Usmle Students Notes

triplehelix notes

2009-04-23T14:10:00.000-07:00

I did MKSAP 14 questions and made notes based on the key points, and I plan to review this note before my test. I thought to share this notes with you guys.

MKSAP 14 neurology notes:
1. A spinal cord disorder should be considered in any patient with bilateral motor and sensory dysfunction in the extremities in the absence of signs or symptoms of brain or brainstem dysfunction.
2. Spinal cord compression due to epidural metastasis is a neurologic emergency for which urgent MRI of the entire spine is appropriate.
3. Vertebral artery dissection typically presents with neck or head pain, Horner's syndrome, dysarthria, dysphagia, decreased pain and temperature sensation, dysmetria, ataxia, and vertigo.

4. Magnetic resonance angiography is a sensitive diagnostic test for vertebral artery dissection as a cause of stroke.
5. Juvenile myoclonic epilepsy is a primary, genetic, generalized epilepsy that typically manifests with myoclonic jerks followed by a generalized tonic–clonic seizure
6. Guillain–Barré syndrome is characterized by proximal and distal weakness, autonomic symptoms, cranial nerve involvement, and respiratory failure.
7. Treatment of Guillain–Barré syndrome with either intravenous immunoglobulin or plasmapheresis is indicated in patients who cannot walk independently or who have impaired respiratory function or rapidly progressive weakness.
8. Small, stable, asymptomatic meningiomas can be followed with serial neuroimaging.
9. In large, symptomatic, or progressive meningiomas, surgical resection offers an 80% chance of cure.
10. Personality change, lost initiative, and slowing of thought, with relative preservation of recent memory, suggest frontotemporal dementia.
11. Frontotemporal dementia is usually associated with disproportionate atrophy of the anterior frontal and temporal lobes, a finding that is usually clearly demonstrated on MRI.
12. Elevation of the cerebrospinal fluid 14-3-3 protein in a patient with rapidly progressive dementia and normal structural imaging suggests Creutzfeldt–Jakob disease.
13. Treatment with interferon-beta decreases the incidence of additional attacks in patients with monosymptomatic demyelination, including optic neuritis and myelopathy.
14. Propranolol and primidone are first-line drugs in the treatment of essential tremor (postural and action tremor).
15. The diagnosis of Parkinson's disease requires the presence of at least two of the following: tremor at rest, bradykinesia, rigidity, and postural reflex abnormality.
16. The characteristics of migraine headache without aura include worsening of the headache with movement, limitation of activities, and photo- and phonophobia
17. Transverse myelitis is an acute or subacute demyelinative or inflammatory disorder of the spinal cord that causes motor, sensory, and autonomic dysfunction below a spinal cord level.
18. High-dose intravenous corticosteroids are indicated for initial treatment of acute transverse myelitis.
19. Secondary prevention of cardioembolic stroke consists of warfarin with a target INR of 2.0 to 3.0.
20. Heparin has no established role in the acute treatment of stroke.
21. The manifestations of partial seizures depend on their neuroanatomic location.
22. Frontal seizures are brief and are usually not associated with aura or postictal confusion.
23. Hereditary sensorimotor neuropathy is an autosomal dominant disorder that usually presents with clumsiness or difficulty running in the first decade of life.
24. Hereditary sensorimotor neuropathy is characterized by distal muscle atrophy, weakness, and sensory loss associated with high arches (pes cavus) and hammertoes
25. Cell type and tumor grade are the most important determinants of survival in glioma.
26. Higher-grade gliomas are more aggressive than lower grade.
27. Alzheimer's disease is characterized by primary dementia with prominent amnesia.
28. Dementia with Lewy bodies, characterized by fluctuating cognition, parkinsonism, and/or visual hallucinations, often coexists with Alzheimer's disease.
29. All patients with relapsing multiple sclerosis should be considered for immunomodulatory therapy with either a form of interferon-beta or glatiramer acetate.
30. Adult-onset idiopathic dystonia is usually focal or segmental and does not generalize to other parts of the body.
31. Botulinum toxin injections can correct the abnormal posture and alleviate the pain associated with cervical dystonia.
32. Approximately 20% of patients with migraine have headache with aura, that is, neurologic problems such as visual hallucinations or numbness or tingling before or during headache.
33. Lhermitte's sign, an “electric shock”–like sensation down the neck, back, or extremities occurring with neck flexion, is a helpful historical clue to a cervical spinal cord disorder.
