medicine

Question 1

3 initial steps for management of arrythmia

Answer 1

IVF, O2, monitor (telemetry)

Question 2

systolic <90, chest pain, SOB, altered w/onset of arrythmia

means?

Answer 2

unstable

Question 3

stable arrythmia: fast + wide rythm

what drug

Answer 3

means ventricular tachycardia: administer amiodarone

Question 4

stable: fast + narrow rythm

what tx

Answer 4

adenosine (3 doses)

Question 5

stable; slow rythm; which drug

Answer 5

atropine and prepare to pace

Question 6

drugs for AFIB/Flutter

if CHF?

Answer 6

B-blocker or Diltiazem/verapamil; if they have CHF you have to avoid these, give Digoxin and Amiodarone

Question 7

during code, what to give for VT/VF in between cycles

Answer 7

alternate between epinephrine and amiodarone every 2 minutes

2 minutes CPR, pulse check, shock if indicated, 2 minutes CPR – cycle repeats

Question 8

during code for PEA/Asystole what do adminster?

Answer 8

alternate between EPI and absent each cycle; no SHOCK

Question 9

first step in mngt focal neurological deficit

Answer 9

non-contrast CT: ischemic vs. hemorrhagic

blood is white on CT

Question 10

if non-contrast CT shows hemorrhagic stroke what is the next step?

Answer 10

decrease BP and call neurosurgery : coil, clip, craniotomy

give FFP if INR is abnormal

Question 11

3 tests to determine etiology of stroke:

Answer 11

ECG, ECHO, cartoid U/S

ECG (afib/aflutter, give warfarin or non vit k anticoag, not heparin), ECHO (look for vegetations, give warfarin, NOAC, heparin bridge), carotid U/S (>70% occlusion, intervene surgically)

Question 12

3 absolute contraindications for tPA

given <3 hrs/4.5 hrs after ischemic stroke (no bleeding)

Answer 12

hx of intracranial bleed, rx of bleeding (often GI bleed), or recent surgery

Question 13

chronix tx for ischemic stroke

Answer 13

LMWH, aspirin 81 mg + dipyridamole, if aspirin fails switch to clopidogrel, high potency statin, A1c < 8%, control BP w. ACEi + diuretics

Question 14

HTN control for acute **ischemic stroke management

Answer 14

Permissive HTN (220/120) – to protect penumbra (tissue surrounding ischemic area)

Question 15

lab findings in stable angina

Answer 15

No troponin-I or ST elevation

Stenosis > 70% + pain alleviated by rest = stable angina

<70% for asymptomatic CAD

Question 16

first test for STEMI

Answer 16

ST elevation shows earlier than troponin-I increase; 12 lead ECG first**

• positive if new LBB or ST elevation in two anatomically contiguous leads = send to cath lab

Troponins peak between 8-11 hours

Question 17

NSTEMI vs. unstable angina

both have pain at rest

Answer 17

NSTEMI has elevated troponins, UA does not

Question 18

Diamond classification for chest pain

Answer 18

1. Chest pain is substernal (often crushing and radiating up arm + jaw)
2. Worse on exertion
3. Improved with nitroglycerin

Associated with pain: dyspnea, diaphoresis, pre-syncope

Pain is Non positional, non-pleuritic, non-tender pain

3/3 typical, 2/3 atypical, 1/3 non angina

Question 19

MONA BASHC stands for

Answer 19

Morphine (give last), Oxygen, Nitro, ASA (aspirin), Beta-blocker, ACEi, Statin, Heparin, Clopidogrel

morphine and oxygen are contested

Reperfusion injury = extra oxygen creates free radicals, damages myocytes – happens if oxygen is left for too long; solution is to titrate down after 100% saturation if possible

Question 20

Stress Tests: stress: treadmill or pharmacology (can’t walk); Test via ECG, if + use ECHO, if + use ??

Answer 20

Nuclear

Question 21

Cath lab – coronary angiogram – release dye

+> 3 vessels or 1 major artery ???

Answer 21

CABG; coronary artery bypass grafting

Question 22

Cath lab: Only 1 or 2 vessels occluded

Answer 22

stent ; inflate balloon and leave stent

metal stent – increased rx of stenosis ; drug-eluting stent – increasing rx of thrombosis

Question 23

when to give tPA in setting of STEMI

Answer 23

Only when transport time to percutaneous intervention > 60 min (small rural hospital)

Question 24

chronic mngt of CAD

Answer 24

Manage with B-Blocker + ACEi, dual antiplatelet therapy: aspirin 81 + clopidogrel 75, high potency statin (atorvastatin, rosuvastatin)

Question 25

Prerenal causes that involve leakage into third space 3

Answer 25

nephrosis, gastrosis (malnutrition), cirrhosis (loss of albumin) other prerenal causes: Diarrhea, diuresis, dehydration, hemorrhage Clot: fibromyalgia (young female) or renal atherosclerotic disease (old man)

Question 26

3 signs of nephrotic syndrome

Answer 26

= \>3.5 g protein/day, increased cholesterol, edema

Question 27

post renal causes:

Answer 27

Ureters: cancer or stones Bladder: cancers, stones, neurogenic Urethra: cancer, stones, BPH, foley

Question 28

prodrome of ATN (3)

Answer 28

Muddy brown casts + first Cr rises, then oliguric phase (decreased urine); then polyuria phase (increase urine)

Question 29

Prerenal lab values Prerenal: BUN:Cr, UNa, FeNa , FeUrea

Answer 29

Prerenal: BUN: Cr \> 20, UNa \< 20, FeNa \< 1%, FeUrea \<35%

Question 30

prerenal AKI tx

Answer 30

Give IVF or diuresis depending on physical exam state (dehydration vs. edema)

Question 31

mngmt of post-renal AKI

Answer 31

U/S or CT – look for hydroureter/hydronephrosis Can relieve with foley, nephrostomy, or surgery

Question 32

CKD Stage 5: GFR \< ?

Answer 32

15 = ESRD

Question 33

CDK Stage 1: GFR \> ? II: ? III: 30-59 IV: 15-29

Answer 33

Stage 1: GFR \>90 II: 60-89 III: 30-59 IV: 15-29

Question 34

stage IV CKD management

Answer 34

prepare for dialysis needed for upcoming Stage 5 CKD AV fistula placement STAGE 5 = need dialysis

Question 35

Goal HTN, DM for CKD

Answer 35

Goal HTN **\< 130/\<80**; use ACEi or ARB DM: **A1c \< 7**, **BG: 80-120** -- Orals or Insulin; metformin should not be used, rx of lactic acidosis bad for CKD Insulin is cleared by kidneys; CKD **increases rx** of **hypoglycemia** w/**insulin** and **sulfonylureas**

Question 36

Anemia of Chronic Kidney Disease is a diagnosis of exclusion how to determine

Answer 36

decreased EPO, Hb \< 12, \*\*normocytic anemia diagnostic: CBC + rule out via iron, folate, VB12 levels

Question 37

Tx and goal for anemia of chronic kidney disease

Answer 37

Goal Hb \> 10 Tx: Fe, EPO, Transfusions if needed

Question 38

Complications of CKD: tx for secondary hyperparathyroidism (high phophorus, low calcium) Dx: BMP- Ca, P

Answer 38

phosphate binders: sevelamer Calcimimetics: cinacalcet Ca + Vit D other complications: Volume overload: loop diuretics (furosemide) +/- thiazide Met acidosis: tx with Sodium Bicarbonate

Question 39

For acid-base disorders first check pH, then check ??

Answer 39

CO2 while tell you whether respiratory or metabolic

Question 40

acidemia CO2 \>40 = ??

Answer 40

respiratory acidosis: hypoventilation (opiate overdose, COPD, asthma, OSA, weak respiratory volume)

Question 41

acidemia CO2 \< 40

Answer 41

metabolic acidosis check anion gap (Na – Cl- Bicarb) Anion gap = Methanol, uremia, DKA, propylene glycol, isopropyl alcohol, ethylene glycol, salicylate (MUDPILES) Non – anion gap metabolic acidosis = check urine anion gap = Na + K+ - Cl positive urine anion gap = renal tubular acidosis Regular anion gap = diarrhea – lose bicarbonate in stool causes acidosis

Question 42

Non – anion gap metabolic acidosis = check ??

Answer 42

urine anion gap = Na + K+ - Cl positive urine anion gap = renal tubular acidosis Regular anion gap = diarrhea – lose bicarbonate in stool causes acidosis

Question 43

Alkalemia CO2 \< 40

Answer 43

respiratory alkalosis: hyperventilation: pain, anxiety, hypoxemia

Question 44

Alkalemia CO2 \> 40

Answer 44

metabolic alkalosis Contraction alkalosis: diuretics, dehydration, and emesis/ng suction not volume responsive = look for HTN, Barter’s and Gettleman’s, SIADH

Question 45

next test for metabolic alkalosis

Answer 45

Urine Chloride \*\* Is the person volume responsive/volume down? increase RAAS, sodium reabsorption draws in chloride = Contraction alkalosis = **urine chloride will be low** Volume responsive/down conditions: diuretics, dehydration, and emesis/ng suction Not volume down/responsive = look for HTN, Barter’s and Gettleman’s, SIADH

Question 46

primary maneuver for tet spells

Answer 46

knee to chest positioning or squatting Knee-chest positioning increases arterial oxygenation via increased systemic vascular resistance and thus left-sided heart pressures. This, in turn, decreases right-to-left shunting across the VSD and promotes blood flow into the pulmonary circulation rather than the aorta.

Question 47

first-line treatment for hemodynamically stable patients with sustained monomorphic VT.

Answer 47

Intravenous procainamide

Question 48

Papillary muscle rupture occurs ??? days after an MI whereas Ventricular aneurysms can develop ??? after an MI because of scar tissue formation that leads to thinning and weakening of the ventricular wall symptoms

Answer 48

2–7 days for pap rupture several weeks to months for ventricular aneurysms

Question 49

Beta blockers (e.g., metoprolol), calcium channel blockers (e.g., amlodipine), and nitrates can reduce the sensitivity of ??? as a result of their antianginal activity.

Answer 49

cardiac exercise stress testing

Question 50

??? may manifest in clinical features ranging from asymptomatic arrhythmias to rapidly fatal cardiac rupture. Blunt chest trauma and/or sudden deceleration can lead to decreased contractility and arrhythmias due to injury to cardiac myocytes and pacemaker cells. Decreased contractility directly contributes to cardiogenic shock with decreased cardiac output and hypotension

Answer 50

cardiac contusion

Question 51

the murmur disappears or becomes softer when patients compress the internal jugular vein, lie in the supine position or flex their heads, as seen here. This feature helps differentiate it from the murmur in a patent ductus arteriosus.

Answer 51

Venous hum is a common benign finding on auscultation in childhood. The murmur is most likely caused by turbulence in the internal jugular vein (e.g., when blood enters the thoracic inlet)

Question 52

patient presents with signs of acute limb ischemia (6 Ps: pain, paresthesia, pallor, paralysis, pulselessness, and poikilothermia), which can be caused by ??

Answer 52

thromboembolism as a result of atrial fibrillation (Afib) tx w/ Warfarin

Question 53

nitrates are contraindicated in patients with ?? infarction and/or hypotension

Answer 53

inferior wall infarction and/or hypotension

Question 54

early reperfusion is associated with improved clinical outcomes, door-to-PCI time should be \< ??

Answer 54

\< 90 minutes

Question 55

When used in combination with amolodpine/calcium channel blockers (CCB), this drug ??? results in reduction of the transcapillary pressure and significantly reduces the risk of developing CCB-related peripheral edema.

Answer 55

ACEi or ARB

Question 56

Since many tumors produce proteins and cytokines with thrombophilic effects, malignancy should be ruled out as an underlying cause in cases of a first unprovoked DVT in an adult via what tests???

Answer 56

\*\* chest x-ray a basic malignancy workup includes a CBC, renal function tests, liver function tests, and urinalysis (within normal limits in this patient)

Question 57

treatment of choice for prosthetic valve IE due to methicillin susceptible staphylocci

Answer 57

Intravenous therapy with nafcillin and rifampin for at least 6 weeks in combination with gentamicin for 2 weeks

Question 58

evidence of right-sided heart failure (peripheral edema, jugular venous distention, split S2), and pronounced central pulmonary arteries, all of which are strongly suggestive of ??

Answer 58

pulmonary hypertension

Question 59

what test to use for diagnosis of pulmonary hypertension??

Answer 59

Right-heart catheterization diagnosis is made when the mean pulmonary artery pressure is ≥ 20 mm Hg at rest and there is no evidence of underlying pulmonary and left heart conditions (e.g., valvular heart disease, systolic dysfunction, diastolic dysfunction). While PAH is often idiopathic, amphetamine and cocaine use have been associated with development of PAH.

Question 60

contraindications to metformin therapy

Answer 60

renal insufficiency and HF with decreased cardiac output

Question 61

strongest independent risk factor for the development of an abdominal aortic aneurysm (AAA)

Answer 61

history of smoking

Question 62

common cause of infective endocarditis following nosocomial UTIs.

Answer 62

Enterococcus faecalis infection

Question 63

Duke's criteria for Infective Endocarditis

Answer 63

patient must have: two major criteria, one major and three minor criteria, or five minor criteria. Major criteria include: (1) two separate blood cultures positive for typical pathogens and (2) evidence of endocardial involvement in echocardiography. Minor criteria include: (1) underlying heart disease or IV drug abuse, (2) fever, (3) signs of embolism, (4) immunologic findings (e.g., Osler nodes), (5) Roth spots, and (6) positive blood culture for an atypical pathogen

Question 64

systolic anterior motion of the anterior mitral valve leaflet is associated with?

Answer 64

hypertrophic cardiomyopathy + symmetrical septal hypertrophy, and septal wall thickness of \>15 mm

Question 65

3 criteria for defining acute liver injury

Answer 65

elevated aminotransferases (often \>1000 U/L) Signs of hepatic encephalopathy (HE) Impaired hepatic synthetic function (defined as INR \>1.5

Question 66

Elevated serum alkaline phosphatase levels are indicative of cholestasis. These patients (with or without hyperbilirubinemia) should be evaluated with what test??

Answer 66

right upper-quadrant ultrasound to assess for intrahepatic or extrahepatic causes of biliary obstruction

Question 67

Osmotic diarrhea occurs due to the presence of a nonabsorbed, osmotically active solute (eg, polyethylene glycol, sorbitol, lactose), which inhibits water resorption and results in a ????? stool osmotic gap. The diarrhea occurs after ingestion of the causative substance (eg, milk in a patient with lactose intolerance) and does not occur during fasting

Answer 67

high \>125

Question 68

Secretory diarrhea occurs due to toxins (eg, produced by Vibrio cholerae), hormones (eg, produced by VIPomas), congenital disorders of ion transport (eg, cystic fibrosis), or bile acids (in postsurgical patients). It is caused by secretion of electrolytes and water into the intestine, resulting in a ?? stool osmolarity gap. The diarrhea is typically large in volume and persists while fasting and at night.

Answer 68

low SOG (\<50 mOsm/kg)

Question 69

presence of a well-circumscribed liver lesion with a central scar likely represents an incidental finding of ?????, a benign regenerative liver nodule common in women age 20-50.

Answer 69

focal nodular hyperplasia (FNH)

Question 70

In a young adult male with a history of hematochezia (UC), the most likely etiology of recurrent acute cholangitis (eg, similar symptoms in the past) is a biliary stricture due to ???

Answer 70

primary sclerosing cholangitis (PSC)

Question 71

??? toxicity can occur in patients receiving prolonged infusions or higher doses of nitroprusside, and is most common in patients with renal insufficiency. It is characterized by altered mental status, lactic acidosis, seizures, and coma.

Answer 71

Cyanide

Question 72

patient with a crescendo-decrescendo systolic murmur best heard at the RIGHT sternal border and brisk carotid pulses most likely has ????

Answer 72

hypertrophic cardiomyopathy (HCM) or aortic stenosis \*\*differentiate by valsalva - only HCM has changes in position

Question 73

which cardiac drug causes hypothyroidism and liver toxicity?

Answer 73

**amiodarone** causes hypothyroidism because the large iodine load suppresses synthesis of thyroid hormone (Wolff-Chaikoff effect), and amiodarone also inhibits the conversion of T4 to T3 in peripheral tissues.

Question 74

crescendo-decrescendo murmur at the right upper sternal border with radiation to the carotid arteries is a classic description of the murmur caused by

Answer 74

aortic stenosis

Question 75

??? are the preferred treatment for patients with viral (or idiopathic) pericarditis

Answer 75

Nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, ibuprofen, indomethacin) in combination with colchicine

Question 76

isolated systolic hypertension (ISH), generally defined as a systolic blood pressure (BP) ≥140 mm Hg with a diastolic BP \<90 mm Hg (specific BP parameters differ among various guidelines) is most common in elderly patients and is likely due to ???

Answer 76

increased stiffness or decreased compliance of the aortic and arterial walls.

Question 77

Patients with Wolff-Parkinson-White syndrome who develop atrial fibrillation with a rapid ventricular rate should be treated with cardioversion or antiarrhythmics such as ??? (2)

Answer 77

procainamide or ibutilide Atrioventricular nodal blockers such as beta blockers, calcium channel blockers, digoxin, and adenosine should be avoided as they can cause increased conduction through the accessory pathway.

Question 78

???, a form of restrictive cardiomyopathy, should be suspected in patients who have manifestations of congestive heart failure (eg, progressive dyspnea, lower extremity edema, jugular venous distension, ascites) with echocardiographic findings of concentric left ventricular (LV) hypertrophy and nondilated LV cavity, especially in the absence of a history of hypertension Other clinical manifestations include: asymptomatic proteinuria (eg, \>300 mg/day), as seen in this patient, or nephrotic syndrome (eg, \>3.5 g/day); waxy skin; anemia (seen in this patient); easy bruising with ecchymosis; hepatomegaly; gastrointestinal bleeding; early satiety (also seen in this patient); subcutaneous nodules; enlarged tongue; and peripheral or autonomic neuropathy.

Answer 78

Cardiac amyloidosis

Question 79

??? should be suspected in patients with sore throat, hoarseness, stridor, pooled oral secretions, and drooling. Risk factors include diabetes mellitus, obesity, and preceding upper respiratory infection. The diagnosis can be confirmed (in those with stable respiratory status) using lateral neck radiograph.

Answer 79

epiglotitis

Question 80

Trastuzumab is used for the treatment of patients with human epidermal growth receptor 2-positive breast carcinoma and is associated with a risk of ???

Answer 80

cardiotoxicity. Cardiac function should be assessed with echocardiography at baseline and at regular intervals in patients treated with trastuzumab

Question 81

Periorbital purpura is a rare but highly characteristic skin finding of this disease \*\*also causes nephrotic syndrome

Answer 81

amyloidosis \*\*waxy skin changes as well

Question 82

Infections are common in patients who undergo liver transplantation. Likely etiology can be discerned based on the length of time since transplantation. Most infections within the **first month** are due to ???; infections during months 1-6 are usually caused by opportunistic pathogens (in the setting of high-dose immunosuppression).

Answer 82

bacterial causes

Question 83

??? can cause hearing loss that may be either temporary or permanent. Ototoxicity is more common in patients taking high doses, those with coexistent renal failure, or those also being treated with other known ototoxic medications (eg, aminoglycosides).

Answer 83

Loop diuretics

Question 84

The majority of patients are diagnosed in adulthood (age 20-45) due to a combination of variable presentation and diagnostic delay. Diagnosis is made by quantitative measurement of immunoglobulin levels (significantly reduced serum IgG with low levels of IgA and/or IgM) as well as by markedly reduced or absent immune response to vaccination.

Answer 84

common variable immunodeficiency (CVID): a collective diagnosis that includes a number of genetic defects resulting in impaired B cell differentiation and hypogammaglobulinemia.

Question 85

The preferred initial treatment for uncomplicated benign prostatic hyperplasia includes ???, which can provide rapid relief of symptoms. 5-alpha-reductase inhibitors can be used as an alternative or in addition to alpha blockers but have a much slower onset of action.

Answer 85

alpha-1 blockers like terazosin / tamsulosin

Question 86

A photosensitive rash, along with multisystemic symptoms (eg, arthralgias, pancytopenia, splenomegaly), raises concern for ???

Answer 86

systemic lupus erythematosus (SLE)

Question 87

Morphine is first metabolized in the liver, producing active metabolites (ie, retaining mu-opioid agonist activity) such as morphine-6-glucuronide. In patients with impaired ??? function accumulation of these metabolites can lead to altered mental status, sedation, and respiratory depression.

Answer 87

kidney metabolites are renally eliminated

Question 88

??? toxicity should be suspected in a patient with possible environmental exposure (eg, pressure-treated wood, pesticides) who has painful sensorimotor polyneuropathy, skin lesions (hypo- and hyperpigmented, hyperkeratotic), pancytopenia, and mild transaminase elevation.

Answer 88

Arsenic

Question 89

??? overdose presents within 6 hours of ingestion with bradycardia, hypotension, cardiogenic shock, bronchospasm, altered mental status, and seizures. Hypoglycemia is often seen. Treatment consists of airway management, gastric decontamination, intravenous fluids, intravenous atropine, and intravenous glucagon

Answer 89

Beta blocker

Question 90

??? toxicity is generally marked by nausea/vomiting, anion gap metabolic acidosis, elevated lactate level, hyperthermia, and tachypnea. Diagnosis is made with serum salicylate level.

Answer 90

Salicylate

Question 91

​​​​​​​Paget disease of bone is characterized by disordered osteoclastic bone resorption. Serum alkaline phosphatase and ??? are increased due to increased bone turnover. Serum calcium will usually be normal in the absence of other complicating factors.

Answer 91

urine hydroxyproline levels \*\*breakdown product of collagen

Question 92

The classic presentation involves the distal interphalangeal joints. Morning stiffness, deformity, dactylitis ("sausage digit"), and nail involvement are common.

Answer 92

​​​​​​​Psoriatic arthritis occurs in 5%-30% of patients with psoriasis.

Question 93

Fracture of a bone containing abundant marrow (eg, pelvis) can release fat into the venous circulation, resulting in fat embolism syndrome. Diagnosis is made based on clinical signs (eg, respiratory distress, neurologic dysfunction, petechial rash), and management is ??

Answer 93

supportive (eg, supplemental oxygen).

Question 94

Hereditary hemochromatosis (HH) arthropathy often resembles osteoarthritis but differs in age at onset (\<40); predilection for the second and third metacarpophalangeal joints and wrists; and presence of chondrocalcinosis. Management is primarily symptomatic (eg, acetaminophen, nonsteroidal anti-inflammatory drugs), but therapeutic ??? is necessary to minimize other systemic complications of HH (eg, liver disease)

Answer 94

phlebotomy

Question 95

Gout initially causes an episodic monoarthritis typically affecting the ??? metatarsophalangeal joints and knees.

Answer 95

first

Question 96

Examination findings include bony enlargement and tenderness, **crepitus with movement**, and painful or decreased range of motion.

Answer 96

**Osteoarthritis** causes chronic joint pain and is most common with advanced age, obesity, and prior joint injury.

Question 97

Methotrexate effects are mediated largely by inhibition of dihydrofolate reductase, which causes folate depletion and leads to impaired DNA synthesis. Side effects include oral ulcers, macrocytic anemia, and ???

Answer 97

hepatotoxicity.

Question 98

??? studies should be checked prior to initiation of methotrexate and periodically thereafter.

Answer 98

Serum liver studies due to hepatotoxicity

Question 99

Bone loss associated with anemia, renal insufficiency, and hypercalcemia suggests ??

Answer 99

multiple myeloma

Question 100

??? is characterized by chronic inflammatory back pain and stiffness, lumbosacral tenderness, and reduced spinal range of motion. In **young patients** with characteristic pain, plain x-rays showing sacroiliitis can confirm the diagnosis.

Answer 100

Ankylosing spondylitis (AS)

Question 101

Rheumatoid arthritis can cause ??? pleural effusions characterized by low glucose, very high lactate dehydrogenase, and (often) low pH and is associated with interstitial lung disease.

Answer 101

exudative

Question 102

??? is commonly associated with calcium pyrophosphate dihydrate crystal deposition in joints, leading to chondrocalcinosis, pseudogout, and chronic arthropathy. Patients commonly also have diabetes and liver disease.

Answer 102

Hereditary hemochromatosis Diagnosis is suggested by iron overload on serum iron studies and can be confirmed by genetic tests.

Question 103

?? is the most common cause of septic arthritis in young, sexually active patients. Diagnosis is confirmed by Gram stain of the synovial fluid, blood cultures, and genital/pharyngeal nucleic acid amplification tests.

Answer 103

Neisseria gonorrhoeae

Question 104

Identifying ??? on x-ray of a joint with acute arthritis establishes a diagnosis of probable CPPD crystal arthritis.

Answer 104

chondrocalcinosis

Question 105

he diagnosis of Sjögren syndrome requires evidence of dry mouth and eyes (eg, positive Schirmer test result for decreased lacrimation) with either histologic evidence of lymphocytic infiltration of the salivary glands or serum autoantibodies against ???

Answer 105

SSA (Ro) and/or SSB (La).

Question 106

​​​​​​​In patients in whom RA is suspected but who have a negative RF test result, ??? testing should be obtained. Seronegative RA often carries a better prognosis; however, many patients with initially seronegative disease will develop positive markers later in their course.

Answer 106

anti-CCP Cyclic citrullinated peptide antibodies (anti-CCP)

Question 107

Myeloproliferative disorders are well-known secondary causes of gout. This patient has a combination of clinical features (in addition to gout) that are highly suggestive of ???, including pruritus triggered by hot baths (aquagenic pruritus), splenomegaly, and headaches.

Answer 107

polycythemia vera (PV)

Question 108

Diseases associated with Erythema nodosum (EN) include streptococcal infection, ????, tuberculosis (TB), endemic fungal disease (eg, histoplasmosis), inflammatory bowel disease (IBD), and Behçet disease.

Answer 108

sarcoidosis

Question 109

The initial workup for Erythema nodosum (EN) includes basic laboratory tests (complete blood count, liver function, renal function), antistreptolysin-O antibodies, TB skin testing, and ????

Answer 109

a chest x-ray should be obtained to assess for findings consistent with sarcoidosis (eg, bilateral hilar lymphadenopathy, reticular opacities) or with TB (unlikely in the absence of symptoms).

Question 110

Scleroderma renal crisis is characterized by the acute onset of hypertension and acute kidney injury in patients with systemic sclerosis. The mainstay of therapy is ??? , which reduce renin-angiotensin-aldosterone system hyperactivity, improve renal function, and normalize blood pressure.

Answer 110

ACE inhibitors (typically captopril)

Question 111

??? is a complication of seropositive rheumatoid arthritis (RA) characterized by neutropenia and splenomegaly. Most patients have high-titer rheumatoid factor and anticitrullinated peptide antibodies (both of which are usually elevated in RA). Risk of recurrent bacterial infection is significantly increased due to neutropenia.

