectal cancers and other malignancies. Lynch syndrome is autosomal dominant, and so identification also has important implications for family screening and surveillance. The most common cancers in Lynch syndrome are colorectal and uterine.

Answer 30

Urine Anion Gap = (Urine Sodium + Urine Potassium) – Urine Chloride An initial diagnostic step in normal anion gap metabolic acidosis is to determine whether the kidney is appropriately excreting acid. Increased acid excretion by the kidney is reflected as a marked increase in urine ammonium. Because ammonium carries a positive charge, chloride is excreted as the corresponding anion. Therefore, the amount of excreted chloride increases as urine ammonium levels increase. The urine anion gap can be used as an indicator of the ability of the kidney to excrete acid. *A NEGATIVE urine anion gap indicates the retained ability of the kidney to excrete acid and thus, represents a GI cause for the acidosis

Answer 31

Metabolic alkalosis

Answer 32

As the splanchnic vasculature progressively dilates and renal perfusion decreases with worsening of portal hypertension, hepatorenal syndrome can develop, which manifests as declining renal function. The initial evaluation of these patients is investigation for a decrease in intravascular volume and for infection and exclusion of other causes of acute kidney injury. Furosemide and spironolactone may be exacerbating renal hypoperfusion and should be stopped. Assessment for oliguria, urinalysis (bland urinary sediment), and urine sodium concentration (low) is also appropriate in the evaluation for suspected hepatorenal syndrome.

Answer 33

Can contribute to renal hypoperfusion and therefore, should be stopped in these patients

Answer 34

-A disease driven by several mutations in the MEFV gene. This gene encodes pyrin, a protein important to the production and/or overproduction of interleukin-1β. -Most commonly found in Jewish, Arab, and Turkish populations and follows an autosomal recessive pattern -Presents as multiple episodes of a systemic inflammatory syndrome characterized by fever, abdominal pain, rash, and arthritis, each lasting only several days -Can also develop to renal amyloidosis, therefore, it is important to treat with LIFELONG COLCHICINE

Answer 35

Papules characteristically erupt on the low back, volar wrists, elbows, knees, and ankles. Other variants include nail, genital, bullous, atrophic, and hypertrophic lichen planus. Mucosal lesions have lacy white streaks (Wickham striae), as shown in this patient, or erosions and ulcerations. -Can exhibit the Koebner phenomenon, which describes its occurrence in areas of trauma, such as those caused by scratching. -Lichen planus is typically treated with topical glucocorticoids or ultraviolet light therapy. Lichen planus tends to resolve over the course of 1 to 2 years, although oral and nail lichen planus are more persistent.

Answer 36

Ticagrelor

Answer 37

It is reasonable to extend DAPT beyond 12 months (up to 36 months) in patients who have successfully tolerated 12 months of DAPT and remain at high risk for recurrent vascular events (e.g., those with depressed left ventricular systolic function, saphenous vein graft stenting, or diabetes mellitus), for whom the benefit exceeds the increased bleeding risk. -Use DAPT bleeding risk score to help make this determination

Answer 38

Calcium oxalate There are several mechanisms responsible, including a urine volume decrease caused by mild volume contraction, which increases calcium oxalate saturation; an increase in oxalate excretion caused by fat malabsorption and decreased availability of calcium to bind oxalate in the gastrointestinal (GI) tract; and metabolic acidosis due to base loss in stools, causing a decrease in citrate excretion. In addition, because of malabsorption of fat-soluble vitamins following Roux-en-Y bypass surgery, patients such as this one are placed on high-dose vitamin D, which may increase GI absorption of calcium.

Answer 39

Trimethoprim-polymyxin ophthalmic solution -Use of topical antibacterial therapy is associated with earlier clinical and microbiological remission compared with placebo in days 2 to 5 of treatment but is ok to defer in more mild cases. Treatment may also reduce transmissibility. - Use of topical antibacterial therapy is associated with earlier clinical and microbiological remission compared with placebo in days 2 to 5 of treatment. Treatment may reduce transmissibility. -Lack of improvement should prompt ophthalmology referral

Answer 40

Febuxostat, a nonpurine, noncompetitive xanthine oxidase -It may be used in patients with CKD without dose adjustment if the estimated glomerular filtration rate is 30 to 60 mL/min/1.73 m2 -The starting febuxostat dosage is 40 mg/d, which may be increased to up to 80 mg/d if needed on the basis of serum urate level -Should coadminister with prednisone for first 3-6 months of therapy

Answer 41

Subacute combined degeneration most commonly occurs with severe and prolonged vitamin B12 deficiency. Repeated use of nitrous oxide inhalants can result in vitamin B12 deficiency due to nitrous oxide-induced conversion of vitamin B12 from its active monovalent state into an inactive bivalent isoform. Nitrous oxide is commonly found as an aerosol spray propellant in whipped cream canisters and cooking sprays. -Myelopathy, myeloneuropathy, and subacute combined degeneration have been reported in abusers of nitrous oxide, as have mood disorders and psychosis.

Answer 42

Stress-dose glucocorticoids HOWEVER, If a random cortisol level is above 18 μg/dL (497.0 nmol/L), hydrocortisone administration can be avoided or discontinued.

Answer 43

Perform LP; looking for xanthochromia

Answer 44

Ferritin (>1000) TSAT (>45%)

Answer 45

Diagnosis is confirmed by flow cytometry, which shows monoclonal B cells that usually co-express CD5 (typically a T-cell marker) along with the B-cell antigens CD19 and CD20. Routinely, cytogenetics and fluorescence in situ hybridization studies are performed, along with determination of immunoglobulin variable region heavy chain (IgVH) status, to help confirm the diagnosis and provide prognostic information. Favorable prognostic features include the presence of del(13), absence of del(17p), and the presence of a mutated IgVH as opposed to unmutated status. Patients with CLL without systemic symptoms, bulky adenopathy, or significant cytopenias should not be treated

Answer 46

-the presence of del(13) -absence of del(17p) -the presence of a mutated IgVH as opposed to unmutated status

Answer 47

Cimetidine Trimethoprim Cobicistat Dolutegravir Bictegravir ****Can consider checking cystatin C levels to more accurately predict kidney function

Answer 48

Tolvaptan; vasopressin receptor antagonist

Answer 49

Small cell lung cancer typically presents as bulky symptomatic masses with mediastinal involvement. It originates from neuroendocrine cell precursors and is characterized by rapid growth and early metastases. Extrathoracic spread is present in 75% to 80% of patients at initial diagnosis. Symptom onset is rapid (typically <8-12 weeks) and includes cough, wheezing, dyspnea, hemoptysis, weight loss, fatigue, anorexia, and manifestations of paraneoplastic syndromes. -The most frequent paraneoplastic syndrome is the syndrome of inappropriate antidiuretic hormone secretion (SIADH). This syndrome results from production of antidiuretic hormone by malignant cells. Other paraneoplastic syndromes associated with SCLC include Cushing syndrome, Lambert-Eaton syndrome, encephalomyelitis, and sensory neuropathy.

Answer 50

A 3-year colonoscopy interval is appropriate for : -larger adenomas (≥10 mm) -5 to 10 tubular adenomas less than 10 mm -adenomas with tubulovillous or villous histology -adenomas with high-grade dysplasia. A 3- to 5-year interval is appropriate for three or four tubular adenomas less than 10 mm.

Answer 51

Hyperparathyroidism hypothyroidism hypophosphatasia hypomagnesemia hemochromatosis TL;DR - Check CMP, PTH, Phos, Mg, iron studies

Answer 52

Prodrug that is activated by the CYP2D6 enzyme to its active form -Therefore, in patients with increased function of this enzyme, they will be at higher risk for codeine (opioid) toxicity

Answer 53

Unlike small-vessel vasculitis, which causes glomerulonephritis, PAN affects the renal vasculature; therefore, it does not generally cause an active urinary sediment but can cause renal insufficiency and hypertension. -Presence of nodular skin lesions suggest medium-vessel vasculitis. -Postprandial abdominal pain points to mesenteric ischemia. -Mononeuritis multiplex, which can be seen in small- or medium-vessel disease, is common in PAN and will present as something like foot drop on one side Dx: When a patient suspected of having PAN has abdominal symptoms, imaging of the mesenteric vasculature can be diagnostic. -Can see multiple aneurysms and luminal irregularities (stenosis) in bigger arteries, with occlusive lesions in smaller ones.

Answer 54

Atelectasis is reported to occur in up to 90% of all anesthetized subjects, and it may persist for several days following surgery. Atelectasis can be the result of impaired respiratory mechanics after thoracic and abdominal surgeries resulting in shallow breathing patterns and avoidance of coughing. -Atelectasis is associated with increased morbidity, including hypoxemia, retained secretions, and pneumonia. Management: Multimodal pain control, which may include increased dosage of morphine, NSAIDs, acetaminophen, gabapentin, or nerve blocks, will improve pain control and chest expansion and may resolve the atelectasis. -In addition to pain control, the application of chest physiotherapy is one of the first steps in management of atelectasis, if it can be tolerated by the patient.

Answer 55

Capnocytophaga canimorsus Howell-Jolly bodies, nuclear remnants seen in erythrocytes, are typically seen in the setting of splenic hypofunction or asplenia. The increased risk for C. canimorsus infection in patients with asplenia/splenic hypofunction results from an impaired ability to clear intravascular bacteria and deficient antibody production. Management includes supportive care, empiric antibiotics with a carbapenem or a β-lactam/β-lactamase inhibitor combination, and possible surgical debridement.

Answer 56

Patients with Sjögren syndrome are at high risk for lymphoma (5% lifetime risk); 60% of these cases are mucosa-associated lymphoid tissue lymphomas. Risk factors: -parotid gland enlargement -depressed C4 complement level, elevated rheumatoid -factor level -elevated anti-Ro/SSA or anti-La/SSB antibody levels, -monoclonal gammopathy -cryoglobulinemic vasculitis

Answer 57

NO NEED FOR AZITHROMYCIN However. this is ONLY if you know they are compliant with ART Therefore, you only need to keep these patients on Bactrim for PCP, toxoplasma prophylactic treatment

Answer 58

Published criteria for outpatient management include: (1) residence ≤1 hour or ≤30 miles (48 km) from the clinic or hospital (2) patient's primary care physician or oncologist agrees to outpatient management (3) ability to comply with logistic requirements, including frequent clinic visits (4) family member or caregiver at home 24 hours/day (5) access to a telephone and transportation 24 hours/day (6) no history of noncompliance with treatment protocols.