34. Cervical spondylosis is a chronic disorder of degenerative and hypertrophic changes of the vertebrae, ligaments, and disks that may narrow the spinal canal and cause cervical spinal cord compression.
35. In patients with stroke not eligible for thrombolytic therapy, aspirin modestly reduces both the short-term risk of recurrent stroke and the long-term risk of stroke-related death and disability.
36. In patients with acute stroke, thrombolytic therapy must be started within 3 hours of the onset of symptoms or of the time the patient was last known to be well.
37. Elderly patients may be particularly sensitive to the cognitive, motor, and coordination side effects of phenytoin, even if the serum phenytoin level is in the therapeutic range.
38. Gabapentin, lamotrigine, and carbamazepine are equally effective at controlling partial onset seizures in the elderly, but gabapentin and lamotrigine are better tolerated.
39. Peripheral nervous system vasculitis usually presents with asymmetric weakness and sensory loss in specific nerve distributions.
40. In an elderly patient with recurrent glioblastoma and poor performance status, referral for hospice care is preferable to additional antitumor treatment.
41. The three specific criteria for dementia with Lewy bodies are fluctuating encephalopathy, parkinsonism, and visual hallucinations.
42. A centrally acting anticholinesterase agent may alleviate the inattention, hallucinations, and fluctuating encephalopathy of dementia with Lewy bodies.
43. Women taking immunomodulatory treatment for multiple sclerosis should use effective contraception, or if they want to become pregnant, stop therapy several months before attempting to conceive.
44. Involuntary brief, irregular, unpredictable movements fleeting from one body part to another are hallmarks of chorea.
45. Chorea can occur as a hereditary and degenerative disease or secondary to drugs, metabolic disorders, infections, immune-mediated diseases, and vascular lesions.
46. Tension-type headache is distinguished from migraine by the fact that patients with tension headache are not disabled and can carry out activities of daily living in a normal, expedient manner.
47. Vitamin B12 deficiency can cause dysfunction of the posterior columns and corticospinal tracts of the spinal cord, causing paresthesias, loss of vibration and position sense, sensory ataxia, weakness, and upper motor neuron signs.
48. Neurologic signs of vitamin B12 deficiency may manifest in the absence of hematologic signs of vitamin B12 deficiency.
49. In a patient with a transient ischemic attack, carotid artery ultrasonography showing a >50% stenosis of the internal carotid artery may be an indication for carotid endarterectomy.
50. A single antiepileptic drug should be used in pregnant women with epilepsy; multiple drug therapy increases the risk for birth defects.
51. Chronic inflammatory demyelinating polyneuropathy, the chronic form of Guillain–Barré syndrome, is characterized by proximal and distal weakness, areflexia, and distal sensory loss.
52. Chronic inflammatory demyelinating polyneuropathy progresses in a stepwise or relapsing course for at least 8 weeks and can occur early in the course of HIV infection.
53. In a young patient with totally resected low-grade glioma, postsurgical management consists of observation with serial neuroimaging.
54. Vascular dementia is suggested by a history of vascular risk factors, abrupt onset with subsequent improvement, periventricular white matter ischemia on imaging, and focal neurologic findings.
55. Intravenous methylprednisolone therapy followed by an oral prednisone taper speeds recovery of visual acuity in optic neuritis
56. The restless legs syndrome consists of abnormal sensations in the legs and restlessness relieved by movement.
57. Patients are at risk for developing analgesic overuse headache if they use prescription or over-the-counter medication for headache more than 2 days a week.
58. Pseudotumor cerebri is characterized by papilledema, postural change with headache, visual changes, recent report of rapid weight gain, or introduction of oral contraceptives or tetracycline.
59. Infarction of the spinal cord typically presents as sudden spinal cord dysfunction.
60. Spinal cord infarction usually affects the territory of the anterior spinal artery, causing weakness and pinprick loss of sensation with sparing of vibration and position sense.
61. CT scan may miss subarachnoid hemorrhage, especially when there is a delay in presentation after the initial hemorrhage.
62. Focal neurologic symptoms 3 to 7 days after a subarachnoid hemorrhage may be due to vasospasm with cerebral ischemia.
63. Patients with epilepsy who are most likely to remain seizure free after medication withdrawal are those with no structural brain lesion, no epileptiform or focal abnormalities on electroencephalogram, a sustained seizure-free period, and no abnormalities on neurologic examination.
