Pics and Highlights Flashcards

Question 1

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Do not screen women for AAA.

Question 2

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Ultrasonography is not accurate for diagnosing a ruptured abdominal aorta.

Question 3

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STEMI is not the only cause of ST-segment elevations. Consider acute
pericarditis, LV aneurysm, stress (takotsubo) cardiomyopathy, coronary
vasospasm, acute stroke, or normal variant.

Question 4

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Do not choose thrombolytic therapy for patients with NSTEMI or for
asymptomatic patients with onset of pain >24 hours ago.

Question 5

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Cardiac enzyme values may be slightly elevated in patients with pericarditis
(myopericarditis).
* Absence of a pericardial effusion on echocardiography does not rule out
pericarditis.

Question 6

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Closure of an ASD is contraindicated if shunt reversal (right to left) is present.
A small ASD with no associated symptoms or right heart enlargement can be
followed clinically.

Question 7

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Obtain BP in the legs in young people presenting with unexplained hypertension.

Question 8

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coarctation of oarota

Question 9

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Livedo reticularis Livedo reticularis in the lower extremities caused by cholesterol emboli following
cardiac catheterization.

Question 10

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Aortic atheromatous plaques represent a CAD risk equivalent, and patients should be
considered for antiplatelet and statin therapies in addition to other risk factor
interventions.

Question 11

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Do not select β-blockers or intra-aortic balloon pumps for patients with acute

AR, because both may worsen the AR.
* Therapy with ACE inhibitors or calcium channel blockers does not delay the need
for surgery in asymptomatic patients with chronic AR.

Question 12

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Echocardiography may significantly underestimate the transvalvular gradient in
patients with severe LV dysfunction.
Do not select exercise stress testing for symptomatic patients with AS.

Question 13

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Do not select balloon valvuloplasty as a definitive treatment for AS in adults.
Medical therapy with statins does not alter the natural history of AS.

Question 14

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Only warfarin is indicated for valvular AF.
* Antiplatelet therapy alone is no longer routinely used for stroke prevention in AF.

Question 15

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Do not begin calcium channel blockers, β-blockers, or digoxin in patients with
AF and WPW syndrome; use procainamide instead.
Adenosine is not effective for cardioversion of AF.

Question 16

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The AF rhythm is
irregular, and fibrillatory waves are clearly seen. RBBB

Question 17

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a flutter

Question 18

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Electrical alternans is characterized by alternating amplitude of the QRS complexes
in any or all leads. Cardiac Effusion and Tamponade

Question 19

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An increased P2, an S3, and an early peaking systolic murmur over the upper left
sternal border are normal findings during pregnancy.

Question 20

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Stress testing is of little diagnostic value in patients with a very low (e.g., <10%)
or very high (e.g., >90%) pretest probability of CAD. In patients with very high
pretest probability, stress testing may provide prognostic information.

Question 21

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Absence of a pericardial effusion excludes a diagnosis of cardiac tamponade.

Question 22

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Signs of serious cardiac disease include an S4, murmur grade ≥3/6 intensity, any
diastolic murmur, continuous murmurs, and abnormal splitting of S2.

Question 23

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Routine testing for unusual causes of HF, including hemochromatosis, multiple
myeloma, amyloidosis, and myocarditis, should not be performed.
Don’t order serial BNPs in ambulatory patients to monitor HF or guide therapy.
Kidney failure, older age, and female sex all increase BNP; obesity reduces BNP.

Question 24

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Do not begin β-blocker therapy in patients with decompensated HF.
Continuous IV infusion of furosemide provides no advantage vs. bolus therapy in
decompensated HF.
Do not prescribe or continue NSAIDs or thiazolidinediones because they worsen
HF.

Question 25

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Nondihydropyridine calcium channel blockers (diltiazem or verapamil) may be
harmful to patients with HFrEF.
Do not implant ICD until guideline-directed medical therapy has been
administered for 3 months (or 40 days after MI) to assess potential recovery of
LVEF

Question 26

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No drug has been clearly shown to decrease morbidity and mortality in patients
with HFpEF.

Question 27

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Avoid vasodilating β-blockers (carvedilol, labetalol, and nebivolol) in HOCM (Metoprolol can use).
Electrophysiologic studies are not useful in predicting sudden cardiac death.
Do not prescribe digoxin, vasodilators, or diuretics, which increase LV outflow
obstruction, for patients with HCM.

Question 28

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Question 29

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Osler nodes are red to purple painful papules, papulopustules, or nodules found in
the pulp of fingers or occasionally on hands and feet. Infective Endocarditis

Question 30

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Janeway Lesions: are macular, erythematous, nontender microabscesses in the dermis
of the palms and soles caused by septic emboli that are considered pathognomonic
for IE.

Question 31

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Septic embolic from IE

Question 32

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Don’t give antimicrobial prophylaxis to patients with MVP or other low-risk
valvular abnormalities.

Question 33

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Look for colon cancer in patients with Streptococcus bovis or Clostridium septicum
endocarditis.

Question 34

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Inf Endos. A fingernail with splinter hemorrhages, which are nonblanching, linear, reddish-
brown lesions found under the nail bed.

Question 35

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ACE inhibitors and ARBs have not been shown to be effective in preventing progression of LV dysfunction in patients with chronic MR.

Question 36

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Treat all patients with mitral stenosis and AF, regardless of CHA2DS2-VASc score,
with warfarin.

Question 37

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Resting ABI should be performed on all patients with a history or physical examination
suggesting PAD. Exercise treadmill ABI testing should be performed for patients with
normal or borderline resting ABI values and unexplained exertional leg symptoms.
Noninvasive angiography with duplex ultrasonography, CTA, or MRA is performed for
anatomic delineation of PAD in patients requiring surgical or endovascular intervention.

Question 38

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When the ABI is >1.40, select a toe-brachial index to provide a better assessment
of lower extremity perfusion.

Question 39

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PAD alone is not an indication for anticoagulation.
Do not use cilostazol in patients with a low LVEF or history of HF.
β-Blockers are not contraindicated in patients with PAD.

Question 40

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Do not choose long-term anticoagulation for patients with bioprosthetic heart
valves.
* Select only warfarin for anticoagulation of mechanical heart valves. Do not select
a DOAC.

Question 41

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The ECG shows low voltage, the most common ECG abnormality associated with
cardiac amyloidosis.

Question 42

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Mobitz Type 1 Heart Block The rhythm strip shows progressive prolongation of the PR interval until the
dropped beat.

Question 43

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Mobitz Type 2 Heart Block The rhythm strip shows constant PR interval. The R-R interval containing the
nonconducted beat is equal to two P-P intervals.

Question 44

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Complete Heart Block
The rhythm strip shows third-degree heart block with three nonconducted atrial
impulses and a pause of 3.5 seconds.

Question 45

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Don’t place a pacemaker for asymptomatic bradycardia in the absence of
second- or third-degree heart block.

Question 46

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The ECG shows RBBB and left anterior hemiblock characteristic of bifascicular block.

Question 47

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Prolonged QT Syndrome
The ECG shows a prolonged QT interval of 590 ms.

Question 48

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Brugada Pattern on ECG
Incomplete RBBB pattern and elevation of the ST segments that gradually descends
to an inverted T wave in leads V1 and V2 are characteristic of the classic variety of
Brugada syndrome.

Question 49

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Narrow-Complex Tachycardia:

Question 50

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Do not treat irregular wide-complex tachycardia or polymorphic tachycardia with

adenosine.

Question 51

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Multifocal Atrial Tachycardia:
The ECG shows an irregular tachycardia with three distinct P-wave morphologies
characteristic of MAT

Question 52

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AV-Nodal Reentrant Tachycardia
The ECG shows a narrow-complex tachycardia at 144/min and no visible P waves.

Question 53

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AV Reciprocating Tachycardia
The ECG shows a narrow-complex tachycardia with the P wave buried in the ST
segment.

Question 54

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Atrial Tachycardia
The ECG shows a narrow-complex tachycardia with P waves most clearly seen in lead
V1 and at the end of the T wave in other leads.

Question 55

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Uncomplicated type B dissection is treated with continued medical therapy alone,
except in patients with complications, including end-organ ischemia.

Question 56

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Do not use hydralazine for acute aortic dissection because it increases shear
stress.
* Schedule surgery for type B dissection if major aortic vessels, such as renal
arteries, are involved.

Question 57

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In patients with structural heart disease, therapy to suppress PVCs does not
affect outcomes.

Question 58

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Monomorphic VT:
Approximately one quarter of the way into this ECG rhythm strip (bottom),
monomorphic VT begins; it is associated with an abrupt change in the QRS axis.

Question 59

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Polymorphic VT
This ECG shows degeneration of the sinus rhythm into polymorphic tachycardia.

Question 60

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Asymptomatic WPW conduction without arrhythmia (WPW pattern) does not
require investigation or treatment.
* Do not select calcium channel blockers, β-blockers, or digoxin for patients who
have AF with WPW syndrome; such treatment may convert AF to VT or VF.

Question 61

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Wolff-Parkinson-White Syndrome
A WPW pattern is identified by a short PR interval, prolonged QRS, and a slurred
onset of the QRS

Question 62

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Do not select sliding scale insulin alone to treat in-hospital hyperglycemia.
* Tight inpatient glycemic control (80-110 mg/dL [4.4-6.1 mmol/L]) is not
consistently associated with improved outcomes and may increase mortality.

Question 63

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A random plasma glucose level ≥200 mg/dL with hyperglycemic symptoms is
diagnostic of diabetes and does not warrant repeat measurement.

Question 64

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If a patient is nonadherent with multiple insulin injections, adherence is unlikely
to increase because a pump is prescribed.
* Hemoglobin A1c will be falsely low in patients with hemolytic anemia, patients
taking erythropoietin, or patients with kidney injury.

Answer 64

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Nonproliferative Diabetic Retinopathy:
Dot-and-blot hemorrhages and clusters of hard, yellowish exudates are
characteristic of nonproliferative diabetic retinopathy.

Answer 65

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Proliferative Diabetic Retinopathy:
A network of new vessels (neovascularization) is shown protruding from the optic
nerve.

Answer 66

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Do not treat diabetic mononeuropathy (e.g., third nerve palsy); symptoms resolve
spontaneously.

Answer 67

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Differentiate gynecomastia from pseudogynecomastia, which is fat deposition
typically seen in men with obesity.
* Obtain mammography for unilateral, nontender, or fixed masses to diagnose
breast cancer.

Answer 68

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In patients with hypercalcemia and normal PTH levels, measure urinary calcium
excretion to exclude familial hypocalciuric hypercalcemia.

Answer 69

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Evaluation for Cushing syndrome should be limited to patients with a significant
clinical suspicion of disease, including specific signs of Cushing syndrome or an
adrenal mass.
* False-positive results (failure to suppress cortisol) with the 1-mg dexamethasone
suppression test are common owing to alcohol use, obesity, and psychological
disorders.

Answer 70

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DKA can present with abdominal pain.
* Reducing the insulin infusion before complete clearing of ketones will cause a
relapse of DKA.
* Treatment of severe acidosis with bicarbonate is controversial, and evidence of
benefit is lacking.