Answer 111

Felty syndrome uncommon but serious complication of long-standing, erosive rheumatoid arthritis (RA)

Question 112

??? typically presents with purulent monoarthritis or the following triad: Polyarthralgia: Migrating asymmetric small and large joint pain Tenosynovitis: Pain along multiple flexor tendon sheaths and with passive range of motion; most common in the wrists, fingers, ankles, and toes Dermatitis: Usually 2-10 pustular/vesiculopustular lesions on the distal extremities that may be confused with pimples or furuncl

Answer 112

disseminated gonococcal infection (DGI)

Question 113

diagnosis of Systemic sclerosis is based primarily on clinical manifestations and serologic markers. Antinuclear antibodies are present in almost all patients but are nonspecific. ??? and anti-RNA polymerase III are less sensitive but more specific and are associated with extensive disease. Anticentromere antibodies may also be seen, primarily in patients with limited disease.

Answer 113

Anti-topoisomerase I (anti-Scl-70)

Question 114

Synovial effusions are common in older patients with OA; communication of the joint space with the gastrocnemius or semimembranosus bursa allows the synovial fluid to flow posteriorly into the bursa, forming a ???

Answer 114

popliteal (Baker) cyst

Question 115

Synovial effusions are common in older patients with ???; communication of the joint space with the gastrocnemius or semimembranosus bursa allows the synovial fluid to flow posteriorly into the bursa, forming a popliteal (Baker) cyst

Answer 115

osteoarthritis

Question 116

patient, an older woman with dry eyes and mouth, has typical features of ??? Exocrine output from lacrimal and salivary glands declines with age, associated with atrophy, fibrosis, and ductal dilation of the glands

Answer 116

age-related sicca syndrome (ARSS), also called age-related dry eye syndrome.

Question 117

Treatment for Raynaud phenomenon involves mainly ??? and avoiding aggravating factors.

Answer 117

calcium channel blockers (eg, nifedipine, amlodipine)

Question 118

??? syndrome presents with localized pain and tenderness over the medial tibial condyle. It is often associated with overuse; risk factors include obesity, diabetes mellitus, knee osteoarthritis, and angular deformity of the knee. The diagnosis is based on clinical features, although x-ray can exclude concurrent osteoarthritis. Management includes quadriceps strengthening exercises and nonsteroidal anti-inflammatory drugs

Answer 118

Pes anserinus pain

Question 119

The pain of hip ??? is typically felt in the groin, buttock, or lateral hip (trochanteric) region and can radiate to the lower thigh or knee. Patients may have mild pain and brief stiffness with prolonged rest, but the worst pain usually occurs with activity and weight bearing. Examination findings often include decreased rotational range of motion, but synovitis (ie, redness, warmth) is absent. Common x-ray findings include loss of joint space, osteophyte formation, and subchondral sclerosis.

Answer 119

osteoarthritis

Question 120

patient with exertional arm pain (likely claudication), systemic symptoms, and left arm pulse deficits (likely left subclavian stenosis) has typical features of ???, a chronic large-artery vasculitis that predominantly affects Asian women age \<40. It primarily involves the aorta and its branches and is characterized by mononuclear infiltrates and granulomatous inflammation of the vascular media, leading to arterial wall thickening with stenosis, occlusion, or aneurysmal dilation

Answer 120

Takayasu arteritis CT or MR angiography, the preferred diagnostic modality, may reveal thickening of large-artery walls and narrowing of the arterial lumen.

Question 121

??? is a seronegative spondyloarthropathy resulting from an infection, typically enteric or genitourinary in origin. Findings may include urethritis, conjunctivitis, mucocutaneous lesions, enthesitis, and oligoarthritis. Nonsteroidal anti-inflammatory drugs are first-line therapy

Answer 121

Reactive arthritis

Question 122

Hydroxychloroquine is used for patients with active systemic lupus erythematosus. However, it can cause ?? toxicity with prolonged use.

Answer 122

retinal Patients treated with hydroxychloroquine should have a baseline ophthalmologic evaluation and periodic reassessment.

Question 123

??? is characterized by clinical features of systemic lupus erythematosus, systemic sclerosis, and polymyositis, which appear sequentially. Important manifestations include Raynaud phenomenon, swelling of the fingers and hands, inflammatory arthritis, and myositis. Autoantibodies for U1 ribonucleoprotein have high sensitivity and specificity.

Answer 123

Mixed connective tissue disease

Question 124

The most important serologic marker for Mixed connective tissue disease is autoantibodies for ??? which has high sensitivity and specificity.

Answer 124

U1 ribonucleoprotein (anti-U1 RNP)

Question 125

??? is a small-vessel vasculitis that causes palpable purpura, glomerulonephritis, arthralgias, and peripheral neuropathy. Laboratory abnormalities include cryoglobulins, rheumatoid factor, and **hypocomplementemia**. Chronic hepatitis C infection is the most common cause, and serologies should be checked in all patients

Answer 125

Mixed cryoglobulinemia syndrome

Question 126

patient has the following characteristic features of ????: Age \>50 Subacute-to-chronic (\>1 month) pain in the shoulder and hip girdles Morning stiffness lasting \>1 hour Constitutional symptoms (eg, malaise, weight loss) Elevated erythrocyte sedimentation rate \>40 mm/h No other apparent explanation for symptoms

Answer 126

polymyalgia rheumatica (PMR)

Question 127

In rheumatoid arthritis, the axial skeleton is also usually spared, with the important exception of the ???

Answer 127

cervical spine RA involvement of the cervical spine can lead to atlantoaxial subluxation, an important and potentially life-threatening complication that can cause spinal cord compression and difficulties with intubation (eg, during anesthesia)

Question 128

Claw toe and hammer toe deformities reflect an imbalance in strength and flexibility between the flexor and extensor muscle groups. these deformities may suggest underlying ????. Other complications include callusing, ulceration, joint subluxation, and Charcot arthropathy

Answer 128

diabetic neuropathy

Question 129

Patients with Paget disease or involvement of high-risk skeletal structures (eg, skull, weight-bearing long bones) should be treated to reduce pain and decrease risk for complications. ???, the preferred therapy, suppress bone turnover.

Answer 129

Bisphosphonates

Question 130

what is the msot definitive diagnostic test for polymyositis???

Answer 130

muscle biopsy is the most definitive diagnostic test and shows a mononuclear infiltrate surrounding necrotic and regenerating muscle fibers. \*\*enodmysial inflammation

Question 131

Involvement of the skull by ???? disease may cause headaches, frontal bossing, cranial nerve impingement, vertigo, or hearing loss.

Answer 131

Paget disease of bone

Question 132

Hearing loss may occur due to enlargement of the temporal bone and encroachment on the cochlea in which disease of the elderly???

Answer 132

Paget disease of bone

Question 133

patient with systemic lupus erythematosus (SLE), who is on prednisone, has atraumatic hip pain with normal x-ray findings, most likely due to ???

Answer 133

osteonecrosis (avascular necrosis) of the femoral head.

Question 134

??? is a common pattern of thyroid function markers often seen in hospitalized patients. A characteristic feature is decreased peripheral conversion of T4 to T3 by 5'-monodeiodinase. Factors that suppress conversion of T4 to T3 include: Caloric deprivation Increased glucocorticoid and inflammatory cytokine (eg, tumor necrosis factor, interferon alpha) levels Elevated free fatty acid levels ​​​​​​​

Answer 134

Euthyroid sick syndrome (ESS)

Question 135

​​​​​​​Chronic pancreatitis or pancreatic resection can cause loss of insulin-producing beta cells, leading to pancreatogenic diabetes; exogenous insulin is required. Patients are at risk for rapid and severe hypoglycemia due to???

Answer 135

loss of glucagon-secreting alpha cells as well

Question 136

Hypercalcemia can be categorized as either parathyroid hormone (PTH) dependent (high-normal or increased PTH [eg, hyperparathyroidism]) or independent (low/suppressed PTH). ???? is the most common cause of PTH-independent hypercalcemia and frequently presents with very high (eg, \>14 mg/dL), symptomatic (eg, polyuria, constipation, nausea) calcium levels.

Answer 136

Humoral hypercalcemia of malignancy (HHM)

Question 137

Radioiodine therapy for Graves disease leads to resolution of hyperthyroidism in 6-18 weeks, but the dose needed for treatment gradually leads to ???? in most patients. This therapy can also acutely worsen Graves ophthalmopathy due to increased titers of thyroid-stimulating autoantibodies.

Answer 137

permanent hypothyroidism

Question 138

Patients with ??? may not have spontaneous hypokalemia, but they are prone to developing diuretic-induced hypokalemia The best screening test is early-morning plasma aldosterone concentration (PAC) to plasma renin activity (PRA) ratio

Answer 138

mild primary hyperaldosteronism

Question 139

Serum Na \>145 mEq/L with dilute urine excludes primary polydipsia and suggests ???

Answer 139

diabetes insipidus The decreased ADH action in both types of DI leads to decreased renal water reabsorption and water loss with polyuria. This results in dilute urine and hypernatremia.

Question 140

i​​​​​​​n patients with diabetes mellitus, intensive blood glucose control with insulin decreases the risk of ??? complications but has an uncertain effect on macrovascular outcomes (eg, stroke, myocardial infarction) and mortality.

Answer 140

microvascular | (eg, retinopathy, nephropathy)

Question 141

The two available ATDs in the United States are propylthiouracil (PTU) and methimazole (MMI). ??? is usually not the preferred drug due to a black box warning of severe liver injury and acute liver failure.

Answer 141

propylthiouracil

Question 142

Graves' disease can be treated with anti-thyroid drugs, radioactive iodine therapy, or thyroidectomy. The most serious side effect of anti-thyroid drugs is ??? (0.3% of patients) the two available ATDs in the United States are propylthiouracil (PTU) and methimazole (MMI).

Answer 142

agranulocytosis

Question 143

Approximately 40%-45% of total blood calcium is bound to ??? and other plasma proteins, the remainder is transported in the blood as ionized calcium (40%-55%) or complexed with phosphate and other anions (5%-15%).

Answer 143

albumin as a result, patients with hypoalbuminemia may have a significant deficit in total blood calcium.

Question 144

Graves ophthalmopathy is due to the effects of activated T cells and thyrotropin receptor antibodies (TRAB) on TSH receptors on retro-orbital fibroblasts and adipocytes. ??? treatment can raise titers of TRAB and worsen the ophthalmopathy. Glucocorticoids and antithyroid drugs can be used to minimize the effects of this tx

Answer 144

Radioactive iodine (RAI)

Question 145

The patient's clinical features - episodic flushing and wheezing, diarrhea, and valvular heart disease with tricuspid regurgitation - are consistent with ???syndrome.

Answer 145

carcinoid

Question 146

Carcinoid tumors are rare neuroendocrine tumors that cause episodic flushing, secretory diarrhea, bronchospasm, and cardiac valvular abnormalities. Carcinoid cells cause increased production of serotonin from tryptophan which causes what def & syndrome?

Answer 146

Tryptophan required for niacin synthesis, resulting in niacin deficiency (ie, pellagra, with dermatitis, diarrhea, and dementia).

Question 147

This patient has significant hypertension at a relatively young age, which raises suspicion for secondary causes of hypertension. In particular, his hypokalemia associated with a 3-cm adrenal mass is highly suggestive of ??

Answer 147

primary hyperaldosteronism (Conn syndrome)

Question 148

Primary hyperaldosteronism (Conn syndrome) causes hypertension, hypokalemia, and metabolic ????. The diagnosis is confirmed by low plasma renin activity with an elevated serum aldosterone level.

Answer 148

alkalosis Aldosterone also stimulates nephrons to secrete hydrogen ions into the urine, resulting in increased reabsorption of bicarbonate, elevated serum bicarbonate levels, and metabolic alkalosis.

Question 149

The most accurate markers indicating resolution of diabetic ketoacidosis are the ??? and serum beta-hydroxybutyrate levels. .

Answer 149

serum anion gap The anion gap estimates the unmeasured anion concentration in the blood and returns to normal with the disappearance of ketoacid anions

Question 150

Hyperosmolar hyperglycemic state in type 2 diabetes mellitus is characterized by severe hyperglycemia and hyperosmolality without significant ketoacidosis. Neurologic symptoms ranging from confusion to coma are due primarily to ????; this patient's calculated osmolality is approximately 336 mOsm/kg (using the reported sodium level, not that corrected for hyperglycemia). Common precipitating factors include infection, medications (eg, glucocorticoids), interruption of insulin therapy, trauma, and acute illness.

Answer 150

high plasma osmolality, usually \>320 mOsm/kg

Question 151

This patient has gynecomastia and testicular atrophy. His laboratory results show low testosterone levels and inappropriately low/normal gonadotropin (ie, LH, FSH) levels, indicating ???

Answer 151

secondary (central) hypogonadism. Causes of secondary hypogonadism include: Mass lesions in the hypothalamus or pituitary (eg, prolactinomas), severe systemic illness: due to gonadotroph cell damage Hyperprolactinemia, long-term use of glucocorticoids or opiates: due to suppression of gonadotropin-releasing hormone

Question 152

Hypothyroidism disrupts the hypothalamic-pituitary-ovarian axis. Low circulating thyroxine levels increase the excretion of hypothalamic thyrotropin-releasing hormone, which in turn stimulates anterior pituitary production of both TSH and ????.

Answer 152

prolactin The resulting hyperprolactinemia suppresses ovulation, leading to abnormal uterine bleeding (eg, oligomenorrhea

Question 153

??? is characterized by hypercalcemia, acute kidney injury, and metabolic alkalosis. It is caused by excessive intake of calcium and absorbable alkali, usually in the form of calcium carbonate taken for heartburn or osteoporosis.

Answer 153

Milk-alkali syndrome

Question 154

Medullary thyroid cancer (MTC) is a calcitonin-producing tumor of the thyroid parafollicular C cells. It often occurs as a component of multiple endocrine neoplasia types 2A and 2B, which are also associated with ???.

Answer 154

pheochromocytoma Patients with MTC should be screened for pheochromocytoma prior to thyroidectomy with a plasma fractionated metanephrine assay.

Question 155

Untreated hyperthyroid patients are at risk for cardiac tachyarrhythmias, including atrial fibrillation, and ???

Answer 155

rapid bone loss from increased osteoclastic activity in the bone cells.

Question 156

Acromegaly causes what change in the heart ???; this may eventually lead to left ventricular dilation and global hypokinesis. This cardiomyopathy is often worsened by concurrent hypertension, obstructive sleep apnea, and valvular heart disease. Complications include heart failure and arrhythmias.

Answer 156

concentric myocardial hypertrophy and diastolic dysfunction

Question 157

Resistance to thyroid hormone is a rare inherited disorder caused by defects in the thyroid hormone receptor. Patients can have elevated T4 levels with a normal or increased TSH, but most have a ????, and this condition is usually apparent in childhood.

Answer 157

a goiter

Question 158

??? is characterized by fever, neck pain, and a tender goiter following an upper respiratory illness. Patients have a self-limited thyrotoxic phase followed by hypothyroidism and eventual recovery of thyroid function. Treatment is symptomatic with beta blockers and nonsteroidal anti-inflammatory drugs.

Answer 158

Subacute (de Quervain) thyroiditis

Question 159

Diabetic neuropathy is the most important contributing factor and is found in \>80% of patients with ulcers. ??? testing predicts the risk of future ulcers.

Answer 159

Monofilament

Question 160

??? is an important cause of hypocalcemia, particularly in alcoholics. It causes decreased release of parathyroid hormone (PTH) and PTH resistance.

Answer 160

Hypomagnesemia

Question 161

Type 1 multiple endocrine neoplasia is characterized by ??? , pituitary tumors (prolactinoma), and gastrointestinal/pancreatic endocrine tumors (eg, gastrinomas). Common complications include symptomatic hypercalcemia and recurrent peptic ulcers.

Answer 161

primary hyperparathyroidism

Question 162

Oral estrogen use (eg, menopausal hormone therapy) causes an increase in ???, leading to decreased free thyroid hormone levels. Patients with hypothyroidism on levothyroxine therapy are unable to increase endogenous thyroid hormone production to compensate and require an increased levothyroxine dose

Answer 162

thyroxine-binding globulin

Question 163

Patients with primary adrenal insufficiency have glucocorticoid and mineralocorticoid deficiency. Most patients require replacement of both glucocorticoid (eg, hydrocortisone) and mineralocorticoid (eg, ????) activity.

Answer 163

fludrocortisone

Question 164

Primary adrenal insufficiency most commonly results from ??? Clinical manifestations result from deficiency of mineralocorticoids, glucocorticoids, and androgens and include fatigue, weight loss, hypotension, and hyperpigmentation of the skin and mucous membranes

Answer 164

an autoimmune response against the bilateral adrenal cortex and often occurs in conjunction with other autoimmune disease (eg, primary hypothyroidism, vitiligo).

Question 165

Thyroid storm is a life-threatening thyrotoxicosis usually triggered by a specific event (eg, surgery, trauma, infection, ?????, childbirth) in patients with undiagnosed or inadequately treated hyperthyroidism. Patients can develop fever, hemodynamic instability, cardiac arrhythmias, and congestive heart failure.

Answer 165

iodine contrast

Question 166

Patients with hyperthyroidism and a suppressed TSH should undergo thyroid radioiodine scintigraphy to distinguish painless thyroiditis from Graves disease. With painless thyroiditis, radioiodine uptake is ??? suggesting the release of preformed thyroid hormone. In contrast, Graves disease causes hyperthyroidism due to increased synthesis of thyroid hormone. Radioiodine uptake will be diffusely ???, and extra-thyroidal manifestations (eg, exophthalmos, pretibial myxedema) are often present

Answer 166

decreased increased in Graves

Question 167

Refeeding syndrome is a potentially fatal complication of nutritional rehabilitation in anorexia nervosa. what is the moa???

Answer 167

Carbohydrate intake stimulates insulin activity, which in turn promotes cellular uptake of phosphorus, potassium, and magnesium, leading to electrolyte deficiency. Cardiac manifestations include arrhythmias and congestive heart failure. Other common complications involve the muscular (eg, weakness, rhabdomyolysis), gastrointestinal (eg, diarrhea, elevated transaminases), and neurologic (eg, tremor, seizure) systems.

Question 168

This patient's hypertension, episodic headaches, and unexplained hyperglycemia should raise suspicion for ????. Paroxysmal hypertension occurs in approximately half of patients and may be associated with orthostasis (possibly reflecting low plasma volume). Vision changes, coinciding with episodes of headache and hypertension, can also occur.

Answer 168

pheochromocytoma Because catecholamines inhibit insulin secretion, hyperglycemia is also common. Therefore, pheochromocytoma should be considered in patients who develop hyperglycemia that is atypical for both type 1 (ie, usually presents with diabetic ketoacidosis) and type 2 (ie, rarely occurs in patients age \<35 with normal BMI, as in this patient) diabetes mellitu

Question 169

pheochromocytoma has what effect on glucose

Answer 169

Because catecholamines inhibit insulin secretion, hyperglycemia is also common. Therefore, pheochromocytoma should be considered in patients who develop hyperglycemia that is atypical for both type 1 (ie, usually presents with diabetic ketoacidosis) and type 2 (ie, rarely occurs in patients age \<35 with normal BMI, as in this patient) diabetes mellitus

Question 170

Symmetric distal sensorimotor polyneuropathy is the most common neuropathy in patients with diabetes; the clinical features depend on the type of nerve fibers involved. small vs. large fiber injury

Answer 170

Small fiber injury is characterized by the predominance of positive symptoms (eg, pain, paresthesia, allodynia) Large fiber involvement is characterized by the predominance of negative symptoms (eg, numbness, loss of proprioception and vibration sense, diminished ankle reflexes).

Question 171

Patients with hypothyroidism should ??? their levothyroxine dose at the time pregnancy is detected, with subsequent dose adjustments based on TSH and total T4 using pregnancy-specific norms.

Answer 171

increase

Question 172

besity and cardiovascular disease are common comorbidities in patients with type 2 diabetes mellitus. In these patients, which two meds ??? can be added to decrease cardiovascular mortality, induce weight loss, and minimize the risk for hypoglycemia.

Answer 172

glucagon-like peptide-1 receptor agonists (eg, exenatide, liraglutide) and/or certain sodium-glucose cotransporter-2 inhibitors

Question 173

which antipsychotic medications has a high frequency of prolactin elevation

Answer 173

Risperidone

Question 174

Infants born to women with Graves' disease are at risk for thyrotoxicosis due to ????. Affected infants are irritable, tachycardic, and gain weight poorly. Methimazole plus a β blocker are given to symptomatic patients until the condition self-resolves over a few weeks to months.

Answer 174

passage of maternal TSH receptor antibodies across the placenta

Question 175

??? most commonly occurs as pruritic, purple/pink, polygonal papules and plaques on the skin of the extremities and trunk, but lesions may also appear on the genitalia or oral mucosa.

Answer 175

​​​​​​​Lichen planus

Question 176

The US Preventive Services Task Force recommends screening mammography for women age 50-74 how often???. Screening at age 40-49 and age ≥75 is not routinely recommended but can be considered on an individual basis

Answer 176

biennial (every 2 years)

Question 177

​​​​​​​Tenderness to gentle percussion over the spinous process of the involved vertebra is the most reliable sign for spinal ???. Pain is not relieved with rest. Fever and leukocytosis are unreliable findings. The erythrocyte sedimentation rate is grossly elevated. MRI is the most sensitive diagnostic study. There should be a very high index of suspicion in patients with a **history of injection drug use** or recent distant site infection (eg, urinary tract infection).

Answer 177

osteomyelitis

Question 178

First-line treatment options for ankylosing spondylitis include ????, which provide substantial relief of symptoms and may inhibit progression of the disease for long periods.

Answer 178

nonsteroidal anti-inflammatory drugs and cyclooxygenase-2 inhibitors

Question 179

The initial treatment of ankylosing spondylitis includes regular exercise and nonsteroidal anti-inflammatory drugs. ??? are used in patients whose conditions do not respond to less aggressive treatment.

Answer 179

tumor necrosis factor inhibitors and IL-17 inhibitors

Question 180

The most common cause of an asymptomatic elevation of alkaline phosphatase in an elderly patient is ????, which is frequently discovered incidentally on routine blood tests. X-rays will show osteolytic or mixed lytic-sclerotic lesions, and radionuclide bone scan can fully stage the disease.

Answer 180

Paget disease of bone

Question 181

??? is an inflammatory disorder that occurs in patients age ≥50; it is characterized by aching pain and stiffness in the hip girdle, shoulders, and/or neck that happens in a short amt of time \*\*acutely. The diagnosis is suggested by the presence of elevated acute-phase inflammatory markers (eg, erythrocyte sedimentation rate, C-reactive protein), and the **condition responds rapidly to low-dose glucocorticoid therapy.**

Answer 181

Polymyalgia rheumatica

Question 182

??? most commonly results from an acquired disruption of the lymphatic system that leads to accumulation of lymphatic fluid in the interstitium. Common causes include malignancy and its treatment (eg, radiation, lymph node dissection), chronic inflammation (eg, recurrent cellulitis, connective tissue disease), and severe chronic venous insufficiency. Obesity is often a strong contributing factor. typically presents with pain, swelling, and heaviness in one or more extremities. **Inability to lift the skin on the dorsum of the second toe (positive Stemmer sign) is highly specific**

Answer 182

Lymphedema

Question 183

which lifestyle intervention works best for hypertension?

Answer 183

the DASH (Dietary Approaches to Stop Hypertension) diet, which is a combination diet rich in fruits, vegetables, legumes, low-fat dairy products, and low in saturated and total fat, can produce a reduction in systolic blood pressure of approximately 11 mm Hg, with a corresponding reduction in diastolic pressure.

Question 184

the primary risk factors for abdominal aortic aneurysm include male gender, smoking history, and age \>65. The US Preventive Services Task Force recommends screening for this condition how ?

Answer 184

a one-time abdominal ultrasound in men age 65-75 who ever smoked.

Question 185

Women with chronic hypertension who are pregnant or considering pregnancy should be managed with a medication safe for use in pregnancy. which medications are first-line and safe??

Answer 185

Beta blockers (labetalol) Calcium channel blockers (nifedipine) Hydralazine Methyldopa

Question 186

Patients with ??? typically have recurrent episodes of chest discomfort that resolve spontaneously within 15 minutes. The episodes commonly occur during sleep and may be accompanied by diaphoresis, nausea, palpitations, and dyspnea. Patients are typically young (age \<50) and lack most risk factors for coronary artery disease (CAD) (eg, hypertension, diabetes); however, smoking is a strong risk factor.

Answer 186

vasospastic angina

Question 187

Vasospastic angina results from hyperreactivity of intimal smooth muscle, leading to intermittent coronary artery vasospasm. ??? are the preferred pharmacologic treatment.

Answer 187

Calcium channel blockers (eg, diltiazem, amlodipine) cause coronary artery vasodilation

Question 188

This complication should be suspected in patients presenting with right-sided heart failure following implantable pacemaker or cardioverter-defibrillator placement.

Answer 188

Transvenous lead placement through the tricuspid valve can cause **severe tricuspid regurgitation** due to direct valve leaflet damage or inadequate leaflet coaptation.

Question 189

??? usually occurs as a congenital defect and can often remain asymptomatic until adulthood. Cardiac auscultation reveals an ejection click (high pitched sound after S1), followed by a crescendo-decrescendo systolic murmur over the left second intercostal space and widened splitting of S2.

Answer 189

Pulmonic valve stenosis

Question 190

??? is a cyanotic congenital heart defect with findings include tall P waves (right atrial enlargement) and left axis deviation (left-sided volume overload) on ECG and decreased pulmonary markings on chest x-ray (hypoplasia of right ventricle and pulmonary outflow tract).

Answer 190

Tricuspid valve atresia

Question 191

Oral contraceptives (OCs) commonly cause a mild elevation in blood pressure and can sometimes lead to overt hypertension. OCs should not be used in patients with hypertension, and those who develop hypertension while taking OCs should ??

Answer 191

discontinue the medication The risk of hypertension increases with the duration of OC use and is elevated in those who have a family history of hypertension or who developed hypertension during a previous pregnancy

Question 192

which HTN drug should be avoided in gout patients ?

Answer 192

Thiazide diuretics can raise circulating uric acid levels and should be avoided. Losartan is an angiotensin II receptor blocker (ARB) that has a mild uricosuric effect and is the preferred first-line antihypertensive drug for patients with gout. Other options include other ARBs, ACE inhibitors, and calcium channel blockers.

Question 193

For patients with osteoporosis, which antihypertensives are generally preferred??

Answer 193

thiazide diuretics thiazides increase calcium reabsorption in the distal tubule, reducing renal calcium wasting and slowing the rate of bone loss.

Question 194

??? is recommended as an initial test for diagnosis and risk stratification in most patients with suspected stable ischemic heart disease

Answer 194

Exercise stress ECG

Question 195

???? is useful for differentiating between cardiac disease– and liver disease–related causes of ascites, splenomegaly, and lower extremity edema.

Answer 195

Hepatojugular reflux Positive hepatojugular reflux (ie, sustained \>3-cm rise in jugular venous pressure elicited by compression of the upper abdomen) is highly specific for right ventricular failure. Hepatojugular reflux is not expected with liver cirrhosis.