64. Patients with epilepsy who discontinue antiepileptic medication should stop driving for at least 3 months and preferably 6 months from the start of the taper.
65. Critical illness polyneuropathy is a common cause of failure to wean from a ventilator in a patient with associated multiorgan failure and sepsis.
66. Critical illness polyneuropathy is characterized by generalized or distal flaccid paralysis, depressed or absent reflexes, and distal sensory loss with sparing of cranial nerve function.
67. Patients with primary central nervous system lymphoma should be evaluated for vitreal or uveal involvement before therapy is begun.
68. Aggressive resection is not recommended in primary central nervous system lymphoma; methotrexate chemotherapy is primary therapy.
69. Donepezil, an acetylcholinesterase inhibitor, may cause mild peripheral cholinergic side effects, including increased vagal tone, with bradycardia, and occasionally atrioventricular block.
70. In at least 50% of patients with relapsing–remitting multiple sclerosis, disease will evolve to a secondary progressive course.
71. In at least 50% of patients with relapsing–remitting multiple sclerosis, disease will evolve to a secondary progressive course.
72. Metoclopramide, which blocks dopamine receptors both in the periphery and inside the central nervous system, can induce parkinsonism.
73. Prednisone is the most appropriate treatment for episodic cluster headache.
74. Acute cervical spinal cord compression due to hyperextension injury is common in elderly patients.
75. Emergent MRI of the cervical spinal cord is indicated in any patient with quadriparesis after a fall.
76. The classic symptoms of cerebellar stroke are headache, vertigo, and ataxia.
77. Patients with epilepsy who fail to respond to three trials of antiepileptic drugs are unlikely to ever become seizure free with drug therapy.
78. Treatment-resistant patients with epilepsy should be evaluated for a surgically remediable epilepsy syndrome.
79. Myasthenia gravis is an autoimmune disease caused by antibodies against the acetylcholine receptor, which results in impaired neuromuscular transmission.
80. Myasthenia gravis is characterized by fatigable weakness with a predilection for ocular, bulbar, proximal-extremity, neck, and respiratory muscles.
81. Leptomeningeal spread of systemic carcinoma manifests as a cranial neuropathy or spinal polyradiculopathy, or as encephalopathy, diffuse brain infiltration, or communicating hydrocephalus.
82. Creutzfeldt–Jakob disease is suggested by subacute progression of dementia with myoclonus and other motor signs and a normal brain MRI.
83. In the setting of subacutely progressive dementia, the presence of 14-3-3 protein in cerebrospinal fluid, or electroencephalography showing periodic sharp waves, can be diagnostic of Creutzfeldt–Jakob disease.
84. Mitoxantrone therapy is of modest benefit in slowing progression of secondary progressive or severe relapsing–remitting multiple sclerosis.
85. The primary concern about mitoxantrone therapy is the risk for cardiotoxicity.
86. Progressive supranuclear palsy is characterized by parkinsonism with early gait and balance involvement, vertical gaze palsy, severe dysarthria, and dysphagia.
87. Normal pressure hydrocephalus is characterized by the classic triad of gait impairment, cognitive decline, and urinary incontinence.
88. Patients with idiopathic intracranial hypertension present with signs and symptoms of increased intracranial pressure without a mass lesion on brain imaging.
89. In patients with possible idiopathic intracranial hypertension, a diagnostic and potentially therapeutic lumbar puncture is indicated after brain imaging excludes a mass lesion.
90. Severe cerebral anoxia from cardiac arrest can cause severe diffuse cerebral hemispheric cortical injury with relative preservation of brainstem function, leading to the development of a vegetative state.
91. A vegetative state is a condition of complete unawareness of self or the environment, accompanied by sleep–wake cycles and preservation of brainstem and hypothalamic functions.
92. Intracerebral hemorrhage with extensive subarachnoid hemorrhage is the hallmark of a ruptured arteriovenous malformation.
93. Conventional angiography is the definitive diagnostic procedure for detecting arteriovenous malformations and berry aneurysms.
94. In a patient with status epilepticus, after the airway is stabilized and plasma glucose determined to be normal, parenteral antiepileptic medications should be started.
95. Lorazepam is the preferred benzodiazepine for initial therapy for a patient in status epilepticus.
96. Myasthenia gravis crisis is characterized by dysphagia requiring nasogastric feeding and/or severe respiratory muscle weakness necessitating ventilation.