Answer 71

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A fever or sore throat in a patient taking methimazole or propylthiouracil should
be presumed to be agranulocytosis until proven otherwise.

Answer 72

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Approximately 50% of patients with autoimmune adrenal insufficiency have other
autoimmune endocrine disorders (thyroid disease, type 1 diabetes, vitiligo),
referred to as autoimmune polyglandular syndrome; testing for these
disorders is indicated.

Answer 73

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Do not prescribe dexamethasone for chronic AI replacement therapy.

Answer 74

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Do not use home glucometers to document hypoglycemia, because they may be
inaccurate.
* Asymptomatic hypoglycemia with a plasma glucose level <60 mg/dL is often
found after fasting in patients without underlying disease and does not require
evaluation.

Answer 75

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Thyroid scan and radioactive iodine uptake tests are not used to make the
diagnosis of hypothyroidism.

Answer 76

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Check thyroid function tests frequently during pregnancy in women with a
known diagnosis of hypothyroidism taking thyroxine, because maternal thyroxine
demand increases by 30% to 50%.

Answer 77

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Do not measure serum testosterone if a patient is having regular morning
erections, has no gynecomastia on examination, and has a normal genital
examination.

Answer 78

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Don’t provide testosterone replacement therapy for nonspecific symptoms such
as fatigue and weakness in the absence of unequivocal testosterone deficiency.
Testosterone therapy does not treat infertility (impairs spermatogenesis).

Answer 79

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About 50% of patients with primary hyperparathyroidism have coexisting vitamin
D deficiency, and serum and urine calcium levels may be decreased. Select
measurement of serum vitamin D levels in all patients with hyperparathyroidism.

Answer 80

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Not all fractures in older adult patients are caused by osteoporosis. Look for
osteomalacia, particularly in nursing-home residents.

Answer 81

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Do not repeat annual DEXA in women with normal DEXA results without risk
factors. The optimal screening interval is unknown.

Answer 82

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The effects of denosumab are not sustained when treatment is stopped, and
bone loss is accelerated.

Answer 83

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Do not use estrogen replacement therapy for osteoporosis in postmenopausal
women.
IV bisphosphonates are contraindicated in patients with severe hypocalcemia
and CKD.

Answer 84

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Paget Disease
X-ray showing “cotton wool” appearance of the skull typical of Paget disease.

Answer 85

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For control of hypertension in patients with pheochromocytoma, select α-
adrenergic blockers first. α-Adrenergic blockade before adequate β-adrenergic blockade can result in severe paroxysmal hypertension.

Answer 86

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The pituitary gland is enlarged diffusely in untreated primary hypothyroidism and
during normal pregnancies.

Answer 87

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Prolactinoma:
A discrete area of hypolucency (arrow) is seen in an otherwise normal-sized pituitary
gland of homogeneous density.

Answer 88

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Psychotropic agents, tricyclic antidepressants, antiseizure medications,
metoclopramide and domperidone, calcium channel blockers, methyldopa,
opioids, and protease inhibitors can cause hyperprolactinemia.
* The prolactin level influenced by drugs and other nonprolactinoma conditions is
usually <150 ng/mL.

Answer 89

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Obtain a pregnancy test in all women with hyperprolactinemia.
Obtain a serum TSH level in all patients with hyperprolactinemia (hypothyroidism
can cause hyperprolactinemia).

Answer 90

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It is not necessary to measure serum FSH/LH levels in women who have normal
menstrual cycles.

Answer 91

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Thyroxine dosing for central hypothyroidism is based on serum free T4 rather
than TSH levels.
* T4 replacement is indicated only after hypoadrenalism has been ruled out or
treated.

Answer 92

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An androgen-secreting ovarian or adrenal tumor should be suspected in a
woman with acute onset of rapidly progressive hirsutism or virilization.

Answer 93

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Women with a history of gestational diabetes are at very high risk for developing
type 2 diabetes and require annual screening following delivery.

Answer 94

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Almost 50% of patients with hyperaldosteronism do NOT have hypokalemia.

Answer 95

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A hyperfunctioning nodule is shown on the lateral aspect of the left thyroid lobe on
thyroid scan.

Answer 96

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Serum thyroglobulin measurement is not helpful in distinguishing benign from
malignant thyroid nodules.
* Calcitonin measurement is considered only in patients with hypercalcemia or a
family history of thyroid cancer or MEN2.

Answer 97

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Do not prescribe T4-suppression therapy for benign thyroid nodules.

Answer 98

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If the patient has a history of travel to South America, suspect Chagas disease as
the cause of achalasia.

Answer 99

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Barium Esophagogram:
The “bird’s beak” finding reflects narrowing of the distal esophagus and is
characteristic of achalasia.

Answer 100

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Do not choose antibiotics for EHEC colitis.
* Do not choose loperamide or diphenoxylate for acute diarrhea with fever or
blood in the stool. Both agents are associated with HUS in EHEC colitis and toxic megacolon in C. difficile infection.

Answer 101

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Kayser-Fleischer Ring Wilson disease ACOPPER
A Kayser-Fleischer ring in the cornea is bracketed with arrowheads.

Answer 102

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Head CT should be performed in patients with acute liver failure and altered
mental status to rule out cerebral edema or intracranial hemorrhage.

Answer 103

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Uncomplicated pancreatitis is not typically associated with rebound abdominal
tenderness, absent bowel sounds, high fever, or melena. When these findings are
present, consider abscess, pseudocyst, or necrotizing pancreatitis.
* Mildly increased amylase values can also be caused by kidney disease, intestinal
ischemia, appendicitis, and parotitis.

Answer 104

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Fluid resuscitation (250-500 mL/h)for pancreatitis is most beneficial in the first 12-24 hours and
may be detrimental after this therapeutic window.
* Do not withhold oral feeding on the basis of persistent elevations in pancreatic
enzyme levels.

Answer 105

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Pancreatic pseudocysts do not require drainage unless they cause significant
symptoms or are infected, regardless of size.

Answer 106

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Do not use glucocorticoids in patients with alcoholic hepatitis and GI bleeding,
infection, pancreatitis, or kidney disease.

Answer 107

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High serum total protein and low serum albumin levels suggest an elevated
serum γ-globulin level, which may be the only clue to hypergammaglobulinemia.

Answer 108

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Women with GERD do not require routine screening for BE.
* Do not select antireflux surgery to prevent the progression of BE to
adenocarcinoma.

Answer 109

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Empiric treatment with a gluten-free diet before serologic testing may result in
false-negative serologic test results.

Answer 110

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Dermatitis herpetiformis is characterized by pruritic papulovesicles over the external
surface of the extremities and on the trunk; test for celiac disease.

Answer 111

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Chronic senna use can lead to benign pigmentation of the colon, known as
melanosis coli. Melanosis coli is an abnormal brown or black pigmentation of the colonic mucosa
and is frequently found in patients with long-term stimulant laxative use.

Answer 112

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Don’t forget other causes of diarrhea such as sorbitol (added as a sweetener to
gum, candy) and medications, including PPIs, magnesium-containing antacids,
metformin, colchicine, and antibiotics.

Answer 113

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Infection with G. lamblia should be considered in patients with exposure to
young children or potentially contaminated water (lakes and streams).

Answer 114

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Normal amylase and lipase levels do not rule out chronic pancreatitis.
* Pancreatic biopsy and endoscopic retrograde cholangiopancreatography are not
indicated in the diagnosis of chronic pancreatitis

Answer 115

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Avoid opioids for the treatment of chronic pancreatitis.

Answer 116

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Although a plasma ammonia level may be helpful in diagnosing suspected cases
of hepatic encephalopathy, monitoring serial ammonia values is not useful.
* Head CT in patients with hepatic encephalopathy and otherwise normal
neurologic examination is not warranted.

Answer 117

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Use IV, not oral, bisphosphonate therapy in patients with esophageal varices.

Answer 118

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Stop ACE inhibitors, ARBs, and NSAIDs in patients with ascites.
* Blood transfusion to hemoglobin >7.0 g/dL leads to increased portal pressures
and risk of further bleeding.
* Antimicrobial prophylaxis should be administered during variceal bleeding even
if ascites is absent.

Answer 119

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Extensive testing is not required to establish the diagnosis of Gilbert syndrome;
verify normal aminotransferase levels and the absence of hemolysis.

Answer 120

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Pneumaturia, fecaluria, or recurrent/polymicrobial UTI suggests a diverticulitis-
related colovesical fistula.

Answer 121

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Avoid colonoscopy in the setting of acute diverticulitis; air insufflation may
increase the risk of perforation.
* A colonoscopy should be performed following recovery to rule out colon cancer.

Answer 122

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Esophageal Candida
White mucosal plaque-like lesions consistent with Candida are seen on upper
endoscopy.

Answer 123

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The absence of oral Candida lesions does not rule out esophageal candidiasis.

Answer 124

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Surgery is generally not indicated for asymptomatic gallstones.

Answer 125

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Chest pain is common in patients with GERD, but a cardiac cause of chest pain
must be ruled out first.
* In patients without alarm features, GERD management consists of once-daily PPI;

twice-daily PPI for 4-8 weeks is indicated in patients not responding to once-
daily treatment.

Answer 126

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Patients with diabetes mellitus should have a blood glucose level <275 mg/dL
during testing for gastroparesis because marked hyperglycemia can acutely impair gastric
emptying.

Answer 127

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Patients with unexplained acute hepatitis or acute liver failure should be tested for IgM
anti-HAV.

Answer 128

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In previously unvaccinated persons, hepatitis B vaccine plus HBIG is indicated for
postexposure prophylaxis after needle-stick injury and for sexual and household
contacts of patients with HBV.

Answer 129

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Because up to 40% of patients with chronic HCV have normal aminotransferase
levels, normal levels cannot exclude a diagnosis of HCV.
* Reactivation of hepatitis B can occur during antiviral therapy for HCV. Test for
hepatitis B before initiating direct antiviral therapy for HCV.

Answer 130

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Leukocytoclastic Vasculitis:
Leukocytoclastic vasculitis consistent with HCV-associated mixed cryoglobulinemia
manifesting as palpable purpura.

Answer 131

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Do not perform a barium enema examination in patients with moderate to
severe ulcerative colitis because this procedure may precipitate toxic megacolon.
In patients with Crohn disease and cystitis, consider the possibility of
enterovesical fistula.

Answer 132

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Before initiating an anti-TNF agent, all patients should be evaluated for TB and
hepatitis B and C virus infections.

Answer 133

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Pyoderma Gangrenosum
A nonhealing ulcer, often occurring on the lower extremities, may be seen in
association with IBD. The ulcer shown has a purulent base and ragged, edematous
borders.

Answer 134

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In the absence of alarm symptoms, CBC, serum chemistry studies, TSH, and
abdominal imaging are unnecessary.
* Screening colonoscopy should be pursued only in patients who otherwise meet
criteria for colon cancer screening.
* Patients with severe or refractory symptoms require diagnostic colonoscopy.

Answer 135

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Alosetron should not be used as first-line therapy for IBS-D because of the risk of
ischemic colitis.