Answer 59

Exanthematous or morbilliform (measles-like) eruptions are the most common form of cutaneous drug reactions, most likely representing a type IV delayed hypersensitivity reaction. The rash appears during the first or second week after drug exposure, although subsequent exposures can produce a reaction much more quickly. Patients develop erythematous papules and macules that coalesce symmetrically to form plaques, beginning on the trunk and progressing distally across the limbs and usually sparing the palms and soles. The papules are often dense and monomorphic and are accompanied by varying degrees of pruritus. Lymphadenopathy is not uncommon Treatment: cessation of the causative agent, use of potent topical glucocorticoids, and oral H1 antihistamines. If widespread rash, may need PO glucocorticoids

Answer 60

Typically, valganciclovir prophylaxis lasts 6 months and these patients may develop fever +/- (esophagitis, adrenalitis, colitis, rash, myocarditis, hepatitis) in this time frame once prophylaxis starts so be highly suspicious if fever develops after prophylaxis ends as these patients are ALWAYS immunosuppressed

Answer 61

Use of triptans, ergot alkaloids, opioids, or combination analgesics for 10 or more days per month or simple analgesics for 15 or more days per month constitutes medication overuse.

Answer 62

Vasodilator single-photon emission CT using perfusion with adenosine, regadenoson, or dipyridamole is the most appropriate and preferred stress testing option for this patient with left bundle branch block (LBBB). In patients with LBBB undergoing myocardial perfusion imaging, vasodilator stress minimizes septal abnormalities frequently seen with exercise and dobutamine, which are associated with higher heart rates.

Answer 63

Presence of LBBB Resting wall motion abnormalities (Contraindications to dobutamine): Acute MI Severe aortic stenosis HOCM Uncontrolled HTN Arrhythmia Heart failure

Answer 64

MLH1 MSH2 MSH6 PMS2 EPCAM -Lifetime risk of colorectal or endometrial cancer is approximately 50-80%

Answer 65

Colorectal: -Start colonoscopy at age 20-25 -Repeat colonoscopy every 2 years -Start upper endoscopy at age 30-35 years -Repeat every 2-5 years

Answer 66

Includes dopamine antagonists (prochlorperazine, promethazine, metoclopramide), hydration, and ketorolac. Diphenhydramine is often added to prevent dystonic reactions. Glucocorticoids are commonly used in this setting as evidence suggests dexamethasone may reduce headache recurrence.

Answer 67

Diagnosis is made by tissue biopsy, which demonstrates a dense lymphoplasmacytic infiltrate, CD4-positive T cells and plasma cells in germinal centers, IgG4-staining plasma cells, storiform fibrosis, obliterative phlebitis or arteritis, and tissue eosinophilia. IgG4 levels are elevated in the serum in 70% to 80% of patients; therefore, a normal serum IgG4 level does not rule out the disease. Initial treatment is prednisone.

Answer 68

5-ASA ENEMAS

Answer 69

Used to diagnose eosinophilic airway inflammation; levels >50ppb are indicative of airway inflammation responsive to glucocorticoid therapy (like asthma) whereas levels <25 make this diagnosis less likely -Can be used as an adjunct for diagnosing asthma when patient has known obstructive lung disease

Answer 70

Skips some windows; low resolution CT takes more "slices"

Answer 71

CJD is a prion-related disorder that often presents with rapidly progressive dementia. The cause of CJD is an abnormally folded prion protein, which occurs by a spontaneous mutation (85%), is acquired by exposure to a transmissible protein, or is an inherited genetic mutation. Prion diseases have no known therapy. Time from disease onset to death is approximately 12 months in as many as 80% of patients with CJD. -The rapid cognitive decline seen with this disorder is associated with myoclonus, gait problems, visual compromise, and interruption of the circadian rhythm. -MRI is one of the most sensitive diagnostic tools for CJD, typically showing a pattern of increased intensity in the diffusion-weighted sequence in the basal ganglia and various cortical regions. *******The real-time quaking-induced conversion assay is the most sensitive and specific test for prion proteins in the CSF. It uses recombinant prion protein and thioflavin T, a fluorescent dye, to detect prion protein present in the CSF despite its being present in only small quantities. The prion protein in the CSF induces the recombinant prion protein to change shape and form fibrils that bind thioflavin T and begin to fluoresce. The quantity of fluorescence is measured in real time.

Answer 72

Several conditions have been implicated in the pathogenesis of PRCA, and chief among them are parvovirus B19 infection, thymoma, autoimmune disease (systemic lupus erythematosus), and lymphoid leukemias and lymphomas; patients with SCD are also at risk -Bone marrow findings: decreased erythrocyte precursors in the bone marrow and with giant proerythroblasts with intranuclear viral inclusions characteristic of parvovirus B19 infection. -Parvovirus infection in adults may be asymptomatic or associated with fever, coryza, headache, nausea, and diarrhea, followed by a rash. In adults, the classic “slapped cheek” rash may not be apparent but other cutaneous manifestations may occur. ***TREATMENT: Immunocompromised patients can have sustained viremia leading to prolonged anemia requiring IVIG treatment to hasten viral clearance.

Answer 73

The indications for aortic valve replacement in severe aortic stenosis are (1) the presence of symptoms, (2) left ventricular systolic dysfunction (ejection fraction <50%) in an asymptomatic patient, or (3) a concomitant cardiac surgical procedure for other indications.

Answer 74

Repeat ultrasonography should be performed in 6 to 12 months for all high-suspicion nodules, 12 to 24 months for intermediate- and low-suspicion nodules, and 24 months or longer for very low-suspicion nodules

Answer 75

Mammogram + MRI breast starting 8 years after completion of therapy or at age 40; whichever comes first

Answer 76

Common signs and symptoms of serotonin syndrome include mental status changes, hyperthermia, diaphoresis, tremor, autonomic instability, muscle and ocular clonus, and hyperreflexia. -Treatment includes supportive measures, such as avoidance of any further serotonergic agents, and sedation with benzodiazepines to reduce agitation. Sedation blunts autonomic surges and reduces the muscle activity that contributes to hyperthermia. --Cyproheptadine, an antihistamine with antiserotonergic activity, is used off-label as an antidote in serotonin syndrome in patients who do not respond to benzodiazepine therapy. Its effectiveness has not been established in clinical trials, and use is based on expert opinion and case series.

Answer 77

Anaplasmosis is transmitted by Ixodes ticks and occurs in areas of Lyme endemicity (primarily the northeastern and midwestern United States). Patients often present with a nonspecific febrile illness 1 to 2 weeks following a tick bite. Symptoms may include malaise, headaches, nausea, and arthralgia. -Laboratory investigation often reveals leukopenia, thrombocytopenia, and increased serum aminotransferases, as in this patient. Lymphopenia and neutropenia can also occur; the degree of neutropenia is inversely related to illness duration. -The diagnosis is confirmed by polymerase chain reaction or antibody testing, although serology is often negative at the time of presentation. -Visualization of morulae in the cytoplasm of leukocytes suggests the diagnosis; however, this finding is insensitive, and morulae are identified in fewer than 50% of patients. -Doxycycline is the recommended treatment and should be started promptly without waiting for confirmatory testing, because mortality rates increase with disease progression.

Answer 78

Reactive arthritis is the least common form of spondyloarthritis (2% of cases). Reactive arthritis typically entails arthritis/enthesitis in the lower extremities 2 to 3 weeks after an enteric infection or a bout of nongonococcal urethritis or cervicitis. -Joint inflammation can be intense, with high leukocyte counts in the synovial fluid. The sacroiliac joints and spine may be involved. -Enthesitis usually affects the heel (plantar fasciitis or Achilles tendinitis) or may present as dactylitis of the fingers or toes. -Extra-articular features can include nonpainful oral ulcers; ocular inflammation (conjunctivitis, keratitis, episcleritis, or anterior uveitis); and a psoriasiform rash (keratoderma blennorrhagicum), typically on the hands and feet. Some patients also develop circinate balanitis on the glans penis or erythema nodosum on the lower extremities. -Reactive arthritis is treated with NSAIDs at anti-inflammatory doses for at least 2 weeks. If relief is incomplete, intra-articular glucocorticoid injections and oral glucocorticoids can be used. If symptoms persist beyond 3 to 6 months, the use of disease-modifying antirheumatic drugs, such as sulfasalazine, methotrexate, or tumor necrosis factor inhibitors, may be necessary for symptom control and to prevent joint erosion. Therapy is discontinued 3 to 6 months following disease remission. Most cases of reactive arthritis last 6 weeks to 6 months; only 25% of patients have persistent disease. -Long-term complications can include erosive arthritis, usually of the metatarsophalangeal joints; aortitis with aortic valve insufficiency; atrioventricular heart block; and uveitis.

Answer 79

Anaplastic T-cell lymphoma; The major association has been with textured breast implants, which are now no longer being used. Patients with these lymphomas typically present with swelling and discomfort with a median time of 8 to 9 years after prosthesis placement. Initial evaluation after physical examination is by ultrasound (which appears to be superior to mammography, CT, or MRI) to look for a fluid collection and aspiration if fluid is present. Cytology may confirm malignant cells compatible with anaplastic T-cell lymphoma. These anaplastic T-cell lymphomas are typically CD30+ and ALK negative. If the disease is diagnosed early, it may be cured with surgery alone with removal of the implant and complete resection of the surrounding capsule. If a contralateral implant was placed, it should be removed as well. In cases of more advanced disease with nodal involvement, more distant spread, or recurrence, chemotherapy and/or radiation therapy may be indicated. Treatment is not yet standardized, and recommendations continue to evolve for this entity.