97. Myasthenia gravis crisis is treated with either plasmapheresis or intravenous immunoglobulin.
98. Radiation-induced leukoencephalopathy is a subcortical process affecting white matter and characterized by the triad of gait apraxia, dementia, and urinary incontinence.
99. Radiation-induced leukoencephalopathy may occur months to years after radiation and is more common after whole-brain compared with focal brain irradiation.
100. Mild cognitive impairment consists of isolated mild amnesia with no impairment of interpersonal, occupational, or daily living activities.
101. The conversion rate from mild cognitive impairment to mild dementia is 10% to 15% per year.
102. Amantadine is the first-line pharmacologic agent for treatment of multiple sclerosis-related fatigue.
103. Multiple system atrophy is characterized by orthostatic hypotension, neurogenic bladder, constipation, and impotence, with gait-predominant parkinsonism and corticospinal tract signs.
104. Carbamazepine is the appropriate treatment for trigeminal neuralgia.
105. Patients with the locked-in syndrome are quadriplegic, have paralysis of horizontal eye movements and bulbar muscles, and can communicate only by moving their eyes vertically or blinking.
106. The locked-in state is due to a lesion of the base of the pons, usually from pontine infarction due to basilar artery occlusion.
107. Antiplatelet therapy, statins, and ACE inhibitors each reduce the risk of recurrent stroke even in the absence of chronic hypertension or a lipid disorder.
108. Headache may be a limiting factor in the use of the combination of aspirin and extended-release dipyridamole for secondary stroke prevention.
109. Nonepileptic seizures of psychogenic origin can be differentiated from epilepsy by their longer duration, normal electroencephalogram findings, and maintenance of consciousness.
110. Nonepileptic psychogenic seizures are often associated with moaning, crying, and arrhythmic shaking of the body.
111. Absence seizures are characterized by a brief loss of awareness with no movement or very subtle movements of the lips and fingers.
112. Juvenile myoclonic epilepsy is characterized by myoclonic seizures and often accompanied by absence and generalized tonic–clonic seizures.
113. Amyotrophic lateral sclerosis is characterized by pathologic hyperreflexia, spasticity, extensor plantar responses, along with atrophy, fasciculations, and weakness.
114. Muscle weakness in amyotrophic lateral sclerosis usually begins distally and asymmetrically in the upper or lower extremities or may be limited initially to the bulbar muscles, resulting in dysarthria and dysphagia.
115. Surgical resection is indicated for an accessible solitary brain metastasis in patients with limited or no systemic tumor.
116. Cholinesterase inhibitors have modest efficacy on cognitive and global function in mild to moderate Alzheimer's disease.
117. Vitamin E and selegiline may delay the progression of Alzheimer's disease, but do not alleviate cognitive or psychiatric symptoms.
118. In patients with possible multiple sclerosis, new MRI white-matter lesions or new gadolinium-enhancing lesions on serial brain or spinal cord MRI at least 3 months after an initial scan, indicate dissemination of demyelination, even without a new clinically evident attack.
119. Carbidopa-levodopa is the first-line treatment for patients older than 70 years with new-onset Parkinson's disease.
120. Complications associated with the use of dopamine agonists, such as somnolence, drug-induced psychosis, and dizziness, are more common in patients older than 70 years.
121. The risk of rupture of a small intracranial aneurysm is less than the risk of complications with clipping or endovascular coiling of the aneurysm.
122. Incidentally discovered small aneurysms should be re-evaluated periodically for enlargement.
123. Oxcarbazepine is effective monotherapy for partial onset seizures.
124. Risk factors for recurrent seizures include multiple previous seizures, a history of significant head trauma, focal electroencephalogram abnormalities, and structural abnormality on MRI.
125. Amyotrophic lateral sclerosis causes progressive respiratory muscle weakness that may present with supine dyspnea, frequent arousals, daytime fatigue, or morning headache.
126. Noninvasive positive-pressure ventilation should be started in patients with amyotrophic lateral sclerosis whose forced vital capacity is less than 50% or who has symptoms of nocturnal hypoventilation.
127. Neurologic symptoms in conjunction with normal brain imaging and the detection of a systemic cancer are most likely due to an immune-mediated paraneoplastic neurologic syndrome.