Answer 136

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HELLP syndrome differs from AFLP in that HELLP syndrome is more closely
associated with microangiopathic hemolytic anemia and AFLP is more associated
with encephalopathy and coagulation abnormalities.

Answer 137

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Ten percent of rapid rectal bleeding has a UGI source.

Answer 138

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CT scan showing segmental wall thickening and pericolonic fat stranding that is
consistent with colonic ischemia.

Answer 139

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Right-sided colonic ischemia may be the harbinger of AMI caused by
involvement of the superior mesenteric artery and requires CTA or MRA.

Answer 140

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Unlike patients with IBD, patients with microscopic colitis are not at increased risk
for colon cancer.

Answer 141

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No drugs are approved for the primary treatment of NAFLD.
Patients with fatty liver disease and elevated aminotransferase levels can be
treated with statin therapy.

Answer 142

A

Patients with refractory symptoms of Dyspepsia despite empiric therapy with PPI should undergo
upper endoscopy.

Answer 143

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All patients with PUD should be tested for H. pylori infection regardless of NSAID use.

Answer 144

A

Negative testing for H. pylori completed in the acute setting should be repeated
after discharge.
False-negative rapid urease tests, urea breath tests, and stool antigen results for
H. pylori may occur in patients who recently took antibiotics, bismuth-containing
compounds, or PPIs; these drugs should be stopped before testing (28 days for
antibiotics, 2 weeks for PPIs) or histologic assessment for H. pylori is performed.
Serum antibody testing for H. pylori will not differentiate between past and
current infection; a negative test excludes infection, but a positive test cannot
confirm current infection.
Duodenal ulcers carry little risk for malignancy and do not require biopsy unless
they are refractory to therapy.

Answer 145

A

Duodenal PUD without complications does not require follow-up upper
endoscopy.
Serologic testing should not be used to confirm H. pylori eradication, because
results may remain positive in the absence of active infection.

Answer 146

A

Do not use capsule endoscopy in the setting of obstruction or strictures (severe
Crohn disease).

Answer 147

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Do not order a barium x-ray when evaluating a GI bleed, because this will interfere with subsequent upper
endoscopy or other studies.

Answer 148

A

H2-receptor antagonists are not beneficial in managing UGI bleeding.
Do not select nasogastric tube placement for diagnosis, prognosis, visualization,
or therapeutic effect.
Consider aortoenteric fistula in patients who previously had aortic graft surgery
and present with UGI bleeding.

Answer 149

A

Pregnancy, including ectopic pregnancy, should always be considered in the
differential diagnosis of abnormal uterine bleeding.
Postmenopausal bleeding is always abnormal and requires evaluation.

Answer 150

A

Rosacea:
Papules, pustules, and dilated blood vessels involving the central face are typical of
rosacea. Rosacea involves the nasolabial folds, whereas the malar rash of SLE does
not.

Answer 151

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The prominent papules and pustules seen in rosacea are not typical of the
maculopapular malar rash seen in SLE.
The rash of SLE does not involve the nasolabial folds.

Answer 152

A

Perioral Dermatitis
Discrete papules and pustules on an erythematous base around the mouth, but
typically sparing the skin directly around the lips, are characteristic of perioral
dermatitis.

Answer 153

A

Avoid oral or topical antibiotic monotherapy for treatment of moderate to severe
acne because of increased antibiotic resistance; combine with topical benzoyl
peroxide.

Answer 154

A

Actinic Keratoses
Multiple white, scaly patches measuring 1-3 mm on the hands are characteristic of
actinic keratoses.

Answer 155

A

Absence of the cremasteric
reflex on the affected side is nearly 99% sensitive for torsion.

Answer 156

A

Screening for alcohol use disorder begins with quantifying the amount of alcohol
consumed, not CAGE or AUDIT-C questions.
Multiple seizures (>1) are not consistent with alcohol withdrawal syndrome and
should prompt an evaluation for another disorder.

Answer 157

A

Give thiamine replacement before administering glucose.
No evidence supports that continuous infusion therapy with short-acting
benzodiazepines provides better outcomes than oral therapy for acute alcohol
withdrawal.

Answer 158

A

Do not refer patients with allergic rhinitis for skin testing/immunotherapy
without a trial of empiric therapy.

Answer 159

A

Basal Cell Carcinoma
This pink, pearly, translucent, dome-shaped papule with telangiectasias is
characteristic of BCC.

Answer 160

A

Bedbugs
Classic grouped pruritic papules (“breakfast, lunch, and dinner”) presentation of bites
from bedbugs.

Answer 161

A

As the prevalence of a condition increases, the positive predictive value increases
and the negative predictive value decreases.
Changes in prevalence do not alter the sensitivity or specificity but do alter the
predictive values.

Answer 162

A

LR+ of 2, 5, and 10 increase the probability of disease by approximately 15%,
30%, and 45%, respectively.
LR− of 0.5, 0.2, and 0.1 decrease the probability of disease by approximately
15%, 30%, and 45%, respectively.

Answer 163

A

Monotherapy
with SSRIs may unmask mania in patients with untreated bipolar disorder.

Answer 164

A

Do not stop the evaluation of a breast mass if mammogram is normal.
On mammography, an irregular mass with microcalcifications or spiculation is
suspicious for malignant disease, and biopsy is mandatory.
Evidence is lacking that breast self-examination offers benefit in screening for
breast cancer in average-risk asymptomatic women; self-examination may be
associated with a higher rate of breast biopsy.

Answer 165

A

Do not screen women following a hysterectomy with cervix removal for benign
disease (e.g., fibroids).
HPV vaccine does not protect against all HPV infections and does not treat
existing HPV.
HPV vaccine can be given to patients who are HIV positive and otherwise
immunosuppressed.

Answer 166

A

Additional evaluation is warranted in a patient with chronic pelvic pain who has a
sudden increase in pain intensity, which may indicate a superimposed acute
process such as appendicitis.

Answer 167

A

Endometriosis does not cause fever or vaginal discharge.

Answer 168

A

Loop diuretic therapy is not recommended as first-line therapy for edema from
chronic venous insufficiency.

Answer 169

A

Mirtazapine causes sedation and weight gain (useful for patients with insomnia
or weight loss).

Answer 170

A

Be alert for serotonin syndrome in patients taking SSRIs, particularly with concurrent
use of other SSRIs, MAOIs, St. John’s wort, trazodone, dextromethorphan, linezolid,
tramadol, or buspirone.

Answer 171

A

Always ask about episodes of mania or hypomania before starting
antidepressant therapy, because unipolar depression treatments may provoke
mania.
Antidepressant drugs should not be stopped abruptly.
Bereavement does not usually require pharmacologic treatment.

Answer 172

A

Xerotic Dermatitis
Xerotic dermatitis is characterized by redness and a “tile-like” pattern on dry skin
(xerosis) with evidence of trauma because of scratching.

Answer 173

A

Actinic Purpura
Actinic purpura appears as purpuric macules or patches.

Answer 174

A

Solar Lentigines
Solar lentigines (solar lentigo) are brown macules and patches that occur in older,
fair-skinned persons in sun-damaged areas.

Answer 175

A

Ecthyma gangrenosum is a characteristic skin lesion of Pseudomonas and other
systemic bacterial, fungal, or viral infections. It begins as a painless, erythematous
macule and quickly develops into a large necrotic ulcer. It is usually seen in an
immunocompromised patient.

Answer 176

A

Pityriasis Versicolor KOH
Hyphae and yeast cells are recognized as a “spaghetti and meatballs” pattern.

Answer 177

A

Tinea cruris spares the scrotum, whereas intertrigo does not.

Answer 178

A

Two feet–one hand tinea is a common presentation of tinea pedis.
Nail dystrophy may be caused by psoriasis, aging, or peripheral vascular disease
and mimics onychomycosis.

Answer 179

A

Tinea Infection
Tinea most commonly presents as a round or oval erythematous scaling patch that
spreads centrifugally with central clearing. It has an active border that is raised,
consisting of tiny papules or vesicles and scale.

Answer 180

A

Chronic Tinea PediS
Extension of tinea pedis onto the sole and sides of the foot (“moccasin” appearance)
presents as chronic scaling.

Answer 181

A

Candida Infection
Bright red papules, vesicles, pustules, and patches with satellite papules and pustules
are characteristic of candidiasis.

Answer 182

A

Onychomycosis
Distal subungual thickening and nail separation (white areas of nail) involving most
of the nails are associated with onychomycosis.

Answer 183

A

Treatment of onychomycosis is typically not necessary but is recommended for
patients with peripheral vascular disease or diabetes to prevent the development of
cellulitis.

Answer 184

A

Do not select antifungal treatment for thick, yellow, and crumbling toenails
without KOH scraping or positive culture for dermatophytes.
Never select a combination of a topical antifungal agent and a glucocorticoid for
treatment of an unknown skin rash or dermatophyte infection.
Do not choose oral ketoconazole as initial antifungal treatment because of the
risk of severe hepatotoxicity.

Answer 185

A

Pityriasis Versicolor
Hypopigmented, scaly macules are present on the chest.

Answer 186

A

Don’t Be Tricked
* The absence of eosinophilia does not rule out drug reaction or DRESS.

Answer 187

A

Fixed Drug Eruption
Discrete round to oval lesions are characteristic of a fixed drug eruption.

Answer 188

A

Drug-Induced Hypersensitivity Syndrome
Acute facial edema in a patient with anticonvulsant-induced hypersensitivity
syndrome.

Answer 189

A

Morbilliform Drug Eruption
Morbilliform drug eruption consisting of symmetrically arranged erythematous
macules and papules—some discrete and others confluent.

Answer 190

A

Toxic Epidermal Necrolysis
Shedding of entire sheets of skin is characteristic of TEN.

Answer 191

A

Do not obtain lipoprotein(a), apolipoprotein B, or LDL particles in the evaluation
of dyslipidemia.

Answer 192

A

Dysplastic nevi are markers for an increased risk of melanoma. Dysplastic Nevi share similar characteristics with melanoma including asymmetry,
indistinct and irregular borders, and variation in pigmentation.

Answer 193

A

Do not choose bupropion for eating disorders because of the increased
incidence of seizures.

Answer 194

A

Neomycin and bacitracin, commonly used for wound care, can cause an allergic
contact dermatitis that mimics a wound infection.

Answer 195

A

Contact Dermatitis
Discretely grouped red vesicles and bullae in a linear distribution are characteristic of
contact dermatitis caused by poison ivy.

Answer 196

A

Atopic Dermatitis
Atopic eczema involves the antecubital fossae, with lichenification and surrounding
excoriations.

Answer 197

A

Seborrheic Dermatitis
Seborrheic dermatitis is shown, with fine, oily scale around the medial eyebrows.

Answer 198

A

Do not select potent glucocorticoids for the face because of the risk of steroid-
induced acne and cutaneous atrophy.

Answer 199

A

Recurrent HSV infection is the most common inciting factor OF Erythema Multiforme

Answer 200

A

Do not confuse EM with erythema migrans, the rash of Lyme disease (red macule
with central clearing as the macule expands).
Do not treat acute EM-associated HSV with antivirals.