Answer 80

Amoxicillin or doxycycline; consider other medications patient is on when choosing

Answer 81

TES is the progressive neurodegenerative syndrome associated with repetitive head trauma. This clinical syndrome is associated with the pathological diagnosis referred to as chronic traumatic encephalopathy. The National Institute of Neurological Disorders and Stroke Consensus Diagnostic Criteria for TES require: (1) substantial exposure to repetitive head impacts from contact sports, military service, or other causes (2) core clinical features of cognitive impairment (in episodic memory and/or executive functioning) and/or neurobehavioral dysregulation (3) a progressive course (4) that the clinical features are not fully accounted for by any other neurologic, psychiatric, or medical conditions. - Supportive features include emotional dysregulation, behavior change, and motor disturbance with parkinsonian features. - Diagnosis is supported by abnormal neuroimaging findings on PET, single-photon emission tomography, structural MRI, or diffusion-tensor imaging. A common but nonspecific finding includes generalized cerebral atrophy.

Answer 82

Hydroxychloroquine is a mainstay of treatment in SLE because it reduces disease-associated damage, prevents disease flares, and improves kidney and overall survival. In addition, hydroxychloroquine may reduce the risk for thrombosis, liver disease, and myocardial infarction and improve lipid profiles.

Answer 83

For acute flares; After disease stabilizes, glucocorticoids are tapered to the lowest effective dosage, preferably to no more than 7.5 mg/d within 4 to 6 months, and should be discontinued entirely if possible ***If first time diagnosis, ALSO START HYDROXYCHLOROQUINE

Answer 84

Empiric coverage for antibiotic-resistant organisms is recommended for patients who have risk factors for antibiotic resistance (previous intravenous antibiotics within 90 days; septic shock at the time of VAP diagnosis; acute respiratory distress syndrome preceding VAP; 5 or more hospitalized days before VAP; or undergoing dialysis before VAP onset). Two antipseudomonal agents from different antibiotic classes (such as a β-lactam and a fluoroquinolone) are indicated Ex: Vanc + Levofloxacin + ceftazidime

Answer 85

Hepatic adenomas are benign neoplasms that often are found incidentally. They can be differentiated from focal nodular hyperplasia by abdominal MRI with gadoxetate sodium. This contrast agent is excreted in the bile ducts and therefore clarifies the presence of a hepatic adenoma, which does not typically excrete bile. -Most hepatic adenomas are found in women (and are eight times more common than in men), particularly those using oral contraceptive agents. -Factors posing an increased risk for malignant transformation of hepatic adenomas include adenomas greater than 5 cm in diameter and adenomas with β-catenin activation. *****Adenomas in men commonly have β-catenin activation; therefore, surgical resection of adenomas found in men is recommended.*****

Answer 86

The Khorana score places highest risk of VTE on gastric and pancreatic cancers (2 points), with lymphoma and lung, gynecologic, bladder, and testicular cancers also being high risk (1 point). An additional point is given for BMI greater than 35, platelet count greater than 350,000/μL (350 × 109/L), hemoglobin level less than 10 g/dL (100 g/L), and leukocyte count greater than 11,000/μL (11 × 109/L).

Answer 87

All patients with non–ST-elevation acute coronary syndrome (NSTE-ACS) should be treated with aspirin and a P2Y12 inhibitor, such as clopidogrel, regardless of reperfusion strategy. Current American Heart Association/American College of Cardiology guidelines recommend administration of aspirin (162-325 mg at presentation, followed by 81-162 mg/d) and P2Y12 inhibition combined with early invasive angiography within 24 hours of presentation in hemodynamically stable patients who have evidence of NSTE-ACS and elevated risk as determined by prognostic assessment with risk scores, such as TIMI and GRACE risk models. -Clopidogrel or ticagrelor is indicated at presentation in patients with acute coronary syndrome managed with an early invasive strategy (class 1 recommendation). ----Ticagrelor/Brilinta (180 mg at presentation followed by 90 mg twice daily) is more effective than clopidogrel (300-600 mg at presentation followed by 75 mg/d) and preferred in patients without increased bleeding risk. However, ticagrelor is associated with higher rates of bleeding than clopidogrel and is associated with an increased incidence of dyspnea and bradycardia.

Answer 88

Tempering the recommendation for primary prevention of ASCVD with aspirin are multiple trials, including ASCEND, ARRIVE, and ASPREE, and a 2019 meta-analysis showing no net mortality benefit with aspirin; reductions in nonfatal myocardial infarction and ischemic stroke were offset by an increased risk for major bleeding, including intracranial hemorrhage. Factors that increase risk for bleeding include increasing age, male sex, concurrent anticoagulant or NSAID use, history of gastrointestinal bleeding, upper gastrointestinal pain, uncontrolled hypertension, chronic kidney disease, and thrombocytopenia. Because of these data, the American College of Cardiology and the American Heart Association recommended that aspirin should be used infrequently in primary prevention of ASCVD and that low-dose (81 mg/d) aspirin (Option A) might be considered for primary prevention of ASCVD only in some individuals aged 40 to 70 years who are at high risk for ASCVD but do not have an increased bleeding risk.

Answer 89

Patients with early disease may be negative for anti-CCP but will have positive RF

Answer 90

Diagnosis is based on a suppressed thyroid-stimulating hormone (TSH) level, with normal free thyroxine (T4) and total triiodothyronine (T3) levels with a thyroid scan showing focal update of radioactive iodine. Approximately 0.5% to 7% of patients with subclinical hyperthyroidism progress to overt hyperthyroidism, and 5% to 12% revert to normal thyroid function. -The most common cause is toxic multinodular goiter. ****Subclinical hyperthyroidism has been associated with an increased risk for atrial fibrillation, cardiovascular events, and hip fracture; however, it is unknown whether treatment reduces hip fracture risk. A higher risk for cardiovascular and skeletal complications is seen with serum TSH level less than 0.1 μU/mL (0.1 mU/L). -Treatment of subclinical hyperthyroidism is recommended for patients with serum TSH levels less than 0.1 μU/mL (0.1 mU/L) and with symptoms, cardiac risk factors, heart disease, or osteoporosis, as well as for postmenopausal women not taking estrogen therapy or bisphosphonates

Answer 91

Because of the potential harmful effects of hypoglycemia, preemptive lowering or discontinuation of some hypoglycemic agents is recommended to prevent the development of hypoglycemia

Answer 92

Type 2 RTA involves a proximal tubular defect in reclaiming bicarbonate and is characterized by a normal anion gap metabolic acidosis, hypokalemia, glycosuria (without hyperglycemia), low-molecular-weight proteinuria, and renal phosphate wasting (known as Fanconi syndrome when all features are present). Because distal urine acidification remains intact, the urine pH is usually <5.5 without alkali therapy, and the urine anion gap ([Urine Sodium + Urine Potassium] – Urine Chloride) would be negative, reflecting increased excretion of acid in the form of ammonium and chloride.

Answer 93

-Patent ductus arteriosus closure is indicated in patients with left-sided cardiac chamber enlargement even in the absence of symptoms, as long as pulmonary artery systolic pressure is less than 50% systemic. -Closure may be considered in patients with some degree of pulmonary hypertension in selected cases (pulmonary artery pressure 50%-66% systemic). -Percutaneous closure is usually performed; referral to a congenital cardiac center for consideration of closure options is recommended. PDA closure should be avoided in patients with irreversible pulmonary vascular disease. -PDA closure in patients with severe pulmonary hypertension (pulmonary artery systolic pressure >66% systemic) is associated with greater risk compared with PDA closure in those without pulmonary hypertension and is not associated with improved survival. In patients with pulmonary hypertension, the existence of right-to-left ductal shunting may be necessary to maintain cardiac output, and closure may result in clinical worsening.

Answer 94

Per the 2022 American College of Gastroenterology GERD guidelines, proton pump inhibitor therapy should be discontinued after an 8-week trial. If symptoms do not adequately respond to treatment or if symptoms recur, upper endoscopy is indicated to evaluate for signs of GERD and to rule out other abnormalities, such as a ring, web, malignancy, eosinophilic esophagitis, erosive esophagitis, stricture, or Barrett esophagus. To maximize the yield of diagnostic upper endoscopy, the patient should not take proton pump inhibitors for the preceding 2 to 4 weeks.

Answer 95

A positive HLA-B27 antigen test result in the setting of a compelling clinical picture (such as coexistence of enthesitis) confirms the diagnosis of axial spondyloarthritis. If the HLA-B27 antigen result is negative, MRI of the pelvis to evaluate for sacroiliac joint inflammation is warranted. In a patient with inflammatory low back pain and a positive HLA-B27 antigen result but no other features of spondyloarthritis, MRI is also indicated. In general, HLA-B27 antigen testing adds probabilistic certainty to the evaluation of low back pain. If diagnostic certainty is already high (i.e., the patient has many features of spondyloarthritis), then a positive test result adds little to the posttest probability; if there are few features of spondyloarthritis, then a positive HLA-B27 antigen result is helpful.

Answer 96

Treatment for a first episode of PSP is observation, oxygen and observation, needle aspiration, or placement of a small-bore thoracostomy, depending on symptomatology. Definitive treatment with pleurodesis to prevent recurrence is usually not provided until a second ipsilateral event has occurred, unless the patient's occupation is considered high risk. ****So give definitive treatment to pilots and scuba divers regardless****

Answer 97

Corticobasal degeneration is characterized by severely asymmetric parkinsonism, fixed dystonia, myoclonus, cortical sensory deficits, apraxia, and cognitive deficits.

Answer 98

Direction changing nystagmus Inability to sit or stand at all due to dizziness

Answer 99

Pituitary hypersecretion should be ruled out by measurement of prolactin and insulin-like growth factor 1. Evaluation for Cushing disease is unnecessary in patients without signs or symptoms of cortisol excess. Pituitary tumors can also cause hypopituitarism. Screening for hypopituitarism is recommended in all patients with pituitary tumors, regardless of symptoms, with measurement of follicle-stimulating hormone (FSH), luteinizing hormone (LH), cortisol, thyroid-stimulating hormone, free thyroxine, and total testosterone in men. Hypogonadotropic hypogonadism can be assessed in premenopausal women through menstrual history. A history of normal menses essentially rules out hypogonadotropic hypogonadism and the need to measure FSH and LH.