Question 196

Heart failure with preserved ejection fraction results from ??? in the setting of a normal left ventricular (LV) ejection fraction (ie, \>50%). Concentric LV hypertrophy due to chronic hypertension is usually the primary contributor. Patients develop typical heart failure symptoms (eg, dyspnea, orthopnea, lower extremity edema) resulting from elevated LV diastolic filling pressure and reduced cardiac output.

Answer 196

impaired diastolic relaxation (ie, diastolic dysfunction)

Question 197

Following myocardial infarction (MI), deleterious cardiac remodeling is mostly driven by neurohormonal mechanisms. Which drugs improve survival following MI, likely due to inhibition of neurohormonal-mediated cardiac remodeling.

Answer 197

ACE inhibitors (eg, enalapril, lisinopril), beta blockers (eg, metoprolol), and aldosterone antagonists (eg, spironolactone)

Question 198

??? is the most common cause of chronic mitral regurg in developed countries. It occurs due to myxomatous degeneration of the mitral valve leaflets and chordae and causes a mid-systolic click followed by a mid-to-late systolic murmur.

Answer 198

Mitral valve prolapse (MVP)

Question 199

??? is recognized by saw-toothed flutter waves on ECG; the rhythm can be regular or irregular depending on the variability of the ventricular response rate. It carries a similar risk of arterial thromboembolization to atrial fibrillation and should be similarly managed with chronic anticoagulation.

Answer 199

Atrial flutter

Question 200

Features of ??? include a wide pulse pressure, "water hammer" pulse, and LV enlargement. The left lateral decubitus position brings the enlarged left ventricle closer to the chest wall and causes a pounding sensation and increased awareness of the heartbeat. the wide pulse pressure (systolic minus diastolic blood pressure) causes a characteristic "water hammer" or Corrigan pulse: rapid, abrupt upstroke followed by rapid collapse of the peripheral pulse

Answer 200

aortic regurgitation

Question 201

What type of murmur should prompt further evaluation with a transthoracic echocardiogram in a healthy patient

Answer 201

Diastolic and continuous murmurs are usually due to an underlying pathologic cause. Midsystolic murmurs in otherwise young, asymptomatic adults are usually benign and do not require further evaluation.

Question 202

??? is the most common cardiac arrhythmia, with a prevalence that increases dramatically with age; approximately 70% of those affected are age ≥65. Patients often have episodes of paroxysmal (intermittent) arrythmia in the initial stages and progress to persistent or permanent over time. Atrial enlargement and subsequent atrial remodeling likely play an important role in the development. Hypertension is the most common underlying comorbidity, contributing to left atrial enlargement via concentric left ventricular hypertrophy and transmission of increased pressure to the left atrium.

Answer 202

Atrial fibrillation (AF)

Question 203

patient's middiastolic murmur preceded by an early diastolic sound (ie, opening snap) is consistent with ???

Answer 203

mitral stenosis (MS)

Question 204

?? is a common complication of mitral stenosis, untreated, that occurs due to left atrial dilation

Answer 204

afib

Question 205

??? are first-line therapy for preventing symptoms and improving exercise tolerance in patients with stable angina. They help prevent angina by decreasing exertional heart rate and myocardial contractility, leading to a reduction in myocardial oxygen demand

Answer 205

Beta blockers

Question 206

Sublingual nitroglycerin is used as a first-line agent for rapid relief of symptoms in patients with angina pectoris. The antiischemic effect of nitrates is mediated by ??

Answer 206

systemic vasodilation with a decrease in left ventricular end-diastolic volume and wall stress resulting in decreased myocardial oxygen demand \*\*Decreased stretching of the walls/stress

Question 207

Postthrombotic syndrome occurs in \>50% of patients with a history of acute deep venous thrombosis and is marked by the development of chronic venous insufficiency distal to the site of thrombus. It usually presents with leg pain, edema, fatigue, superficial venous dilation, and/or ulcer. Treatment includes ???

Answer 207

exercise and compression.

Question 208

??? is usually secondary (functional), resulting from right ventricular cavity enlargement in the setting of chronic right-sided volume or pressure overload. A prominent V wave in jugular venous pulsation is highly specific

Answer 208

Tricuspid regurgitation

Question 209

patient with early-onset hypertension and bilateral upper abdominal masses likely has ???

Answer 209

autosomal dominant polycystic kidney disease (ADPKD)

Question 210

patient's elevated blood pressure and ECG findings consistent with ??? (high-voltage QRS complexes, lateral ST segment depression, lateral T wave inversion) are suggestive of long-standing systemic hypertension.

Answer 210

left ventricular hypertrophy (LVH)

Question 211

​​​​​​​Hypertrophic cardiomyopathy is a common cause of exertional syncope and may also cause fatigue, dyspnea, chest pain, palpitations, and presyncope. Symptomatic patients should be treated with a ??? as the negative chronotropy and inotropy increase left ventricular volume to reduce left ventricular outflow tract obstruction and improve symptoms.

Answer 211

beta blocker (eg, metoprolol)

Question 212

??? occur when there is premature activation of the atria originating from a site other than the sinoatrial node. ECG will show an early P wave. By themselves represent a benign arrhythmia that can occur both in healthy individuals and in patients with a variety of cardiovascular and systemic diseases.

Answer 212

Atrial premature beats, also called premature atrial complexes (PACs)

Question 213

??? pericarditis can occur in patients with blood urea nitrogen levels \>60 mg/dL. It presents like other etiologies of acute pericarditis except that classic ECG findings (ie, diffuse ST-segment elevation and PR-segment depression) are typically absent. Dialysis is the best treatment.

Answer 213

Uremic

Question 214

Degeneration of the sinus node and replacement with fibrous tissue is the most common cause of ???? . Elderly patients are typically affected and have bradycardia, leading to fatigue, dyspnea on exertion, lightheadedness, confusion, and syncope or presyncope. ECG demonstrates sinus bradycardia with delayed or dropped P waves.

Answer 214

sick sinus syndrome

Question 215

??? most commonly affects relatively young adults (eg, age \<55), and patients typically present with dilated cardiomyopathy and signs and symptoms of decompensated heart failure. Less commonly, patients will not develop DCM but will present with chest pain that can mimic myocardial infarction. Sudden cardiac death is rare but can occur.

Answer 215

Viral myocarditis

Question 216

??? heart failure is caused by decreased systemic vascular resistance that leads to an increase in stroke volume, cardiac output, and venous return and is recognized by a wide pulse pressure and prominent point of maximal impulse. Hyperthyroidism is a common cause

Answer 216

High-output

Question 217

??? is the most likely diagnosis in this patient with sudden severe chest pain radiating to the back, significant hypertension, decrescendo diastolic murmur of aortic regurgitation (due to proximal extension of the dissection into the aortic valvular annulus), and elevated creatinine of 2.1 mg/dL (possibly due to distal extension into the renal arteries).

Answer 217

Acute type A (ascending) aortic dissection

Question 218

??? has excellent sensitivity and specificity for the diagnosis of aortic dissection and is the preferred diagnostic study in patients with hemodynamic instability or renal insufficiency.

Answer 218

Transesophageal echocardiogram

Question 219

Pulsus paradoxus is defined as an exaggerated fall in systemic blood pressure \>10 mm Hg during inspiration. It is a frequent finding in cardiac tamponade but can also occur in conditions without pericardial effusion such as ???

Answer 219

severe asthma or chronic obstructive pulmonary disease.

Question 220

??? infarction commonly involves vagal symptoms (eg, nausea) and bradyarrhythmias and often primarily affects the right ventricle. Right ventricular myocardial infarction presents with jugular venous distension, clear lungs, and often profound hypotension caused by impaired delivery of blood to the left ventricle.

Answer 220

Inferior wall myocardial

Question 221

?? ​​​​​​​ is the most common underlying arrhythmia responsible for sudden cardiac arrest (SCA) in acute MI and is the most common cause of acute MI-related death.

Answer 221

Ventricular fibrillation

Question 222

Patients with cocaine-associated chest pain should be treated initially with intravenous ????. These improve the symptoms of psychomotor agitation, reduce myocardial oxygen demand, and alleviate cardiovascular symptoms.

Answer 222

benzodiazepines

Question 223

??? is a narrowing of the descending aorta that leads to a proximal arterial pressure load. Patients typically present with **upper extremity hypertension** and **diminished femoral pulses with brachial-femoral delay.** Chest x-ray usually demonstrates inferior notching of the third to eighth ribs due to pressure-induced enlargement of the intercostal arteries.

Answer 223

Coarctation of the aorta

Question 224

​​​​​​​Nonallergic rhinitis usually presents with nasal congestion and rhinorrhea without specific allergic triggers. Patients should be treated with ???

Answer 224

intranasal glucocorticoids; intranasal antihistamines can be added if needed.

Question 225

Bisphosphonate-related osteonecrosis of the ??? is characterized by chronic swelling, mild pain, and exposed, necrotic bone. It is often triggered by tooth extractions or other invasive dental procedures. The course can be intractable, and treatment is largely supportive with careful oral hygiene and antibacterial rinses

Answer 225

jaw

Question 226

??? are the most effective single agent for allergic rhinitis, although maximal benefits may require continuous treatment for several days or weeks

Answer 226

Glucocorticoid nasal sprays

Question 227

This patient has typical features of ??? including nasal congestion, clear rhinorrhea, and pale, edematous nasal mucosa. Patients may also have nasal creases, pharyngeal cobblestoning, conjunctival edema, or thick, green nasal discharge.

Answer 227

allergic rhinitis

Question 228

Barotrauma to the ear occurs most commonly after flying and can result in injury (eg, ear pain, hearing loss) to the tympanic membrane (TM). Most barotraumatic TM injuries are treated how??

Answer 228

heal spontaneously within a few weeks.

Question 229

This patient has a painless, white mucosal lesion on the lateral and inferior surface of the tongue that cannot be scraped off with a tongue depressor. This is most consistent with ???, a potentially malignant or premalignant lesion with risk factors similar to those of squamous cell carcinoma.

Answer 229

oral leukoplakia

Question 230

??? are the greatest risk factors and have a synergistic effect (ie, multiplicative rather than additive) on the risk for developing both oral leukoplakia and oral squamous cell carcinoma

Answer 230

Tobacco use and alcohol use

Question 231

patient has tinnitus, hearing loss, and a **retracted tympanic membrane (TM)**, findings consistent with ???

Answer 231

eustachian tube dysfunction.

Question 232

??? causes fixation of the stapes, which results in conductive hearing loss. It often presents in young women and may progress during pregnancy.

Answer 232

Otosclerosis

Question 233

Tuberculin skin testing can be used to identify patients with latent tuberculosis infection. In the United States, an induration size ? mm is considered negative in healthy patients with a low likelihood of tuberculosis infection.

Answer 233

15 | (ie, ≥15 mm is considered positive)

Question 234

If serum TSH is normal, a thyroid ultrasound is the next step to determine nodule sonographic features and size. Certain sonographic features (eg, microcalcifications, irregular margins, internal vascularity) carry a much higher risk of malignancy than others (eg, cystic or spongiform lesions). Thyroid nodules \>1 cm with these high-risk sonographic features should undergo ????

Answer 234

fine-needle aspiration (FNA) biopsy

Question 235

Presbyopia is a common age-related that leads to difficulty with near vision. Caused by??? A history of a middle-aged individual who has to hold books at an arms length to read is classic.

Answer 235

decrease in lens elasticity

Question 236

which eye condition?

Answer 236

Herpes simplex keratitis presents acutely with eye pain, redness, photophobia, tearing, and blurred vision. Slit-lamp examination reveals characteristic **dendritic ulcers (linear branching).**

Question 237

Oral hairy leukoplakia typically presents as multiple white lesions on the lateral tongue with a distinct corrugated appearance. Because it occurs almost exclusively in patients with significant immunodeficiency, ??? should be performed, especially in patients with signs of systemic illnes different then oral leukoplakia which is benign and found in smokers/alcohol

Answer 237

HIV testing

Question 238

??? infection that most commonly manifests as rhino-orbital-cerebral disease in patients with immunocompromise (particularly **poorly controlled diabetes mellitus).** Symptoms include acute fever, nasal congestion, purulent nasal discharge, headache, and sinus pain. Local, necrotic spread is common. Diagnosis requires sinus endoscopy with tissue sampling.

Answer 238

Mucormycosis ; an invasive fungal Rhizopus is the most common cause

Question 239

Hand-foot-and-mouth disease caused by ??? presents with oral vesicles and ulcers in addition to a maculopapular or vesicular exanthem classically involving the palms and soles. Diagnosis is clinical, and treatment is supportive

Answer 239

coxsackievirus

Question 240

patient has a slowly expanding, annular, pruritic rash with a raised border and central clearing consistent with ???

Answer 240

tinea corporis (TC). the fungi thrive in warm, moist areas (eg, shower surfaces, pools, gym mats) and can be transmitted by skin-to-skin contact, contact with animals (eg, cats), or via fomites.

Question 241

tinea corporis First-line treatment is a ???

Answer 241

topical antifungal (eg, terbinafine, miconazole).

Question 242

Small, pruritic, erythematous papules in a linear pattern are suggestive of ??? bites

Answer 242

bedbug

Question 243

Chronic, low-level ??? exposure can lead to itching and lichenification. Treatment includes topical corticosteroids and allergen avoidance.

Answer 243

allergic contact dermatitis ex. nickel on a belt

Question 244

??? is characterized by a recurrent, pruritic, vesicular rash that primarily affects the palms, soles, and sides of the digits. The diagnosis is based on clinical features, and treatment includes high- and super high–potency topical corticosteroids.

Answer 244

Dyshidrotic eczema (acute palmoplantar eczema)

Question 245

Whereas idiopathic lichen planus occurs most commonly at the wrists and ankles, ??? lichen planus can have a more diffuse presentation. Treatment includes topical glucocorticoids and discontinuation of the suspected medication.

Answer 245

Drug-induced lichen planus (lichenoid drug reaction) is associated with a number of medications, including ACE inhibitors, thiazide diuretics, beta blockers, and hydroxychloroquine. drug-induced

Question 246

5 "Ps" of Lichen planus

Answer 246

pruritic, purple/pink, polygonal papules & plaques

Question 247

Squamous cell carcinoma in situ of the skin (Bowen disease) presents as a slowly enlarging, well-demarcated, scaly, erythematous patch or plaque that is asymptomatic. It most commonly occurs on sun-exposed skin. Due to its invasive and metastatic potential, timely diagnosis with a ??? is recommended.

Answer 247

punch biopsy

Question 248

??? is characterized by erythematous, scaly plaques. It is classically found on the extensor surfaces of the knees and elbows (large plaque) but can also occur on the scalp, hands, and trunk (eg, gluteal cleft) as small plaques.

Answer 248

Psoriasis

Question 249

Lichen planus is often associated with ???. Although this disorder resolves spontaneously, topical glucocorticoids can be used to accelerate healing and alleviate pruritus.

Answer 249

hepatitis C

Question 250

??? is a lifelong, inherited disorder characterized by diffuse dry and rough skin with fish-like scales. These features are most noticeable on the extensor legs and during the winter. There is no associated erythema or other cutaneous lesions (eg, vesicles, papules) to indicate an alternate diagnosis.

Answer 250

​​​​​​​Ichthyosis vulgaris

Question 251

??? in infants is characterized by yellow, greasy scales of the face (eg, eyebrows, retroauricular areas) and scalp, as well as glistening, confluent erythema of intertriginous areas. The diagnosis is clinical, and the rash typically self-resolves.

Answer 251

Seborrheic dermatitis

Question 252

​​​​​​​Ichthyosis vulgaris is a chronic, inherited disorder characterized by rough and dry skin with fish-like scales. Treatment includes topical ??? to help remove the scales. In addition, frequent bathing and application of moisturizers are also recommended.

Answer 252

keratolytics, such as alpha hydroxy acid (eg, lactic acid), urea, and salicylic acid

Question 253

??? is an idiopathic inflammatory disorder that presents with round, pruritic, scaly plaques, most commonly on the extremities. It is often associated with dry skin. The diagnosis is based primarily on clinical findings. Treatment includes topical glucocorticoids, emollients, and avoidance of harsh soaps.

Answer 253

Nummular eczema

Question 254

??? is characterized by retained keratin plugs in the hair follicles. It occurs most commonly on the posterior surface of the upper arm and manifests as small, painless papules; a roughened skin texture; and mottled, perifollicular erythema. Exacerbations are common in cold, dry weather. Treatment includes emollients and topical keratolytics (eg, salicylic acid, urea).

Answer 254

Keratosis pilaris

Question 255

Inflammatory acne (pustules) is treated with topical retinoids and benzoyl peroxide. When this regimen is inadequate, the addition of topical or oral ???is recommended.

Answer 255

antibiotics

Question 256

. Bullous impetigo presents with enlarging, yellow fluid-filled, flaccid bullae that leave a collarette of scale after rupture. This condition is caused by ???, and treatment is with oral antibiotics.

Answer 256

Staphylococcus aureus

Question 257

??? is a self-limited exanthem that classically begins with a solitary, large herald patch followed by clusters of smaller oval lesions oriented in a "Christmas tree" pattern. Management is reassurance alone, although symptomatic relief of pruritus (eg, antihistamines, topical corticosteroids) may be indicated.

Answer 257

Pityriasis rosea

Question 258

Female pattern hair loss (FPHL) usually presents with gradual thinning of the hair at the vertex and midline and is characterized by replacement of terminal hairs by smaller vellus hairs (follicular miniaturization). Hair loss can be seen in women with hyperandrogenic states, but androgen levels in most women with FPHL are normal. The first-line treatment is topical ???

Answer 258

minoxidil a direct vasodilator that increases blood flow to the scalp.

Question 259

Recurrent tinea cruris is common and suggests reexposure to an external source or autoinfection from a concurrent dermatophyte infection elsewhere on the body (eg, tinea pedis, tinea corporis, onychomycosis). Patients should have a thorough ???

Answer 259

skin inspection, and any other sites of infection should be treated.

Question 260

Scabies is an intensely pruritic rash characterized by small erythematous papules and burrows in the axillae, periumbilical area, genitalia, and interdigital web spaces. First-line treatment is ???

Answer 260

topical 5% permethrin or oral ivermectin.

Question 261

??? presents with erythematous patches and plaques with greasy scales, most commonly on the central face, ears, and scalp. It is more common in patients with HIV and CNS disorders (eg, Parkinson disease).

Answer 261

Seborrheic dermatitis

Question 262

lSeborrheic dermatitis tx??

Answer 262

Diagnosis is made clinically, and topical antifungals (eg, ketoconazole, selenium sulfide) are effective for treatment.

Question 263

Erythema nodosum is a delayed hypersensitivity reaction characterized by 2- to 3-cm, tender, erythematous nodules, most often on the shins. Common triggers include infection, i**nflammatory bowel disease, sarcoidosis, and malignancy**. It can also be triggered by ???

Answer 263

medications, such as penicillins, sulfonamides, and oral contraceptives.

Question 264

Oral ??? presents with white papules and plaques on the oral mucosa; variants may also show erythematous mucosal atrophy or ulceration. It is often associated with hepatitis C. Treatment includes topical high-potency glucocorticoids.

Answer 264

lichen planus (LP) white papules or plaques connected by white, lacy markings known as Wickham striae

Question 265

Tinea pedis most commonly presents with a pruritic rash between the toes. The diagnosis is usually made clinically but can be confirmed with a potassium hydroxide preparation of skin scrapings. A variety of topical ??? is effective for treatment, but nystatin is not effective

Answer 265

antifungal agents (eg, miconazole, terbinafine, tolnaftate)

Question 266

​​​​​​​???, the second most common type of melanoma, usually grow vertically and have symmetric borders and a uniform, dark color. Suspicion should be raised when the lesion appears different from other lesions on the patient ("ugly duckling sign") or the lesion grows continuously, is elevated, or is firm.

Answer 266

Nodular melanomas ​​​​​​​The ABCDE criteria can assist in evaluation of superficial spreading melanoma but are less sensitive for other types of melanoma (eg, nodular, atypical).

Question 267

Alopecia areata is characterized by patchy, nonscarring hair loss. It is an autoimmune disorder and is often associated with other autoimmune conditions. Treatment includes topical or intralesional corticosteroids like ????. A recurring course is common, but most patients have regrowth over time.

Answer 267

triamcinolone

Question 268

??? is recommended for patients with gross hematuria or with microscopic hematuria and other risk factors for bladder cancer. Risk factors for bladder cancer include cigarette smoking, certain occupational exposures (eg, painters, metal workers), chronic cystitis, iatrogenic causes (eg, cyclophosphamide), and pelvic radiation exposure.

Answer 268

Cystoscopy

Question 269

??? is a common disorder of uncertain etiology, characterized by irritative voiding symptoms (eg, frequency, urgency, hesitancy); perineal or genital pain; and pain or blood on ejaculation. Urine culture is sterile. Treatment includes antibiotics, alpha blockers, and 5-alpha-reductase inhibitors.

Answer 269

Chronic prostatitis/chronic pelvic pain syndrome

Question 270

is a major complication of systemic sclerosis and should be suspected with signs of right-sided heart failure and a vascular pattern on pulmonary function testing (isolated, reduced DLCO despite normal mechanics).

Answer 270

Pulmonary arterial hypertension: vessel wall thickening can lead to luminal narrowing, elevated pulmonary vascular resistance, and eventual right ventricular failure. SS can cause interstitial lung disease and PAH both have reduced diffusion, but interstitial has restrictive lung findings

Question 271

??? is the most common lung cancer in adolescents and young adults. It typically presents with proximal airway obstruction, leading to dyspnea, wheezing, and recurrent pneumonia in the same lobe of the lung.

Answer 271

Bronchial carcinoid Carcinoid syndrome is much less common than with gastrointestinal carcinoid tumors.

Question 272

Treatment of an acute asthma exacerbation includes a short-acting bronchodilator to manage immediate bronchoconstriction and a ??? to dampen late-phase inflammation and prevent symptom relapse.

Answer 272

systemic glucocorticoid (eg, prednisone) Corticosteroids are continued at home (eg, prednisone 40-60 mg daily for 5-7 days) to prevent relapse and decrease the need for hospitalization

Question 273

Initial treatment of an acute asthma exacerbation focuses on relaxing bronchoconstriction with ??? (3)

Answer 273

short-acting beta agonist (eg, albuterol), a short-acting muscarinic antagonist (eg, ipratropium), and intravenous magnesium

Question 274

??? presents with dullness to percussion, increased intensity of breath sounds, and increased tactile fremitus.

Answer 274

Lung consolidation (eg, lobar pneumonia)

Question 275

Comorbid ??? is common in patients with asthma and can worsen asthma symptoms as a result of microaspiration.

Answer 275

gastroesophageal reflux disease (GERD) In asthma patients with signs and/or symptoms suggestive of comorbid GERD, proton-pump inhibitor therapy has shown benefit in improving asthma symptoms and peak expiratory flow rate.

Question 276

??? is a common cause of cough that may be productive of purulent, blood-tinged sputum. Upper respiratory viral infection is the typical etiology, and symptoms are usually self-limiting. Symptomatic treatment and close clinical follow-up are the best management strategies. Cough for \>5 days to 3 weeks (± purulent sputum) Absent systemic findings (eg, fever, chills) Wheezing or rhonchi, chest wall tenderness

Answer 276

Acute bronchitis

Question 277

Croup is a viral infection in which edema and narrowing of the proximal ???result in a barky cough and inspiratory stridor. Treatment with corticosteroids with or without nebulized epinephrine decreases airway inflammation.

Answer 277

trachea

Question 278

patient with dyspnea and inspiratory crackles has pulmonary restriction and a high-resolution CT (HRCT) of the chest showing a pattern of subpleural honeycombing and reticular opacities (ie, usual interstitial pneumonia [UIP]). There is no evidence for underlying connective tissue disease (ie, normal skin and joint examinations) or history of relevant exposure (eg, asbestos, pneumotoxic drugs). This presentation is most consistent with ???

Answer 278

idiopathic pulmonary fibrosis (IPF)

Question 279

first line treatment for idiopathic pulmonary fibrosis (IPF)

Answer 279

**Antifibrotic therapy** has revolutionized IPF treatment. These small-molecule inhibitors block profibrotic growth factor signaling (eg, transforming growth factor β), reducing fibroblast proliferation and collagen production. They are approved for IPF patients with diminished lung function, such as reduced forced vital capacity (FVC).

Question 280

???? can result from airway obstruction (eg, mucus plug) and lead to mediastinal displacement toward the side effected. Dullness to percussion and decreased or absent breath sounds are expected over the area

Answer 280

Large-volume atelectasis

Question 281

??? has been proven to prolong survival in patients with chronic obstructive pulmonary disease and significant chronic hypoxemia. Resting arterial oxygen tension (PaO2) \<55 mm Hg or pulse oxygen saturation (SaO2) \<88% on room air PaO2\<59 mm Hg or SaO2 \<89% in patients with cor pulmonale, evidence of right heart failure, or hematocrit \>55%

Answer 281

Long-term supplemental oxygen therapy

Question 282

??? is associated with a mortality benefit and reduced progression of disease in patients with chronic obstructive pulmonary disease.

Answer 282

Smoking cessation In those diagnosed with COPD, smoking cessation has been shown to decrease the rate of decline of FEV1 and decrease mortality. Long-term supplemental oxygen therapy (LTOT) and lung reduction surgery have shown mortality benefit in specific subpopulations of patients with COPD.

Question 283

Patients who are asymptomatic after nonfatal drowning should undergo ???

Answer 283

prolonged (ie, ≥8 hr) observation due to the risk of delayed pulmonary complications. Direct tissue injury from chemicals or contaminants in the fluid, leading to inflammation Washout of alveolar surfactant, leading to alveolar collapse Disruption of the osmotic gradient of the alveolar-capillary membrane, leading to increased fluid permeability

Question 284

New-onset asthma can present as an acute exacerbation with cough, wheezing, and shortness of breath. Treatment includes ???

Answer 284

albuterol (inhaled short-acting beta agonist) for bronchodilation and a systemic glucocorticoid (eg, prednisone) to reduce airway inflammation.

Question 285

PE causes what change in A-a oxygen gradient

Answer 285

ventilation/perfusion (V/Q) mismatch, resulting in an increase from the expected alveolar-arterial (A-a) oxygen gradient. A-a gradient elevation occurs in processes that cause impaired gas exchange

Question 286

Croup, a viral infection that causes subglottic edema and narrowing, presents with a barky cough and inspiratory stridor. Patients with stridor at rest are treated with corticosteroids and ??

Answer 286

nebulized epinephrine

Question 287

High doses of beta-2 agonists used in asthma treatment (eg, albuterol) can cause ???, which may present with muscle weakness, hyporeflexia, and life-threatening arrhythmias.

Answer 287

hypokalemia Beta-2 agonists such as albuterol reduce serum potassium by driving potassium into cells via stimulation of the sodium-potassium pump (ie, Na+/K+-ATPase).