Answer 201

A

Erythema Multiforme

Answer 202

A

Ramsay Hunt Syndrome
These vesicular lesions on and in the ear canal are characteristic of Ramsay Hunt
syndrome caused by VZV infection.

Answer 203

A

The combination of red eye, ocular pain, and visual loss warrants emergent referral to
an ophthalmologist.

Answer 204

A

Do not treat a red eye with topical glucocorticoids.

Answer 205

A

Bacterial Conjunctivitis The conjunctiva is diffusely erythematous with mucopurulent discharge consistent
with bacterial conjunctivitis. Consider gonorrhea in sexually active adult.

Answer 206

A

Herpes Zoster
Herpes zoster infection involving the forehead, top of the head, and eye, with
evident hyperemic conjunctivitis. Corneal ulceration, episcleritis, and lid droop can
occur.

Answer 207

A

Viral Conjunctivitis
Acute adenovirus conjunctivitis is characterized by diffuse injection of the palpebral
and bulbar conjunctivae and pseudomembrane formation involving the palpebral
conjunctiva.

Answer 208

A

Allergic Conjunctivitis
Allergic conjunctivitis with prominent cobblestoning of the palpebral conjunctiva is
shown.

Answer 209

A

Episcleritis
The nontender, prominent, superficial dilated blood vessels of episcleritis are shown.

Answer 210

A

Iritis
Intense ciliary flush around the corneal-scleral junction and an irregularly shaped
pupil are characteristic of iritis.

Answer 211

A

The USPSTF recommends against vitamin D supplementation to prevent falls in
community-dwelling adults ≥65 years who are not known to have osteoporosis
or vitamin D deficiency.
Hip protectors in older people who fall are ineffective in preventing hip fractures.

Answer 212

A

Severe, complicated, or recurrent herpes zoster should trigger testing for possible
associated HIV infection.

Answer 213

A

Administer recombinant varicella-zoster vaccine to patients 50 years and older
regardless of previous history of varicella infection or previous immunization with
live attenuated vaccine.
Do not select topical acyclovir or penciclovir for the treatment of herpes zoster.
Do not select glucocorticoids to treat herpes zoster.

Answer 214

A

Herpes Zoster
Herpes zoster is characterized by the dermatomal distribution of painful grouped
vesicles on an erythematous base.

Answer 215

A

Minors who are not living independently of their parents, not married, or not in
the armed forces cannot legally make their own decisions.
Any physician can determine whether a patient has decision-making capacity.

Answer 216

A

Lentigo Maligna
This melanoma in situ appears as a brown patch on sun-exposed skin.

Answer 217

A

Melanoma
This asymmetric pigmented skin lesion has irregular, scalloped, notched, and
indistinct borders with variegated coloration.

Answer 218

A

Acral Melanoma
Acral melanoma on the toe.

Answer 219

A

Do not order hormone levels to diagnose menopause.

Answer 220

A

Olecranon bursitis does not
cause restricted movement with range of motion of the elbow, whereas joint pathology
causes pain and restricted movement.

Answer 221

A

Do not obtain imaging studies in patients with findings compatible with
epicondylitis.

Answer 222

A

Collapsed Vertebral Body
Unenhanced T2-weighted MRI of the thoracic spine shows collapse of the vertebral
body and compression of the spinal cord from posteriorly displaced bony fragments
in a patient with metastatic breast cancer.

Answer 223

A

True hip joint pain usually presents as groin pain.

Answer 224

A

Select ankle x-ray following ankle sprain only if the patient cannot bear weight or
if bone pain is localized to the lateral or medial malleolus, base of the fifth
metatarsal, or navicular bone.

Answer 225

A

De Quervain tenosynovitis is typically seen in young women with pain on the radial
side of the wrist during pinch grasping or thumb and wrist movement. The diagnosis is
established with a positive Finkelstein test.

Answer 226

A

Finkelstein test for de Quervain stenosing tenosynovitis. Pain elicited by flexing the
thumb into the palm, closing the fingers over the thumb, and then bending the wrist
in the ulnar direction is confirmatory.

Answer 227

A

Biceps Tendon Rupture
Biceps tendon rupture showing a visible mass (“Popeye sign”) at the mid arm with associated ecchymoses.

Answer 228

A

Constant shoulder pain with normal shoulder examination suggests referred pain
(e.g., Pancoast tumor) or neuropathic pain (e.g., cervical spine radiculopathy).

Answer 229

A

Pityriasis Rosea
Pityriasis rosea, presenting with an oval herald patch on the abdomen, followed by a
more generalized rash.

Answer 230

A

Pityriasis rosea can resemble secondary syphilis but does not involve the palms
and soles; obtain RPR in sexually active persons.

Answer 231

A

Oxygen supplementation is helpful if the patient is hypoxic but is otherwise
ineffective.
Fans are effective in reducing dyspnea in nonhypoxic patients.

Answer 232

A

Pemphigus
This patient has multiple erosions and crusting with only an occasional intact blister;
mucosal surfaces are typically involved.

Answer 233

A

Bullous Pemphigoid
An autoimmune blistering disease characterized by multiple tense bullae and
occasional erosions; mucosal surfaces are typically not involved.

Answer 234

A

The blisters of pemphigus vulgaris are so fragile that they are rarely seen; look
instead for erosions, crusting, and sores in the mouth.

Answer 235

A

If a patient has no history, symptoms, or risk factors for CAD, no preoperative
coronary evaluation is necessary.
Low-risk surgeries (cataract extraction, carpal tunnel release, breast biopsy,
inguinal hernia repair) do not require cardiac testing even if a calculated risk
score is elevated.

Answer 236

A

No survival benefit is associated with revascularization in stable patients with
CAD before noncardiac surgery unless they otherwise meet the general
requirements for revascularization

Answer 237

A

Do not routinely initiate β-blockers before surgery to reduce cardiovascular risk.
In the absence of ASCVD, do not routinely initiate statin therapy before surgery
to reduce cardiovascular risk.
Do not use aspirin before surgery to reduce cardiovascular risk.
Do not choose routine postoperative surveillance with ECG or cardiac biomarkers
unless symptoms of an ACS are present.

Answer 238

A

Nutritional supplementation to enhance wound healing remains controversial.
Hydrotherapy and hyperbaric oxygen therapies are not effective in the treatment
of pressure injuries.

Answer 239

A

Guttate Psoriasis
Note the characteristic lesions consisting of multiple, discrete, drop-like papules with
a salmon-pink hue. A fine scale, which is usually absent in early-stage lesions, may
be observed on more established lesions.

Answer 240

A

Nail Findings in Psoriasis
Psoriatic nails are shown, with characteristic discoloration, crumbling, subungual
debris, and separation of the nail plate from the nail bed (white areas of nail).

Answer 241

A

Chronic Plaque Psoriasis
The image depicts classic plaque psoriasis, showing erythematous plaques with a
silvery scale on an extensor surface.

Answer 242

A

Inverse Psoriasis
Inverse psoriasis presents as a bright red, smooth patch in the folds of the skin,
typically occurring under the breasts, in the armpits, near the genitals, under the
buttocks, or in abdominal folds.

Answer 243

A

Never select systemic glucocorticoids for the treatment of psoriasis.

Answer 244

A

Scabies Rash
Multiple pink to red, glistening papules and erosions with diffuse scaling,
predominately in the finger webs, characteristic of scabies.

Answer 245

A

Scabies
Sarcoptes scabiei, the organism responsible for scabies, is shown after KOH
preparation from skin scraping.

Answer 246

A

Do not re-treat scabies because of persistent itching, which can continue for 2
weeks after successful treatment.
Avoid topical lindane because of its associated neurotoxicity.

Answer 247

A

For pregnant women, do not select live vaccines, including MMR, intranasal
influenza, yellow fever, and varicella; delay recombinant zoster vaccine until after
pregnancy.
All available influenza vaccines are safe in egg-allergic patients.

Answer 248

A

Seborrheic Keratoses
Brown to tan, sharply demarcated, waxy-like papules, plaques, and nodules are
characteristic of seborrheic keratoses.

Answer 249

A

Rapid onset of multiple pruritic seborrheic keratoses can be a sign of GI
adenocarcinoma.

Answer 250

A

Nicotine replacement therapy is not contraindicated following MI and can be
started in the hospital.

Answer 251

A

Choose conversion disorder if a patient has abnormal sensation or motor
function (such as limb weakness) that is not explained by a medical condition
and is inconsistent with physical examination findings.
Choose illness anxiety disorder (previously hypochondriasis) if the patient has
excessive worry about general health and preoccupation with health-related
activities but has no or only minor symptoms.

Answer 252

A

Cutaneous Squamous Cell Carcinoma
Typically presents as a slowly evolving, isolated, keratotic, or eroded macule, papule,
or nodule that commonly appears on the scalp, neck, pinna, or lip.

Answer 253

A

Keratoacanthoma
A form of SCC that appears as a rapidly growing, pink, “volcaniform” nodule with a
prominent central plug of scale and crust.

Answer 254

A

Do not order carotid vascular studies to diagnose cause of syncope.
Do not order brain imaging, cardiac enzymes, or EEG to evaluate syncope.

Answer 255

A

Do not obtain viral titers to evaluate Systemic Exertion Intolerance Disease.

Answer 256

A

Do not order urodynamic testing because outcomes are no better than those
associated with management based on clinical evaluation alone.

Answer 257

A

Painful lesions persisting >24 hours with purpura/ecchymoses on resolution are
likely the result of urticarial vasculitis. Definitive diagnosis is made by skin biopsy.

Answer 258

A

Measurement of C1 inhibitor levels is not indicated in patients with urticaria,
because C1 inhibitor deficiency, seen in hereditary angioedema, is not associated
with hives.

Answer 259

A

Trichomoniasis is the only cause of vaginitis that is sexually transmitted.

Answer 260

A

Candida albicans
This wet mount specimen exhibits the typical filaments and spores associated with
candidal vaginitis.

Answer 261

A

Clue Cell
This image shows clue cells (epithelial cells with borders obscured by small bacteria)
on saline microscopy that are consistent with bacterial vaginosis.

Answer 262

A

Do not order vaginal cultures to diagnose the cause of vaginitis.
Treatment of vulvovaginal candidiasis can be initiated empirically if symptoms
are accompanied by characteristic findings.

Answer 263

A

Because vaginal yeast is found in 10% to 20% of healthy women, the
identification of Candida species in patients without symptoms does not require
treatment.

Answer 264

A

In older patients, acute leukemia may present with pancytopenia, but bone
marrow examination will demonstrate a hypercellular marrow with 20% or more
blasts.

Answer 265

A

Auer Rod
This myeloblast has findings associated with AML: a large nucleus, displaced nuclear
chromatin, azurophile cytoplasmic granules, and a rod-shaped inclusion (Auer rod).

Answer 266

A

Mild thrombocytopenia (platelet count >100,000/μL) occurring late in pregnancy
is likely to be gestational thrombocytopenia, not ITP, and requires no therapy.