Answer 100

ANCA ANCA-associated glomerulonephritis accounts for >50% of all cases of RPGN, with a particularly high prevalence in patients ≥65 years of age. In patients ≥80 years of age who are undergoing kidney biopsy for acute kidney injury, one in three biopsies will show a pauci-immune crescentic ANCA-associated glomerulonephritis. -It is important to serially check the ANCA subtype and titer in patients with ANCA-associated glomerulonephritis, as these can provide measures of treatment efficacy (disappearance of antibody); monitor for relapse (reappearance of antibody); and provide prognostic information about disease course. (A higher rate of relapse is seen in patients with anti-PR3 antibodies.)

Answer 101

Patients with end-stage kidney disease (ESKD) are at increased risk for renal cell carcinoma compared with the general population. Acquired cystic changes of the kidney are common in patients with severe chronic kidney disease (CKD) and ESKD and are at risk for malignant transformation. Risk factors for acquired cystic kidney disease include longer duration of ESKD and dialysis and male sex. For patients with ESKD and acquired kidney cysts, decisions about screening must be individualized based on the competing issues of risk for renal cell carcinoma versus a shortened overall life expectancy.

Answer 102

Pseudoachalasia results from malignant tumor infiltration or other secondary causes and can present similarly to achalasia. Three clinical features suggest cancer as a cause of pseudoachalasia: short duration of dysphagia (<1 year), weight loss (>6.8 kg [>14.9 lb]), and age older than 55 years. Has otherwise similar signs and symptoms of classic achalasia

Answer 103

1. Colchicine - minor disease 2. Apremilast is an oral phosphodiesterase-4 inhibitor approved for treatment of psoriasis, psoriatic arthritis, and prevention of oral ulcers in Behçet syndrome. It is a reasonable alternative to colchicine as a glucocorticoid-sparing agent for patients with recurrent oral ulcers. Apremilast must be started at a low dose and uptitrated over a few days to achieve a maintenance dosage of 30 mg twice daily.Apremilast is usually well tolerated but is associated with adverse events, such as diarrhea, nausea, and headache. It should be used cautiously in patients with depression. Systemic glucocorticoids in tapering doses can be used in patients who are refractory to colchicine and apremilast. 3. However, if the patient requires continued systemic glucocorticoid therapy, azathioprine, thalidomide, or tumor necrosis factor inhibitors are most appropriate.

Answer 104

Doxycycline + ceftazidime

Answer 105

Calcitonin gene-related peptide (CGRP) inhibitor used to treat refractory migraine as a prophylactic therapy

Answer 106

The most common cause of chronic lung infection worldwide. Cavitary lung disease is seen classically in middle-aged, or older adult men, especially those with underlying lung disease, such as COPD, who smoke cigarettes. Additionally, because of the relatively indolent nature of MAC lung disease, lung destruction may be quite extensive at the time of diagnosis with very large cavities on chest radiograph. The infection is frequently associated with weight loss and night sweats. The chest radiograph generally reveals classic fibrocavitary changes, and respiratory secretions stain positive for acid-fast bacilli

Answer 107

1. Wheezing 2. Aspirin atopy 3. Nasal polyps

Answer 108

If symptoms do not adequately respond to treatment or if symptoms recur, upper endoscopy is indicated to evaluate for signs of GERD and to rule out other abnormalities, such as a ring, web, malignancy, eosinophilic esophagitis, erosive esophagitis, stricture, or Barrett esophagus. To maximize the yield of diagnostic upper endoscopy, the patient should not take proton pump inhibitors for the preceding 2 to 4 weeks.

Answer 109

Approximately 25% of such patients will have tumors that show HER2 amplification; such tumors achieve a superior response to chemotherapy when the anti-HER2 monoclonal antibody trastuzumab is added to standard chemotherapy. For this reason, determination of HER2 amplification status is necessary when initiating chemotherapy.

Answer 110

YES as long as not GI or renal contraindication

Answer 111

Patients present with systemic nonspecific illness, however, labs reveal leukopenia, thrombocytopenia, and increased LFTs -Endemic in areas of Lyme and also transmitted by the Ixodes tick Tx: Doxycycline

Answer 112

Most important is the clustering of infections among cotravelers exposed to a common water source. Legionella has been associated with inhalation of infectious aerosols from water sources, including air conditioning cooling units, spas, pools, fountains, and showers. Features that are variably present but may suggest Legionella include gastrointestinal symptoms (including diarrhea), altered mentation, pulse-temperature dissociation, increased liver enzymes, and hyponatremia. Legionella urine testing checks for L. pneumophila serogroup 1, which accounts for between 70% and 90% of laboratory diagnosed CAP in the United States; other species or serogroups would be missed through urinary antigen testing but may be identified by culture of respiratory specimens on selective media.

Answer 113

A patient whose oxygenation as measured by pulse oximetry (SpO2) is 90% at sea level may only have an SpO2 of 84% at 2500 meters (~8200 feet), which can result in symptoms of hypoxia. *** Resting pulse oximetry is helpful in screening patients for in-flight hypoxemia. Patients with resting SpO2 greater than 95% are unlikely to experience significant hypoxemia in flight. Patients with resting SpO2 between 92% and 95% require assessment of risk factors and may need additional testing such as high-altitude simulation testing, if available. For those whose resting SpO2 is less than 92%, supplemental oxygen should be prescribed and there is no need for additional testing. Typically, if patients do not require oxygen at baseline, then prescribing 2 L/min of oxygen is sufficient.

Answer 114

"High ankle sprain" Results from excessive external rotation of a dorsiflexed ankle or planted foot, causing injury of the distal tibiofibular syndesmosis ligament. Pain is typically located anterolaterally, just above the ankle joint. Swelling and ecchymosis are less frequent than in lateral ankle sprains. -In a high ankle sprain, the squeeze test is performed by placing the base of the hands on either side of the calf, just above the middle of the calf, and squeezing, directing the force in an anteromedial to posterolateral direction. A test with a positive result elicits pain just above the ankle. -Treatment is similar to that for other ankle sprains, including intermittent application of ice or immersion in ice water for 20 minutes every 2 to 3 hours, elevation, rest (crutches), elastic wrapping to limit swelling, and splinting to prevent ankle movement using a posterior leg brace or other devices. -Early referral to an orthopedic specialist is encouraged if a high ankle sprain is suspected because of the potential for protracted disability.

Answer 115

Handheld fan; Studies have shown that use of a handheld fan reduces breathlessness in this patient population and has no adverse effects; a handheld fan should be considered in all patients with refractory dyspnea. In some studies, up to 85% of patients report improvement in dyspnea and half of patients report an increase in physical activity

Answer 116

Necrotic migratory erythema Weight loss Hypoalbuminemia *also impaired glucose tolerance obviously

Answer 117

In the PARADIGM-HF trial of patients with symptomatic heart failure and left ventricular ejection fraction less than 40%, valsartan-sacubitril reduced mortality and heart failure hospitalization by 20% compared with enalapril. -ACA now recommends replacing ACEi/ARB with Entresto in symptomatic chronic HFrEF

Answer 118

Colchicine within the first 24 hours of the episode. In the absence of chronic kidney disease, the initial dose is 1.2 mg, followed by a single 0.6-mg dose 1 hour later and then 0.6 mg daily thereafter if needed.

Answer 119

PJS is caused by mutations in the STK11 (LKB1) gene. PJS is a hamartomatous polyposis syndrome, and PJS-type polyps are found primarily in the small bowel as well as the stomach and colon. Small-bowel hamartomas develop at a young age (average age, 18.5 years), and patients may present with rectal bleeding (most commonly), bowel obstruction, and intussusception. A clinical diagnosis of PJS may be made when two of the following three criteria are met: two or more PJS-type hamartomatous polyps in the gastrointestinal tract; typical mucocutaneous hyperpigmentation (melanotic macules) in the mouth, buccal mucosa, nose, eyes, genitalia, or fingers; and family history of PJS. Patients with PJS have increased lifetime risk for multiple malignancies: colorectal (39%), gastric (29%), small bowel (13%), breast (32%-54%), ovarian/sex cord tumor with annular tubules (21%), cervical/adenoma malignum (1%), uterine (9%), testicular/Sertoli cell tumor (9%), lung (7%-17%), and pancreatic (11%-36%).

Answer 120

Cholinergic muscarinic agonist, stimulates salivation and is appropriate for moderate oral dryness (similar to pilocarpine) Cholinergic adverse effects of cevimeline and pilocarpine can include sweating, abdominal pain, nausea, flushing, and increased urination.

Answer 121

Ischemic heart disease; QRS widening; history of recurrent ventricular arrhythmia

Answer 122

***Amiloride blocks the epithelial sodium channel in the collecting tubule and prevents the uptake of lithium by these cells. Intracellular lithium appears to decrease the number of aquaporin water channels inserted in the membrane, thereby decreasing water reabsorption causing increased excretion of dilute urine. If amiloride is ineffective and lithium must be continued, the treatment of nephrogenic DI is aimed at decreasing the amount of urine excreted and is best accomplished by limiting solute intake and causing mild volume depletion with the use of a thiazide diuretic. Because the amount of urine excreted daily is dependent on solute intake and minimum urine osmolality, decreasing solute will limit urine volume. By causing mild volume depletion with a thiazide diuretic, more salt and water will be reabsorbed in the proximal tubule and loop of Henle, further decreasing urine output.

Answer 123

Antiviral therapy, especially protease inhibitors, may WORSEN liver failure; therefore, DO NOT TREAT until after transplant

Answer 124

Emergent treatment includes elevation of the head of the bed to 30 degrees, hyperventilation (usually with mechanical ventilation) to an arterial PCO2 of 20 to 25 mm Hg (2.7-3.3 kPa), infusion of either hypertonic saline or mannitol and administration of dexamethasone (for patients with peritumoral edema). ***Mannitol is a diuretic that reduces brain edema by osmotically transferring water from brain tissue into the circulation, where it is renally excreted. The impact of mannitol on ICP is evident within minutes and peaks in 1 hour.

Answer 125

IPF is associated with the histopathologic appearance of usual interstitial pneumonia, the most common idiopathic form of diffuse parenchymal lung disease (DPLD). It typically presents in patients between 50 and 70 years of age who have a greater than 6-month duration of a dry cough and dyspnea on exertion. History will reveal no potential cause for the development of fibrosis, and lung examination is notable for Velcro-like inspiratory crackles that are predominant at the bases. Clubbing is present in up to 50% of patients. The best diagnostic test is high-resolution CT (HRCT) of the chest, which may show abnormalities such as bilateral, peripheral, and basal predominant septal line thickening with honeycomb changes. The patient's diagnosis can be made in a multidisciplinary meeting involving a thoracic radiologist, a pathologist, and a pulmonologist; a multidisciplinary discussion may yield a confident diagnosis of IPF, without the need for a lung biopsy.