128. Memantine may alleviate cognitive symptoms and improve global function in moderate to severe Alzheimer's disease when added to cholinesterase inhibitor therapy.
129. Estrogen replacement in post-menopausal women with Alzheimer's dementia has not been shown to alleviate cognitive symptoms or delay disease progression.
130. Drug-induced psychosis in Parkinson's disease consists primarily of visual hallucinations, evolving at times into paranoid-type delusions.
131. Infection with fever can temporarily exacerbate a chronic neurologic defect in a patient with a previous stroke.
132. Partial complex epilepsy consists of stereotyped nonconvulsive seizures with loss of awareness and amnesia for events.
133. Myotonic dystrophy is an autosomal dominant disorder that presents with distal weakness and muscle stiffness and is characterized by cataracts, frontal balding, temporal muscle atrophy, and cognitive dysfunction.
134. Cardiac disease resulting in arrhythmias and respiratory failure due to diaphragmatic weakness are common features of myotonic dystrophy.
135. Lambert-Eaton myasthenic syndrome is characterized by symmetrical proximal muscle weakness and autonomic dysfunction.
136. Lambert-Eaton myasthenic syndrome is diagnosed by motor nerve conduction studies with repetitive stimulation.
137. Cognitive impairment accompanied by fluctuating lethargy and inattention, hallucinations, and asterixis is likely the result of a toxic encephalopathy.
138. Drugs that block dopamine receptors can induce acute dystonic reactions.
139. In acute ischemic stroke, tissue plasminogen activator is indicated if therapy is started within 3 hours of onset of symptoms, there is no hemorrhage on CT scan, and all other eligibility criteria are met.
140. All states require that an episode of loss of awareness be reported to government authorities, either to the Department of Health or to the Department of Motor Vehicles.
141. Hypothyroid myopathy is characterized by muscle pain, cramps, stiffness, fatigue, and paresthesias.
142. In hypothyroid myopathy, creatine kinase levels may be 10 to 100 times normal, but thyroid function tests should be performed before electromyography or muscle biopsy.
143. Paraneoplastic limbic encephalitis is most commonly associated with small-cell lung cancer.
144. Paraneoplastic limbic encephalitis is characterized by rapidly progressive decline in short-term memory and seizures.
145. The most common heritable form of Alzheimer's disease results from a mutation in presenilin-1.
146. Testing for presenilin-1 may be useful when a heritable form of Alzheimer's disease is suspected.
147. CT scan of the brain is indicated to diagnose suspected intracerebral hemorrhage.
148. Head trauma increases the relative risk for epilepsy by 10 only if there is penetration of the dura or loss of consciousness for more than 30 minutes.
149. Critical illness myopathy is common in ventilator-dependent patients who have been treated with corticosteroids and neuromuscular blocking agents.
150. Critical illness myopathy is characterized by ventilator dependence, generalized or proximal flaccid paralysis, muscle atrophy, and high creatine kinase levels.
151. Primary impairment of concentration and attention, as opposed to memory, is likely the result of depression rather than a neurodegenerative condition.
152. Carotid endarterectomy is the appropriate intervention in patients with symptomatic carotid artery stenosis, especially within the first few weeks after initial symptoms.
153. Depression is a possible side effect of many antiepileptic drugs, including phenobarbital, phenytoin, valproate, levetiracetam, and topiramate.
154. Selective serotonin reuptake inhibitors, moclobemide, venlafaxine, and nefazodone do not increase the seizure threshold in patients with epilepsy and therefore are the preferred pharmacologic agents in depression.
155. Polymyositis is characterized by proximal muscle weakness, elevated creatine kinase levels, and needle electromyography showing diffuse fibrillations and myopathic motor unit potentials.
156. Results of creatine kinase measurement and needle electromyography are invariably normal in steroid myopathy but abnormal in inflammatory myopathy.
157. Antiplatelet therapy is the mainstay of secondary stroke prevention in patients with cryptogenic stroke.
158. Clopidogrel is the preferred antiplatelet therapy for aspirin-allergic patients with a history of stroke.
My Cardiology Note:
160. Right ventricular infarction should be suspected in patients with inferior myocardial infarction who present with hypotension, clear lung fields, and elevated jugular venous pressure.
161. An echocardiogram establishes the diagnosis of right ventricular infarction by demonstrating right ventricular enlargement and hypokinesis.