Answer 267

A

Aplastic Anemia
Profoundly hypocellular bone marrow is characteristic, with the marrow space
composed mostly of fat cells and marrow stroma.

Answer 268

A

Treatment of aplastic anemia with hematopoietic growth factors is ineffective.
PNH may present as a DAT-negative hemolytic anemia or as aplastic anemia.

Answer 269

A

If DVT is diagnosed, a CTA is not needed because the treatment is the same.
Parenteral anticoagulant administration must overlap with warfarin for at least 5
days and until the INR is >2 for 24 hours.

Answer 270

A

Hemochromatosis
These hook-like osteophytes (arrows) are characteristic of hemochromatosis.

Answer 271

A

Advanced liver disease commonly causes an elevated ferritin level, but the iron
saturation is usually normal.
A nondiagnostic HFE genotype does not rule out a diagnosis of
hemochromatosis.

Answer 272

A

Screen for HCC with ultrasonography every 6 months in patients with cirrhosis.

Answer 273

A

A personal or family history of anemia, jaundice, splenomegaly, or gallstones
suggests hereditary spherocytosis.

Answer 274

A

The results of a mixing study will normalize in a patient with a factor deficiency but will
remain abnormal if an inhibitor is present.

Answer 275

A

For HIT or HITT, warfarin or LMWH cannot be substituted for UFH.

Answer 276

A

Hypersegmented Polymorphonuclear Cel The erythrocytes are large ovalocytes, and a single PMN cell has more than five
nuclear lobes. Consider vitamin B12 or folate deficiency (megaloblastic anemia).

Answer 277

A

Reticulocytosis (e.g., secondary to hemolysis) can increase the MCV.
Vitamin B12 deficiency can present with subacute combined degeneration of the
nuclear lobes. Consider vitamin B12 or folate deficiency (megaloblastic anemia).

spinal column (weakness, paresthesias, ataxia) without anemia or macrocytosis.
* Folate supplementation can improve the anemia of B12 deficiency but does not
prevent the associated neurologic sequelae.

Answer 278

A

The erythrocytes show hypochromia, anisocytosis, and poikilocytosis. Erythrocytes in
thalassemia have less variability in size and shape, and target cells are seen.

Answer 279

A

All tyrosine kinase inhibitors can prolong the QT interval; periodic ECG
monitoring is recommended.

Answer 280

A

Hepatic vein thrombosis (the Budd-Chiari syndrome) or portal vein thrombosis
should prompt consideration of PV even if erythrocytosis is absent.
Do not prescribe high-dose aspirin, which may cause increased bleeding.

Answer 281

A

The most common causes of thrombocythemia are iron deficiency anemia and
infection, and platelet counts will improve within a couple of weeks following
treatment of the underlying condition.
A negative JAK2 test does not exclude the diagnosis of essential
thrombocythemia.

Answer 282

A

Myelofibrosis
Peripheral blood smear showing teardrop erythrocytes, nucleated erythrocytes, and
giant platelets characteristic of myelofibrosis.

Answer 283

A

In Primary Myelofibrosis Splenectomy should be avoided because it is associated with hemorrhagic and
thrombotic complications, increased risk of progression to leukemia, and no
effect on survival.

Answer 284

A

This peripheral blood smear shows small erythrocytes with loss of usual central
pallor. Consider acquired immune hemolytic anemia or hereditary spherocytosis.

Answer 285

A

Erythrocyte Fragmentation
The erythrocytes show marked anisocytosis and poikilocytosis with prominent
fragmentation. Consider DIC, TTP, or other thrombotic microangiopathy.

Answer 286

A

In patients with myeloma and back pain, MRI should also be performed to assess
for spinal cord impingement, even in the absence of motor or sensory deficits.
Do not use bone scans in patients with suspected myeloma because they are not
as sensitive as a CT or PET-CT.

Answer 287

A

Do not treat MGUS.
Bortezomib and thalidomide used in induction chemotherapy are associated with
a high risk of peripheral neuropathy.
Thalidomide, lenalidomide, or pomalidomide used in induction chemotherapy is
associated with an increased risk of VTE.

Answer 288

A

Abdominal fat pad or bone marrow biopsy has a high yield and is safer than liver,
kidney, or heart biopsy in establishing the diagnosis of AL amyloidosis.

Answer 289

A

Hydroxyurea is contraindicated in pregnancy and kidney failure.
Iron overload resulting from multiple transfusions may require chelation therapy.

Answer 290

A

Pseudothrombocytopenia occurs if patients have antibodies to EDTA, causing
platelets to clump together in vitro; an accurate count can be obtained from
blood drawn in citrate or heparin.

Answer 291

A

Do not wait to initiate therapy until ADAMTS13 activity and inhibitor results are
available if clinical features suggest TTP; results may be delayed, and these tests
have poor sensitivity and specificity in the diagnosis of TTP.

Answer 292

A

Do not order platelet transfusion in TTP-HUS because it can exacerbate the
microvascular occlusion.
PT, aPTT, D-dimer, and fibrinogen levels are normal in TTP-HUS and abnormal in
DIC.
Plasma exchange is superior to simple plasma infusion for TTP.

Answer 293

A

Do not use cryoprecipitate to treat vWD because of its increased transfusion

infection risk.

Answer 294

A

Aspergilloma
This enlarged image from a frontal chest x-ray shows a cavitary lesion (arrowheads)
containing a round mass (arrow) representing a fungus ball.

Answer 295

A

Patients with aspergilloma who are asymptomatic and have stable x-rays do not
require therapy.

Answer 296

A

Babesiosis
Peripheral blood smear that shows intraerythrocytic parasites arranged in tetrads,
resembling a Maltese cross.

Answer 297

A

The two most common organisms causing bacterial meningitis are S. pneumoniae and
Neisseria meningitidis, accounting for >80% of cases.

Answer 298

A

LP is contraindicated in patients with brain abscess because of the potential for
increased intracranial pressure and risk for herniation.

Answer 299

A

Acute oral candidiasis presenting as white plaques that are painful in a patient with
HIV infection.

Answer 300

A

When Candida is isolated from the sputum, it usually reflects contamination from
the oral mucosa.
Candida in a blood culture is never a contaminant.

Answer 301

A

Treatment is not indicated for Candida in the sputum of patients receiving
mechanical ventilation.
Do not treat asymptomatic candiduria except in neutropenic patients or those undergoing invasive urologic procedures.

Answer 302

A

In patients with a urinary catheter, do not obtain routine urinalysis or cultures
and do not treat asymptomatic bacteriuria.
Don’t treat asymptomatic candiduria with antifungal therapy; do remove the
catheter.

Answer 303

A

Treat chlamydial infection with azithromycin or doxycycline.

Answer 304

A

Glucocorticoids are not routinely recommended in CAP and should be reserved
for patients with documented adrenal insufficiency or refractory septic shock.
Macrolides (azithromycin and clarithromycin) are recommended as monotherapy
only for pneumonia in nonhospitalized patients if the regional prevalence of
pneumococcal resistance to this class is known to be less than 25%.

Answer 305

A

Macrolides and quinolones may prolong the QT interval, and alternative agents
should be considered in patients at risk for torsades de pointes, including those
with a history of a long QT interval, those taking other medications that can
prolong the QT interval, and those with electrolyte abnormalities.
Follow-up chest x-ray is not routine; consider in adults aged >50 years with risk
factors for lung cancer.

Answer 306

A

Trimethoprim-sulfamethoxazole should not be used FOR uti if it was taken in the

preceding 3 months.

Answer 307

A

Human Granulocytic Ehrlichiosis:
HME (left) and HGA (right); demonstration of morulae recognized as clumps of
organisms in the cytoplasm. HGA is transmitted by the same vector as Lyme disease and babesiosis, so
double or triple infection is possible.

Answer 308

A

Sporotrichosis
The most common presentation of sporotrichosis is lymphocutaneous
sporotrichosis. The primary lesion is located at the site of inoculation and consists of
an ulcerated nodule. Similar lesions occur proximally along the lymphatics.

Answer 309

A

The morbilliform rash appearing in patients with infectious mononucleosis
following the administration of ampicillin is not an allergic reaction; patients can
subsequently use ampicillin without rash recurrence.

Answer 310

A

Order HSV PCR in all suspected cases of encephalitis, even if not typical for HSV
encephalitis.
Do not order CSF culture for HSV or serologic testing for HSV.

Answer 311

A

A positive HSV-2 antibody test indicates only previous infection and is not a
useful diagnostic test.
Don’t order a Tzanck test to diagnose HSV infection; it is neither sensitive nor
specific.
Recurrent erythema multiforme is most commonly caused by HSV recurrences.

Answer 312

A

Perianal Herpes Simplex
Perianal herpes simplex in an immunocompromised patient (HIV/AIDS). In patients
with HIV disease, herpes simplex may appear as painful, shallow ulcers rather than
the classic vesicle.

Answer 313

A

If a HIV test is positive on the initial antigen/antibody combination immunoassay but
negative on the antibody differentiation immunoassay and NAAT testing, the
initial test result was a false positive.

Answer 314

A

Do not stop ART in the setting of IRIS.

Answer 315

A

Live vaccines are contraindicated in immunocompromised patients, but the
MMR, varicella, and recombinant zoster vaccines can be given to patients with
HIV with CD4 cell counts >200/μL.

Answer 316

A

Do not administer live attenuated influenza vaccine to persons who have close
contact with immunocompromised patients.

Answer 317

A

Do not administer amantadine or rimantadine to prevent or treat influenza virus
because of the high rate of resistance.
Zanamivir (inhaled) has been associated with bronchospasm and is
contraindicated in patients with pulmonary or cardiovascular disease.

Answer 318

A

Do not test for Lyme disease in patients with nonspecific symptoms of fatigue,
myalgia, arthralgia, or fibromyalgia in the absence of exposure history or
appropriate clinical findings.

Answer 319

A

Erythema Migrans
A large erythematous ring characterizes erythema migrans and early Lyme disease.

Answer 320

A

Do not select the diagnosis “chronic Lyme disease.”
Do not treat post-Lyme disease syndrome (fatigue, arthralgia, myalgia, memory
disturbance) with antibiotics.
Do not rely on serologic test results to decide on the adequacy of treatment.
Figure 4. Erythema Migrans: Open in New Window
A large erythematous ring characterizes erythema migrans and early Lyme disease.
Do not prescribe doxycycline for pregnant women.

Answer 321

A

Plasmodium falciparum Infection
In the center of the peripheral blood smear is a banana-shaped gametocyte diagnostic of P. falciparum infection.

Answer 322

A

Any traveler who has returned from a malaria-endemic area in the past year and
has an undiagnosed febrile illness should undergo malaria evaluation.

Answer 323

A

Do not select Gram stain to diagnose gonorrheal cervicitis.
Test for chlamydia, syphilis, and HIV infection in patients with gonorrhea.

Answer 324

A

Gonorrhea Several necrotic pustules and surrounding erythema on the leg associated with
disseminated gonorrhea infection.

Answer 325

A

Do not select fluoroquinolones to treat gonorrhea because of antibiotic
resistance.