Answer 126

Patients with cryptogenic organizing pneumonia (COP) typically present with cough, fever, and malaise for 6 to 8 weeks. Initial chest radiographs will demonstrate patchy opacities that mimic pneumonia, and as a result, patients are often initially misdiagnosed with community-acquired pneumonia and treated with standard antibiotics. HRCT scans will demonstrate ground-glass opacities or areas of alveolar consolidation resembling an infectious pneumonia, but findings can include peripheral nodules and nodules along the bronchovascular bundle.

Answer 127

Nonspecific interstitial pneumonia (NSIP) is the most common DPLD associated with autoimmune disorders, but it can occasionally be idiopathic. NSIP affects a younger population than IPF. HRCT scans will demonstrate bilateral lower-lobe reticular changes and an absence of honeycombing, but they can also demonstrate areas of ground-glass opacification.

Answer 128

Respiratory bronchiolitis-associated interstitial lung disease (RB-ILD) is the histopathologic diagnosis associated with the HRCT finding of centrilobular micronodular disease in CURRENT smokers. On physiologic testing, RB-ILD may have combined restriction and obstruction.

Answer 129

Anaplasmosis is caused by Anaplasma phagocytophilum, which is transmitted by Ixodes ticks and occurs in areas of Lyme endemicity (primarily the northeastern and midwestern United States). Patients often present with a nonspecific febrile illness 1 to 2 weeks following a tick bite. Symptoms may include malaise, headaches, nausea, and arthralgia. Laboratory investigation often reveals leukopenia, thrombocytopenia, and increased serum aminotransferases, as in this patient. Lymphopenia and neutropenia can also occur; the degree of neutropenia is inversely related to illness duration. The diagnosis is confirmed by polymerase chain reaction or antibody testing, although serology is often negative at the time of presentation. Visualization of morulae in the cytoplasm of leukocytes suggests the diagnosis; however, this finding is insensitive, and morulae are identified in fewer than 50% of patients. Doxycycline is the recommended treatment and should be started promptly without waiting for confirmatory testing, because mortality rates increase with disease progression.

Answer 130

Also known as benign familial hematuria, inheritance in this disease is autosomal dominant. The inherited type IV collagen abnormality causes thinning of the GBM, which results in hematuria but usually without proteinuria or abnormal kidney function. Thin GBM disease may affect up to 5% of the population, with up to 50% of patients who are diagnosed reporting a family history of hematuria without kidney failure. Both microscopic and macroscopic hematuria can be seen, first manifesting in young adulthood. Although diagnosis can be made by kidney biopsy, this is not usually required in the setting of a good clinical and family history. Genetic testing may also be used to make the diagnosis.

Answer 131

NO DAPT Consult neurosurg Send to tele/ICU Follow recs, keep your hands off the chart

Answer 132

NO USE EFFERK OR IV

Answer 133

Interventional cards ya dingus

Answer 134

FeNO may be useful if there is uncertainty in choosing, monitoring, or adjusting anti-inflammatory therapies based on history, clinical findings, and spirometry as part of an ongoing asthma monitoring and management strategy. In adults with respiratory symptoms, FeNO levels above 50 ppb correlate with eosinophilic airway inflammation and predict response to inhaled glucocorticoids. FeNO levels below 25 ppb indicate that eosinophilic airway inflammation and glucocorticoid responsiveness are less likely; values between 25 and 50 ppb should be interpreted cautiously. In patients with asthma that is being treated with inhaled glucocorticoids, serial measurement of FeNO may help to monitor patient response to glucocorticoid therapy.

Answer 135

Dystonia is characterized by sustained or intermittent muscle contractions that are slow, repetitive, and directional. It can be generalized or focal and can involve isolated body parts, such as the vocal cords, face, or neck. Persistent worsening of movements with certain sounds, resolution of spasms with different tasks (such as singing), and direct observation of slow and sustained pulling of vocal cords support a diagnosis of dystonia.

Answer 136

Cardiac magnetic resonance (CMR) imaging is the most appropriate test in patients with suspected cardiac amyloidosis. Although CMR is highly sensitive and specific for cardiac amyloidosis, it cannot differentiate between the two major forms of disease: light-chain amyloid (AL) amyloidosis and transthyretin amyloid (ATTR) amyloidosis. Differentiation between these causes is crucial because treatment and prognosis differ significantly. 99m-Technetium pyrophosphate scintigraphy has excellent sensitivity and specificity for ATTR amyloidosis and is the next best test to assess the likelihood of this disease if there is no evidence of monoclonal gammopathy.

Answer 137

Postexposure prophylactic antibiotic therapy must begin immediately after any local or systemic infection has been excluded. Ciprofloxacin and doxycycline are the preferred first-line agents. Because antibiotics are only active against vegetative bacilli, they are administered for 60 days, helping to ensure that late germination of spores lying dormant in the lungs and macrophages does not evolve into active disease. Postexposure protocols for anthrax include immunization along with antibiotics. The approved vaccine should be given within 10 days of exposure and is administered subcutaneously on weeks 0, 2, and 4.

Answer 138

Ifosfamide metabolites are toxic to the proximal tubule, resulting in a generalized decrease in cell energetics and a decrease in transport of various substances across the luminal membrane, including phosphorus, glucose, amino acids, and protons. In addition to phosphate wasting, as identified by the fractional excretion of phosphorus >5%, patients can have glycosuria despite having a normal serum glucose; this is commonly seen in patients with ifosfamide-induced Fanconi syndrome. The urinalysis finding of proteinuria is most likely secondary to the loss of amino acids in the urine. The treatment of the hypophosphatemia in this disorder requires large quantities of phosphorus, typically intravenously.

Answer 139

Mycophenolate mofetil Azathioprine Cyclosporine Tacrolimus

Answer 140

Check for G6PD deficiency

Answer 141

Treat with 14 days of antibiotics tailord towards most recent culture data -If no culture data, treat with empiric 14 day course that also provides Pseudomonas coverage

Answer 142

. PCNSL is typically a B-cell non-Hodgkin lymphoma. Immunodeficiency, including HIV infection, is the most consistent risk factor, but PCNSL incidence is increasing in older, immunocompetent patients. On MRI, PCNSL appears as a single, well-demarcated, deep white matter (periventricular) lesion with minimal to no mass effect or edema. The finding of lymphomatous cells in vitreous or cerebrospinal fluid samples (identified by cytology and flow cytometry) may obviate the need for biopsy. When these less invasive diagnostic measures are negative, brain biopsy should be obtained to confirm the diagnosis. -Avoid giving steroids prior because this can produce a false negative result on CSF sample

Answer 143

Repeat ultrasonography should be performed in 6 to 12 months for all high-suspicion nodules, 12 to 24 months for intermediate- and low-suspicion nodules, and 24 months or longer for very low-suspicion nodules.

Answer 144

IPF is progressive, with a median survival of 3 to 5 years after diagnosis. In 2014 the FDA approved two medications: pirfenidone, an antifibrotic agent, and nintedanib, a tyrosine kinase inhibitor, for use in patients with IPF. In clinical trials the two agents were found to have comparable efficacy in mitigating the rate of FVC decline by approximately 50% over the course of 1 year. They have also shown some efficacy in reducing severe respiratory events such as acute exacerbations and hospitalization. Common side effects are anorexia, nausea, photosensitivity (pirfenidone), and diarrhea (nintedanib). Although these medications delay IPF progression, they are not curative.

Answer 145

Amantadine, a glutamate N-methyl-D-aspartate receptor antagonist, is an efficacious treatment for levodopa-induced dyskinesia

Answer 146

Intranasal esketamine is approved as an adjunct to oral antidepressant agents for treatment-resistant major depressive disorder and major depressive disorder with suicidal ideation. Esketamine is a glutamate receptor modulator, which offers a novel mechanism of action for depression treatment. Unlike most other antidepressant therapies, treatment effect is almost immediate; however, there are several barriers to its use. Labeling indications restrict the drug to patients whose symptoms have failed to respond to two courses of appropriately prescribed antidepressant therapy, and patients cannot drive or operate machinery for 24 hours after administration. Esketamine must be administered intranasally in a physician's office under direct supervision, and physicians must be enrolled in an FDA-mandated Risk Evaluation and Mitigation Strategies (REMS) program. Esketamine carries a black box warning for dissociation, sedation, and suicidal thoughts. The cost of the month-long induction is very expensive

Answer 147

. Treatment options for gastric varices along the greater curvature of the stomach depend on the anatomy of the abdominal vasculature. For isolated gastric varices due to splenic vein thrombosis, splenectomy can be performed to decompress varices. If the portal vein is patent and a suitable splenorenal shunt is available, balloon-occluded retrograde transvenous obliteration of varices can be considered. If the anatomy of the hepatic veins and portal vein branches is favorable, a transjugular intrahepatic portosystemic shunt may be an option. To determine the best therapy, contrast-enhanced cross-sectional imaging is required. Therefore, abdominal CT with contrast is the best next action.

Answer 148

LHC/RHC to evaluate for causes

Answer 149

Patients with atypical features of Bell palsy, including multiple cranial nerve palsies, require additional evaluation. This patient should undergo MRI of the brain with and without gadolinium and with attention to the brainstem and internal auditory canal. Bell palsy is an acute-onset (usually over a period of hours) peripheral mononeuropathy involving the facial nerve (cranial nerve VII) that leads to weakness in the muscles of facial expression in both the upper and lower face, hyperacusis, and impaired taste. In classic Bell palsy, initial brain imaging and laboratory testing are not required. However, muscles of mastication are innervated by the motor branch of the trigeminal nerve (cranial nerve V) and ocular abduction (ability to bury the sclera on lateral gaze) is innervated by the abducens nerve (cranial nerve VI). Presence of these findings and a subacute progressive course over 10 days are red flags that should prompt further workup, including brain imaging. In addition, serologic testing for causes of multiple cranial neuropathies and, if needed, cerebrospinal fluid analysis with cytology should also be considered.