Question 288

Positive pressure ventilation (PPV) is a mainstay lifesaving treatment for acute cardiogenic pulmonary edema. what effect does it have on LV afterload and preload

Answer 288

PPV lowers left ventricle (LV) preload and afterload to promote LV diastolic filling and systolic ejection, decreasing pulmonary congestion and enhancing oxygen delivery. Application of PPV directly raises the intrathoracic pressure, causing a drop in venous return to the right heart (decreased right ventricular [RV] preload). Elevated intrathoracic pressure compresses alveolar capillaries, raising the pulmonary vascular resistance (increased RV afterload). PPV decreases MAP through baroreceptor effects and by lowering adrenergic tone through decreasing neurohormonal activation, reducing LV afterload

Question 289

?? is characterized by a normocytic anemia with decreased serum iron, decreased total iron-binding capacity, decreased iron saturation, and normal/elevated serum ferritin. Tx is ??

Answer 289

Anemia of chronic disease Treating the underlying inflammatory disorder will often improve the anemia.

Question 290

how is HTN caused by autosomal dominant polycystic kidney disease (ADPKD).

Answer 290

It is believed the hypertension results from cyst expansion leading to localized renal ischemia and consequent increased renin release.

Question 291

patient has ureteric colic secondary to a distal ureteral stone. Uncomplicated stones \<1 cm can be managed conservatively with hydration, analgesics, and ???

Answer 291

alpha blockers. Alpha-1 receptor blockers such as tamsulosin act on the distal ureter, lowering muscle tone and reducing reflex ureteral spasm secondary to stone impaction. These agents facilitate stone passage and reduce the need for analgesics.

Question 292

Adverse metabolic effects of thiazide diuretics include ???, increased LDL cholesterol and plasma triglycerides, and hyperuricemia. Electrolyte abnormalities that can be induced by thiazide diuretics include hyponatremia, hypokalemia, hypomagnesemia, and hypercalcemia ​​​​​​​

Answer 292

hyperglycemia Thiazide-induced glucose intolerance is seen more commonly in patients with diabetes mellitus and metabolic syndrome (ie, hypertension, dyslipidemia, and abdominal obesity).

Question 293

Diabetic kidney disease, a microangiopathic glomerular process suggested by persistent ????, more likely occurs in long-standing diabetes mellitus, suboptimal glycemic and blood pressure control, and other systemic microvascular damage (eg, retinopathy). It is associated with increased risk for cardiovascular mortality.

Answer 293

proteinuria

Question 294

?? ​​​​​​​is the most sensitive test to detect early diabetric nephropathy. This test should be performed at least annually in patients with type 2 diabetes mellitus starting at diagnosis.

Answer 294

Random urine albumin-to-creatinine ratio testing elevations in albumin excretion.

Question 295

??? is the first-line pharmacotherapy for nocturnal enuresis. It can provide immediate improvement when behavioral modifications and alarm therapy have failed. When used as monotherapy, it has a high rate of relapse on discontinuation of therapy. Primary nocturnal enuresis is defined by urinary incontinence in children age ≥5 who have never achieved nighttime dryness and have no underlying medical condition explaining enuresis.

Answer 295

Desmopressin Oral desmopressin, an antidiuretic hormone analogue, decreases urine production during sleep. ​​​​​​​

Question 296

positive nitrites are specific for gram-negative bacteria belonging to the Enterobacteriaceae family (eg, ???) because these organisms convert urinary nitrates to nitrites.

Answer 296

E coli, Klebsiella, Proteus

Question 297

Timely surgical repair is the best treatment for chronic severe mitral regurgitation (MR) of primary etiology. The measured left ventricular ejection fraction (LVEF) significantly overestimates the effective LVEF in patients with severe MR; therefore, surgery is indicated for both symptomatic and asymptomatic patients with LVEF ≤ ???

Answer 297

60%.

Question 298

patient's acute cerebellar infarction (eg, imbalance, dizziness) occurred in the setting of small mitral valve densities, concerning for cardioembolic stroke from endocarditis. Although most cases of endocarditis are infectious, this patient has no fever, leukocytosis, or positive blood cultures. This presentation is consistent with ????

Answer 298

nonbacterial thrombotic endocarditis (NBTE), a noninfectious endocarditis primarily seen with malignancy (80%) or systemic lupus erythematosus (SLE), which is sometimes associated with the antiphospholipid antibody syndrome (APLS).

Question 299

??? should be recommended as a part of an initial treatment regimen in all patients with intermittent claudication. Pharmacologic therapy with cilostazol and percutaneous or surgical revascularization should be reserved for those with persistent symptoms despite adequate supervised exercise therapy.

Answer 299

A supervised exercise program + smoking cessation, low-dose aspirin, and stain therapy

Question 300

Patients with cardiac tamponade usually have clinical features of Beck's triad: hypotension, distended neck veins, and muffled heart sounds. These symptoms are due to an exaggerated shift of the interventricular septum toward the ???

Answer 300

left ventricular cavity, which reduces left ventricular preload, stroke volume, and cardiac output.

Question 301

??? is a complication of mediastinal irradiation and an important cause of right heart failure. It should be suspected in patients with progressive peripheral edema, elevated jugular venous pressure, hepatomegaly, and ascites. Other findings include the presence of hepatojugular reflux, Kussmaul's sign (lack of decrease or increase in jugular venous pressure on inspiration), and a pericardial knock (mid-diastolic sound).

Answer 301

Constrictive pericarditis

Question 302

??? are indicated for the management of acute myocardial infarction (MI) complicated by decompensated heart failure and flash pulmonary edema.

Answer 302

Loop diuretics stimulate potent diuresis to reduce cardiac preload and relieve acute pulmonary edema.

Question 303

?? improve mortality in acute MI but should be avoided in the setting of decompensated heart failure (pulmonary edema)

Answer 303

Beta blockers

Question 304

which type of beat?

Answer 304

Monomorphic ventricular tachycardia is a regular wide-complex tachycardia that may demonstrate fusion and capture beats.

Question 305

Monomorphic ventricular tachycardia is a regular wide-complex tachycardia that may demonstrate fusion and capture beats. Hemodynamically stable patients can be managed initially with antiarrhythmic drugs like??? Immediate synchronized electrical cardioversion is indicated for hemodynamically unstable patients with a pulse.

Answer 305

amiodarone

Question 306

The initial management of atrial fibrillation usually focuses on rate control; a ???? is given initially. Emergency electrical cardioversion is indicated only in patients who are hemodynamically unstable (eg, severe hypotension).

Answer 306

beta blocker (eg, metoprolol) or nondihydropyridine calcium channel blocker (eg, verapamil, diltiazem)

Question 307

Digoxin toxicity can cause a wide range of cardiac arrhythmias, typically resulting from increased automaticity of myocardial conduction and/or increased vagal tone. ??? involves both of these mechanisms and is the most specific arrhythmia for digoxin toxicity.

Answer 307

Atrial tachycardia with atrioventricular block

Question 308

which rash

Answer 308

Erythema multiforme is an acute inflammatory disorder characterized by erythematous, round papules that evolve into target lesions, although the appearance can vary. It is associated with certain infections (especially herpes simplex) as well as medications, malignancies, and connective tissue diseases.

Question 309

Atrial fibrillation is recognized on ECG by an absence of organized P waves and irregularly irregular R-R intervals. It is most commonly caused by ???

Answer 309

ectopic electrical foci within the pulmonary veins.

Question 310

???? can occur within 5 days or up to 2 weeks following transmural myocardial infarction. Affected patients have sudden-onset chest pain and rapid development of cardiac tamponade that quickly leads to obstructive shock and pulseless electrical activity cardiac arrest.

Answer 310

Left ventricular free wall rupture

Question 311

patient's isolated "puffiness" of the lower face is concerning for angioedema, and she should be advised to go to the emergency department immediately. Angioedema is a potential adverse effect of ??? used to treat heart failure with reduced ejection fraction.

Answer 311

sacubitril-valsartan, an angiotensin receptor–neprilysin inhibitor (ARNI)

Question 312

Pulmonary toxicity is a serious adverse effect of which cardiac drug? can occur months to several years after the initiation of therapy. Interstitial pneumonitis presents with progressive dyspnea, nonproductive cough, and new reticular or ground-glass opacities on chest radiograph.

Answer 312

amiodarone

Question 313

patient with dermal blisters on the hands and untreated hepatitis C has typical features of

Answer 313

porphyria cutanea tarda (PCT): acquired disorder of heme synthesis PCT is characterized by painless blisters that heal with scarring, increased skin fragility on the dorsal surfaces of the hands, facial hypertrichosis, and hyperpigmentation. It can be triggered by ingestion of certain substances (eg, ethanol, estrogens) and is most common in patients with underlying hepatitis C. Elevated plasma or urinary porphyrin levels confirm the diagnosis. Phlebotomy or hydroxychloroquine may provide relief, as can treatment for hepatitis C.

Question 314

which bug can cause megacolon and cardiac dysfunction??

Answer 314

Chagas disease is a chronic disease that can cause megaesophagus, megacolon, and/or cardiac dysfunction. The protozoan Trypanosoma cruzi, endemic to South America, is responsible.

Question 315

patient's ECG shows both an inferior and posterior wall myocardial infarction (MI): ST segment elevations in the inferior leads II, III, and aVF (green arrows) with reciprocal ST depression in leads I and aVL (red arrows) are consistent with acute inferior wall MI. ST-segment depression in leads V1 and V2 (orange arrows) suggests a posterior wall MI which artery ??

Answer 315

Right coronary artery occlusion can cause acute inferior and posterior wall myocardial infarctions (MIs).

Question 316

what should be limited in hypertrigylceridemia what is the cutoff for mild triglyceridemia?

Answer 316

limit alcohol; 500

Question 317

young patient's exertional syncope and ECG demonstrating T-wave inversions in the lateral leads (V4-V6) raise suspicion for ??

Answer 317

hypertrophic cardiomyopathy (HCM)

Question 318

Diagnosis for burn wound sepsis requires ??

Answer 318

quantitative wound culture (\>105 bacteria/g of tissue) and biopsy for histopathology (to determine tissue invasion depth).

Question 319

treatment for burn wound sepsis??

Answer 319

Treatment involves empiric, broad-spectrum intravenous antibiotics (eg, piperacillin/tazobactam, carbapenem) with the addition of potential coverage for methicillin-resistant Staphylococcus aureus (eg, vancomycin) or multidrug-resistant Pseudomonas aeruginosa (eg, an aminoglycoside). Local wound care and debridement are usually necessary.

Question 320

​​​​​​​Under normal circumstances, ??? does not cause any significant prolongation of the QRS duration or QT interval; however, in patients with rapid heart rates, the drug has less time to dissociate from sodium channels, leading to a higher number of blocked channels, which results in a progressive decrease in impulse conduction and widening of the QRS complex. This phenomenon is termed use dependence and is seen most frequently with class IC antiarrhythmic agents (less commonly with class IA drugs and rarely with class IB drugs).

Answer 320

flecainide

Question 321

Intravenous ???? is useful in the initial diagnosis and management of patients with narrow-QRS-complex tachycardia. It slows the sinus rate, increases atrioventricular (AV) nodal conduction delay, or can cause a transient block in AV node conduction.

Answer 321

adenosine Intravenous adenosine can be useful in identifying P waves to clarify diagnosis of atrial flutter or atrial tachycardia. It can also terminate paroxysmal supraventricular tachycardias by interrupting the AV nodal reentry circuit.

Question 322

Statins inhibit intracellular HMG-CoA reductase enzyme, prevent conversion of HMG CoA to mevalonic acid, and increase the number of cell membrane LDL receptors. How do statins cause myopathy????1

Answer 322

Statins also decrease coenzyme Q10 synthesis, which is involved in muscle cell energy production and possibly contributes to statin-induced myopathy.

Question 323

Which cardiac drug has a narrow therapeutic window and toxicity is common in elderly patients as they are susceptible to acute renal dysfunction with decreased clearance of the drug. Symptoms of toxicity include **gastrointestinal disturbances (eg, anorexia, nausea, vomiting), neurologic disturbances (eg, confusion, changes in color vision), and cardiac arrhythmias.**

Answer 323

digoxin

Question 324

findings suggestive of severe ??? include: Delayed (slow-rising) and diminished (weak) carotid pulse ("pulsus parvus and tardus") Presence of single and soft second heart sound (S2) Mid- to late-peaking systolic murmur with maximal intensity at the second right intercostal space radiating to the carotids

Answer 324

aortic stenosis

Question 325

Tamponade is treated with emergency ??

Answer 325

pericardiocentesis to relieve pericardial pressure.

Question 326

?? lab finding is common in chronic decompensated heart failure with reduced ejection fraction and parallels disease severity and predicts mortality. It likely results primarily from ongoing and profound nonosmotic stimulation for antidiuretic hormone secretion in the setting of reduced renal perfusion.

Answer 326

Hyponatremia

Question 327

hypovolemic shock causes what change in cardiac output and LA pressure

Answer 327

Loss of intravascular volume decreases right ventricular preload, leading to a downstream decrease in pulmonary capillary wedge pressure (PCWP), a representation of left atrial pressure (and left ventricular end-diastolic pressure). There is a **consequent decrease in left ventricular preload, resulting in decreased cardiac output (CO)** and decreased systemic blood pressure (BP). This in turn stimulates the sympathetic nervous system, leading to increased heart rate and peripheral vasoconstriction (increased systemic vascular resistance [SVR]) in an attempt to maintain BP.

Question 328

?? is a potential cause of dilated cardiomyopathy in relatively young adults (eg, age \<55). Patients usually present with decompensated heart failure that is often preceded by a viral prodrome. Echocardiography typically shows biventricular enlargement with diffuse ventricular wall hypokinesis.

Answer 328

Viral myocarditis

Question 329

Viral myocarditis is a potential cause of dilated cardiomyopathy in relatively young adults (eg, age \<55). Patients usually present with decompensated heart failure that is often preceded by a viral prodrome. Echocardiography typically shows ???

Answer 329

biventricular enlargement with diffuse ventricular wall hypokinesis.

Question 330

Post–cardiac injury syndrome is a form of acute pericarditis that results from ??? deposition in the pericardium. It can occur following any event or intervention (eg, myocardial infarction, coronary artery bypass graft surgery, percutaneous coronary intervention) that exposes the immune system to cardiac antigens and typically has a latency period of several weeks to months.

Answer 330

immune-complex

Question 331

these chest x-ray findings indicate????

Answer 331

Pulmonary embolism

Question 332

vasospastic angina (formerly known as variant or Prinzmetal angina)=vascular smooth muscle hyperreactivity leads to focal or diffuse spasm of the coronary arteries, transient myocardial ischemia, and resulting angina. Patients typically have recurrent episodes of chest discomfort that occur at rest or during sleep. Cigarette smoking is a known risk factor, but patients are typically young and lack other risk factors for coronary artery disease (eg, hypertension, diabetes). As the vasospasm leads to transmural myocardial ischemia, the diagnosis is typically made by ???

Answer 332

ambulatory ECG showing contiguous ST elevation during an episode of chest discomfort.

Question 333

?? typically occurs 3-5 days after an acute myocardial infarction and presents with sudden-onset cardiogenic shock with hypotension, biventricular failure, and a new harsh holosystolic murmur with palpable thrill at the left sternal border.

Answer 333

Rupture of the interventricular septum

Question 334

Torsades de pointes (TdP) refers to polymorphic ventricular tachycardia that occurs in the setting of a congenital or acquired prolonged QT interval. Immediate defibrillation is indicated in hemodynamically unstable patients with TdP, while ??? is the first-line therapy for stable patients with recurrent episodes of TdP.

Answer 334

intravenous magnesium

Question 335

In developing countries and endemic areas (eg, Africa, India & China), ??? is a common cause of constrictive pericarditis. In the United States, the most common causes include idiopathic or viral pericarditis (\>40%), radiation therapy (~30%), cardiac surgery (~10%), and connective tissue disorders.

Answer 335

tuberculosis

Question 336

?? is an adrenergic agonist with predominant activity on beta-1 receptors, some activity on beta-2 receptors, and little activity on alpha-1 receptors. It is used for the management of decompensated HF associated with severe left ventricular systolic dysfunction and cardiogenic shock. It stimulates increased myocardial contractility and heart rate, leading to improved ejection fraction, reduced left ventricular end-systolic volume, and increased cardiac output.

Answer 336

Dobutamine

Question 337

what effect does beta 1 agonism have on the heart (dobutamine)

Answer 337

overall decrease in LV end-systolic volume; increased EF Positive inotropic effect: Increased intracellular cAMP causes increased intracellular calcium release. This allows for enhanced calcium binding to tropomyosin and increased actin-myosin interaction, resulting in increased contractility. Positive chronotropic effect: Heart rate is increased due to increased intracellular cAMP concentration in the pacemaker cells

Question 338

Ankylosing spondylitis is a rheumatologic inflammatory arthropathy that commonly involves chronic lower back pain, impaired spinal mobility, and enthesitis. Which cardiac defect is associated???

Answer 338

Aortic regurgitation is a potential complication of ankylosing spondylitis, resulting from chronic inflammation of the aortic root and valve cusps. Other cardiac valves are not affected

Question 339

The degree of right ventricular outflow tract obstruction can fluctuate in tetralogy of Fallot. Placement of patients in a knee-chest position during a hypercyanotic spell helps how?

Answer 339

increases systemic vascular resistance which prevents R to L shunting via VSD; this increases pulmonary blood flow, and improves hypoxemia

Question 340

Infants of diabetic mothers are at increased risk for **transient** hypertrophic cardiomyopathy with dynamic left ventricular outflow tract obstruction (LVOT). Management includes ??? Treatment is rarely required for more than a few weeks because insulin levels quickly normalize, leading to reduced septal thickening and self-resolution of HCM.

Answer 340

beta blockers (eg, propranolol), which reduce LVOT obstruction by increasing LV filling time and end-diastolic volume (due to reduction in heart rate) and decreasing the pressure gradient between the LVOT and aorta (due to reduction in contractility).

Question 341

In neonates with cyanosis and hypoxemia, oxygen administration typically improves oxygenation in primary pulmonary pathologies. In contrast, minimal improvement is seen in ???

Answer 341

cyanotic congenital heart disease (eg, transposition of the great arteries) due to right-to-left shunting.

Question 342

Trisomy 18 (Edwards syndrome) is characterized by micrognathia, microcephaly, rocker-bottom feet, **overlapping fingers**, and absent palmar creases. ???? is common in these patients and presents with a holosystolic murmur at the left lower sternal border.

Answer 342

Ventricular septal defect

Question 343

?? is characterized by ≥5 days of fever and ≥4 of the following: nonexudative conjunctivitis, mucositis (eg, strawberry tongue), rash, extremity changes, and cervical lymphadenopathy. Echocardiogram is indicated for all patients to assess for coronary artery aneurysms.

Answer 343

Kawasaki disease

Question 344

Aortic coarctation can present with acute heart failure and cardiogenic shock upon closure of the ductus arteriosus. Administration of ??? maintains ductal patency, which restores systemic blood flow by shunting blood from the pulmonary artery to the aorta (right-to-left).

Answer 344

prostaglandin E1

Question 345

Aortic coarctation can present with acute heart failure and cardiogenic shock upon closure of the ductus arteriosus. Administration of prostaglandin E1 helps how???

Answer 345

maintains ductal patency, which restores systemic blood flow by shunting blood from the pulmonary artery to the descending aorta (right-to-left shunting), restoring distal perfusion.

Question 346

1-day-old neonate has rapid onset of hypotension, cyanosis, and hypoxia that fails to improve with 100% inspired oxygen (hyperoxia challenge). This presentation most likely reflects a ductal-dependent congenital heart defect, with sudden clinical deterioration after an initial normal period suggesting that ???

Answer 346

closure of the patent ductus arteriosus (PDA) has affected blood flow \*\*\*give prostoglandin E1

Question 347

??? maintains the patency of the ductus arteriosus and is life-saving in infants with ductal-dependent congenital heart disease: Coarctation of the aorta, D-transposition of the great arteries, Hypoplastic left heart syndrome, Total anomalous pulmonary venous connection, Tricuspid atresia

Answer 347

Prostaglandin E1

Question 348

Patients with congenital long QT syndrome are at risk for polymorphic ventricular tachycardia that leads to syncope or sudden cardiac death, especially during periods of rapid heart rate and high sympathetic activity. ??? treatment dampen sympathetic activity and shorten the QT interval at high heart rates to reduce the risk of these complications.

Answer 348

Beta blockers (eg, propranolol, nadolol)

Question 349

patient's presentation - recurrent episodes of dyspnea, fever, tenacious sputum production, and hemoptysis along with the physical examination findings of crackles and digital clubbing - is consistent with an exacerbation of ????, a disease of bronchial thickening and dilation due to a recurrent cycle of bacterial infection, inflammation, and tissue damage

Answer 349

bronchiectasis

Question 350

Impaired immune defense contributes to the development of bronchiectasis. Impaired mucociliary clearance in ??? typically leads to bronchiectasis located predominantly in the upper lobe.

Answer 350

cystic fibrosis

Question 351

Positive pleural fluid Gram stain or culture is diagnostic of a complicated effusion and is an indication for ??

Answer 351

chest tube placement.

Question 352

COPD exacerbation is less likely to cause bilateral crackles and more likely to cause significant (rather than occasional) wheezing and which acid-base ??(acute or acute-on-chronic) due to CO2 retention

Answer 352

respiratory acidosis

Question 353

Management of acute respiratory distress syndrome (ARDS) involves mechanical ventilation to provide adequate oxygenation and ventilation without causing further injury to the lungs. ??? is a lung-protective strategy that reduces alveolar overdistension to decrease mortality in patients with ARDS. Prone positioning also decreases mortality, likely by homogenizing ventilation throughout the lung

Answer 353

Low-tidal-volume ventilation

Question 354

Patients with ??? who are treated with chemotherapy and radiation are at high risk for secondary malignancy later in life (generally \>10 years after therapy). Solid tumors in the lung (especially in smokers), breast, and gastrointestinal system (eg, colorectal, esophageal, gastric tumors) are most common.

Answer 354

Hodgkin lymphoma \*\*not recurrence; HL usually responds well to treatment; the survival rate is generally \>90% at 5 years. Recurrence after 20 years is very uncommon

Question 355

which two lung changes are normal in pregnancy?

Answer 355

progesterone-induced sensation of dyspnea and an i**ncrease in minute ventilation** that is driven mostly by increased tidal volume. Basilar lung compression by the gravid uterus **decreases residual volume and functional residual capacity**. Vital capacity and FEV1 are unchanged from normal levels.

Question 356

positive pressure mechanical ventilation can cause 3 complications including

Answer 356

alveolar damage, pneumothorax, and hypotension.

Question 357

Know the complications of positive pressure ventilation. ?? presents with sudden-onset shortness of breath, hypotension, tachycardia, tracheal deviation, and unilateral absence of breath sounds.

Answer 357

Pneumothorax

Question 358

??? typically presents with several weeks of fever, cough, and pleurisy. Imaging usually shows a lobar infiltrate, **significant hilar lymphadenopathy**, and (sometimes) pleural effusion. Suspicion should be raised in those who reside in high-risk settings or have impaired immunity, particularly when treatment for common pulmonary diseases (eg, pneumonia) does not improve symptoms.

Answer 358

Primary pulmonary tuberculosis

Question 359

Recurrent pneumonia occurring in the same anatomic location of the lung raises suspicion for localized airway obstruction, which, if present, can lead to impaired bacterial clearance and predisposition to infection (eg, postobstructive pneumonia). Potential causes of localized airway obstruction include: External bronchial compression due to lymphadenopathy, expanding neoplasm, or vascular anomaly. Internal bronchial obstruction due to a foreign body, bronchiectasis, bronchial stenosis, or, rarely, endobronchial carcinoid what test?

Answer 359

CT scan of the chest; especially is neoplasm is suspected (smoker)

Question 360

Cor pulmonale refers to isolated right-sided heart failure (RHF) from pulmonary hypertension, most commonly due to ???? Signs of RHF include jugular venous distension, increased intensity of P2 (pulmonic component of the 2nd heart sound), right ventricular heave, hepatomegaly, dependent pitting edema, and possible ascites

Answer 360

chronic obstructive pulmonary disease.

Question 361

??? primarily affects immunocompromised patients and typically causes the triad of fever, pleuritic chest pain, and hemoptysis. CT scan often reveals multiple **pulmonary nodules with surrounding ground-glass opacities** ("halo sign").

Answer 361

Invasive aspergillosis

Question 362

Invasive aspergillosis primarily affects immunocompromised patients and typically causes the triad of fever, pleuritic chest pain, and hemoptysis. CT scan often reveals pulmonary nodules with surrounding ground-glass opacities ("halo sign"). Treatment usually requires a combination of ???

Answer 362

voriconazole and an echinocandin (eg, caspofungin).

Question 363

Patients with chronic obstructive pulmonary disease who have resting arterial oxygen tension (PaO2) ≤??? mm Hg or pulse oxygen saturation (SaO2) ≤88% are candidates for long-term home oxygen treatment.

Answer 363

55mm Hg and 88% sat Those with signs of right heart failure or hematocrit \>55% should be started on home oxygen if PaO2 ≤59 mm Hg or SaO2 ≤89%.

Question 364

In pneumonia, the alveoli become filled with inflammatory exudate, leading to hypoxemia due to marked impairment of alveolar ventilation in the affected portion of the lungs. The result is ???, an extreme form of ventilation/perfusion (V/Q) mismatch in which there is perfusion of lung tissue in the absence of alveolar ventilation (V ≈ 0).

Answer 364

right-to-left intrapulmonary shunting

Question 365

Pneumonia causes hypoxemia due to ????, an extreme form of ventilation/perfusion mismatch. Depending on how much of the lungs are affected , the resulting hypoxemia may be difficult to correct with an increase in the fraction of inspired oxygen.

Answer 365

right-to-left intrapulmonary shunting

Question 366

Cocaine can induce acute lung toxicity in the form of ??? it presents with rapid onset of dyspnea; diffuse, **bilateral airspace opacities;** and hypoxemia soon after inhaled cocaine exposure.

Answer 366

diffuse alveolar hemorrhage (DAH)

Question 367

The first step in evaluation of solitary pulmonary nodules is to ???

Answer 367

obtain any previous radiographic lung images. Absence of growth over 2-3 years rules out malignancy. If previous films are not available, a CT should be performed to further characterize the lesion.

Question 368

Interstitial lung disease (eg, idiopathic pulmonary fibrosis) involves excessive collagen deposition in the perialveolar tissues. This leads to decreased diffusion capacity across the alveolar-capillary membrane, increasing ??? and causing hypoxemia.

Answer 368

the alveolar-arterial oxygen gradient

Question 369

High-volume blood transfusion can cause symptomatic ??? due to chelation by citrate in transfused blood. Patients with impaired hepatic function are at increased risk due to decreased clearance of citrate by the liver.

Answer 369

hypocalcemia due to chelation of ionized calcium by citrate in transfused blood

Question 370

All pheochromocytomas should undergo surgical resection, which is a high-risk procedure due to the potential for intraoperative catecholamine surges and related complications. To reduce this risk, patients should initiate preoperative what pharm???

Answer 370

alpha-adrenergic blockade 7-14 days prior to surgery, followed by beta-adrenergic blockade 2-3 days prior to surgery. Beta-blocker therapy should never be given in the absence of alpha blockade due to the risk of precipitating hypertensive crisis.