Answer 326

A

Surgery is not needed for uncomplicated hematogenous vertebral osteomyelitis.
A positive MRI persists long after effective therapy for osteomyelitis; do not
obtain follow-up MRI in patients improving clinically.

Answer 327

A

Hematogenous Osteomyelitis
MRI shows moderate destruction of the inferior L3 and superior L4 vertebral bodies
compatible with osteomyelitis. Moderate narrowing of the thecal sac is seen at this
level owing to retropulsion of an enhancing bony fragment.

Answer 328

A

The most common cause of a pneumothorax in a patient with AIDS is P. jirovecii
pneumonia.
P. jirovecii pneumonia may occur in patients not infected with HIV, typically in
association with immunosuppressant drug therapy.

Answer 329

A

Follow-up urine cultures FOR pYELO are indicated only in pregnant women.

Answer 330

A

The Rocky Mountain spotted fever rash may not be present until 3 days after
onset of illness.

Answer 331

A

Cellulitis
Cellulitis is characterized by demarcated areas of tender erythema.

Answer 332

A

Primary treatment for abscesses, furuncles, and carbuncles is incision and
drainage. Gram stain and culture should be obtained when antibiotic
administration is planned.
Skin abscesses may have higher cure rates when incision and drainage is
accompanied by antibiotic treatment with MRSA coverage.

Answer 333

A

Vibrio vulnificus Infection
Deep tissue infection associated with hemorrhagic bullae caused by V. vulnificus in a
patient with cirrhosis.

Answer 334

A

Impetigo
Erosions with golden-yellow crusts confirm the presence of impetigo.

Answer 335

A

Do not use vancomycin, because it is associated with higher rates of relapse and
microbiologic failure in the treatment of MSSA bacteremia.
Patients with concomitant S. aureus pneumonia should not receive daptomycin,
because it is inactivated by surfactant.

Answer 336

A

Primary syphilis is characterized by a clean-based, nonpainful genital ulcer (chancre).

Answer 337

A

Secondary Syphilis
Pink to reddish brown macules and papules on the palms are characteristic of
secondary syphilis.

Answer 338

A

Pregnant patients who are allergic to penicillin must be desensitized and treated
with penicillin.
The Jarisch-Herxheimer reaction is an acute febrile illness occurring within 24
hours of treatment for any stage of syphilis and is not an allergic reaction to
penicillin.

Answer 339

A

Do not select glucocorticoids to treat Toxic Shock Syndrome, select penicillin plus clindamycin for streptococcal TSS..

Answer 340

A

MRI showing a single ring-enhancing brain lesion associated with edema consistent
with toxoplasmosis. Most patients with AIDS and cerebral toxoplasmosis have
multiple ring-enhancing brain lesions.

Answer 341

A

Muddy Brown Granular Casts
Muddy brown granular casts consistent with kidney injury secondary to tubular
necrosis.

Answer 342

A

Do not use oral or intravenous acetylcysteine or IV bicarbonate to prevent AKI
secondary to radiocontrast.

Answer 343

A

Calcium Oxalate Crystals
Characteristic envelope-shaped calcium oxalate dihydrate crystals, which may be
seen in late ethylene glycol intoxication.

Answer 344

A

A reduced anion gap (<4 mEq/L) suggests multiple myeloma or
hypoalbuminemia.

Answer 345

A

If the kidneys are markedly scarred and small (<9 cm), do not select aggressive
diagnostic or therapeutic measures.

Answer 346

A

Nephrogenic Systemic Fibrosis: This patient with CKD developed nephrogenic systemic fibrosis after an MRI with
gadolinium injection. The skin demonstrates erythema, edema, and a peau d’orange
appearance.

Answer 347

A

The anemia of CKD is a diagnosis of exclusion.
Do not use magnesium-containing antacids in patients with ESKD.

Answer 348

A

Nephrotic range proteinuria in a patient with diabetes but without microvascular
(e.g., retinopathy) or macrovascular (e.g., CAD) disease is not caused by diabetes.
Kidney biopsy is required for definitive diagnosis.

Answer 349

A

Typical “Maltese cross” appearance of a fat droplet under polarized light microscopy
commonly found in the nephrotic syndrome.

Answer 350

A

Glomerulonephritis
Erythrocyte casts consistent with glomerulonephritis.

Answer 351

A

The absence of erythrocyte casts does not rule out glomerulonephritis.

Answer 352

A

Dysmorphic Erythrocytes
Erythrocytes with abnormal morphology seen in glomerulonephritis, including those
with “Mickey Mouse ears.”

Answer 353

A

A reduction or loss of muscle mass because of advanced age, liver failure, or
malnutrition may cause a disproportionately low serum creatinine concentration,
which results in overestimation of the GFR.
When the MDRD study equation is used to estimate GFR, higher levels of GFR
are reported only as >60 mL/min/1.73 m2
, but this does not guarantee an absence of structural kidney disease.

Answer 354

A

Significant hyperkalemia associated with a normal ECG suggests
pseudohyperkalemia.

Answer 355

A

Characteristics of Hyperkalemia
ECG showing flattened P waves; prolonged PR interval; widened QRS; and tall,
peaked T waves characteristic of hyperkalemia.

Answer 356

A

Before labeling a person as having hypertension, use an average BP based on two or
more readings obtained on two or more occasions. Out-of-office ABPM and HBPM are recommended to confirm the diagnosis of hypertension and for titration of BP-
lowering medication.

Answer 357

A

Thiazide diuretics are not effective in patients with kidney disease (GFR <30 mL/
min/1.73 m2); select a loop diuretic.

Answer 358

A

In young persons with fibromuscular dysplasia, angioplasty may improve BP and cure
hypertension.

Answer 359

A

Systolic BP should be lowered no more than 25% within the first hour, then to <160/
100 mm Hg within the next 2 to 6 hours, then cautiously to target during the following
24 to 48 hours.

Answer 360

A

Treatment of gestational hypertension does not prevent the occurrence of
preeclampsia or chronic hypertension.

Answer 361

A

Correction of hypokalemia and hypocalcemia is difficult unless magnesium
depletion is also corrected.

Answer 362

A

Vaptan agents should not be used to treat hypovolemic hyponatremia or acute
symptomatic hyponatremia.
Unless documentation indicates that hyponatremia is acute, treat all cases of
hyponatremia as chronic.

Answer 363

A

Asymptomatic nonobstructing kidney stones found on imaging studies do not
require urgent stone removal.
Do not select a low-calcium diet for patients with kidney stones. Calcium
restriction does not prevent stones and may actually increase stone formation
and contribute to bone demineralization.

Answer 364

A

Dipstick urinalysis does not detect immunoglobulin light chains associated with
multiple myeloma.
Because moderately increased albuminuria may go undetected by dipstick, direct

quantification using a random (spot) protein-creatinine ratio or albumin-
creatinine ratio is required when screening patients at high risk.

Answer 365

A

Positional (orthostatic) proteinuria, a benign cause of isolated proteinuria, is
diagnosed by obtaining split daytime (standing) and nighttime (supine) urine
collections.

Answer 366

A

Absence of eosinophiluria does not rule out AIN, postinfectious GN,
atheroembolic disease of the kidney, septic emboli, or small-vessel vasculitis.

Answer 367

A

Findings not typical for ALS include predominant sensory symptoms or pain,
early cognitive impairment, and ocular muscle weakness.
* Fasciculations in the absence of associated muscle atrophy or weakness are not
caused by ALS.
* Weakness in the absence of fasciculations is not a result of ALS.

Answer 368

A

Respiratory drive and motor posturing signs are incompatible with a diagnosis of
brain death.

Answer 369

A

Brain imaging is usually not helpful in diagnosing delirium unless a history of falls
or evidence of focal neurologic impairment is present.

Answer 370

A

Always select behavioral interventions first instead of using restraints or drugs.
Benzodiazepines may worsen delirium and are not recommended, except in the
management of alcohol withdrawal.

Answer 371

A

No medications or supplements prevent progression of mild cognitive
impairment to dementia.

Answer 372

A

Do not order apolipoprotein E genotyping in patients with suspected Alzheimer
disease.
When dementia occurs well after the motor symptoms of Parkinson disease, it is
considered Parkinson disease dementia; when dementia and motor symptoms
develop within 1 to 2 years of each other, it is classified as dementia with Lewy
bodies.

Answer 373

A

First-generation antipsychotic agents are strongly contraindicated in patients
with dementia with Lewy bodies, because they may worsen symptoms and may
result in neuroleptic malignant syndrome.
No drug is beneficial for frontotemporal dementia; SSRIs may help compulsive
behaviors.
Benzodiazepines are not recommended to treat behavioral symptoms in patients
with dementia.
Do not select tricyclic antidepressants in patients with dementia, because they
may exacerbate confusion.

Answer 374

A

Diagnostic evaluation may not be needed for a provoked seizure if the patient
has normal findings on neurologic examination.

Answer 375

A

Syncope may be associated with brief loss of consciousness and occasional
tonic-clonic jerking, but recovery is quick and complete, unlike a seizure.
Do not choose absence seizure in an adult.

Answer 376

A

Primary prophylaxis with AEDs is not indicated for a new stroke or tumor.
Patients with juvenile myoclonic epilepsy require lifelong medication.
Carbamazepine, oxcarbazepine, phenytoin, and topiramate inactivate many
forms of hormonal contraception.

Answer 377

A

Rigidity and resting tremor are not features of essential tremor.
Screen patients <40 years with “essential tremor” or dystonia for Wilson disease
with serum ceruloplasmin and 24-hour urine copper measurements.

Answer 378

A

Do not select nitroglycerin or nitroprusside to lower BP because they can
increase intracerebral pressure.
Platelet transfusions or glucocorticoids are not recommended for intracranial
hemorrhage.

Answer 379

A

Warfarin is the only approved drug for valvular AF.

Answer 380

A

Patients with suspected cardioembolic stroke should undergo prolonged cardiac
rhythm monitoring to rule out AF.
Consider vertebrobasilar stroke in older adults with persistent, acute-onset
vertigo.

Answer 381

A

Administer rtPA to all patients with ischemic stroke within 3 hours of stroke onset (if
unknown onset, then within 3 hours of the last time the patient was seen to be well).

Answer 382

A

If the patient is unable to report the time of onset, and no other person
witnessed the onset, rtPA treatment is contraindicated.
Do not select heparin for most patients with ischemic stroke.
Do not select anticonvulsant medications after stroke unless the patient has had
a seizure.
Do not select carotid endarterectomy for 100% carotid artery stenosis

Answer 383

A

Meningioma
Coronal MRI with contrast shows meningioma with the enhancing dural “tail” inferior
to the tumor’s dural attachment.

Answer 384

A

MRI is required for all patients with systemic cancer and new neurologic findings.
In patients with active, biopsy-proven systemic malignancy and multiple
enhancing brain lesions, brain biopsy is not indicated.

Answer 385

A

MS generally is not associated with cortical syndromes, such as aphasia and
neglect.
* Migraine, microvascular ischemic disease, and head trauma may also cause white
matter lesions on MRI.