Answer 150

Alkalinizes the urine Can use this to help uric acid stones pass

Answer 151

A chylothorax is diagnosed by a triglyceride level greater than 110 mg/dL (1.24 mmol/L), and it is typically a lymphocytic predominant effusion. Although chylothorax is often milky in appearance, as is a cholesterol effusion, it can appear serous or sanguineous.

Answer 152

The American College of Chest Physicians 2021 guidelines suggest 45 days of anticoagulation for SVT in the setting of increased risk of progression to deep venous thrombosis (DVT) or pulmonary embolism (PE). Risk factors for progression include: extensive SVT greater saphenous vein involvement thrombus above the knee or close to the saphenofemoral junction recent surgery active cancer or a history of thrombus.

Answer 153

Mesial temporal sclerosis with hippocampal atrophy is the most common cause of drug-resistant adult-onset focal epilepsy. Therefore, brain MRI is also an appropriate next step because surgical candidacy requires confirmation that seizure manifestations on video EEG match the location of pathology on MRI or other advanced functional imaging (single-photon emission CT or PET). These steps are required to determine if the patient can be considered for temporal lobectomy

Answer 154

In a randomized trial, the addition of very low-dose rivaroxaban (2.5 mg twice daily) to aspirin (81 mg daily) was shown to reduce the occurrence of cardiovascular death, myocardial infarction, or stroke in patients with peripheral artery disease (PAD). The absolute risk reduction, when compared with aspirin alone, was 2% in 7470 patients enrolled with either lower extremity PAD or carotid stenosis. Major bleeding, primarily gastrointestinal bleeding, was increased by 1% in patients assigned to aspirin plus rivaroxaban. Thus, low-dose rivaroxaban should be avoided in patients with PAD who have a higher risk for bleeding. It should be noted that use of rivaroxaban in patients with PAD is at odds with the 2016 American Heart Association/American College of Cardiology (AHA/ACC) PAD guideline, which recommends against anticoagulation to reduce the risk for cardiovascular events in patients with PAD due to lack of benefit and increased risk for harm from major bleeding events, including intracranial bleeding. The studies that informed the AHA/ACC recommendation used warfarin as the anticoagulant

Answer 155

The most common bacteria causing brain abscesses are streptococci (e.g., Streptococcus milleri), Staphylococcus aureus, Enterobacteriaceae, and anaerobes. The diagnosis is usually made by CT or MRI with contrast. Aspiration is especially recommended if the brain abscess is larger than 2.5 cm. The yield of blood cultures is low (around 25%); even with a positive blood culture, aspiration should be performed for a large abscess

Answer 156

Neuropsychiat

Answer 157

SVT often affects the lower extremities and is thought to account for 10% of lower extremity thromboses. The lesser saphenous vein is a distal superficial vein. Treatment is indicated for SVT when the thrombus is 5 cm or greater in length or is close to the deep venous system or if other thrombophilic risk factors are present.

Answer 158

MACE is a condition characterized by ACTH-independent cortisol secretion that may result in metabolic (hyperglycemia and hypertension) and bone (osteoporosis) effects of hypercortisolism, but not the more specific features of Cushing syndrome (centripetal obesity, facial plethora, abnormal fat deposition, and wide violaceous striae). The preferred diagnostic test for MACE is a 1-mg overnight dexamethasone suppression test; a morning cortisol level greater than 5 μg/dL (138 nmol/L) is considered positive. After a positive test result, measurement of ACTH, dehydroepiandrosterone sulfate (DHEAS), urine free cortisol, and an 8-mg overnight dexamethasone suppression test are often required to confirm autonomous cortisol secretion.

Answer 159

First step in management should be removal of the offending drug, as was done in this patient. If dyskinesia persists and causes functional or social impairment, treatment with a vesicular monoamine transporter 2 inhibitor, such as valbenazine, deutetrabenazine, or tetrabenazine, can be helpful. Potential adverse effects include sedation, depression, and suicidality; patients should be monitored closely for psychiatric side effects. In trials, valbenazine and deutetrabenazine have shown a lower rate of psychiatric adverse effects compared with tetrabenazine. Other options include amantadine, clonazepam, and, in the case of tardive dystonia, botulinum toxin injection. In refractory cases, deep-brain stimulation can be beneficial.

Answer 160

Malignant hyperthermia is a rare autosomal dominant inherited disorder characterized by diffuse skeletal muscle activation that results from intracellular calcium release. It is triggered most often by inhaled anesthetics and the depolarizing neuromuscular blocker succinylcholine. Presenting signs and symptoms reflect hypermetabolism and include muscle rigidity (including masseter muscle rigidity), tachycardia, tachypnea, laboratory evidence of rhabdomyolysis (elevated serum creatine kinase, potassium, and phosphorus levels and myoglobinuria), and temperature that can be strikingly high, 45.0 °C (113.0 °F) or more. Mortality can reach 10%. Treatment consists of discontinuing the triggering agent, active cooling, and administration of the muscle relaxant dantrolene every 5 to 10 minutes until muscle rigidity and hyperthermia resolve. Dantrolene interferes with intracellular calcium release and is considered an antidote to malignant hyperthermia.

Answer 161

The painful arc test consists of the patient performing full abduction of the arm; pain that occurs between 60 degrees and 120 degrees supports the diagnosis of rotator cuff tendinopathy. The painful arc test has the highest positive likelihood ratio (3.7) of all testing maneuvers for rotator cuff tendinopathy. A rotator cuff tear should be suspected when the pain is complicated by weakness in external rotation or abduction or the patient is unable to lower the arm smoothly from a fully abducted position (positive drop arm test). Rotator cuff tendinopathy is more common in patients older than 50 years who have repetitive overhead stress to the shoulder. Initial therapy includes rest, acetaminophen, and physical therapy to strengthen the rotator cuff muscles and improve flexibility

Answer 162

Although there are no FDA-approved pharmacologic treatments for frontotemporal dementia, SSRIs have shown effectiveness in treating some of its symptoms, especially by decreasing the frequency of compulsive behaviors. Consequently, SSRIs are considered first-line treatment of the behavioral disturbances of frontotemporal dementia and should be used before any agents with a sedative effect.

Answer 163

Chorea gravidarum: Pregnancy should be considered as a potential cause of chorea in a young woman. Chorea can emerge early in pregnancy as a result of gestational hormonal changes and usually abates after childbirth. A history of rheumatic fever and antiphospholipid antibodies are risk factors for chorea gravidarum. Other acquired causes of acute or subacute chorea include medications, autoimmune disorders, endocrine disorders, and paraneoplastic syndromes.

Answer 164

Nonvasodilating β-blockers and/or nondihydropyridine calcium channel blockers (verapamil, diltiazem) are first-line choices. For patients with persistent symptoms, adding disopyramide, a class IA antiarrhythmic drug with potent negative inotropic activity, to one of the other drugs is a recommended option. Patients receiving guideline-directed medical therapy but with New York Heart Association functional class III to IV heart failure symptoms or recurrent syncope believed to be related to left ventricular outflow tract (LVOT) obstruction and an LVOT gradient of 50 mm Hg (resting or provoked) or greater should be considered for (septal reduction therapy) SRT. Adult patients in whom surgical septal myectomy is contraindicated or the risk is considered unacceptable because of serious comorbidities or advanced age, alcohol septal ablation, performed at experienced centers, is recommended.

Answer 165

An ICD is recommended for patients with HCM and previous documented cardiac arrest or sustained ventricular tachycardia. ICD placement is considered reasonable in the presence of one or more major risk factors for sudden cardiac death, including: sudden death in a first-degree or close relative at age 50 years or younger left ventricular (LV) hypertrophy of 30 mm or greater syncope thought to be arrhythmogenic, LV aneurysm an LV ejection fraction of 50% or less.

Answer 166

Lone Star tick is the vector for Heartland virus, with human infections reported in the Midwestern and southern United States. Ehrlichia chaffeensis is transmitted by the same tick; therefore, the regional distribution of these infections is similar and they are clinically indistinguishable, with common nonspecific symptoms, including fever, headache, myalgia, arthralgia, and malaise Both typically present with leukopenia (and, more specifically, lymphopenia), thrombocytopenia, and elevated aminotransferase levels. Heartland virus does not respond to doxycycline, and the treatment for this infection is supportive care, whereas rapid defervescence with doxycycline is an almost universal feature for ehrlichiosis, anaplasmosis, and spotted fever group rickettsioses, including Rocky Mountain spotted fever (RMSF). Lack of improvement within 48 hours of doxycycline initiation suggests an alternative diagnosis. In patients with a presentation consistent with ehrlichiosis who do not improve with doxycycline therapy, testing for Heartland virus by the Centers for Disease Control and Prevention can be requested through the state health department.

Answer 167

Pulse oximetry calculates the differential between absorption of infrared light by oxygenated and deoxygenated blood and is widely used to monitor oxygenation. Conventional probes used on the finger, toe, and earlobe rely on transmission technology, utilizing emitting and detecting sensors applied on opposing sides of the digit or earlobe. Inaccurate readings can be caused by vasoconstriction, low perfusion states, skin pigmentation, motion artifact, or nail polish. A normal signal shows a sharp waveform with a clear dicrotic notch. The absence of a clear dicrotic notch suggests the device is not providing an accurate reading. For example, patients with Raynaud phenomenon and clinical signs of peripheral vasoconstriction, pulse oximetry with a finger probe is likely to be erroneous. Options include changing to an earlobe probe or use of reflectance technology with a forehead probe in which the emitter and detector sensors are adjacent to each other.

Answer 168

In older adults and patients with cardiovascular disease, lower initial doses (25-50 μg/d) are recommended. Thyroid hormone therapy, with its inotropic and chronotropic effects on the heart, is a potential cause of angina in patients with severe cardiovascular disease. This risk is the reason for starting patients with low doses of thyroid hormone replacement, and increasing the dose slowly. Assessment of the adequacy of treatment should be done with a repeat serum TSH level at least 6 weeks after initiation or change in dose.

Answer 169

Pregabalin, milnacipran and off-label use of tricyclic antidepressants (amitriptyline and nortriptyline)

Answer 170

Cardiac resynchronization therapy (CRT) is indicated for patients who have refractory heart failure symptoms despite guideline-directed medical therapy with left ventricular ejection fraction less than 35% and QRS duration greater than 150 ms, optimally with left bundle branch block configuration and sinus rhythm.