Question 371

The range of presenting manifestations can be broad due to varied organ involvement: Bone marrow infiltration results in thrombocytopenia and anemia, which is likely the cause of this patient's chronic fatigue. Leukopenia may also be present. Visceral organ involvement leads to splenomegaly, which is typically more prominent than hepatomegaly. Blood cell destruction due to splenic enlargement can also contribute to cytopenias. Skeletal involvement causes diffuse bony pain and may result in joint collapse or pathologic fractures. Delayed puberty (eg, absence of breast development by age 13) and poor growth (eg, ≤5th percentile for height and weight) are common findings in children.

Answer 371

Gaucher disease is a lysosomal storage disease that can present from infancy to adulthood and is due to glucocerebroside accumulation in macrophages of the bones, liver, and spleen

Question 372

patient has typical features of ????, including pruritus, fatigue, hepatomegaly, elevated serum bilirubin, and a positive antimitochondrial antibody assay.

Answer 372

primary biliary cholangitis (PBC)

Question 373

???? is a progressive autoimmune disease characterized by destruction of intrahepatic bile ducts. It can be associated with severe hyperlipidemia, leading to xanthelasmas. Other complications include malabsorption, metabolic bone disease (eg, **osteoporosis, osteomalacia**), and hepatocellular carcinoma.

Answer 373

Primary biliary cholangitis

Question 374

In most patients with nonbleeding varices, prophylactic treatment with ???? is recommended to reduce the likelihood of progression to large varices as well as the risk of variceal hemorrhage. Endoscopic variceal ligation can be used as an alternate primary preventive therapy in patients with contraindications

Answer 374

nonselective beta blockers (eg, propranolol, nadolol)

Question 375

??? is marked by segmental, transmural inflammation of medium-sized arteries, which leads to luminal narrowing, thrombosis, and organ ischemia. Mesenteric angiography typically reveals multiple arteries with microaneurysms, irregular luminal narrowing, and distal occlusions.

Answer 375

Polyarteritis nodosa \*\*spares lungs; renal, coronary, and skin involvement common (rash) \*\*also associted with hep B and C

Question 376

patient with a history of vascular disease and commonly presents with crampy, postprandial epigastric pain (intestinal angina), food aversion, and weight loss. Patients may also report nausea, early satiety, and diarrhea. The anginal pain frequently starts within the first hour of eating and slowly resolves over the next 2 hours ​​​

Answer 376

chronic mesenteric ischemia (CMI)

Question 377

Patients with cirrhosis should undergo screening ??? to exclude varices, indicate the risk of variceal hemorrhage, and determine strategies for primary prevention of variceal hemorrhage.

Answer 377

upper GI endoscopy

Question 378

Most pancreatic cysts are benign and can be managed conservatively (eg, surveillance imaging); however, some carry a risk for malignant transformation. Cysts with high-risk features (large size, solid components or calcifications, main pancreatic duct involvement, thickened or irregular cyst wall) require further evaluation with ???

Answer 378

endoscopic ultrasound–guided biopsy and possibly surgical resection.

Question 379

??? should be strongly suspected in this patient given his old age, persistent burning chest pain, significant weight loss, and possible dysphagia (although carefully chewing food before swallowing is sometimes used as a weight loss technique, it can be a subtle sign of progressive dysphagia). risk factors include: uncontrolled gastroesophageal reflux, obesity, male Smoking, alcohol use, n-nitroso containing food

Answer 379

Esophageal cancer

Question 380

For a patient with ascites - cell count and differential are also performed in all patients to rule out spontaneous bacterial peritonitis, a life-threatening infection of the ascitic fluid. Peritonitis symptoms usually include fever, abdominal pain, and mental status changes; however, findings may be subtle in early infection. The diagnosis is confirmed by ????

Answer 380

an absolute polymorphonuclear cell count ≥250/mm3.

Question 381

prednisone induced adrenal insufficiency causes what type?? does not have hyperpigmentation or hyperkalemia

Answer 381

Exogenous glucocorticoids can suppress pituitary secretion of ACTH and hypothalamic production of corticotropin-releasing hormone, leading to central (secondary) adrenal insufficiency. In contrast to PAI, secretion of melanocyte-stimulating hormone is not increased so patients do not display hyperpigmentation. Also, because mineralocorticoid production is controlled by the renin-angiotensin system, aldosterone levels are normal and hyperkalemia is not seen with central adrenal insufficiency

Question 382

Hyperthyroidism from ??? is due to autonomous production of thyroid hormones from the hyperplastic thyroid follicular cells. The radioactive iodine uptake scan reveals uptake only in the hyperactive nodule, with suppression of uptake in the rest of the gland.

Answer 382

toxic adenoma \*\*typically need goiter and opthal for diagnosing Graves

Question 384

The initial step in the evaluation of Cushing syndrome is to confirm hypercortisolism with a ??

Answer 384

late-night salivary cortisol assay, 24-hour urine free cortisol measurement, and/or overnight low-dose dexamethasone test. If hypercortisolism is confirmed, ACTH levels are measured to differentiate ACTH-dependent from ACTH-independent causes.

Question 385

Decreased activity, hoarse cry, and jaundice are commonly associated with congenital hypothyroidism, but the majority of infants with congenital hypothyroidism are asymptomatic. ???? is the most common cause of congenital hypothyroidism worldwide.

Answer 385

Thyroid dysgenesis

Question 386

The management of irritable bowel syndrome includes limited testing (eg, complete blood count, serologies for celiac disease, inflammatory markers) and reassurance. However, the presence of alarm features requires further workup; these include older age of onset (≥50 years), ??? diarrhea, gastrointestinal bleeding, worsening pain, unintended weight loss, abnormal laboratory tests (eg, iron deficiency anemia, elevated inflammatory markers), or a family history of inflammatory bowel disease or early colon cancer.

Answer 386

nocturnal

Question 387

Alcoholic hepatitis is generally characterized by a ratio of aspartate aminotransferase (AST) to alanine aminotransferase (ALT) \>2, elevated gamma-glutamyltransferase, and elevated ????. The absolute values of AST and ALT are almost always \<500 IU/L in alcoholic liver disease.

Answer 387

ferritin

Question 388

??? is typically painless, but large-volume bleeding may be associated with lightheadedness and hemodynamic instability. Low- or moderate-volume bleeding from the right colon will mix with stool and pass as dark or maroon-colored stools. Large-volume hemorrhage can lead to passage of frank red blood. Irritation due to bleeding can cause an urge to defecate.

Answer 388

Diverticular bleeding most cases of diverticular hemorrhage will resolve spontaneously, but a minority of patients will require endoscopic or surgical intervention.

Question 389

isoniazid causes idiosyncratic liver injury with histological features similar to those seen in patients with

Answer 389

viral hepatitis.

Question 390

??? nutrition, when feasible, is the optimal form of nutrition for critically ill patients and has multiple clinical benefits (eg, reduction in infections, maintenance of gut integrity) when initiated early (ie, ≤48 hr).

Answer 390

Enteral | (often via nasogastric tube)

Question 391

Mild ulcerative colitis (UC) is defined as \<4 bowel movements a day, intermittent hematochezia, normal inflammatory markers, and no anemia. First-line treatment is with ??? ; suppositories or enemas are preferred in patients with UC limited to the rectosigmoid, whereas oral therapy is used for more extensive disease.

Answer 391

5-aminosalicylic acid medications; mesalamine, sulfasalazine, balsalazide

Question 392

??? commonly affects young men and is frequently associated with other atopic disorders. It can present with intermittent solid food dysphagia and refractory heartburn. More than 50% of patients have a history of food impaction.

Answer 392

Eosinophilic esophagitis The diagnosis is confirmed with biopsies demonstrating eosinophilic infiltration of the esophageal mucosa.

Question 393

Intermittent scleral icterus and conjugated hyperbilirubinemia with otherwise normal liver function tests suggest benign ????. This condition impairs hepatic excretion of conjugated bilirubin and is characterized by dark granular pigments within hepatocytes on histopathology.

Answer 393

hereditary hyperbilirubinemia (eg, Dubin-Johnson syndrome)

Question 394

In evaluating ascites, a serum-to-ascites albumin gradient (SAAG) \>1.1 g/dL indicates ???

Answer 394

portal hypertensive etiologies (eg, cardiac ascites, cirrhosis) while a SAAG \<1.1 suggests non-portal hypertensive etiologies (eg, malignancy, pancreatitis, nephrotic syndrome, tuberculosis)

Question 395

Hereditary hemochromatosis is characterized by increased intestinal iron absorption, tissue iron deposition, and multisystem end-organ damage (eg, hepatotoxicity). The diagnosis is confirmed by testing for HFE genetic mutations, but patients with extreme hyperferritinemia (eg, serum ferritin \>1000 ng/mL) should receive urgent therapeutic ???

Answer 395

phlebotomy without waiting for genetic testing results.

Question 396

??? 2 ??? are the most appropriate diagnostic tests for acute hepatitis B infection as they are both elevated during initial infection and one will remain elevated during the window period.

Answer 396

HBsAg and anti-HBc

Question 397

Fecal impaction is common in older patients with impaired mobility, chronic constipation, or decreased sensation of stool in the rectal vault. Obstruction of fecal flow in the rectum can cause backup of stool; passage of liquid stool around the impaction can lead to ????. Initial management includes manual disimpaction and enemas to clear the rectal vault.

Answer 397

incontinence

Question 398

Diffuse esophageal spasm is characterized by uncoordinated contractions of the esophagus and presents with chest pain and dysphagia. Esophageal manometry reveals multiple simultaneous contractions of the middle and lower esophagus. Esophagram may show a "corkscrew" pattern. First-line treatment includes ???

Answer 398

calcium channel blockers.

Question 399

??? is a multisystemic, inflammatory granulomatous disease. Asymptomatic liver involvement (eg, abnormal LFTs, hepatomegaly) is common (~65%). Patchy infiltration by noncaseating granulomas can cause cholestatic (eg, mild alkaline phosphatase elevation) followed by hepatocellular (eg, mild aminotransferase elevations) changes. Reticuloendothelial granulomatous infiltration can also cause splenomegaly.

Answer 399

Sarcoidosis Other common sarcoidosis findings seen in this patient include lung involvement (\>90%), with radiographs showing evidence of hilar lymphadenopathy (eg, described as upper lobe reticulonodular opacities, diffuse or nodular parenchymal infiltrates), and hypercalcemia (due to vitamin D conversion by macrophages in granulomas).

Question 400

Symptoms of ??? include dyspepsia, postprandial fullness and nausea, and gastrointestinal bleeding; worsening pain during fasting and nocturnal pain can also occur.

Answer 400

peptic ulcers by Helicobacter pylori; a urease-producing organism that can cause peptic ulcer disease GERD does not typically have GI bleeding

Question 401

This asymptomatic patient has elevated alkaline phosphatase with normal hepatic transaminase (alanine aminotransferase [ALT], aspartate aminotransferase [AST]) levels, normal right upper quadrant ultrasound, and positive antimitochondrial antibody assay. This is consistent with early ???

Answer 401

primary biliary cholangitis (PBC, previously primary biliary cirrhosis), a chronic, progressive liver disease characterized by cholestasis with autoimmune destruction of intrahepatic bile ducts

Question 402

D-xylose is a monosaccharide that is absorbed in the proximal small intestine without degradation by pancreatic or brush border enzymes. Patients with small intestinal mucosal disease will have impaired absorption of D-xylose. Patients with malabsorption due to enzyme deficiencies will have normal absorption of D-xylose which is a small intestinal mucosal disease??

Answer 402

celiac disease is a common cause of malabsorption and is characterized by atrophy of intestinal villi in the proximal small bowel due to exposure to gluten-containing wheat products

Question 403

Small intestinal bacterial overgrowth (SIBO), characterized by alterations in small intestinal flora (due to abnormal intestinal anatomy or motility), leading to bacterial fermentation of the D-xylose before it can be absorbed. SIBO is treated with ???

Answer 403

rifaximin

Question 404

??? typically presents with severe abdominal distension, pain, vomiting, and obstipation. Common causes include electrolyte imbalance (eg, hypokalemia, hypomagnesemia) and factors that lead to autonomic disruption of the colon (eg, major surgery, neurologic disease, anticholinergic medication). The diagnosis is made by CT scan showing colonic dilation without anatomic obstruction, and treatment involves bowel rest and colonic decompression, sometimes aided by intravenous neostigmine.

Answer 404

Acute colonic pseudoobstruction (Ogilvie syndrome)

Question 405

??? is characterized by dilated submucosal veins and arteriovenous malformations, and has an **increased incidence after age 60**. It presents as painless GI bleeding. It is more frequently diagnosed in patients with advanced renal disease and von Willebrand (vW) disease and aortic stenosis (AS), possibly due to acquired vW factor deficiency (from disruption of the vW multimers as they traverse the turbulent valve space induced by AS).

Answer 405

angiodysplasia

Question 406

Typical symptoms of ??? esophagitis include sudden-onset odynophagia and retrosternal pain that can sometimes cause difficulty swallowing. It is most common in the mid-esophagus due to compression by the aortic arch or an enlarged left atrium. The diagnosis is usually made clinically but can be confirmed on endoscopy, which shows discrete ulcers with relatively normal-appearing surrounding mucosa.

Answer 406

medication-induced esophagitis (pill esophagitis) Treatment includes primarily stopping the offending medication to prevent future injury.

Question 407

???? typically occurs in adolescents or young adults practicing unprotected sexual intercourse. Rectal infection can occur via receptive anal intercourse or proximal spread from the vagina. Manifestations include tenesmus, mucopurulent anal discharge, and pruritus; rectal fullness, bleeding, anorectal pain, and constipation may also occur.

Answer 407

Gonococcal proctitis Because patients are often coinfected with Chlamydia trachomatis, they should be treated with dual antibiotic therapy (ie, ceftriaxone + doxycycline) to cover both pathogens (azithromycin has not been studied for treatment of proctitis).

Question 408

For average-risk adults, screening for colorectal cancer (CRC) is recommended beginning at age ???. Commonly used modalities include annual fecal occult blood testing, multitarget stool DNA testing every 1-3 years, and colonoscopy every 10 years.

Answer 408

45

Question 409

Patients with a first-degree family history of CRC (as in this case) or advanced adenomatous polyps (eg, ≥10 mm, high-grade dysplasia, villous elements) are at increased risk and should undergo earlier testing. Of the available screening methods, colonoscopy has the greatest sensitivity and is the recommended option for individuals at increased risk. When should they get a colonoscopy???

Answer 409

Patients with a first-degree family history of CRC should undergo initial colonoscopy at age 40 or 10 years prior to the age of diagnosis of that relative, whichever is earlier

Question 410

woman with persistent asymptomatic elevations in aspartate aminotransferase (AST) and alanine aminotransferase (ALT) and a large gamma gap (total protein − albumin = \>4 g/dL) has ????