Answer 386

A

Interferon agents are contraindicated in patients with liver disease or depression.
Pregnancy does not cause additional permanent disability in women with MS.
Combining glatiramer acetate with interferon beta provides no added benefit to
either drug alone.

Answer 387

A

Multiple Sclerosis Lesions
Fluid-attenuated inversion recovery MRI shows MS lesions in the paraventricular
white matter bilaterally.

Answer 388

A

Pyridostigmine monotherapy should be avoided in patients with myasthenic
crisis because the drug increases respiratory secretions.

Answer 389

A

Check methylmalonic acid and homocysteine measurements for patients with
borderline vitamin B12 values.

Answer 390

A

Spinal cord compression caused by leukemia, lymphoma, myeloma, and germ
cell tumors may be treated urgently with radiation therapy rather than surgery.
Do not use glucocorticoids to treat spinal cord compression caused by infection
or hematoma.

Answer 391

A

Lipophilic statins (atorvastatin, simvastatin, and lovastatin) have a higher
propensity to cause statin myopathy compared with hydrophilic statins
(fluvastatin, pravastatin, and rosuvastatin).

Answer 392

A

In patients who experience severe peripheral adverse effects of levodopa (nausea
or orthostatic hypotension), prescribe higher doses of carbidopa.

Answer 393

A

Begin drug therapy for Parkinson disease when symptoms begin to interfere with
function.
Failure to respond to dopamine therapy is the most important red flag indicating atypical parkinsonism.

Answer 394

A

When the presentation of Bell palsy is classic and without any additional
neurologic deficits, brain imaging and routine laboratory testing are not
necessary.
Do not treat Bell palsy with antiviral drugs.
Screening for glucose intolerance should be performed in all nondiabetic
patients who have distal sensory neuropathy.
Glucocorticoids are not beneficial in Guillain-Barré syndrome and may even slow
the recovery.

Answer 395

A

Empiric glucocorticoids for Primary Central Nervous System Lymphoma should be avoided before biopsy because they can
temporarily suppress lymphoma and prevent or delay a tissue diagnosis.
* Resection of PCNSL is not indicated and may worsen patient outcomes.

Answer 396

A

Ninety percent of patients with “sinus headache” have migraine headache that
will respond to migraine treatment.
Neuroimaging is indicated only for atypical headache features or for headaches
that do not meet the strict definition of migraine.

Answer 397

A

Avoid butalbital and opioid analgesics in headache management.
Muscle relaxants, benzodiazepines, and botulinum toxin A have no role in the
acute or prophylactic treatment of tension-type headache.

Answer 398

A

Do not choose oral medications for patients with severe nausea and vomiting.
Triptans are contraindicated in the presence of CAD and cerebrovascular disease,
brainstem aura, and hemiplegic migraine.
Do not use acute therapies more than 2 to 3 days per week to avoid medication
overuse headaches.
Estrogen-containing contraceptives must be avoided in women experiencing
aura with migraine because of the increased risk for stroke.

Answer 399

A

Papilledema
Fully developed papilledema is often present in patients with idiopathic intracranial
hypertension. On funduscopic examination, loss of disc margins, cotton-wool spots,
and flame-shaped hemorrhages may be seen. Funduscopic findings are usually
bilateral.

Answer 400

A

Bleeding under the vitreous membrane (subhyaloid hemorrhage) is a finding
associated with SAH.

Answer 401

A

Epidural Hematoma
CT scan of an epidural hematoma shows biconvex lens appearance between the
skull and outer margin of the dura (arrow).

Answer 402

A

Subdural Hematoma
CT scan of a subdural hematoma shows the crescent shape of blood separating the
dura from the arachnoid membrane (arrows).

Answer 403

A

A normal mammogram or ultrasound does not rule out breast cancer.
A breast lump should always be biopsied, even if a mammogram is normal.
Bone scan, CT, PET scan, and tumor marker tests are not routine studies for
staging DCIS (stage 0) or early-stage (I and II) breast cancer.

Answer 404

A

Aromatase inhibitors are contraindicated in premenopausal women.
Ovarian ablation or suppression can be used for premenopausal women with
contraindications to tamoxifen.
Do not select mastectomy in patients with metastatic disease unless required for
local cancer control.
Pregnancy following breast cancer treatment does not increase the risk for breast
cancer recurrence.

Answer 405

A

Biopsy new metastatic lesions; primary tumor and metastatic tumor ER and HER2
status differs in up to 15% of patients.

Answer 406

A

Do not order plain x-rays or bone scans to diagnose spinal cord compression.

Answer 407

A

Most patients with SVC syndrome do not require emergency intervention; a
tissue diagnosis should be obtained first with treatment directed by the type of
cancer.

Answer 408

A

Do not select routine radiographic contrast studies of the GI tract.
Do not measure CA-19-9, CA-15-3, and CA-125, because they are rarely helpful
and virtually never diagnostic.
Do not order PET scans, because the findings are rarely definitive and do not
improve long-term outcome.

Answer 409

A

A single positive FOBT finding constitutes a positive screening test and requires
prompt follow-up colonoscopy.

Answer 410

A

Do not obtain a serum CEA level to screen for or diagnose colon cancer.
Do not obtain a PET scan for initial staging of colorectal cancer.

Answer 411

A

Women taking tamoxifen are at increased risk for endometrial cancer.
Symptom monitoring and physical examination are as effective as imaging for
diagnosing recurrent endometrial cancer.

Answer 412

A

Invasive Aspergillosis
CT scan showing a dense infiltrate surrounded by a ground-glass–appearing halo
(“halo sign”) suggestive, but not diagnostic, of invasive aspergillosis.

Answer 413

A

Always obtain upper endoscopy and biopsy in a patient with “achalasia” to rule
out gastric cancer.

Answer 414

A

Serum AFP measurement alone is not recommended for HCC screening or
surveillance.

Answer 415

A

Vancomycin is not recommended as standard initial therapy for febrile
neutropenia.
Do not use myeloid colony-stimulating factors for treatment of febrile
neutropenia.
Antiviral treatment is indicated only for clinical evidence of active viral infection.
Typhlitis (necrotizing enterocolitis) should be suspected in patients with
neutropenia and even minimal RLQ abdominal pain; obtain an abdominal CT
scan.
Diagnose angioinvasive aspergillosis in neutropenic patients with leukemia
receiving prolonged antibiotic therapy.

Answer 416

A

Biopsy can distinguish tumors as either NSCLC or SCLC. Select the biopsy site that will
simultaneously diagnose and stage the disease (peripheral lymph node, mediastinal
node).

Answer 417

A

Avoid chemotherapy in patients with NSCLC with poor performance status
(extreme fatigue or weakness, weight loss >10%, severe symptoms).

Answer 418

A

CLL “Smudge Cel
Peripheral blood smear showing a “smudge cell,” which is a lymphocyte that appears
flattened or distorted and is characteristic of CLL.

Answer 419

A

Hairy Cell Leukemia
Atypical lymphocytes with cytoplasmic projections characteristic of hairy cell
leukemia.

Answer 420

A

Prophylaxis for tumor lysis syndrome should be started before initiation of
chemotherapy for Burkitt lymphoma.

Answer 421

A

Cutaneous T-Cell Lymphom
Cutaneous T-cell lymphoma (mycosis fungoides) is characterized by scaling or
nonscaling plaques of different red hues. In early stages, the condition is superficial
and may not be well defined, but as the disease progresses, the lesions become
thicker, round, oval, arciform, or annular.

Answer 422

A

AIP can be mistaken for pancreatic cancer; look for elevated serum levels of IgG4.

Answer 423

A

Acute urinary retention significantly increases the PSA level regardless of the
cause of obstruction.

Answer 424

A

Survival is no different for patients with low-risk, localized prostate cancer
treated with active surveillance, surgery, or radiation therapy.
Orchiectomy is a rapidly acting and cost-effective way to achieve androgen
depletion.

Answer 425

A

Patients with CT findings pathognomonic for renal cell cancer do not need a
confirmatory kidney biopsy.

Answer 426

A

Radioiodine is not taken up by C cells and is not a treatment option for

medullary thyroid cancer.
* Chemotherapy does not prolong or improve the quality of life for patients with
metastatic thyroid carcinoma.

Answer 427

A

Consider latex allergy as the cause of anaphylaxis during surgery or anaphylaxis
in a woman during coitus.

Answer 428

A

Glucocorticoids are not first-line therapy for anaphylaxis; evidence for an
adjunctive role is weak.

Answer 429

A

In patients with urticaria and angioedema, do not diagnose hereditary
angioedema.

Answer 430

A

Normal spirometry does not rule out asthma.
A normal bronchoprovocation test rules out asthma; a positive test confirms
airway hyperresponsiveness, of which asthma is but one cause; clinical
correlation of this finding with symptoms and other testing is needed.
Wheezing does not equal asthma; consider HF, COPD, vocal cord dysfunction,
and upper airway obstruction.

Answer 431

A

For mild asthma, an inhaled glucocorticoid–formoterol combination as needed or
low-dose inhaled glucocorticoid whenever a SABA is taken.
Regular inhaled glucocorticoid or inhaled glucocorticoid + LABA daily plus SABA
when needed.
Maintenance and rescue treatment with inhaled glucocorticoid–formoterol.

Answer 432

A

Do not administer theophylline with fluoroquinolones or macrolides (may result
in theophylline toxicity).

Answer 433

A

A normal arterial PCO2 in a patient with severe symptomatic asthma indicates
impending respiratory failure.
Consider vocal cord dysfunction for patients with “asthma” that improves
immediately with intubation.

Answer 434

A

Pulse oximetry data are unreliable because the oximeter is unable to differentiate
carboxyhemoglobin from oxyhemoglobin.

Answer 435

A

Do not use short-acting and long-acting anticholinergic agents together.
Do not use theophylline.
PDE-4 inhibitors are not indicated for acute bronchospasm.
Lung volume reduction therapy is not indicated for patients with an FEV1 <20%
of predicted or a DLCO <20% of predicted.

Answer 436

A

Patients with dyspnea for days or weeks (vs months) are more likely to have
pneumonia or HF than DPLD.
Plain radiography may be normal in 20% of patients with early DPLD; continue
evaluation if suspicion remains high.
Consider DPLD in patients with dyspnea and pulmonary crackles but no other
findings of HF.

Answer 437

A

Neuroleptic malignant syndrome may occur in patients who have abruptly
discontinued L-dopa for Parkinson disease.
The serotonin syndrome is often caused by the use of SSRIs and the addition of a
second drug that increases serotonin release or blocks its uptake or metabolism.

Answer 438

A

Do not intubate and mechanically ventilate patients with respiratory failure
caused by IPF.
Glucocorticoids are ineffective in IPF.

Answer 439

A

Do not select synchronized intermittent mandatory ventilation as a weaning
mode, because studies have demonstrated it actually takes longer to liberate
patients from the ventilator.

Answer 440

A

The risks of screening outweigh the benefit in patients at low risk for lung cancer.

Answer 441

A

total parenteral nutrition
should not be started before day 7 of an acute illness.