Answer 171

LVADs are reasonable either as a bridge to heart transplant or as primary therapy in patients with advanced heart failure. Survival at 1 year is near the survival after heart transplant, and an LVAD would be worth considering in patients who have several markers of increased mortality.

Answer 172

Powassan virus is transmitted to humans through the bite of the Ixodes tick, the same vector as Lyme disease, babesiosis, and anaplasmosis. Unsurprisingly, most Powassan virus infections occur in regions where this tick species is plentiful. Risk is highest from late spring to mid fall when Ixodes ticks are most active. Almost all reported cases of Powassan virus present with encephalitis, although this may represent a bias toward testing patients with more severe disease. No specific neurologic, laboratory, or radiographic findings differentiate Powassan virus encephalitis from the many other causes of encephalitis. Residence in the Northeast or Middle Atlantic region and seasonality might suggest the diagnosis, but other arboviruses, including Eastern equine encephalitis virus and West Nile virus would share these features as well. Definitive diagnosis of Powassan virus infection requires serologic testing.

Answer 173

Distinguishing between liver disease and DIC may be challenging, but measuring the factor VIII activity is a theoretical means of separating these disorders. Factor VIII is often normal or elevated in patients with liver disease because factor VIII is produced in hepatic and nonhepatic endothelial cells; however, factor VIII is consumed in DIC.

Answer 174

Pegloticase is recombinant pegylated uricase administered intravenously every 2 weeks. All patients should be screened for glucose-6-phosphate dehydrogenase (G6PD) activity before administration of pegloticase; low activity of G6PD poses a risk for hemolytic anemia and methemoglobinemia, and pegloticase is contraindicated in that setting. Pegloticase rapidly lowers the serum urate level, and prophylactic therapy (colchicine, NSAIDs, or glucocorticoids) must be administered concurrently with treatment. Formation of antibody to pegloticase may occur (30%-50% of patients) and cause severe infusion reactions. Serum urate level must be checked before each infusion. After the initial dose, a serum urate level greater than 6.0 mg/dL (0.35 mmol/L) on two consecutive assessments indicates loss of efficacy due to antibody formation, necessitating discontinuation of pegloticase. Pegloticase should not be given with any other urate-lowering therapy so that interpretation of the serum urate level before each infusion is clear.

Answer 175

Artesunate is the drug of choice, with transition to an oral antimalarial medication such as artemether-lumefantrine, atovaquone-proguanil, doxycycline, or quinine sulfate to complete the course of treatment when significant improvement has been achieved. Intensive medical care, including hemodynamic and respiratory support, management of fluid and electrolytes, blood replacement, and possibly hemodialysis, is also immediately required.

Answer 176

Although the incidence of infection with this gram-negative, intracellular, coccobacillus is highest in Mediterranean countries, it is also commonly encountered in the Middle East and South and Central America. Infection with the Brucella species that cause illness in humans (B. abortus, B. melitensis, B. suis, B. canis) generally follows ingestion of undercooked meat, raw milk, or contaminated milk products or through direct contact with secretions and excretions of infected animals. Symptom onset may be sudden, with chills and fever, severe headache, joint and back pain, malaise, and overall lethargy. Intermittent fever with periods of remission lasting several weeks is common and may persist for months. Depression is commonly reported. Hepatosplenomegaly and lymphadenopathy are frequently detected on physical examination. Cytopenias and abnormal liver chemistry results are nonspecific laboratory findings. Diagnosis is best made by isolation of the bacteria from blood cultures; however, the rate of detection is variable.

Answer 177

The four phases of infection are categorized on the basis of immune response to the virus: immune tolerant, immune active, immune control, and reactivation. The immune control phase of chronic HBV infection is also known as inactive chronic HBV infection. The immune control phase is characterized by normal serum alanine aminotransferase (ALT) measurement, indicating absence of liver inflammation; positive results for hepatitis B core (HBc) antigen IgG antibody, indicating previous infection; hepatitis B e antigen (HBeAg)–negative and anti-HBe–positive serology, indicating lack of viral replication and infectivity; and HBV DNA level less than 2000 U/mL, indicating immune control of viral replication and infection.

Answer 178

Factors associated with increased risk for rupture include rapid growth detected over serial imaging, active tobacco use, and uncontrolled hypertension. Other predictors of aneurysmal rupture that should prompt surgical consideration include a previous aneurysmal subarachnoid hemorrhage, rapid aneurysm growth, or the presence of cranial nerve palsy. Annual noninvasive imaging is recommended in patients with an unruptured aneurysm.

Answer 179

Montelukast has been associated with significant adverse mental health effects and may be the cause of the patient's depression. Depressive symptoms can occur in patients with and without a previous history of depression or other neuropsychiatric disorders. In March 2020 the FDA added a boxed warning to montelukast, strengthening previous warnings about behavior and mood-related changes, including suicides, associated with this medication. The FDA also advised against using montelukast for allergic rhinitis because other first-line medications, such as intranasal glucocorticoids, are widely available and more efficacious and because many physicians are unaware of montelukast's potential adverse mental health effects. Other ADRs include edema, dizziness, dyspepsia, muscle weakness, and elevated transaminases occurring in less than 2% of all patients.

Answer 180

The diagnosis of androgen deficiency should be made only when a patient has two separate early morning (8:00 AM) serum total testosterone levels less than 300 ng/dL (10.41 nmol/dL) combined with suggestive symptoms and/or signs.

Answer 181

Withdrawal of alcohol and drugs such as benzodiazepines, opioids, and antidepressants can also precipitate delirium. Antidepressant medications should be gradually tapered to avoid discontinuation syndrome. Discontinuation symptoms can occur with any selective serotonin reuptake inhibitor but is most commonly reported with paroxetine. The most common symptoms are dizziness, fatigue, and headache. Other commonly reported symptoms are agitation, anxiety, and insomnia. Symptoms may start from 1 to 7 days following abrupt discontinuation of antidepressant medications.

Answer 182

Eculizumab is a monoclonal antibody directed against complement component C5 and inhibits complement activation. It has been shown to be effective for use in paroxysmal nocturnal hemoglobinuria and atypical hemolytic uremic syndrome (aHUS). Although thrombocytopenia, thrombotic microangiopathy, and kidney disease are seen with aHUS, it is not associated with coagulation abnormalities.

Answer 183

High-dose acyclovir can cause acute AKI due to intratubular obstruction from acyclovir crystal precipitation. Predisposing factors for crystal-induced AKI include chronic kidney disease and volume depletion. Aggressive volume expansion is recommended during high-dose acyclovir therapy for these patients. Correction of volume depletion is also critical for the treatment of crystal-induced AKI as well as discontinuation of the drug if possible.

Answer 184

Often develops 4-12 weeks after last radiation treatment. Classic symptoms are dyspnea on exertion, nonproductive cough, and hypoxemia; low-grade fevers are also common. A subset of patients develop radiation fibrosis 6 to 12 months after treatment. Radiation pneumonitis will also cross lung fissure as opposed to immune-therapy pneumonitis (which does not). Finally, a radiation recall pneumonitis can occur years later in patients who are on maintenance immunotherapy.

Answer 185

Tocilizumab, an interleukin-6 blocker, is highly effective for the treatment of GCA when administered during glucocorticoid tapering or as monotherapy following discontinuation of glucocorticoids. The 2021 American College of Rheumatology guidelines make a conditional recommendation for glucocorticoids with tocilizumab over oral glucocorticoids alone in patients with newly diagnosed GCA.

Answer 186

Short-course treatment regimens with rifamycins are recommended over longer (6- to 9-month) courses. In persons without HIV infection, other preferred regimens include isoniazid and rifapentine once weekly for 3 months or rifampin daily for 4 months. Alternatively, daily isoniazid alone for 6 or 9 months is now considered a second-line treatment option; it carries a higher toxicity risk and lower completion rate than short-course regimens. Short-course treatment regimens are also recommended for LTBI in patients with HIV infection; these include isoniazid and rifapentine once weekly for 3 months or isoniazid plus rifampin daily for 3 months in patients who are not taking antiretroviral therapy that interacts with rifapentine.

Answer 187

A SLAP tear is an injury to the glenoid labrum, the fibrocartilaginous rim around the margin of the glenoid cavity, leading to biceps tendon instability and a feeling of instability of the joint. SLAP tears are most common in patients older than 40 years who engage in repetitive overhead activities, such as weightlifting or throwing. Pain is often deep and difficult to localize and worsens with repetition of the overhead movement. Patients report crepitus, catching of the joint with movement, and overall joint instability.

Answer 188

Dalfampridine, an oral voltage-gated potassium channel antagonist, can improve gait speed and endurance in patients with relapsing-remitting multiple sclerosis (MS) with ambulatory dysfunction. Dalfampridine cannot induce healing or remyelination. However, this medication likely improves neuronal conduction, allowing signals to be processed through the corticospinal tract more efficiently and thus leading to improvements in gait in those with injury to this tract. Dalfampridine has a rare risk of seizures and should not be used in patients with known epilepsy or with kidney impairment.

Answer 189

Although animal bite wounds are common, subsequent wound infection is not, occurring in approximately 20% of patients. When infections do occur, culprit pathogens often include animal oral flora like Pasteurella, Capnocytophaga, and anaerobes, as well as human skin flora like Streptococcus and Staphylococcus species. patients with severe injuries (including deep puncture wounds, crush injuries, and injuries to sensitive areas including the face, hands, and joints) or with underlying conditions that impair wound healing (such as immunocompromise, advanced liver disease, asplenia, and chronic edema) are more prone to infection and infectious complications. The Infectious Diseases Society of America recommends giving 3 to 5 days of prophylactic antibiotic therapy to patients with an animal bite who are at increased risk for wound infection or complication. Amoxicillin-clavulanate is the first-line oral therapy option for animal bite infection prophylaxis (when indicated) and for treatment of infected animal bite wounds.