Answer 410

``` autoimmune hepatitis (AIH) High levels of autoantibodies (typically IgG) result in hypergammaglobulinemia and a gamma gap, a helpful characteristic feature (not seen in all cases). Positive serology (eg, anti–smooth muscle, anti–liver/kidney microsomal type 1, antinuclear antibodies) or hypergammaglobulinemia confirms the diagnosis ```

Question 411

??? is the most consistent reversible risk factor for pancreatic cancer

Answer 411

Cigarette smoking

Question 412

Obesity and type 2 diabetes are associated with an increased risk of which cancer???

Answer 412

colorectal adenocarcinoma, likely due to hyperinsulinemia. Hyperinsulinemia results in increased circulating levels of insulin-like growth factor-1, which inhibits colorectal epithelial cell apoptosis and promotes neoplastic progression.

Question 413

Nonalcoholic fatty liver disease typically presents in patients with type 2 diabetes mellitus, obesity, and elevated aminotransferases with an AST/ALT ratio ??

Answer 413

1

Question 414

This patient has epigastric pain/tenderness and weight loss in the setting of nonspecific systemic symptoms and a significant smoking history. This combination strongly suggests ??

Answer 414

malignancy affecting the upper gastrointestinal tract or associated solid organs, such as the liver, gallbladder, or pancreas.

Question 415

Dermatitis herpetiformis is a extraintestinal manifestation of ??? and presents as grouped pruritic papules or vesicles (eg, fluid-filled) typically on extensor surfaces (eg, elbows, knees). Erosions and excoriations due to pruritus may be observed.

Answer 415

celiac disease

Question 416

elderly woman has progressive abdominal pain, nausea/vomiting (leading to dehydration with dry mucous membranes and elevated creatinine), abdominal distension, and **high-pitched bowel sounds** on examination. In association with the abdominal x-rays demonstrating distended loops of bowel with air-fluid levels, this presentation suggests

Answer 416

small bowel obstruction (SBO)

Question 417

Diarrhea that is not explained after extensive evaluation suggests possible factitious diarrhea. Helpful studies include ????

Answer 417

stool osmolality (hypoosmolality suggests addition of water or dilute fluid; hyperosmolality suggests addition of concentrated fluid [eg, urine]), stool electrolytes (elevated magnesium or phosphate suggests use of saline osmotic laxatives), and stool osmotic gap (osmotic laxatives cause a high osmotic gap diarrhea).

Question 418

Primary sclerosing cholangitis is often asymptomatic but may present with fatigue and pruritus, and laboratory studies usually reveal cholestasis. It is strongly associated with ulcerative colitis. The diagnosis is confirmed with ???? demonstrating multifocal bile duct strictures alternating with segments of ductal dilation (eg, beaded appearance).

Answer 418

magnetic resonance cholangiopancreatography

Question 419

Paraesophageal hiatal hernias occur when the gastric fundus migrates into the thoracic cavity; large defects can result in herniation of the surrounding stomach and intraabdominal organs. Manifestations include nausea and vomiting, postprandial fullness, dysphagia, and epigastric and/or chest pain. Chest imaging typically reveals a ???

Answer 419

retrocardiac air-fluid level within the thoracic cavity. tx is surgery

Question 420

???? best explains this patient's presentation with fever, jaundice, anorexia, tender hepatomegaly, **mild (\<300 U/L) elevation in aminotransferases** (aspartate aminotransferase [AST] and alanine aminotransferase [ALT]) with an AST:ALT ratio ≥2:1, macrocytic anemia (mean corpuscular volume [MCV] \>100/µm3), bilirubin elevation, thrombocytopenia, and mild elevation in the International Normalized Ratio.

Answer 420

Alcoholic hepatitis (AH)

Question 421

Persistently bloody ascites after multiple diagnostic paracenteses is concerning for an underlying ???.

Answer 421

malignancy Hepatocellular carcinoma is the most common cause, although bloody ascites can also occur with peritoneal metastases from distant primary sites (eg, ovaries, prostate). Cytologic analysis of the ascitic fluid can help identify the primary tumor.

Question 422

Chronic pancreatitis is a progressive inflammatory disorder of the pancreas characterized by recurrent bouts of upper abdominal pain, diarrhea/steatorrhea, and weight loss. Diagnosis is established by ????.

Answer 422

presence of pancreatic calcifications on CT scan or plain film

Question 423

??? typically presents with chronic epigastric abdominal pain that can radiate to the back and is partially relieved by sitting upright or leaning forward.

Answer 423

chronic pancreatitis

Question 424

Giardia duodenalis disrupts the ???? between small intestinal enterocytes, leading to malabsorption (eg, oily, nonbloody, foul-smelling diarrhea; weight loss) typically lasting up to a month. Chronic infection in children may lead to failure to thrive and poor linear growth.

Answer 424

epithelial tight junctions

Question 425

Older patients with a history of chronic antacid use are at risk for ??? deficiency due to achlorhydria.

Answer 425

vitamin B12 Vitamin B12 is ingested bound to animal protein and must be liberated in the stomach by pepsin, which is activated from pepsinogen by gastric acid.

Question 426

Which drugs are among the most common offenders that may trigger pancreatitis via hypersensitivity to the sulfonamide molecule (a structural component of these drugs), pancreatic ischemia due to reduced blood volume, and/or increased viscosity of pancreatic secretions.

Answer 426

Diuretics, including thiazides (eg, hydrochlorothiazide) and most loop diuretics (eg, furosemide)

Question 427

Clostridioides difficile is a common cause of nosocomial and outpatient infectious diarrhea. Major risk factors include recent antibiotic use, age \>65, and ???. Less common risk factors include underlying inflammatory bowel disease and cancer chemotherapy

Answer 427

gastric acid suppression (eg, proton pump inhibitors)

Question 428

Alarm features for constipation include acute onset at an older age, weight loss, and hematochezia. This disease has nonspecific symptoms (eg, lower abdominal pain, bloating, early satiety, constipation). Therefore, older women (eg, postmenopausal, age ≥50) with new-onset abdominal pain and/or concerning gastrointestinal symptoms, ??? should be considered.

Answer 428

Ovarian cancer

Question 429

the HBV vaccine contains HBsAg, which stimulates production of anti-HBs and confers immunity in the host. However, the vaccine does not contain the ??? antigen

Answer 429

core antigen; so antibodies are not made against it and patients are consequently anti-HBc negative \*pateints who have resolved Hep B have anti-HBc

Question 430

Lactose intolerance is characterized by a ??? breath test, positive stool test for reducing substances, low stool pH and increased stool osmotic gap. There is no steatorrhea.

Answer 430

positive hydrogen

Question 431

A priority of cirrhosis management is to protect patients from further hepatic insult. Patients should be vaccinated against ????

Answer 431

both hepatitis A virus (HAV) and hepatitis B virus (HBV) if there is no evidence of immunity (eg, positive HAV IgG, positive HBV surface antibody)

Question 432

Clinical manifestations of ??? deficiency in adults include hypogonadism, impaired wound healing, **impaired taste**, and immune dysfunction. Characteristic physical examination findings include alopecia as well as a skin rash consisting of erythematous pustules around body orifices (eg, mouth) and on the extremities Risk factors include malabsorption, bowel resection, poor nutritional intake, and dependence on parenteral nutrition.

Answer 432

zinc

Question 433

Patients with cirrhosis and portal hypertension frequently have abdominal ascites and peripheral edema due to low albumin levels and abnormal extracellular fluid volume regulation. A small number of these patients may also develop ???, a transudative pleural effusion that is thought to occur due to small defects in the diaphragm.

Answer 433

hepatic hydrothorax

Question 434

acute diverticulitis causes bladder symptoms (eg, urgency, frequency, dysuria) and what lab finding ???

Answer 434

sterile pyuria (eg, positive leukocyte esterase, negative nitrite/bacteria) due to bladder irritation from adjacent sigmoid colon inflammation

Question 435

primary biliary cholangitis can cause xanthelasma how???

Answer 435

can cause hyperlipidemia

Question 436

what is this finding and what does it increase the risk for???

Answer 436

Porcelain gallbladder is usually diagnosed on abdominal imaging showing a calcified rim in the gallbladder wall with a central bile-filled dark area. It is associated with an increased risk for gallbladder adenocarcinoma and usually requires cholecystectomy

Question 437

Minimal rectal bleeding usually is due to hemorrhoids or other benign conditions. In patients with no clinical features suggesting a serious cause (eg, blood mixed with stool, fever, weight loss, change in bowel habits or stool caliber) and no other indication for colonoscopy (eg, age ≥45), initial evaluation with ??? is appropriate.

Answer 437

anoscopy

Question 439

this finding in a neonate with no bowel movement passed is ???

Answer 439

jejunal atresia triple bubble !

Question 440

Bilious emesis in a neonate with hemodynamic instability or peritoneal signs (eg, rigid abdomen) warrants ???

Answer 440

emergency exploratory laparotomy likely 2/2 to malrotation with midgut vovulus

Question 441

????, which can cause intestinal perforation and necrosis, should be considered in patients who also have a normal rectal examination and **air-fluid levels on x-ray.**

Answer 441

Malrotation with midgut volvulus

Question 443

Acute pancreatitis complicated by ???? is thought to arise from intravascular volume loss secondary to local and systemic vascular endothelial injury.

Answer 443

hypotension the two effects cause vasodilation, increased vascular permeability, and plasma leak into the retroperitoneum, resulting in systemic hypotension.

Question 444

Tumors in the ??? of the pancreas can present with weight loss, jaundice, and a nontender, distended gallbladder (eg, Courvoisier sign) on examination. **Imaging can demonstrate dilation of both the intra- and extrahepatic bile ducts as well as the pancreatic duct (ie, double duct sign).**

Answer 444

head

Question 445

Primary sclerosing cholangitis is often diagnosed in asymptomatic individuals with high alkaline phosphatase and gamma-glutamyl transpeptidase levels (cholestatic pattern). Magnetic resonance cholangiopancreatography findings of multifocal intrahepatic and extrahepatic biliary strictures with segmental dilations are diagnostic. A colonoscopy is recommended at the time of diagnosis because many patients also have ?????

Answer 445

inflammatory bowel disease

Question 446

patients diagnosed with a sexually transmitted infection (STI) and those who ask for screening for an STI should undergo evaluation for the following:

Answer 446

N gonorrhoeae (eg, NAAT) C trachomatis (eg, NAAT) HIV (eg, HIV antigen/antibody testing) Syphilis (eg, rapid plasma reagin)

Question 447

????, a group of commensal bacteria in the mouth and upper respiratory tract, are the most likely organisms to cause infectious endocarditis following dental manipulation (eg, tooth extraction) or respiratory mucosa penetration. This group includes Streptococcus sanguinis, Streptococcus mitis, Streptococcus mutans, and Streptococcus milleri.

Answer 447

Viridians streptococci

Question 448

Bright red, firm, friable, exophytic nodules in a patient with HIV are most likely bacillary angiomatosis. The classic lesion is shown in the above picture. Bacillary angiomatosis is caused by Bartonella, a Gram-negative bacillus. Oral ??? is the antibiotic of choice

Answer 448

erythromycin

Question 449

Mycobacterium avium complex is seen primarily in patients with advanced AIDS (CD4 \<50/mm3). MAC is diagnosed with blood cultures or bone marrow aspirate. First-line treatment includes a ??? combined with ethambutol. Antiretroviral therapy should also be initiated a few days after MAC therapy begins.

Answer 449

macrolide (eg, clarithromycin, azithromycin)

Question 450

??? typically presents with subacute or chronic fevers, weight loss, fatigue, and pulmonary symptoms. Chest x-ray classically reveals a **diffuse reticulonodular pattern**. The most common behavioral risk factor for tuberculosis in the United States is substance abuse.

Answer 450

Miliary tuberculosis millet seed pattern on x -ray

Question 451

Patients who receive a solid organ transplant are at risk for opportunistic infections, most notably which two???

Answer 451

Pneumocystis pneumonia and cytomegalovirus (CMV).

Question 452

In the absence of prophylaxis, patient who are immunocompromised who present with a systemic illness involving multiple organ systems (eg, pneumonitis, hepatitis, gastroenteritis) should be tested for ??

Answer 452

pulmonary symptoms (dyspnea on exertion, dry cough), gastrointestinal symptoms (abdominal pain, diarrhea, hematochezia), pancytopenia, mild hepatitis, and interstitial infiltrates on chest x-ray. This combination of findings strongly suggests tissue-invasive **CMV disease** (causing pneumonitis, gastroenteritis, and hepatitis) cytolomegalovirus

Question 453

???? is a free-living marine bacterium that causes food-borne illness (through oysters) and wound infections. Wound infections may be mild, but some patients develop rapid-onset, severe, necrotizing fasciitis with hemorrhagic bullous lesions and septic shock. Patients with liver disease such as cirrhosis, viral hepatitis, and hereditary hemochromatosis are at particularly high risk

Answer 453

​​​​​​​Vibrio vulnificus

Question 455

??? infection typically presents with gastrointestinal complaints (eg, abdominal pain, nausea, vomiting) followed by the characteristic triad of **periorbital edema, myositis, and eosinophilia (hallmark of the disease).** Other findings include fever, subungual splinter hemorrhages, and conjunctival or retinal hemorrhages. ​​​​​​​ The organism is prevalent worldwide, but the infection is more common in Mexico, China, Thailand, parts of central Europe, and Argentina. Infection usually occurs after eating undercooked or raw meat (usually pork) containing larvae

Answer 455

Trichinellosis Trichinella larvae in food

Question 456

??? mononucleosis is marked by persistent fever, malaise, and fatigue with absolute lymphocytosis on complete blood count and atypical lymphocytes on peripheral blood smear. Unlike Epstein-Barr virus, this infx usually causes mild pharyngitis, lymphadenopathy, and splenomegaly (or these symptoms may be absent).

Answer 456

Cytomegalovirus (CMV)

Question 457

Malaria chemoprophylaxis is recommended for most travelers who visit malaria endemic countries. In areas with high rates of chloroquine resistance, patients typically receive atovaquone-proguanil, doxycycline, or mefloquine for how long ???

Answer 457

treatment should begin \>2 weeks prior to travel, continued during the stay, and discontinued 4 weeks after returning

Question 458

those with risk factors (eg, age ≥65, chronic medical problems, pregnancy) for influenza complications should receive antiviral therapy (eg, oseltamivir), regardless of symptom duration. Antivirals can also be considered in those without risk factors who come to the office within 48 hours (not 4 days) of symptom onset as treatment may reduce symptom duration what is the treatment for a healthy individual with influenza??

Answer 458

\*\*just supportive

Question 459

The Jarisch-Herxheimer reaction is an acute, febrile reaction that commonly occurs \<12 hours after initial treatment of ???. Symptoms include fever, headache, myalgias, rigors, sweating, hypotension, and worsening rash (if present). Manifestations are self-limited and typically resolve spontaneously within 48 hours

Answer 459

syphilis

Question 460

in the absence of lung abscess or empyema, empiric treatment for aspiration pneumonia is the same as for community-acquired pneumonia; this patient who failed azithromycin therapy should be given a broader spectrum agent such as ???

Answer 460

amoxicillin-clavulanate.

Question 461

Erysipelas is a superficial skin infection that manifests with the acute onset of systemic symptoms (rapid fever, chills), regional lymphadenitis, and a warm, tender, erythematous rash with raised, sharply demarcated borders. The majority of erysipelas cases are caused by ???

Answer 461

group A Streptococcus

Question 462

??? infection should be considered in patients with a liver abscess who have lived or traveled in a developing country; abscesses may occur following an episode of dysentery. Patients typically develop fever, right upper quadrant pain, anorexia, elevated liver enzymes, and leukocytosis. Treatment includes a tissue agent (ie, metronidazole, tinidazole) followed by paromomycin to eradicate intestinal colonization.

Answer 462

Entamoeba histolytica

Question 463

Entamoeba histolytica treatment?

Answer 463

Treatment includes a tissue agent (ie, metronidazole, tinidazole) followed by paromomycin to eradicate intestinal colonization.

Question 464

??? occurs when gram-positive skin flora gain access to the subcutaneous space via breaks in the skin. Tinea pedis, one of the most common risk factors for lower extremity infx, causes fissuring, erosions, and ulceration that allow bacterial entry into the tissue.

Answer 464

Cellulitis

Question 465

patient with erythema, warmth, and swelling of the foot associated with fever and lymphadenopathy has ???

Answer 465

cellulitis , a bacterial infection that involves the deep dermis or subcutaneous fat

Question 467

Patients with febrile neutropenia should be started on empiric broad-spectrum antibiotics as soon as possible after blood cultures are obtained. Empiric monotherapy with an ??? agent (eg, cefepime, meropenem, piperacillin-tazobactam) is recommended for initial management.

Answer 467

antipseudomonal Gram-negative organisms, particularly Pseudomonas aeruginosa, are frequently identified and cause severe infection; gram-positive bacteria are also commonly identified in bloodstream infections.

Question 468

Lemierre syndrome (LS) is caused by an oropharyngeal infection, usually pharyngitis or tonsillitis, that leads to local invasion of the lateral pharyngeal wall and infection of the neurovascular bundle, especially the internal jugular vein. Thrombosis of this vein allows dissemination of septic emboli to distal sites. ??? is the most frequent bacterial cause of LS.

Answer 468

Fusobacterium necrophorum

Question 469

??? can mimic the presentation of sarcoidosis and should be considered when a patient with suspected sarcoidosis deteriorates after immunosuppressive therapy. (patient in mississipi)

Answer 469

Histoplasmosis In endemic regions, dimorphic fungi (eg, Histoplasma, Blastomyces, Coccidioides) should be excluded before immunosuppression is initiated.

Question 470

how to test for histoplasma??

Answer 470

The diagnosis is confirmed most rapidly with serum or urine Histoplasma antigen immunoassay (sensitivity \>95%).

Question 471

This patient has fever, right upper quadrant (RUQ) pain, and a hepatic lesion, findings suggestive of liver abscess. He also has a history of recent travel to a resource-limited country. This presentation is concerning for ???

Answer 471

amebiasis (infection due to Entamoeba histolytica)

Question 472

A single dose of intramuscular benzathine penicillin G is the treatment of choice for early syphilis. However, patients with severe penicillin allergy (who do not have neurosyphilis) generally require an alternate regimen such as ???

Answer 472

oral doxycycline or IV/IM ceftriaxone.

Question 473

which infx??

Answer 473

Cutaneous larva migrans is a creeping cutaneous eruption due to dog (Ancylostoma caninum) or cat (A braziliense) hookworm larvae. Most infections arise from walking barefoot on contaminated sand or soil. Symptoms include a pruritic, papular lesion at the portal of entry and intensely pruritic, migrating, serpiginous reddish-brown tracks. Ivermectin is typically given to speed resolution and clearance.

Question 474

?? is the most common valvular abnormality detected in patients with infective endocarditis.

Answer 474

Mitral valve disease, usually mitral valve prolapse with coexisting mitral regurgitation

Question 475

prosthetic joint infection (PJI) Infections within the first 3 months after surgery ?? vs. delayed onset (3-12 months) ???

Answer 475

early: Staphylococcus aureus, Pseudomonas aeruginosa Staphylococcus epidermidis is a coagulase-negative staphylococcus commonly implicated in delayed-onset PJI.

Question 476

???? is a pork tapeworm whose eggs cause neurocysticercosis. Most infections are asymptomatic, but patients can develop seizure (without other symptoms) or signs of increased intracranial pressure (vomiting, headaches, papilledema) months or years after inoculation. Diagnosis is made largely by clinical and radiographic findings (\>1 cyst often with enhancement/edema on brain MRI).

Answer 476

Taenia solium

Question 477

??? are a common cause of endocarditis associated with nosocomial urinary tract infections.

Answer 477

Enterococci, especially Enterococcus faecalis

Question 478

Legionella pneumophila is an intracellular, gram-negative organism commonly spread by aerosols or droplets from contaminated water supplies. Legionnaires' disease is treated with antibiotics that achieve high intracellular concentration, particularly ??? or ???. The latter are favored when the illness is severe enough to warrant admission. ​​​​​​​

Answer 478

newer macrolides (eg, azithromycin) or fluoroquinolones (eg, levofloxacin)

Question 480

what is the tx for TB?

Answer 480

Treatment involves 2 months of 4-drug therapy with isoniazid, rifampin, pyrazinamide, and ethambutol followed by 4 months of 2-drug therapy with isoniazid and rifampin; initial 2-drug therapy is ineffective and increases the risk of resistance

Question 481

What is the gold standard of TB diagnosis ?

Answer 481

Sputum culture Although culturing Mycobacterium tuberculosis from sputum is the gold standard for diagnosis, culture results are often unavailable for \>4 weeks due to the slow replication rate of the organism. Therefore, a tentative diagnosis is often established with rapid testing

Question 482

can TB be ruled out with one negative acid fast test ??

Answer 482

no Direct microscopy with acid-fast bacillus (AFB) stain: Because this technique requires a high burden of organisms (\>10,000/mL) for a positive result, the sensitivity of a single sample is low (~50%). TB cannot be ruled out with one negative AFB sputum stain. However, sensitivity is increased to ~85% by taking 3 samples 8-24 hours apart. AFB stain cannot differentiate tuberculous from nontuberculous mycobacteria. Nucleic acid amplification testing (NAAT): Fewer bacilli (~10/mL) are required for positive testing, so sensitivity is higher than with AFB stain. NAAT also specifically identifies M tuberculosis. However, results take 24-48 hours. Patients with a high pretest probability of pulmonary TB (as in this case), require airborne isolation, a series of sputum tests/cultures, and initiation of empiric therapy while awaiting test results to reduce transmission and progression.

Question 483

?? can be used to treat cytomegalovirus (CMV) but is not typically used for primary prophylaxis in patients with AIDS. It is used for primary prophylaxis against CMV in some patients with solid organ transplantation

Answer 483

Ganciclovir

Question 484

Toxoplasmosis is a common opportunistic infection in patients with AIDS who have CD4 counts \<100/mm3. Primary prophylaxis with ??? prevents active infection

Answer 484

trimethoprim-sulfamethoxazole (TMP-SMX)

Question 485

Babesiosis is a tick-borne protozoal illness found primarily in the northeastern United States. Transmission occurs via Ixodes scapularis, and coinfection with other microbes (eg, Borrelia burgdorferi, Anaplasma phagocytophilum) is possible. Symptoms are often flu-like (fever, chills, malaise), and laboratory studies usually show anemia with signs of intravascular hemolysis and thrombocytopenia. Diagnosis is made primarily by ???

Answer 485

identifying organisms on peripheral blood smear ("Maltese cross")

Question 486

???? is a chronic granulomatous disease of the skin and peripheral nerves that is found primarily in developing regions. Symptoms include chronic, anesthetic, hypopigmented lesions with peripheral nerve involvement (nodular/painful nerve deformations with diminished sensory/motor activity). Diagnosis usually requires a biopsy from the active edge of the lesion

Answer 486

Leprosy; c​​​​​​​aused by the acid-fast bacillus Mycobacterium leprae.

Question 487

Neisseria gonorrhoeae is a common sexually transmitted infection that can cause ??? (due to orogenital contact) and pelvic inflammatory disease (due to ascending infection from the lower to the upper genital tract).

Answer 487

pharyngitis can almost mimic EBV, but no splenomegaly, lower quadrant pain from PID

Question 488

Cryptosporidium parvum causes what infx??

Answer 488

Although bacterial and viral pathogens are the most common causes of **travelers' diarrhea**, parasitic organisms such as Cryptosporidium parvum, Cyclospora, and Giardia are responsible for most cases of prolonged, profuse, watery diarrhea.

Question 489

Ecthyma gangrenosum is a rapidly progressive cutaneous disorder seen most commonly in immunocompromised patients with ???? bacteremia/sepsis. Lesions begin as painless red macules, quickly progress to pustules/bullae, and then form "punched-out" gangrenous ulcers. Patients are usually febrile and ill. Blood cultures and empiric, intravenous antibiotics are required.

Answer 489

Pseudomonas aeruginosa

Question 490

Oral ??? is the primary agent used for prophylaxis for Pneumocystis pneumonia in patients who have had solid organ transplantation. Many patients also require cytomegalovirus prophylaxis with ganciclovir or valganciclovir.

Answer 490

trimethoprim-sulfamethoxazole

Question 491

Antimicrobial chemoprophylaxis against Neisseria meningitidis is indicated for close contacts (regardless of vaccination status) who have had exposure during the 7 days before symptom onset until 24 hours after appropriate antibiotic initiation. Medication regimens include ???? and should be given as soon as possible.

Answer 491

rifampin, ciprofloxacin, or ceftriaxone

Question 492

Patients with ? encephalitis usually develop headaches, focal neurologic deficits, altered mental status, and fever. Laboratory studies may be normal, but MRI of the brain usually reveals multiple ring-enhancing lesions (with a preference for the basal ganglia and grey-white matter junction).

Answer 492

toxoplasmic There is no reliable test for toxoplasmic encephalitis. The diagnosis is generally made by the presence of suspicious clinical symptoms, positive T gondiiIgG serology, and characteristic CNS findings on MRI.

Question 493

tx for toxoplasmosis in AIDS patient???

Answer 493

Treatment with several weeks of sulfadiazine and pyrimethamine plus leucovorin (to prevent hematologic side effects) is required.

Question 494

Splenic abscess usually presents with the classic triad of fever, leukocytosis, and left upper-quadrant abdominal pain. Patients can also develop left-sided pleuritic chest pain, left pleural effusion, and splenomegaly. Risk factors for splenic abscess include hematogenous spread, immunosuppression, intravenous drug use, trauma, and hemoglobinopathies. ???? is most commonly associated with splenic abscess.

Answer 494

Infective endocarditis

Question 495

immunocompromised patient has systemic symptoms, lung nodules, and brain abscess (causing seizures), and the cultures grow gram-positive, partially acid-fast, filamentous, branching rods. This finding is highly consistent with ???

Answer 495

Nocardia

Question 496

The treatment of choice for pulmonary nocardiosis is ???. When the brain is involved, the carbapenems are added for better coverage.

Answer 496

trimethoprim-sulfamethoxazole

Question 497

nocardia vs. actinomyces both branching, filamentous rods

Answer 497

Actinomyces is not acid-fast; and sulfur granules may be found with Actinomyces infection. tx with penicillin Nocardia is acid-fast and is treated with TMP-SMS

Question 498

which two genital ulcers are painless??

Answer 498

syphilis and chlaymydia trachomatis (usually turns to painful buboes)

Question 499

Infectious mononucleosis typically presents with prolonged fever, malaise, exudative pharyngitis, splenomegaly, and generalized lymphadenopathy. Patients may develop anemia and thrombocytopenia up to 2-3 weeks after the onset of initial symptoms due to ???

Answer 499

autoimmune hemolytic anemia In particular, IgM cold agglutinin antibodies cause complement-mediated destruction of red blood cells. This hemolysis, which can occur 2-3 weeks after the onset of EBV symptoms, may lead to jaundice, elevated bilirubin, and increased reticulocyte count, as seen in this patient.

Question 500

The diagnosis of syphilis is generally made how ?

Answer 500

using 2 categories of serologic tests: Nontreponemal testing (eg, VDRL) is quantitative (eg, titers) and identifies the reactivity of infected serum to cardiolipin-cholesterol-lecithin antigen; it is not specific for treponemal antigens. Treponemal testing (eg, fluorescent treponemal antibody absorption [FTA-ABS]) is qualitative (either positive or negative) and identifies antibodies to specific treponemal antigens.

Question 501

given this patient's aortic aneurysm, the use of which antibioitic is contraindicated ???

Answer 501

fluoroquinolones (eg, levofloxacin, moxifloxacin, ciprofloxacin) Fluoroquinolones upregulate cell matrix metalloproteases, leading to increased collagen degradation; this mechanism is likely responsible for several associated adverse effects, including Achilles tendon rupture, retinal detachment, and aortic aneurysm rupture.

Question 502

Meningococcal vaccine is recommended for adolescents age 11-12 with a booster at age ???. Additional indications include those with complement deficiency or asplenia, college students living in dormitories, and travelers to endemic regions. Live-attenuated vaccines should be avoided in patients receiving immunosuppressants (eg, tumor necrosis factor antagonists).

Answer 502

16

Question 503

Pregnant patients whose screening urine cultures are positive require antibiotic therapy even if asymptomatic. The most common pathogen is Escherichia coli, as in this patient. First-line antibiotic therapy includes ??(3)???. A repeat urine culture (ie, test of cure) is performed after antibiotic completion to ensure clearance of the bacteriuria.

Answer 503

cephalexin, amoxicillin-clavulanate, or nitrofurantoin

Question 504

what is the course of Bordetella pertussis (gram-negative coccobacilli) infection ??

Answer 504

Catarrhal (weeks 1-2): mild cough, rhinitis Paroxysmal (weeks 2-8): severe coughing spells ± Inspiratory whoop, posttussive emesis, apnea/cyanosis (infants); posttussive syncope (older patients) Convalescent (weeks 8+): symptoms resolve gradually

Question 506

Osteomyelitis is a bacterial infection of the bone that typically presents with fever and focal bony pain. Infection is most often caused by hematogenous spread of ??

Answer 506

Staphylococcus aureus

Question 507

The treatment of measles is supportive; however, vitamin ??? reduces morbidity and mortality rates in children with severe measles and should be administered to hospitalized patient

Answer 507

vitamin A

Question 508

Acute infectious lymphangitis is marked by the formation of proximal, tender, erythematous streaks at the site of skin wound with regional lymphadenopathy and systemic symptoms (eg, fever). Most cases are caused by Streptococcus pyogenes or methicillin-sensitive Staphylococcus aureus; therefore, treatment with ??? is generally curative

Answer 508

cephalexin

Question 509

Acute epididymitis typically manifests with unilateral testicular pain and epididymal swelling. Those age \>35 usually develop epididymitis due to bacteruria from bladder outlet obstruction; ascending coliform organisms such as ??? are the most likely pathogens. Patients age \<35 are far more likely to have epididymitis due to sexually transmitted infections with Chlamydia trachomatis or Neisseria gonorrhoeae.

Answer 509

Escherichia coli

Question 510

Viral pharyngitis typically lacks exudates, fever is typically low-grade, and cervical lymphadenopathy is ??? Symptoms generally self-resolve within a week, and symptomatic treatment (eg, nonsteroidal anti-inflammatory drugs) alone is often sufficient

Answer 510

minimal or absent vs. present in bacterial pharyngitis (strep)

Question 511

Travelers' diarrhea presents after travel to a resource-limited area with poor sanitation. The most common cause is ???? which is a generally self-limited illness that causes the acute onset of watery diarrhea and abdominal pain.

Answer 511

enterotoxigenic Escherichia coli

Question 512

Diagnosing IE in patients who use intravenous drugs can be difficult and requires a high degree of suspicion. ???, usually due to Staphylococcus aureus, occur in up to 75% of patients with tricuspid involvement. Chest CT typically shows multiple nodular, peripheral opacities, often with cavitation.

Answer 512

Septic pulmonary emboli

Question 513

Bacterial infection of a chronic diabetic foot ulcer may be minimally symptomatic and requires specific assessment. When the bone can be palpated with a probe, the risk of underlying osteomyelitis is greatly increased. what is the next step in management??

Answer 513

Biopsy and culture of affected bone is critical to confirming the diagnosis and guiding management.