Answer 442

A

Do not confuse obesity-hypoventilation syndrome with OSA. Obesity-
hypoventilation syndrome is usually associated with COPD and always with

elevated arterial PCO2 levels when awake.
* Obesity-hypoventilation syndrome may coexist with OSA.
* Overnight oximetry has not been validated as a screening tool for OSA.

Answer 443

A

Supplemental oxygen is not recommended as a primary therapy for OSA.
Upper airway surgery is not recommended as initial therapy.
Uvulopalatopharyngoplasty is a recommended surgical option in patients
requiring surgery.

Answer 444

A

The incidence of TB is increased in those with silicosis and should be evaluated in
patients with silicosis, fever, and cough.

Answer 445

A

Always obtain thoracentesis for moderate to large effusions associated with
pneumonia.
Pleural effusions associated with nephrotic syndrome are common, but PE should
be excluded in such patients because PE and renal vein thrombosis often occur in
patients with nephrotic syndrome.
Consider pulmonary LAM when chylothorax is diagnosed in a premenopausal
woman.

Answer 446

A

Do not wait for chest x-ray results before treating suspected tension
pneumothorax with needle decompression.

Answer 447

A

Flow-volume loops plot flow (L/sec) as a function of volume.

Answer 448

A

In patients with low lung volumes, a normal DLCO suggests an extrapulmonary
cause (e.g., obesity).

Answer 449

A

Pulse oximetry is normal in patients with carbon monoxide and cyanide
poisoning.
Pulse oximetry may be falsely low in patients with shock.

Answer 450

A

Most cases of PH are attributed to left-sided heart disease and hypoxic
respiratory disorders.
Do not select CTA to diagnose CTEPH. A V/Q scan is superior.

Answer 451

A

Do not select calcium channel blockers if pulmonary artery pressure is not
decreased with a vasoreactivity test.

Answer 452

A

Waxy Papular Lesion
Waxy papular lesions on the nose consistent with sarcoidosis.

Answer 453

A

Do not treat asymptomatic pulmonary sarcoidosis.

Answer 454

A

Sarcoidosis
X-ray shows bilateral hilar lymphadenopathy characteristic of sarcoidosis.
Sarcoidosis can be associated with interstitial lung disease.

Answer 455

A

Patients with inhalational injury involving the lower airways typically present with
a clear chest x-ray; wheezing, cough, and dyspnea manifest 12 to 36 hours after
exposure.
Normal oxygen saturation does not exclude either carbon monoxide or cyanide
poisoning.

Answer 456

A

Before ordering contrast CT, bronchoscopy, or PET scan, compare current image
with previous image to determine stability over time.
PET scans may be falsely negative in alveolar cell carcinoma or lesions <1 cm in
diameter and falsely positive in various inflammatory lesions.
A nonspecific negative result from fiberoptic bronchoscopy or transthoracic
needle aspiration biopsy does not reliably exclude the presence of a malignant
growth.

Answer 457

A

Serum ferritin levels >2500 ng/mL are highly
specific for this condition CALLED stills disease

Answer 458

A

Linear calcifications of the meniscus and articular cartilage are characteristic of
CPPD.

Answer 459

A

The absence of chondrocalcinosis on x-ray does not rule out CPPD.

Answer 460

A

Do not obtain ANA, rheumatoid factor, or anti-CCP antibodies in the evaluation
of fibromyalgia.
Do not diagnose fibromyalgia in the presence of red flags such as anemia, fever,
synovitis, and weight loss.
Do not use opioids or NSAIDs in the treatment of fibromyalgia.

Answer 461

A

Monosodium Urate Crystals- Gout
Aspiration of a tophus showing monosodium urate crystals (needle-shaped,
negatively birefringent crystals) as viewed with polarized microscopy.

Answer 462

A

An elevated serum urate level alone is not diagnostic of gout.
A normal serum urate level at the time of an acute attack does not rule out gout.
Synovial fluid leukocyte counts greater than 50,000/μL should raise suspicion for
a concurrent bacterial joint infection even when monosodium urate crystals have
been identified.

Answer 463

A

Chronic Tophaceous Gout
Swollen interphalangeal joints and multiple tophi characteristic of chronic
tophaceous gout.

Answer 464

A

Do not select NSAIDs for patients with gout who also have CKD or PUD.
Urate-lowering therapy is of no benefit in the treatment of an acute gout attack.
Do not use allopurinol or febuxostat with azathioprine, because the combination
can result in elevated azathioprine levels.
Do not use uricosuric therapy (e.g., probenecid) in patients with a low estimated
GFR who are at risk for nephrolithiasis or CKD.
Do not prescribe colchicine for patients with kidney failure.

Answer 465

A

Infectious arthritis can develop in patients with gout or acute CPP crystal arthritis
(pseudogout), and the presence of crystals in synovial fluid does not exclude a
concomitant infection.
* X-rays are not helpful in the early diagnosis of acute native joint infection.

Answer 466

A

Suspect tubercular or fungal arthritis if the appropriate empiric antibacterial
therapy is unsuccessful.

Answer 467

A

Serum AST and ALT levels may be elevated in myositis, mimicking liver disease.
Muscle pain in patients with an inflammatory myopathy is atypical and, if
present, is generally mild.

Answer 468

A

Heliotrope Rash
The heliotrope rash of dermatomyositis is a distinctive purple or lilac, symmetrical
erythema of the eyelids that may be accompanied by slight edema, generally
focused around the orbits.

Answer 469

A

Suspect glucocorticoid-induced myopathy in patients with continued or new-
onset worsening of proximal muscle weakness despite normalization of muscle

enzyme levels.
* Always check TSH levels when evaluating myopathy.

Answer 470

A

Gottron Papules
Red patches and plaques over the knuckles (Gottron papules) characteristic of
dermatomyositis.

Answer 471

A

Positive anti-Sm or anti-dsDNA antibodies support the diagnosis of SLE, not
MCTD.

Answer 472

A

Hand Photograph, Osteoarthritis
Bony enlargement of the DIP joints and squaring of the first carpometacarpal joint
characteristic of OA.

Answer 473

A

A ruptured Baker cyst (herniation of fluid-filled synovium of the posterior knee)
or ruptured gastrocnemius muscle can mimic a DVT.

Answer 474

A

Patients with signs of inflammation should not undergo intra-articular
glucocorticoid therapy until synovial fluid analysis excludes infection.
Do not select arthroscopic lavage, debridement, or closed lavage for knee OA.
Do not select oral NSAIDs for patients with CAD, HF, CKD, or ulcer disease.

Answer 475

A

Hand X-ray, Osteoarthritis
Joint-space narrowing, sclerosis, and osteophyte formation are shown. Prominent
involvement of the PIP and DIP joints indicates OA.

Answer 476

A

Knee X-ray, Osteoarthritis
Medial compartment joint-space narrowing and subchondral sclerosis consistent
with OA are shown.

Answer 477

A

A negative rheumatoid factor does not exclude RA; anti-CCP antibody assay may

be positive, or the patient may have seronegative RA.
* A positive rheumatoid factor alone is not diagnostic of RA.
* Fluctuations in rheumatoid factor do not mirror disease activity, and serial testing
is not indicated.
* Not all symmetric arthritis is RA.

Answer 478

A

All patients with RA undergoing general anesthesia should have cervical spine x-
rays to assess for atlantoaxial subluxation.

Answer 479

A

vHand X-ray, Rheumatoid Arthritis
Carpal, metacarpal, and PIP joints show periarticular osteopenia, joint-space
narrowing, and marginal erosions, all characteristic of RA.

Answer 480

A

An isolated positive ANA result associated with nonspecific symptoms and
normal findings on clinical examination does not establish the diagnosis of a
connective tissue disease.
ANA subserology testing should not be routinely performed, even in the setting
of a positive ANA result, without strong clinical suspicion of an underlying
connective tissue disease.

Answer 481

A

Parotid Gland Enlargement
Bilateral parotid gland enlargement in a patient with Sjögren syndrome.

Answer 482

A

Don’t Be Tricked
* HLA-B*27 testing may support, but cannot independently confirm or exclude, a
diagnosis of ankylosing spondylitis or other forms of spondyloarthritis.

Answer 483

A

Dactylitis
Diffuse swelling of the left third and fourth toes and right fourth toe characteristic of
dactylitis.

Answer 484

A

Psoriasis
Tiny pits scattered over the nail plate resulting from psoriatic involvement of the nail
matrix.

Answer 485

A

Keratoderma Blennorrhagicum
Keratoderma blennorrhagicum, a psoriasis-like lesion of the palms and soles, is
associated with reactive arthritis.

Answer 486

A

Do not prescribe methotrexate, sulfasalazine, or hydroxychloroquine for patients
with axial disease ankylosing spondylitis because they are ineffective. Select a TNF inhibitor.

Answer 487

A

NSAIDs may result in worsening of associated IBD.

Answer 488

A

Don’t Be Tricked
* Do not diagnose SLE in a patient with a positive ANA and facial rash that involves
the nasolabial folds; consider rosacea instead.

Answer 489

A

An isolated low-titer ANA by immunofluorescence assay (1:40-1:80) is not likely
to indicate systemic lupus.
Myalgia, arthralgia, and fatigue are insufficient reasons by themselves to check
an ANA panel.
Monitoring serial ANA titers is not warranted because these values do not reflect
disease activity.

Answer 490

A

Malar Skin Rash
Bright red, sharply demarcated plaques in a butterfly pattern that spares the
nasolabial folds and areas beneath the nose and lower lip are associated with SLE.

Answer 491

A

Nailfold capillary destruction and dilated capillary loops distinguish early SSc
with Raynaud phenomenon from primary Raynaud disease.

Answer 492

A

Sclerodactyly
Thickening and induration of the skin over the fingers and wrists are characteristic of
scleroderma.

Answer 493

A

Raynaud Phenomenon
Areas of vasospastic skin blanching seen in a patient with Raynaud phenomenon.

Answer 494

A

Glucocorticoid therapy is a risk factor for scleroderma renal crisis and may be
associated with normotensive renal crisis (AKI in the absence of hypertension);
do not use glucocorticoids to treat scleroderma.

Answer 495

A

Aortic aneurysm and aortic dissection are potential complications of giant cell
arteritis; aortic dissection may occur with or without preceding aneurysm
formation.
Polyarteritis nodosa kidney disease does not involve the glomerulus (no urine
erythrocytes, casts, or proteinuria).
Do not make a diagnosis of eosinophilic granulomatosis with polyangiitis in the
absence of eosinophilia.

Answer 496

A

Palpable Purpura
The hallmark of leukocytoclastic vasculitis is palpable purpura, consisting of bright
red macules and papules and occasionally hemorrhagic bullae confined to the lower
leg and foot.

Answer 497

A

The classic triad of arthritis, conjunctivitis, and urethritis (or cervicitis) is found in
only one third of patients with reactive arthritis.
Do not prescribe chronic antibiotic therapy for patients with reactive arthritis.

Answer 498

A

Methotrexate is absolutely contraindicated in pregnancy and must be
discontinued before conception.
Hydroxychloroquine and sulfasalazine can be used during pregnancy.

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