Answer 190

Hyperuricemia and gout are comorbidities associated with psoriasis. It is thought that the rapid turnover of skin cells in patients with psoriasis drives protein metabolism and increases serum urate levels. A recent study of two large cohorts, the Health Professionals Follow-up Study and the Nurses' Health Study, found that the risk for gout in participants with psoriasis was almost double that of participants without psoriasis; the risk was five times greater in participants with PsA than in those without either condition.

Answer 191

Fundic gland polyps are the most common benign epithelial gastric polyp incidentally found on upper endoscopy. These polyps are typically asymptomatic, smaller than 1 cm, and located in the gastric fundus and/or gastric body; they can be solitary but are more often multiple. They can be sporadic or can result from long-term proton pump inhibitor (PPI) use (>12 months). Dysplasia is exceedingly rare; sporadic fundic gland polyps progressing to cancer have not been reported. In fact, dysplastic changes typically affect only polyps larger than 1 cm. Some polyp characteristics can raise concern: symptomatic polyps, polyps larger than 1 cm, polyps in the gastric antrum, or polyps with an abnormal appearance. In these patients, the polyp should be completely resected rather than being biopsied. Polyps later found to contain dysplasia on biopsy are also of concern, and repeat upper endoscopy should be promptly performed to completely remove these polyps. If fundic gland polyps are histologically confirmed and no dysplasia or concern for syndromic polyps is present (as in this patient), no further endoscopic follow-up is needed.

Answer 192

Patients at intermediate risk for TLS can be managed with monitoring of laboratory values, hydration, and allopurinol, and those at high risk, such as this patient, should receive vigorous intravenous hydration and rasburicase, a urate oxidase enzyme that metabolizes urate to allantoin, before receiving chemotherapy. Rasburicase is contraindicated in patients with glucose-6-phosphate dehydrogenase deficiency, and allopurinol should be used instead.

Answer 193

Because of the high risk of reactivation, patients with chronic HBV infection (hepatitis B surface antigen positivity for >6 months) who will be receiving immunosuppressive therapy, including immunosuppression immediately after solid organ transplantation, should begin potent antiviral therapy (entecavir or tenofovir) directed against HBV. Therapy should be initiated at the time of transplantation and be continued indefinitely afterward.

Answer 194

Mycophenolate mofetil is a mainstay of therapy for ILD in systemic sclerosis. Data from open-label trials suggest that mycophenolate mofetil can stabilize and, in some cases, improve lung function. The Scleroderma Lung Study II compared oral cyclophosphamide for 1 year to mycophenolate mofetil for 2 years. Both agents were equally efficacious in improving and stabilizing FVC; however, mycophenolate mofetil was better tolerated and can be used for many years, whereas cyclophosphamide has a time-limited utility due to toxicity. Expert opinion places mycophenolate mofetil first for both induction and maintenance therapy in patients with systemic sclerosis and ILD.

Answer 195

Binging episodes include at least three of the following characteristics: abnormally rapid consumption, eating until uncomfortably full, consuming large amounts of food when not hungry, eating alone due to embarrassment, and feelings of guilt related to overconsumption. These characteristics distinguish binge eating disorder from overeating. The main treatment for binge eating disorder is cognitive a behavioral therapy (CBT). For medical therapy, a systematic review found that CBT, lisdexamfetamine, selective serotonin reuptake inhibitors (SSRIs), and topiramate all reduced binge eating. Lisdexamfetamine and topiramate reduced weight in adults with binge eating disorder and should be considered for this patient, who has partial response to CBT and an SSRI. Side effects are common with lisdexamfetamine and include headache, gastrointestinal upset, and sleep disturbance. Lisdexamfetamine has been shown to reduce the frequency of binge eating days and is FDA approved to treat binge eating disorder.

Answer 196

American Academy of Neurology guidelines recommend discontinuation of all disease-modifying therapy in patients with secondary progressive MS who have been nonambulatory for more than 2 years and who have had no relapsing activity during that same period.

Answer 197

Zoledronic acid; routinely administered to patient's with bony metastatic disease

Answer 198

The mainstay of treatment is immunosuppression. Induction of remission is typically with prednisone or a combination of prednisone and azathioprine. Depending on response, maintenance therapy may consist of prednisone or azathioprine monotherapy or combination therapy. Because of the high rate of relapse, therapy is recommended for at least 2 to 3 years. Biochemical response may occur within 3 to 8 months of treatment in 85% of patients whose disease responds to standard treatment, but histologic response can lag by several months. Therefore, a liver biopsy is recommended to demonstrate absence of active inflammation before cessation of therapy.

Answer 199

Dermatophytosis of non–hair-bearing skin with limited involvement can be treated topically with the use of topical terbinafine or imidazole creams, such as miconazole, clotrimazole, and ketoconazole, applied once to twice daily for 2 to 4 weeks, ensuring that the application extends a few centimeters beyond the advancing border.

Answer 200

Patients with newly diagnosed primary forms of membranous nephropathy (MN) are typically observed for 3 to 6 months on conservative therapy, which comprises renin-angiotensin system blockers, statin therapy, and edema management, before initiating a course of immunosuppression for patients with persistent nephrotic-range proteinuria. The observation period allows newly diagnosed patients the time to achieve spontaneous remission, which occurs within 1 to 2 years from diagnosis in approximately 30% of patients. If symptoms persist after 6-12 months, primary regimen starts with a combination of oral prednisone and cyclosporine

Answer 201

Well-differentiated neuroendocrine tumors are indolent, frequently discovered incidentally, and often initially only require observation and serial imaging.

Answer 202

In patients with neutropenic fever, antibiotics should usually be continued until either the absolute neutrophil count recovers (>500/μL [0.5 × 109/L]) or the patient has completed a full course of antibiotic therapy, whichever is longest.

Answer 203

Seizures in temporal lobe epilepsy typically manifest as 30-second to 2-minute episodes of staring and arrest of previous activity, along with stereotyped movements of the hands (picking, fidgeting) and mouth (chewing or lip smacking). The patient usually has impaired consciousness during the seizure. Auras, ictal phenomena that precede seizures, are common and can include sensations of fear or déjà vu, epigastric sensations or nausea, and auras of taste or smell. Postictal confusion is typically brief. Patients suspected of having temporal lobe epilepsy should undergo electroencephalography (EEG). EEG findings during a seizure show well-defined discharges in the temporal region. Between seizures, EEG can be normal or may show sharp epileptiform waves over the temporal region. Hippocampal sclerosis or atrophy is commonly associated with temporal lobe epilepsy and may be seen on MRI with epilepsy protocol.

Answer 204

Used for suspected food allergies; Use of SPT in patients with low pretest probability of IgE-mediated food allergy is not recommended because of high false-positive rates. SPT is not appropriate for patients at high risk for anaphylaxis, and patients must avoid antihistamines before SPT.

Answer 205

Commonly referred to as “undulant fever” because of its up-and-down fever pattern. Although the incidence of infection with this gram-negative, intracellular, coccobacillus is highest in Mediterranean countries, it is also commonly encountered in the Middle East and South and Central America. Infection with the Brucella species that cause illness in humans (B. abortus, B. melitensis, B. suis, B. canis) generally follows ingestion of undercooked meat, raw milk, or contaminated milk products or through direct contact with secretions and excretions of infected animals. Symptom onset may be sudden, with chills and fever, severe headache, joint and back pain, malaise, and overall lethargy. Intermittent fever with periods of remission lasting several weeks is common and may persist for months. Depression is commonly reported. Hepatosplenomegaly and lymphadenopathy are frequently detected on physical examination. Cytopenias and abnormal liver chemistry results are nonspecific laboratory findings. Diagnosis is best made by isolation of the bacteria from blood cultures; however, the rate of detection is variable. The organism may also be isolated from bone marrow culture, especially in chronic disease. Serologic testing is often relied on when cultures are negative

Answer 206

Otherwise known as, acute febrile neutrophilic dermatosis, is a reactive eruption most commonly appearing 1 to 3 weeks after an upper respiratory or gastrointestinal infection. It is characterized by tender edematous (“juicy”) red-to-violaceous papules and plaques. In addition to the skin eruption, patients have fever, neutrophilia, elevated inflammatory markers, and muscle or joint pain. Biopsy of the dermis exhibits a dense infiltrate of mature neutrophils. Sweet syndrome may also be seen in the setting of acute myeloid leukemia and myelodysplastic disorders, and it has been associated with solid malignancies and medications (particularly neutrophil-stimulating medications, such as granulocyte colony-stimulating factor and all-trans retinoic acid). Rapid response to systemic glucocorticoids is characteristic.

Answer 207

For all patients with FSGS, conservative therapy plays a central role in management and includes dietary sodium restriction; renin-angiotensin system–blocking drugs such as lisinopril to control proteinuria; statin therapy; and edema management. These conservative measures alone frequently suffice for patients who have FSGS with subnephrotic proteinuria, such as this patient.

Answer 208

If solar lentigines or ephelides (freckles) have irregular shape or pigmentation, expand rapidly, or are symptomatic (bleeding, pain, itching), then lentigo maligna and lentigo maligna melanoma are in the clinical differential diagnosis and biopsy should be considered.

Answer 209

Worry about RVT; check doppler renal ultrasounds and anticoagulate if needed

Answer 210

fecal osmotic gap can be calculated as follows: 290 – (2 × [stool sodium + stool potassium]) An osmotic gap of greater than 100 mOsm/kg suggests an unmeasured osmotically active substance. Such substances include malabsorbed carbohydrates (e.g., lactose or fructose) and sorbitol.

Answer 211

ESBL-producing gram-negative organisms are capable of hydrolyzing higher generation cephalosporins that have an oxyimino side chain such as cefotaxime, ceftazidime, ceftriaxone, and cefepime. The carbapenem class of antibiotics (imipenem, meropenem, doripenem, ertapenem) is the preferred group of agents for treating infections with ESBL-producing organisms. Ertapenem has an advantage over the other carbapenems with once-daily dosing, but some ESBL-producing organisms are resistant to it.

Answer 212

Urine sediment needing flushed And Bladder spasm

Answer 213

Aggressive IVF; no need to hold off due to decreased cardiac function

Answer 214

G6PD assay

Answer 215

NSAIDS for 7 days

Answer 216

Only FDA approved medication for MASH with stage 2 to 3 fibrosis Works as a thyroid receptor beta agonist Very expensive and only available at specialty pharmacies