Question 514

Ankle pain after trauma may be caused by a sprain or fracture. The Ottawa ankle rules are used to help determine which patients require imaging. X-ray of the ankle is indicated for patients with pain in the malleolar region in association with either ????

Answer 514

1) bony tenderness at the posterior margin or tip of the lateral or medial malleolus or 2) inability to bear weight.

Question 515

Patients who undergo splenectomy are at high risk for fulminant sepsis with encapsulated organisms. They should be prescribed ???? to take immediately in the setting of fever and then should be advised to proceed directly to the nearest emergency department.

Answer 515

amoxicillin-clavulanate amoxicillin-clavulanate is used most often due to its broad spectrum of activity against common encapsulated pathogens, but those with penicillin allergy can take levofloxacin, which has similar broad efficacy

Question 516

Pregnant patients with early localized Lyme disease are typically treated with ???. This treatment is generally curative and does not pose a risk to the fetus.

Answer 516

amoxicillin doxy can be harmful to fetus

Question 517

Human bite wounds often result in polymicrobial infections with aerobic and anaerobic oral organisms. Empiric treatment with ??? provides adequate coverage for the majority of virulent oral bacteria. \*\*this includes punches to the mouth/teeth that cause open wounds

Answer 517

amoxicillin-clavulanate

Question 518

Patients with malnutrition, pregnancy, or certain comorbid conditions (eg, diabetes mellitus) should be started on pyridoxine supplementation when treated for latent or active tuberculosis with isoniazid (INH). This helps prevent INH-induced ????, which is due to INH-mediated pyridoxine deficiency.

Answer 518

peripheral neuropathy

Question 519

?? back pain is characterized by the gradual onset of pain and stiffness that begins at a young age (\<40), **worsens with rest (eg, at night), and improves with activity.**

Answer 519

Inflammatory back pain It suggests spondyloarthropathy (eg, ankylosing spondylitis, psoriatic arthritis, reactive arthritis, arthritis associated with inflammatory bowel disease). vs. Ligamentous sprains can often be traced to a specific event or action. Patients typically experience **more pain with movement and improvement with rest.**

Question 520

Carpal tunnel syndrome is common in pregnancy. Most patients with mild symptoms respond to what tx?

Answer 520

nocturnal wrist splinting, which holds the wrist in a neutral position and prevents excessive flexion during sleep. In most cases, symptoms resolve spontaneously after childbirth

Question 521

Major risk factors for osteoporosis include advanced age, postmenopausal status, and low body weight. Modifiable risk factors include excessive alcohol intake, sedentary lifestyle, and smoking. In patients with osteoporosis, the risk for fragility fracture is highest in those with ???

Answer 521

a prior history of fragility fracture.

Question 523

??? presents with hip pain and limp in young children following a mild viral illness. In contrast to septic arthritis, patients are typically well-appearing, weight-bearing, and afebrile with normal laboratory results (ie, white blood cell count, inflammatory markers). Treatment is rest and nonsteroidal anti-inflammatory medications (eg, ibuprofen).

Answer 523

Transient synovitis

Question 524

??? presents as a swelling over the upper medial tibial region. It is typically caused by overuse and poor knee mechanics. Treatment includes quadriceps and hamstring strengthening exercises to optimize strength, flexibility, and stability of the knees area of swelling in the anteromedial knee region below the joint line

Answer 524

Pes anserine bursitis

Question 525

Multifocal atrial tachycardia is a supraventricular tachyarrhythmia characterized by distinct P waves with \>3 different morphologies, atrial rate \>100/min, and an irregular rhythm. It is usually precipitated by ??? in patients with underlying lung disease. Treatment should be directed at correcting the underlying inciting disturbance.

Answer 525

acute respiratory illness ex COPD exacerbation

Question 526

what does CT finding for lung abscess shows +fever, night sweats, weight loss, blood-tinged sputum

Answer 526

chest x-ray and CT scan typically reveal cavitary infiltrates, often with air-fluid levels in the superior lower lobe or posterior upper lobe (sections that are dependent with recumbency).

Question 527

patients with suspicious symptoms of lung abscess generally receive empiric antibiotics with an agent that has good pulmonary penetration and efficacy against obligate and facultative anaerobes. ??? is considered first-line therapy. Clindamycin is reserved for those with beta-lactam allergy due to high risk of subsequent Clostridioides (formerly Clostridium) difficile infection. A prolonged course is indicated; surgical intervention (eg, pneumonectomy, lobectomy) may be required in the rare cases that do not improve with antibiotic therapy.

Answer 527

Ampicillin-sulbactam

Question 528

athlete has episodic dyspnea and noisy breathing during exercise. Empiric treatment for exercise-induced asthma had no effect, and examination during exercise revealed inspiratory stridor (in contrast to expiratory wheezing seen in asthma). This presentation is suspicious for

Answer 528

paradoxical vocal fold motion (PVFM) (also called vocal cord dysfunction) . an episodic, inappropriate closing of the vocal cords during inspiration, which results in laryngeal obstruction and inspiratory stridor.

Question 529

???, cystic fibrosis, and right-to-left cardiac shunts are the most common causes of secondary digital clubbing. Pathophysiology involves megakaryocytes that skip the normal route of fragmentation within pulmonary circulation (due to circulatory disruption from tumors, chronic lung inflammation) to enter systemic circulation and get trapped in finger tips

Answer 529

Lung malignancies Chronic obstructive pulmonary disease (with or without hypoxemia) does not cause digital clubbing, and the presence of clubbing should prompt a search for occult malignancy.

Question 530

histoplasma vs. coccidioidomycosis

Answer 530

histoplasma often has bilateral infiltrate with granulomas w/yeast cocc has unilateral infilgrate and biopsy shows spherules w/endospores (not yeast)

Question 531

which lab finding is a sensitive indicator for hypovolemia ???

Answer 531

Due to decreased renal perfusion and activation of the renin-angiotensin-aldosterone system, **decreased urine sodium** is usually present in patients with hypovolemia

Question 532

Pulmonary pathology may lead to the ????, which is characterized by hypotonic hyponatremia in a euvolemic patient. Infusion of normal saline may worsen hyponatremia in patients

Answer 532

syndrome of inappropriate antidiuretic hormone secretion (SIADH)

Question 533

Which lung disease is a common manifestation of systemic sclerosis ???

Answer 533

Pulmonary arterial hypertension (PAH); results from intimal hyperplasia of the pulmonary arteries.

Question 534

patient with sickle cell disease has ????, a life-threatening complication that presents with a new pulmonary density plus fever and/or respiratory symptoms (eg, hypoxia, chest pain).

Answer 534

acute chest syndrome

Question 535

​​​​​​​Acute chest syndrome is a life-threatening complication of sickle cell disease caused by ???. The most common trigger in adults is acute vasoocclusive pain causing fat embolism from bone necrosis and/or hypoventilation from pain causing atelectasis

Answer 535

vasoocclusion of pulmonary microvasculature

Question 536

Asbestos exposure increases the risk of pulmonary fibrosis and malignancy. ??? is the most common malignancy diagnosed in patients exposed to asbestos. Smoking acts synergistically with asbestos to further increase the risk of lung cancer

Answer 536

Bronchogenic carcinoma

Question 537

COPD causes what change in inspiratory/expiratory flow?

Answer 537

COPD is characterized by progressive expiratory airflow limitation which causes air trapping, decreased VC and increased total lung capacity. FEV1 is disproportionately decreased as compared to VC. \*\*air trapping during expiration

Question 538

​​​​​​​Bronchiectasis causes permanent bronchial dilation due to recurrent cycles of infection and inflammation. Hallmark symptoms include chronic copious, thick sputum production; episodic hemoptysis; and recurrent exacerbations with mucopurulent sputum. Bronchiectasis is diagnosed based on ????

Answer 538

high-resolution CT scan of the chest ​​​​​​​it clearly visualizes the **bronchial wall thickening (tram tracking),** lack of distal airway tapering, and bronchial dilation (bronchial diameter larger than adjacent pulmonary artery, a finding referred to as the "signet ring" sign).

Question 539

Signs and symptoms of aldosterone deficiency (eg, hypovolemia, hyperkalemia) combined with fevers, pulmonary airspace disease (eg, daily cough) with lymphadenopathy, and prior residence in a tuberculosis-endemic region (\>30% of global tuberculosis burden in Southeast Asia) indicating miliary tuberculosis what adrenal condition?

Answer 539

Primary adrenal insufficiency (PAI) is a potential complication of miliary tuberculosis. Signs and symptoms of aldosterone deficiency (eg, hypovolemia, hyperkalemia) are present in PAI and can help differentiate PAI from secondary adrenal insufficiency.

Question 540

Postnasal drip, gastroesophageal reflux disease, and asthma account for \>90% of chronic cough in nonsmokers who do not have pulmonary disease. For patients with cough following upper respiratory infection, initial empiric treatment includes ???

Answer 540

oral first-generation antihistamine (eg, chlorpheniramine) or combined antihistamine-decongestant (eg, brompheniramine and pseudoephedrine).

Question 541

​​​​​​​this patient's dry cough is most likely due to postnasal drip associated with allergic rhinitis. The diagnosis is confirmed by the improvement of the nasal discharge and cough with the use of first-generation antihistamines. Chlorpheniramine is a specific H1 antihistaminic receptor blocker that reduces the action of histamine on H1 receptors, decreasing the allergic response. In addition to blocking H1 histamine receptors, chlorpheniramine exhibits anti-inflammatory effects by blocking histamine release from mast cells and limiting the ???

Answer 541

secretory response to inflammatory cytokines. \*\*Decreased nasal secretions help improve symptoms

Question 542

??? medications increase the risk of CAP in elderly patients

Answer 542

​​​​​​​Atypical antipsychotic medications (eg, quetiapine)

Question 543

Advanced ??? increases the risk of recurrent bacterial aspiration pneumonia due to impaired coordination of the muscles involved in swallowing. The dependent portions of the lungs are generally involved.

Answer 543

dementia

Question 544

Aspiration typically introduces microbes into the dependent portions of the lungs. Aspiration events that occur while the patient is upright usually affect the lower lobes, and those that occur when the patient is recumbent (eg, bed-bound) usually affect the ???

Answer 544

superior portions of the lower lobes or posterior portions of the upper lobes.

Question 545

??? medication, which cause profound vasoconstriction, can also cause ischemia of peripheral structures such as the distal digits. The resulting digital tissue necrosis is usually bilateral and symmetric.

Answer 545

Vasopressors (eg, norepinephrine)

Question 546

Patients with ??? can develop restrictive lung disease due to diminished chest wall and spinal mobility. Pulmonary function tests show a mildly restrictive pattern with reduced vital capacity and total lung capacity but normal FEV1/FVC

Answer 546

ankylosing spondylitis

Question 547

Patients with ankylosing spondylitis can develop restrictive lung disease due to diminished chest wall and spinal mobility. Pulmonary function tests show a mildly restrictive pattern with reduced vital capacity and total lung capacity but normal FEV1/FVC what happens to functional residual capacity ????

Answer 547

Functional residual capacity (FRC) and residual volume (RV) are normal or increased due to fixation of the rib cage in an inspiratory position.

Question 548

Aspirin-exacerbated respiratory disease occurs how??? The classic triad includes asthma, chronic rhinosinusitis with nasal polyposis, and NSAID sensitivity

Answer 548

pathogenesis involves **increased production of proinflammatory leukotrienes** and decreased production of anti-inflammatory prostaglandins. NSAIDs inhibit the cyclooxygenase arm of the arachidonic acid pathway (COX-1, COX-2) to block prostaglandin synthesis, shunting it toward the leukotriene production arm. AERD symptoms are due to this leukotriene excess and mimic asthma or rhinosinusitis flares

Question 549

patient with recurrent sinusitis and otitis, auditory canal ulceration, fatigue, anemia, and microscopic hematuria most likely has ???

Answer 549

granulomatosis with polyangiitis (GPA) (formerly known as Wegener granulomatosis), a small- and medium-sized vessel vasculitis upper respiratory tract is the most commonly involved

Question 550

what happens when you lay on the side of a pneumonia?

Answer 550

Alveolar consolidation in pneumonia causes hypoxemia due to ventilation-perfusion (V/Q) mismatch from localized intrapulmonary shunting. Positional changes that promote gravity-dependent blood distribution to the consolidated areas create a more profound V/Q mismatch and worsen the hypoxemia.

Question 551

PaO2 is influenced mainly by FiO2 and PEEP. In this case, the patient's initial ABG values indicate excessive oxygenation (PaO2 \>90 mm Hg), or hyperoxia. Prolonged exposure to a ??? can induce oxygen toxicity via the formation of proinflammatory reactive oxygen species, leading to cellular toxicity and the propagation of lung injury.

Answer 551

high FiO2 the lowest feasible FiO2 (ideally \<60%) should be set to prevent oxygen toxicity. As FiO2 is lowered, a compensatory increase in PEEP may be required to maintain adequate oxygenation by recruiting collapsed alveoli and keeping them open.

Question 552

In contrast to bacterial or viral pneumonia, which cause prolonged chest x-ray findings, patients with ??? can have rapid resolution of chest x-ray findings following diuretic administration.

Answer 552

CHF

Question 553

A ??? will decrease the airflow rate during inspiration and expiration, flattening both the top and bottom of the flow-volume loop.

Answer 553

fixed upper-airway obstruction ex. laryngeal edema

Question 554

what are the parameters for light's criteria???

Answer 554

Effusion protein/serum protein ratio greater than 0.5. Effusion lactate dehydrogenase (LDH)/serum LDH ratio greater than 0.6. Effusion LDH level greater than two-thirds the upper limit of the laboratory's reference range of serum LDH \*\*\*only need 1

Question 555

Peak airway pressure is the sum of airway resistance and plateau pressure. The plateau pressure is the sum of the elastic pressure and positive end-expiratory pressure (PEEP) and is calculated by performing the end-inspiratory hold maneuver. PEEP is calculated with the end-expiratory hold maneuver. meaning??

Answer 555

Increased peak pressure associated with an unchanged plateau pressure suggests a pathological process causing increased airway resistance, such as bronchospasm, mucus plug, or endotracheal tube obstruction. Elevation of both peak and plateau pressures indicates a process causing decreased pulmonary compliance, such as pulmonary edema, atelectasis, pneumonia, or right mainstem intubation

Question 556

All patients with acute exacerbation of chronic obstructive pulmonary disease should receive ???. In addition, supplemental oxygen, antibiotics, and ventilatory support should be administered when indicated.

Answer 556

inhaled bronchodilators (β2 agonists and anticholinergics) and systemic glucocorticoids

Question 557

D-dimer has what statistic for PE?

Answer 557

\*\*good for ruling OUT In patients with unlikely probability of VTE, D-dimer has a NPV \>95%, so a normal result (\<500 ng/mL) reliably excludes VTE ​​​​​​​D- dimer has 95%-97% sensitivity and 45% specificity for VTE

Question 558

which COPD med ??? toxicity can manifest as central nervous system stimulation (eg, headache, insomnia, seizures), gastrointestinal disturbances (eg, nausea, vomiting), and cardiac toxicity (arrhythmia). Inhibition of the cytochrome oxidase system by other medications, diet, or underlying disease can alter its narrow therapeutic window.

Answer 558

Theophylline

Question 559

Occupational asthma is induced by workplace antigen exposure (eg, animal proteins, isocyanates). Chronic occupational asthma may produce persistent airway inflammation and bronchoconstriction that subside only after prolonged absence from work. Once asthma is diagnosed (eg, baseline spirometry), occupational asthma is confirmed by ??

Answer 559

demonstrating workplace-specific worsening of airflow obstruction w/ serial peak expiratory flow rate (PEFR) measurements using a portable peak flow meter @ home and work

Question 560

Hyponatremia due to the syndrome of inappropriate antidiuretic hormone secretion is a common complication of small cell lung cancer. ??? is the initial treatment of choice in asymptomatic or mildly symptomatic patients

Answer 560

Fluid restriction

Question 561

Exercise-induced bronchoconstriction is very effectively prevented by premedication with an ???

Answer 561

inhaled corticosteroid and beta agonist (eg, budesonide-formoterol) 10 minutes prior to exercise.

Question 562

Empyemas are exudative effusions with a low glucose concentration due to the ???

Answer 562

high metabolic activity of leukocytes and bacteria within the pleural fluid

Question 563

Obesity hypoventilation syndrome is defined by obesity (BMI ≥30 kg/m2), and which two features \*\*different from obstructive sleep apnea

Answer 563

daytime hypercapnia (PaCO2 \>45 mm Hg), and alveolar hypoventilation. Arterial blood gas will show hypercapnia, hypoxemia, and respiratory acidosis as a result of altered lung mechanics due to obesity and hypoventilation.

Question 564

??? is the test of choice in clinically stable patients in whom PE is likely. Empiric anticoagulation in these patients is often appropriate, but clinical judgment is needed regarding clinical stability and contraindications.

Answer 564

CT angiography

Question 565

Penetrating trauma accompanied by shock (eg, severe hypotension) is attributed to hemorrhage until proven otherwise. Intrathoracic hemorrhage can cause massive hemothorax (\>1,500 mL), which requires ??? to prevent exsanguination.

Answer 565

emergent thoracotomy

Question 566

alveolar hypoventilation vs. atelectasis

Answer 566

alveolar hypoventilation has normal A-a gradient whereas atelectasis does not due to V/Q mismatch

Question 567

Acute salicylate intoxication should be suspected in patients with the triad of tinnitus, fever, and tachypnea. It usually causes what acid-base condition??

Answer 567

mixed primary respiratory alkalosis and primary metabolic acidosis with arterial pH often within the normal range.

Question 568

Exercise-associated hyponatremia occurs due to a combination of excessive fluid intake and ????. In severe cases, patients may experience seizures, profound confusion, and even death.

Answer 568

nonosmotically mediated release of inappropriately high levels of antidiuretic hormone excessive ADH secretion is triggered by nonosmotic stimuli (eg, exertion, pain, hypoglycemia, nausea) that occur during intense exercise

Question 569

Hepatorenal syndrome is seen in patients with severe liver cirrhosis. Patients have acute renal failure (creatinine \>1.5 mg/dL) with a very low urine sodium level, typically \<10 mEq/L, and an absence of blood, casts, or protein in urine. Renal function does not improve with intravenous fluid resuscitation what is the cause???

Answer 569

secondary to systemic and **renal hypoperfusion.**

Question 570

Severe hypercalcemia can cause weakness, gastrointestinal distress, and neuropsychiatric symptoms. Initial treatment includes ???? Bisphosphonates further reduce calcium levels and are given after initial administration of saline.

Answer 570

saline hydration to restore intravascular volume and calcitonin to inhibit bone resorption Patients are typically volume depleted due to polyuria and decreased oral intake

Question 571

Hyperkalemia is usually asymptomatic until potassium rises to ≥6.5 mEq/L, but acute hyperkalemia can sometimes cause symptoms at lower levels. Common manifestations include ascending muscle weakness with flaccid paralysis, cardiac arrhythmia (eg, heart block, bradycardia), and ECG changes (eg, peaked T waves → short QT interval → QRS widening → sine wave).Urgent therapy (eg, calcium gluconate, insulin with glucose) is typically reserved for ECG changes, potassium ≥6.5 mEq/L, and/or rapidly rising potassium due to tissue breakdown. The next step is to exclude acute secondary causes (eg, uncontrolled hyperglycemia, tumor lysis syndrome). What is the next step ???

Answer 571

A review of recent/current medications should be conducted to determine whether any trigger hyperkalemia. Common offending agents include nonselective beta-adrenergic blockers, potassium-sparing diuretics (eg, triamterene), ACE inhibitors, angiotensin II receptor blockers, and nonsteroidal anti-inflammatory drugs

Question 572

what is the levels of renin in renal artery stenosis (ipsilateral and contralateral)

Answer 572

Decreased renal perfusion in the poststenotic kidney results in atrophy of the affected kidney. Low perfusion pressures lead to increased renin secretion by the juxtaglomerular cells of the affected kidney and activation of the renin-angiotensin-aldosterone system (RAAS). This results in secondary hyperaldosteronism. In contrast, the unaffected kidney is exposed to high systemic pressures, leading to suppression of local renin secretion and pressure natriuresis.

Question 573

Damage to the renal tubules causes intrinsic renal failure with limited resorptive capacity. This results in ??? urine sodium and a normal blood urea nitrogen/creatinine ratio (~10-15:1).

Answer 573

high (\>40 mEq/L)

Question 574

Damage to the renal tubules causes intrinsic renal failure with limited resorptive capacity. This results in high urine sodium (\>40 mEq/L) and a normal blood urea nitrogen/creatinine ratio (~10-15:1). Renal injury usually results in hypocalcemia; the presence of **hypercalcemia** suggests ?? cause

Answer 574

underlying malignancy, particularly multiple myeloma.

Question 575

???? tumors are the most common lung malignancy in young nonsmokers. They typically arise in the proximal airway and cause airway obstruction (eg, dyspnea, wheezing, postobstructive pneumonia) or hemoptysis. CT scan with contrast usually reveals an avidly enhancing (ie, hypervascular) mass with an endobronchial component.

Answer 575

Bronchial carcinoid

Question 576

??? can lead to large-volume atelectasis (lung collapse) due to airway obstruction. Chest x-ray demonstrates opacification of the affected lung area and mediastinal shifting toward the side of atelectasis.

Answer 576

Mucus plugging in mainstem bronchi Surgery (under anesthesia) and smoking increase the risk of mucus plugging

Question 577

Fracture of ≥3 contiguous ribs in ≥2 locations can result in flail chest, with paradoxical movement of the fractured flail segment during respiration. Flail chest can cause hypoxia due to ???, pulmonary contusion, and atelectasis.

Answer 577

ineffective ventilation Impaired generation of negative intrathoracic pressure during inspiration and increased dead space during expiration cause ineffective ventilation.

Question 578

​​​​​​​ Aspiration of gastric contents can lead to either chemical pneumonitis or bacterial pneumonia. Symptoms of ??? (eg, cough, dyspnea, hypoxemia) typically occur within a few minutes/hours of aspiration and resolve spontaneously within 36 hours.

Answer 578

chemical pneumonitis

Question 579

??? is typically marked by subacute fever, putrid-smelling sputum, and a cavitary lung infiltrate with **air-fluid level** in a dependent portion of the lung

Answer 579

Lung abscess

Question 580

Lung abscess is typically marked by subacute fever, putrid-smelling sputum, and a cavitary lung infiltrate with air-fluid level in a dependent portion of the lung. Patients often have history of swallowing dysfunction or impaired consciousness. Sputum culture should be obtained but is rarely useful; empiric treatment with ??? is recommended.

Answer 580

ampicillin-sulbactam or a carbapenem

Question 581

This young man without prior medical problems who presents with a pneumothorax likely has a ???. It occurs in patients without a history of lung disease and is most common in tall, thin men in their early 20s.

Answer 581

primary spontaneous pneumothorax (PSP)

Question 582

Small pneumothoraces in clinically stable patients, such as this patient, can be managed with observation and ???, which enhances the speed of resorption. Stable patients with large pneumothoraces should undergo decompression with a large-bore needle (eg, 14- to 18-gauge) inserted in the second or third intercostal space in the midclavicular line or at the fifth intercostal space in the mid or anterior axillary

Answer 582

supplemental oxygen (regardless of oxygen saturation)

Question 583

Venous air embolism (VAE) is suggested by sudden-onset respiratory distress following removal of a central venous catheter. Patients with suspected VAE should immediately be placed in the ??? to trap air on the lateral right ventricular wall and help prevent right ventricular outflow tract obstruction and embolization of air into the pulmonary circulation. High-flow oxygen is also important to encourage absorption of the air embolus.

Answer 583

left lateral decubitus position

Question 584

Chronic alcohol use is associated with a high incidence of several electrolyte abnormalities, of which ??? is the most common (likely due to poor nutritional intake, alcohol-induced renal losses, and diarrhea).

Answer 584

hypomagnesemia

Question 585

​​​​​​​??? can lead to refractory hypokalemia due to removal of inhibition of renal potassium excretion and should be suspected in patients with hypokalemia that is difficult to correct with potassium replacement.

Answer 585

Hypomagnesemia

Question 586

Intracellular magnesium is thought to have what effect on potassium??? . Therefore, low intracellular magnesium concentrations result in excessive renal potassium loss and refractory hypokalemia. Normalization of magnesium levels restores ROMK channel potassium transport regulation, decreases renal potassium losses, and allows for successful correction of hypokalemia with oral (preferred) or intravenous potassium replacement

Answer 586

inhibit potassium secretion by renal outer medullary potassium (ROMK) channels in the collecting tubules of the kidney

Question 587

​​​​​​​Focal segmental glomerulosclerosis (FSGS) and membranous nephropathy are the most common causes of nephrotic syndrome in adults in the absence of a systemic disease. ??? is more common in African American patients and in those with obesity, heroin use, and HIV.

Answer 587

​​​​​​​Focal segmental glomerulosclerosis (FSGS)

Question 588

??? nephropathy is the second leading cause of nephrotic syndrome in the overall population. Associated with: adenocarcinoma (eg, breast, lung); nonsteroidal anti-inflammatory drugs (NSAIDs); hepatitis B; systemic lupus erythematosus

Answer 588

Membranous

Question 589

prerenal AKI vs. acute tubular necrosis

Answer 589

ATN has BUN:Cr ratio ~10-15; whereas prerenal is much higher also brown casts and some WBCs in ATN

Question 590

Unilateral varicoceles that fail to empty when a patient is recumbent raise suspicion for an underlying mass pathology, such as ???, that obstructs venous flow. CT scan of the abdomen is the most sensitive and specific test for diagnosing this condition.

Answer 590

renal cell carcinoma (RCC)

Question 591

Nephrotic syndrome is a ??? condition which manifests as venous or arterial thrombosis, and even pulmonary embolism. Renal vein thrombosis is the most frequent manifestation. Complications of nephrotic syndrome include: protein malnutrition, iron-resistant microcytic hypochromic anemia, increased susceptibility to infection, and vitamin D deficiency.

Answer 591

hypercoagulable

Question 592

??with respiratory failure is a common cause of mixed metabolic and respiratory acidosis.

Answer 592

Sepsis

Question 593

patient's presentation is most consistent with ??? due to intravenous acyclovir. The kidneys rapidly excrete acyclovir into the urine, but the drug has low urine solubility. As a result, it easily precipitates in renal tubules, causing intratubular obstruction and direct renal tubular toxicity.

Answer 593

crystal-induced acute kidney injury (AKI) Crystal-induced AKI is more common with large intravenous doses of acyclovir and occurs only rarely with oral acyclovir

Question 594

Acyclovir, Sulfonamides, Methotrexate, Ethylene glycol, Protease inhibitors, Uric acid (tumor lysis syndrome) can cause what kidney problem??

Answer 594

crystal-induced acute kidney injury (AKI) treatment involves holding or discontinuing the drug (if possible) and providing volume repletion. A loop diuretic (eg, furosemide) may be given concurrently with volume repletion to help flush the renal tubules. Preemptive administration of intravenous fluids while giving the drug can help prevent AKI.

Question 595

patient with chronic alcohol use disorder developed diffuse weakness and hyporeflexia hours after receiving dextrose-containing intravenous fluids, suggesting the development of ???

Answer 595

refeeeding syndrome.

Question 596

Refeeding syndrome occurs in the setting of ???, typically due to chronic malnutrition (eg, alcohol use disorder, anorexia). Manifestations include muscle weakness, hyporeflexia, rhabdomyolysis, hemolysis, arrhythmias, and congestive heart failure

Answer 596

hypophosphatemia Patients with alcohol use disorders are at particularly elevated risk due to alcohol-induced chronic diarrhea (reduces intestinal phosphate absorption) and gastritis (calcium-based antacids bind intestinal phosphorus). The reintroduction of carbohydrates (ie, 5% dextrose-containing intravenous fluids) in patients with chronic hypophosphatemia leads to increased insulin secretion. This stimulates the intracellular shift of electrolytes (ie, phosphate, potassium, magnesium) and increases phosphate utilization during glycolysis (eg, formation of ATP, 2-3 diphosphoglycerate), resulting in phosphate depletion and failure of cellular energy metabolism.

Question 597

Renal vein thrombosis is an important complication of all causes of nephrotic syndrome. However, it is most commonly associated with which nephropathy??

Answer 597

membranous glomerulopathy

Question 598

The dietary recommendations for patients with renal calculi are: Increased fluid intake, Normal dietary calcium intake, and ???

Answer 598

Decreased sodium intake Increased sodium intake enhances calcium excretion (hypercalciuria), and low sodium intake promotes sodium and calcium reabsorption through its effect on the medullary concentration gradient. Reabsorption of sodium and calcium is coupled via complex mechanisms involving the calcium-sensing receptor in the thick ascending limb of the loop of Henle

Question 599

metabolic alkalosis with high urine chloride; how to differentiate??

Answer 599

volume status in high volume status: hyperaldosteronism - causes increase in Na and Hydrogen ion exchange, loss of acid in urine

Question 600

Because exocrine pancreatic secretions are high in ???, Nonanion gap metabolic acidosis (NAGMA) is expected with large-volume fluid losses from the pancreas (eg, pancreatic duct leak) or small intestine (eg, high ileostomy output, enterocutaneous fistula).

Answer 600

HCO3−

Question 601

tx for uncomplicated cystitis

Answer 601

Nitrofurantoin for 5 days (avoid in suspected pyelonephritis or creatinine clearance \<60 mL/min) Trimethoprim-sulfamethoxazole for 3 days (avoid if local resistance rate \>20%) Fosfomycin single dose Fluoroquinolones only if above options cannot be used \*\* no urine culture needed

Question 602

conditions for complicated cystitis??

Answer 602

refers to infections associated with factors that increase the risk of antibiotic resistance or treatment failure. Such factors include diabetes, chronic kidney disease, pregnancy, immunocompromised state, or urinary tract obstruction; hospital-acquired infection; or infection associated with a procedure (eg, cystoscopy) or indwelling foreign body (eg, catheter, stent)

Question 603

tx for complicated cystitis 1 step you do need compared to uncomplicated cystitis

Answer 603

\*\*do need urine culture Tx: Fluoroquinolones\*\* (5-14 days), extended-spectrum antibiotic (eg, ampicillin/gentamicin) for more severe cases

Question 604

tx for pyelonephritis ? outpatient vs. inpatient

Answer 604

Outpatient: Fluoroquinolones (eg, ciprofloxacin, levofloxacin) Inpatient: Intravenous antibiotics (eg, fluoroquinolone, aminoglycoside ± ampicillin)

Question 605

??? crystals (square, envelope-shaped) are seen in patients with ethylene glycol (antifreeze) poisoning.

Answer 605

Calcium oxalate

Question 606

Rheumatoid arthritis predisposes to ???. Renal involvement is characterized by nephrotic syndrome. The classic pathologic finding is deposits that stain with Congo red and demonstrate apple-green birefringence under polarized light.

Answer 606

amyloidosis Multiple myeloma is the most common cause of AL (light chain) amyloidosis, and rheumatoid arthritis is the most common cause of AA (abnromal protein folding) amyloidosis

Question 607

Calcineurin inhibitors (eg, tacrolimus, cyclosporine) have ??? properties that are responsible for much of their toxicity. Acute calcineurin inhibitor toxicity is often triggered by impaired hepatic clearance of the drug and presents with hypertension and prerenal acute kidney injury.

Answer 607

vasoconstrictive

Question 608

??? is characterized by systemic arteriolar calcification and soft-tissue calcium deposition with local ischemia and necrosis. It is primarily seen in patients with longstanding end-stage renal disease. Risk factors include hyperparathyroidism, hyperphosphatemia, and hypercalcemia, although serum calcium is often normal.

Answer 608

Calciphylaxis (calcific uremic arteriolopathy)

Question 609

Prerenal acute kidney injury (AKI) can occur in volume-overloaded states. Prerenal AKI in an acute heart failure exacerbation is most likely due to cardiorenal syndrome, which is ?

Answer 609

Elevated central venous pressure is likely the major driver of AKI in cardiorenal syndrome. The elevated central venous pressure leads to elevated renal venous pressure and congestion. This reduces the glomerular capillary filtration gradient, possibly due to interstitial edema (from venous congestion) increasing Bowman capsule hydrostatic pressure; the result is a reduction in the glomerular filtration rate (GFR). Decreased renal perfusion due to reduced cardiac output also has a role in the reduced GFR. Diuretics are usually the most effective therapy for AKI due to cardiorenal syndrome; the resulting reduction in renal venous pressure restores the glomerular capillary filtration gradient and improves GFR.

Question 610

how does contraction alkolisis work???

Answer 610

fluid depletion from vomiting triggers RAAS in an attempt to conserve sodium and water. Aldosterone functions to retain water at the expense of excreting both potassium and acid in the urine, despite total body acid depletion (contraction alkalosis).

Question 611

Severe hypercalcemia can cause weakness, gastrointestinal distress, and neuropsychiatric symptoms. Patients are typically volume-depleted due to polyuria and decreased oral intake. Initial treatment for severe hypercalcemia (\>14) includes ?? Long term treatment is: Bisphosphonates to further reduce calcium levels

Answer 611

saline hydration to restore intravascular volume and calcitonin to inhibit bone resorption. \*\*only need treatment if severe, Ca \> 14

Question 612

Patients with tinea corporis are at risk for developing additional foci of infection elsewhere on the body, toes, groin, or nails due to autoinoculation. Patients with compromised immunity due to diabetes mellitus, systemic glucocorticoid therapy, or ??? infection can develop extensive, widespread involvement.

Answer 612

HIV

Question 613

??? are an important cause of phototoxic drug eruptions. These eruptions manifest as exaggerated sunburn reactions with erythema, edema, and vesicles in sun-exposed areas. ​​​​​​​These drugs are frequently prescribed in the treatment of acne

Answer 613

Tetracyclines (eg, doxycycline)

Question 614

Porphyria cutanea tarda is characterized by fragile, photosensitive skin with vesicles or bullae in areas of trauma or sun exposure. It is strongly associated with ?? infection and warrants screening \*\*often see bullae on hands

Answer 614

hepatitis C virus

Question 615

Factors that can lead to worsening of psoriasis include local skin trauma (Koebner phenomenon), withdrawal from systemic glucocorticoids, and certain medications (eg, antimalarials, indomethacin, propranolol). In addition, certain infections, especially ???, are associated with psoriasis - especially the kind that is severe and sudden in onset

Answer 615

HIV and streptococcal pharyngitis (which can also trigger guttate psoriasis)

Question 616

Toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS) are similar disorders distinguished how???

Answer 616

by the percentage of involved skin: SJS involves \<10% of the body surface area, TEN involves \>30%, and SJS/TEN overlap syndrome involves 10%-30%.

Question 617

Non-anion gap metabolic acidosis and hyperkalemia that occur out of proportion to the renal dysfunction indicate a ???

Answer 617

Type 4 renal tubular acidosis (hyperkalemic renal tubular acidosis) is characterized by non-anion gap metabolic acidosis, persistent hyperkalemia, and mild-to-moderate renal insufficiency. It commonly occurs in patients with poorly controlled diabetes.

Question 618

??? and other CNS depressants (eg, ethanol, benzodiazepines) can cause rhabdomyolysis by inducing impaired consciousness with prolonged immobilization and ischemic compression of dependent areas of skeletal muscle (eg, mottled skin over back, buttocks, and posterior thighs).

Answer 618

Opioids

Question 619

4 lab findings for rhabdomyolysis

Answer 619

**Hyperkalemia** and **hyperphosphatemia**, which result from the release of these electrolytes from lysed muscle cells into the bloodstream. **Hypocalcemia**, which is often present due to deposition of calcium in damaged muscle tissue. **Moderate transaminase elevations**, which characteristically show greater elevation in aspartate aminotransferase (AST) than alanine aminotransferase (ALT) due to relatively higher levels of AST in skeletal muscle.

Question 620

Autosomal dominant polycystic kidney disease is commonly associated with what fatal condition??

Answer 620

cerebral aneurysms that may rupture and lead to intracranial bleeding

Question 621

In patients with chronic kidney disease, ??? is the most common cause of abnormal hemostasis (eg, easy bruising, nonpalpable purpura). PT and PTT are normal; platelet count is normal or mildly low.

Answer 621

platelet dysfunction Patients with CKD have elevated urea, the end product of ammonia breakdown and immediately derived from arginine. As urea levels rise, arginine and its precursors are shunted to a different pathway that leads to nitric oxide production. Inappropriately high nitric oxide levels in CKD inhibit primary hemostasis via decreased platelet adhesion, activation, and aggregation.

Question 622

what is the mechanism of platelet dysfunction in CKD

Answer 622

Patients with CKD have elevated urea, the end product of ammonia breakdown and immediately derived from arginine. As urea levels rise, arginine and its precursors are shunted to a different pathway that leads to nitric oxide production. Inappropriately high nitric oxide levels in CKD inhibit primary hemostasis via decreased platelet adhesion, activation, and aggregation.

Question 623

Uric acid stones are often radiolucent but may be seen on renal ultrasound or CT scan. They are highly soluble in alkaline urine; alkalization of the urine to pH 6.0-6.5 with ??? is the treatment of choice.

Answer 623

oral potassium citrate

Question 624

glomerulonephritis in association with fatigue, cytopenias, and **hypocomplementemia** suggests ???? labs show low serum C3 and C4 levels.

Answer 624

systemic lupus erythematosus (SLE) with lupus nephritis.

Question 625

In patients with suspected toxic alcohol ingestion and a high anion gap metabolic acidosis (AGMA), the ??? should be calculated.

Answer 625

serum osmolal gap \*need serum osmolality for this In addition to causing AGMA, methanol or ethylene glycol ingestion also causes an elevated serum osmolal gap.

Question 626

Measures to prevent urinary calcium stone formation include increasing fluid intake, following a low-sodium, low-protein diet, maintaining moderate calcium intake, and taking ??? to lower urinary calcium excretion.

Answer 626

thiazide diuretics

Question 627

Patients with AIDS are at high risk for infectious esophagitis with Candida albicans (most common), herpes simplex virus, and cytomegalovirus. Patients with concurrent oral thrush are generally treated with empiric ???. Those who do not respond to this treatment or have no evidence of thrush often require further evaluation with upper endoscopy and biopsy to clarify the diagnosis.

Answer 627

oral fluconazole

Question 628

In this patient with a recent CD4 count of 94/mm3, severe watery diarrhea, weight loss, and low grade fevers, ?? is the most likely diagnosis.

Answer 628

cryptosporidiosis CD4 \<180 commonly spread through drinking water, animal contact (eg, horse breeding), and person-to-person contact ​​​​​​​tool examination with modified acid-fast stain reveals cryptosporidial oocytes measuring 4-6 µm

Question 629

??? is an invasive fungal infection most commonly seen in patients with poorly controlled diabetes mellitus (especially in ketoacidosis). Treatment involves surgical debridement, antifungal medication (eg, liposomal amphotericin B), and the elimination of promoting factors (eg, hyperglycemia, ketoacidosis). ​​​​​​​

Answer 629

Mucormycosis Rhino-orbital-cerebral mucormycosis is the most common manifestation. \*\*surgical debridment + amphotericin B

Question 630

​​​​​​​patient works as a landscaper and developed a finger papule that ulcerated, expressed odorless discharge, and progressed proximally, raising strong suspicion for infection with ???

Answer 630

Sporothrix schenckii, a dimorphic fungus found in decaying plant matter and soil Treatment with several months of oral itraconazole is almost always curative.

Question 631

Infective endocarditis usually presents with subacute nonspecific (eg, fever, fatigue, myalgia, arthralgia), cardiac (eg, dyspnea), immunologic (eg, glomerulonephritis, Osler node), and/or embolic symptoms. Diagnosis is typically confirmed with ??

Answer 631

3 sets of blood cultures and echocardiogram.

Question 632

patient's constitutional symptoms (headache), confusion, signs of septic shock (eg, fever, tachycardia, hypotension), petechial rash, and minimal leukocytosis on lumbar puncture raise strong suspicion for ??? This bacterium attacks vascular endothelial cells, which causes progressive capillary permeability, fluid extravasation, hypovolemia, and poor tissue perfusion.

Answer 632

Rocky Mountain spotted fever (RMSF), a tick-borne illness caused by Rickettsia rickettsii. LP helps distinguis from meningococcal meningitis

Question 633

Patients with AIDS who have CD4 counts \<50/mm3 are at high risk for infectious colitis with opportunistic bacterial, viral, and protozoal pathogens. ??? colitis should be suspected in those with frequent, small-volume, bloody stools and abdominal pain. Diagnosis is confirmed by colonoscopy with biopsy.

Answer 633

Cytomegalovirus Any patient with HIV who has active CMV disease requires ocular examination to rule out concurrent retinitis.

Question 634

HIV-associated Kaposi sarcoma (KS) is an AIDS-defining malignancy caused by human herpesvirus 8. Cutaneous KS develops most commonly on the lower extremities, face, oral mucosa, and genitalia. The lesions usually appear as multiple violaceous papules. First-line treatment for limited disease is ??

Answer 634

antiretroviral initiation; local and systemic therapy are not generally required

Question 635

Patients with HIV who have subacute-onset of low-grade fever, headache, and signs of increased intracranial pressure should be evaluated for ??? \*\*also negative MRI

Answer 635

cryptococcal meningitis. Diagnosis is established by detection of the cryptococcal antigen or isolation of the organism in cerebrospinal fluid. patients with HSV have MRI findings in temporal lobe

Question 636

Actinomyces is part of the normal oral flora but may cause an invasive infection in patients who have dental infections or trauma (especially in those with weakened immunity). A pathognomonic feature is the presence of purulent discharge with "sulfur granules" (discrete yellow granules that resemble sulfur but do not contain it). Fine needle aspiration with culture is usually required to establish a diagnosis (cultures often take \>14 days). ??? is the first-line treatment for mild cases (no fistulas)

Answer 636

High-dose oral penicillin more severe cases require intravenous penicillin and (often) concomitant surgery. \*\*tx for nocardia is TMP-SMX

Question 637

Ventilator-associated pneumonia occurs ≥48 hours after intubation and usually presents with fever, purulent secretions, and abnormal chest x-ray. Patients need what management?

Answer 637

should have lower respiratory tract sampling (Gram stain and culture) and receive empiric antibiotics. \*tracheobronchial aspiration

Question 638

Which infection ??? Manifestations typically include high fever; diffuse maculopapular rash; and symmetric, progressive joint pain that is severe enough to interfere with daily activities. Joint symptoms begin in the distal small joints of the hands and feet but may affect proximal joints over time. Transient lymphopenia and thrombocytopenia often occur. Although fever and rash resolve spontaneously in a few days, up to 70% of patients develop chronic arthralgia/arthritis that lasts months or years

Answer 638

Chikungunya is a mosquito-borne viral illness endemic to tropical and subtropical regions

Question 639

??? is a dog tapeworm endemic to rural, developing countries. Humans are incidental hosts and usually acquire the infection through the consumption of food or water contaminated with dog feces. Tapeworm eggs hatch in the small intestine and spread to the viscera (eg, liver, lung), causing hydatid cysts. Symptoms are initially rare, but **hepatic cysts may grow over time**, resulting in right upper quadrant pain, nausea, vomiting, and hepatomegaly. Imaging typically reveals a large, smooth cyst, often with internal septations.

Answer 639

Echinococcus granulosus Small cysts (\<5 cm) are typically treated with albendazole; larger or complex cysts usually also require percutaneous therapy or surgery.

Question 640

??? should be suspected in a patient from an endemic region (southeastern and south central United States) with a history of tick bite, febrile illness with systemic symptoms, leukopenia and/or thrombocytopenia, and elevated aminotransferases. Rash is uncommon, and the drug of choice is doxycycline.

Answer 640

Ehrlichiosis ​​​​​​​ "Rocky Mountain spotted fever (RMSF) without the spots."

Question 641

Right-sided endocarditis should be considered in patients with presumed history of intravenous drug use. Empiric antibiotic treatment of native-valve endocarditis should be geared toward methicillin-resistant Staphylococcus aureus, streptococci, and enterococci. ??? is the most appropriate empiric antibiotic for these patients.

Answer 641

Vancomycin

Question 642

Empiric antibiotics must not be delayed while awaiting results of CT scan or performing lumbar puncture to diagnose bacterial meningitis. ??? is the regimen of choice for immunocompromised patients with suspected bacterial meningitis. Corticosteroids should be started at the same time as antibiotics and discontinued if cultures show an organism other than Streptococcus pneumoniae.

Answer 642

Cefepime plus vancomycin plus ampicillin Cefepime is a fourth-generation cephalosporin that covers most of the major organisms of bacterial meningitis (eg, Streptococcus pneumoniae, Neisseria meningitidis, group B streptococci, Haemophilus influenzae) as well as Pseudomonas aeruginosa. Vancomycin provides coverage against cephalosporin-resistant pneumococci, and ampicillin covers Listeria monocytogenes.

Question 643

HIV patients with CD4 counts ≤200 cells/mm3 require primary prophylaxis with trimethoprim-sulfamethoxazole to prevent Pneumocystis pneumonia. This medication is also used for primary prophylaxis against toxoplasmosis in those with positive serology and CD4 counts ≤100/mm3. Primary prophylaxis against mycobacterium avium complex (azithromycin) is no longer required. **???** other primary prophylaxis is routinely given; however, patients in Histoplasma-endemic areas with CD4 counts ≤150/mm3 are **sometimes given prophylactic itraconazole.**

Answer 643

\*\*no other besides for TMP-SMX

Question 644

Rabies postexposure prophylaxis (PEP) for mammalian bites includes rabies vaccine and rabies immune globulin. PEP is indicated when the animal is ???. Available, asymptomatic animals can either be observed (pets, for 10 days) or tested (wild animals) to determine the need for PEP.

Answer 644

unavailable or symptomatic

Question 645

Secondary bacterial pneumonia is the most common influenza complication and should be suspected when fever and pulmonary symptoms worsen after initial improvement. Most cases occur in patients age \>65, but community-acquired ??? has a predilection for young patients with recent influenza. This pathogen causes rapidly progressive, necrotizing pneumonia with high fever, productive cough (often with hemoptysis), leukopenia, and multilobar cavitary infiltrates.

Answer 645

methicillin-resistant Staphylococcus aureus

Question 646

??? can cause bacillary angiomatosis in immunocompromised individuals (eg, advanced HIV). Patients develop vascular cutaneous lesions, systemic symptoms, and sometimes organ involvement (liver, central nervous system, bone). Treatment requires antimicrobials (eg, doxycycline, erythromycin) and antiretroviral initiation.

Answer 646

Bartonella henselae and Bartonella quintana \*\*typically occurs after cat-scratch

Question 647

hypocomplementemic glomerulonephritis associated with systemic vasculitis is usually due to membranoproliferative glomerulonephritis (positive serum ???) or lupus nephritis (positive antinuclear antibodies).

Answer 647

cryoglobulins

Question 648

?? is the inability of the kidneys to concentrate urine and can occur in patients with sickle cell disease and sickle cell trait. Patients have polyuria, **low urine specific gravity**, and normal serum sodium.

Answer 648

Hyposthenuria

Question 649

initial vs. terminal hematuria initial means blood at the start of urination, then clear

Answer 649

initial: urethral injury terminal: bladder or porstate damage

Question 650

??? is the most common cause of death (up to 50%) in patients with end-stage renal disease (ESRD).

Answer 650

Cardiovascular disease contributing factors include an increased prevalence of traditional cardiovascular risk factors (eg, hypertension, diabetes) and ESRD-related risks (eg, anemia, oxidative stress). Aggressive risk-factor modification is required to reduce mortality.

Question 651

what test must be done if BPH or obstructive uropathy is suspected; also slowly rising Cr ??

Answer 651

A renal ultrasound examination, which should be performed in all patients being evaluated for creatinine elevation or chronic kidney disease, typically reveals hydronephrosis and may help assess the extent and reversibility of kidney injury.

Question 652

what type of cyst??

Answer 652

Simple renal cysts are almost always benign and do not require further evaluation. Features concerning for malignant renal mass include a multilocular mass, irregular walls, thickened septa, and contrast enhancement.

Question 653

patient with a history of renal transplant has severe, persistent hypertension. In association with the acute kidney injury (AKI) that developed after initiation of lisinopril, this presentation suggests renovascular hypertension due to ???

Answer 653

transplant renal artery stenosis (RAS) can occur in the renal allograft, typically within 2 years of transplant. The diagnosis is made with renal vascular imaging (eg, renal Doppler ultrasonography). Management of transplant RAS usually includes angioplasty, possibly with stent placement.

Question 654

Aminoglycosides (eg, amikacin) can cause acute kidney injury in the form of toxic acute tubular necrosis, usually after \>5-7 days of use. Fractional excretion of sodium is typically ????, and urinalysis usually shows muddy brown (granular) or epithelial cell casts.

Answer 654

\>2%

Question 655

Hematuria (gross or microscopic) can be due to glomerular or non-glomerular causes. The source of hematuria is more likely to be ?? if the urine studies reveal proteinuria, dysmorphic red blood cells (RBCs) or RBC casts.

Answer 655

glomerular

Question 656

Leukemoid reaction (LR) occurs as a response to severe infection and is marked by leukocyte counts \>50,000/mm3. Compared to chronic myeloid leukemia, LR is characterized by the presence of a ?? alkaline phosphatase score, a greater proportion of late neutrophil precursors (metamyelocytes, bands), and a lack of absolute basophilia.

Answer 656

high vs. low in CML

Question 657

Infections are a common complication of chronic lymphocytic leukemia (CLL). CLL is diagnosed by ???

Answer 657

flow cytometry (clonality of mature B cells).

Question 658

Most bacterial infections cause a mild to moderate leukocytosis with a predominance of neutrophils. This patient's complete blood count demonstrates a dramatic leukocytosis, primarily with lymphocytes. In an elderly patient, severe lymphocytosis combined with hepatosplenomegaly, lymphadenopathy, and bicytopenia (anemia, thrombocytopenia) strongly suggests underlying ???

Answer 658

chronic lymphocytic leukemia (CLL).

Question 659

​​​​​​​patient in this vignette has several signs and symptoms suggestive of a ???including **generalized lymphadenopathy,** splenomegaly, and constitutional symptoms (eg, fatigue) + anemia

Answer 659

lymphoproliferative disorder, most likely lymphoma,

Question 660

??? anemia usually manifests as microcytic/hypochromic anemia simulating iron-deficiency anemia, but iron studies reveal elevated serum iron level and normal or decreased total iron binding capacity.

Answer 660

Sideroblastic

Question 661

patient is on isoniazid (INH), a well-known pyridoxine (vitamin B6) antagonist that can cause acquired ???. It frequently manifests as microcytic hypochromic anemia, simulating iron deficiency anemia.

Answer 661

sideroblastic anemia

Question 662

Sideroblastic anemia usually manifests as microcytic/hypochromic anemia simulating iron-deficiency anemia, but iron studies reveal elevated serum iron level and normal or decreased total iron binding capacity. In patients with an identifiable cause of vitamin B6 deficiency (alcohol, medications), the administration of ??? can easily correct the problem.

Answer 662

pyridoxine

Question 663

??? is marked by dramatic leukocytosis, absolute basophilia, and a shift towards very early neutrophil precursor cells (promyelocytes, myelocytes). The leukocyte alkaline phosphatase score, a marker of neutrophil activity, typically is low.

Answer 663

Chronic myeloid leukemia (CML)

Question 664

???? should be suspected in patients receiving heparin anticoagulation who have thrombocytopenia, thrombosis (arterial or venous), or a \>50% drop in the platelet count from baseline 5-10 days after the initiation of treatment.

Answer 664

Heparin-induced thrombocytopenia

Question 665

??? is a B-cell neoplasm associated with elevated monoclonal IgM. High levels of IgM may cause hyperviscosity syndrome (vision changes, headaches, vertigo, dizziness, ataxia), peripheral neuropathy, cryoglobulinemia, and/or renal insufficiency. Diagnosis requires serum protein electrophoresis and bone marrow biopsy

Answer 665

Waldenström macroglobulinemia

Question 666

​​​​​​​manifestations typically include slowly progressive lower back pain or functional impairment (eg, motor weakness, incontinence). ??? usually causes osteoblastic bone lesions on the spine with normal or low calcium, elevated alkaline phosphatase, and radiographic evidence of focal, sclerotic lesions.

Answer 666

Prostate cancer

Question 667

Sickle cell disease patients are at high risk of ??? due to alloimmunization from frequent transfusions. Reactions develop \>24 hours and up to a month after transfusion and can cause hemolytic anemia. Diagnosis is confirmed with a newly positive Coombs test.

Answer 667

delayed hemolytic transfusion reactions

Question 668

??? inhibit the osteoclastic activity of bone, stabilizing destructive bony tumors and reducing the risk of skeletal-related events such as pathologic fracture and malignant hypercalcemia.

Answer 668

Bisphosphonates (eg, zoledronic acid)

Question 669

Chronic lymphocytic leukemia is associated with ??? anemia.

Answer 669

warm autoimmune hemolytic anemia Red blood cells (RBCs) coated with IgG are identified by the Fc receptor on splenic macrophages and partially or wholly phagocytized, leading to extravascular, immune-mediated hemolysis (ie, autoimmune hemolytic anemia). The diagnosis is confirmed with a direct antiglobulin (Coombs) test, which detects the presence of IgG or C3 (a complement fragment) on erythrocytes.

Question 670

Glucose-6-phosphate dehydrogenase (G6PD) deficiency causes episodic hemolytic anemia after oxidative insults (eg, sulfa drugs, primaquine, infection, fava beans) what is the limitation of the enzyme activity level test?

Answer 670

Diagnosis is made by G6PD activity level, but sensitivity is low in acute hemolytic crises; therefore, this test cannot be relied on to rule out the condition in the acute setting.

Question 671

In an elderly patient with evidence of osteolytic lesions on x-ray, ?? should always be suspected.

Answer 671

MM The screening tests of choice for MM are serum protein electrophoresis, urine protein electrophoresis, and free light chain analysis. Diagnosis can be confirmed with bone marrow biopsy.

Question 672

??? are the drugs of choice for treating and preventing chemotherapy-induced nausea and vomiting.

Answer 672

Serotonin (5HT) antagonists that block 5HT3 receptors ondansetron and other -setron drugs

Question 673

patient, who is exposed to automobile exhaust in an enclosed space, has intermittent headaches, dizziness, nausea, and polycythemia (elevated hematocrit), most likely due to ??? poisoning.

Answer 673

chronic carbon monoxide (CO) Carboxyhemoglobin shifts the oxygen dissociation curve to the left, impairing the ability of heme to unload oxygen at the tissue level. This results in tissue hypoxia. The kidney responds to tissue hypoxia by producing more erythropoietin (EPO). EPO stimulates the bone marrow to differentiate more red blood cells. Chronic CO toxicity is a cause of **secondary polycythemia.**

Question 674

The adrenal glands are a common site of metastatic cancer spread, and extensive metastatic involvement can lead to ???. Clinical manifestations include hypotension/orthostasis, hyponatremia, hyperkalemia, and hypoglycemia.

Answer 674

primary adrenal insufficiency (PAI) Diagnosis is made by cosyntropin stimulation testing.

Question 675

primary adrenal insufficiency (PAI): Diagnosis is made by ??

Answer 675

cosyntropin stimulation testing. Cosyntropin is a synthetic form of ACTH; absence of the expected increase in cortisol levels following cosyntropin administration reflects adrenocortical destruction. The test is usually performed in the morning, when cortisol responses in healthy individuals are normally the most pronounced. Measuring basal ACTH (before cosyntropin injection) can help differentiate primary AI (high basal ACTH) from AI due to hypothalamic-pituitary deficiency (low basal ACTH).

Question 676

??? is a common cause of a mediastinal mass that often presents with compressive symptoms (eg, cough, shortness of breath, retrosternal pain). Peripheral lymphadenopathy, B symptoms, pruritus, and alcohol-associated pain may also be present. Laboratory evaluation often reveals **elevated serum lactate dehydrogenase and eosinophilia.**

Answer 676

Hodgkin lymphoma \*\*\*bimodal distribution; age 15-35 or \>60

Question 677

Anemia of chronic disease is caused by ????. It is primarily mediated by hepcidin, a small peptide produced by the liver that destroys iron channels on enterocytes and reticuloendothelial macrophages. This limits iron availability for erythropoiesis, which causes a normocytic or slightly microcytic anemia with a low reticulocyte response.

Answer 677

long-term elevation in inflammatory cytokines

Question 678

Microcytic anemia with an inappropriately low reticulocyte response is primarily seen in iron deficiency anemia and ???

Answer 678

anemia of chronic disease (ACD)

Question 679

Splenic infarction usually occurs in the setting of splenic artery (or subbranch) occlusion due to hypercoagulable states, embolic disease, or hemoglobinopathy (eg, ????).

Answer 679

sickle cell disease or trait although patients with sickle cell trait are generally asymptomatic, they occasionally develop splenic infarction and intravascular hemolysis in the setting of certain stressors such as **air travel or dehydration**. Diagnosis of most hemoglobinopathies is made by hemoglobin electrophoresis.

Question 680

?? should be considered in patients who have elevated liver enzymes, diabetes mellitus, and skin hyperpigmentation. It can progress to cirrhosis and is associated with a significantly increased risk for hepatocellular carcinoma.

Answer 680

Hereditary hemochromatosis

Question 681

Patients with hereditary hemochromatosis have an approximate 20-fold increased risk for ???, accounting for 45% of deaths in HH patients.

Answer 681

hepatocellular cancer (HCC)

Question 682

vit b12 causes which neurologic deficits primarily

Answer 682

loss of proprioception and vibration in the lower extremeties

Question 683

the??? veins are the most common source of symptomatic pulmonary embolism.

Answer 683

proximal deep leg (femoral/popliteal) distal calf are more common in general, but less common to embolize

Question 684

??? should be suspected in patients who have a combination of hemolytic anemia, cytopenias, and hypercoagulable state (intraabdominal or cerebral venous thrombosis). Flow cytometry tests are used to confirm the diagnosis by assessing for absence of the CD55 and CD59 proteins on the surface of red blood cells.

Answer 684

Paroxysmal nocturnal hemoglobinuria

Question 685

Acute promyelocytic leukemia (APL), a unique form of acute myelogenous leukemia, generally presents with symptoms related to pancytopenia. Individuals with APL are at an extremely high risk for ????. Therefore, patients require urgent treatment with all-trans retinoic acid, which differentiates the abnormal promyelocytes into mature myelocytes and rapidly reduces bleeding risk.

Answer 685

catastrophic hemorrhage due to tumor-induced consumptive coagulopathy

Question 686

absence of splenomegaly and the presence of diminished, morphologically normal cells on peripheral smear suggest the pancytopenia is due to ???

Answer 686

aplastic anemia (AA), a form of bone marrow failure caused by damage to multipotent hematopoietic stem cells

Question 687

Thrombotic thrombocytopenic purpura (TTP) is caused by autoantibodies to plasma protease ADAMTS13 and is marked by microangiopathic hemolytic anemia and thrombocytopenia. TTP is life threatening and requires emergent treatment with ???

Answer 687

plasma exchange.

Question 688

what causes pentad of: Thrombocytopenia, Microangiopathic hemolytic anemia (MAHA), Renal insufficiency, Neurologic changes (eg, headache, confusion, coma, stroke), Fever

Answer 688

Thrombotic thrombocytopenic purpura (TTP)

Question 689

ITP is categorized as either primary (no discernible cause) or secondary (due to an underlying condition). HIV and hepatitis C are the most common secondary causes, so testing for these 2 conditions is generally performed. Additional testing is warranted when specific signs or symptoms of another disorder are present. This patient's myalgias and arthralgias raise concern for an autoimmune disease, therefore ?? testing is advised

Answer 689

(eg, systemic lupus erythematosus) therefore, antinuclear antibody testing is advisable.

Question 690

Von Willebrand Disease vs. Immune Thromobyctopenic Purpura

Answer 690

VWD has normal number of platelets vs. ITP which has isolated thrombocytopenia (acquired disorder marked by the formation of autoantibodies to platelet surface glycoproteins, which increases platelet clearance in the spleen and inhibits megakaryocytosis)

Question 691

patient was initiated on enoxaparin due to an acute deep venous thrombosis. A week later, laboratory studies show a significant reduction in platelet count, suggesting ???

Answer 691

type 2 heparin-induced thrombocytopenia (HIT) \*\*greatly increases the risk of arterial and venous clots

Question 692

Patients with antiphospholipid antibodies (particularly LA) generally have what coag finding???

Answer 692

prolonged PTT because antiphospholipid antibodies bind the phospholipids used in most testing assays and prevent them from inducing coagulation.

Question 693

patient's presentation (joint pains, oral ulcer, hypertension, pancytopenia, impaired renal function) suggests possible ???

Answer 693

systemic lupus erythematosus (SLE)

Question 694

Chronic myeloid leukemia (CML) is driven by a reciprocal translocation of chromosomes 9 and 22 forming the ??? fusion gene

Answer 694

BCR-ABL

Question 695

treatment for chronic myeloid leukemia: chromosomes 9 and 22 forming the BCR-ABL fusion gene.

Answer 695

This gene creates a constitutively active tyrosine kinase. Tyrosine kinase inhibitors such as **imatinib** are a key therapy in the treatment of CML

Question 696

pentad of ???, which includes thrombocytopenia, microangiopathic hemolytic anemia (MAHA), renal insufficiency, neurologic changes (eg, acting "weird"), and fever.

Answer 696

Without treatment, the mortality rate from **TTP** is as high as 90%; therefore, TTP must be treated emergently with plasma exchange. Glucocorticoids are often added.

Question 697

Nontender, solitary cervical lymph nodes are concerning for ???, especially in an adult patient with a smoking history \*\*no B-symptoms (Hodgkin), no other surrounding lymphadenopathy, and normal CBC

Answer 697

mucosal head and neck squamous cell carcinoma

Question 698

A mechanical or severely calcified aortic valve can cause hemolytic anemia due to erythrocyte shearing. Patients also frequently have mildly low platelets due to concurrent mechanical platelet injury. What test should be done???

Answer 698

A transthoracic echocardiogram should be performed to visualize valve function and determine valvular pressure gradients.