162. Implantable cardioverter-defibrillator therapy reduces risk of sudden death in survivors of cardiac arrest due to ventricular tachycardia or ventricular fibrillation without a reversible cause.
163. Spontaneous coronary dissection may occur during pregnancy.
164. In patients with ST-elevation myocardial infarction, successful fibrinolysis is suggested by resolution of chest pain and ST-segment elevation and/or transient ventricular arrhythmias early after reperfusion.
165. In patients with ST-elevation myocardial infarction, reperfusion arrhythmias, typically manifested as a transient accelerated idioventricular arrhythmia, usually do not require additional antiarrhythmic therapy.
166. Thrombosis of mechanical valves may present with valve dysfunction rather than embolic events.
167. Intravenous heparin should be started immediately while diagnostic evaluation is in progress.
168. Chest CT scan with contrast is indicated to detect acute aortic dissection.
169. In patients at risk for radiocontrast nephropathy and contraindication to MRI, transesophageal echocardiography is the test of choice for possible aortic dissection.
170. Breast and lung carcinoma are the most common causes of malignant pericardial disease.
171. The epicardium is the most common location of metastatic cardiac neoplasm.
172. An ACE inhibitor and a β-blocker are indicated in all patients with systolic heart failure, including asymptomatic patients.
173. Spironolactone and digoxin are not indicated in patients with asymptomatic systolic heart failure.
174. Fixed splitting of the S2 is the auscultatory hallmark of atrial septal defect.
175. A divergence between electrocardiography showing low-voltage and echocardiography demonstrating a substantial increase in left ventricular wall thickness is a useful diagnostic clue for cardiac amyloidosis.
176. Abdominal fat aspiration biopsy is a safe and reasonably sensitive test for the diagnosis of amyloidosis.
177. Physical examination is helpful is identifying the presence, but not the severity, of valve disease.
178. The most sensitive sign on physical examination to exclude the diagnosis of severe aortic stenosis is a physiologically split S2.
179. Most patients with peripheral vascular disease have an ABI grade 3/6 in intensity, continuous murmurs, or any diastolic murmur.
192. Surgery for native valve endocarditis is indicated if there is significant hemodynamic instability or evidence of paravalvular extension.
193. Factors favoring earlier timing of surgery include significant congestive heart failure, resistant infections, and large mobile vegetations.
194. Even if active bacteremia is still present or if the antibiotic treatment course is ongoing, surgery for endocarditis should not be delayed if surgical criteria are met.
195. Medical therapy for acute, recent myocardial infarction includes β-blockers, aspirin, angiotensin-converting enzyme inhibitors, and statins.
196. Smoking cessation is the single most effective intervention for patients with peripheral vascular disease.
197. β blockade does not promote clinical claudication.
198. Cilostazol is relatively contraindicated in patients with congestive heart failure.
199. Patients with heart failure who have severe symptoms and evidence for ventricular dyssynchrony benefit from implantation of a biventricular pacemaker.
200. Biventricular pacing improves cardiac performance and quality of life and may also improve survival.
201. Glycoprotein receptor blockade is indicated for patients with acute coronary syndrome who will undergo coronary angiography and intervention.
202. Patients with ST-elevation myocardial infarction treated with stents require aspirin and clopidogrel at discharge.
203. Patients with ST-elevation myocardial infarction treated without stents may be managed with aspirin alone or with warfarin if indicated for atrial fibrillation or anterior akinesis or aneurysm.
204. In low-risk patients with lone atrial fibrillation, warfarin anticoagulation is not required. Aspirin or no therapy is recommended.
205. A systolic murmur, an S3 gallop, and mild peripheral edema are normal findings during pregnancy.
206. In the absence of significant mitral regurgitation, primary mitral valve prolapse has a benign prognosis.
207. Antibiotic prophylaxis for endocarditis is indicated in mitral valve prolapse if there is more than mild mitral regurgitation, if a murmur is heard on auscultation, or if the patient has high-risk echocardiographic features.
208. Initial management of acute coronary syndrome related to a systemic process, such as anemia, is treatment of the precipitating factor.
209. Medical therapy for NSTEMI in patients with TIMI low-risk status has acceptable outcomes.
210. Patients with atrial fibrillation and risk factors for stroke require anticoagulation with warfarin.
211. Risk factors for stroke in nonrheumatic atrial fibrillation include prior embolic event or stroke, hypertension, advanced age, congestive heart failure, coronary artery disease, and diabetes mellitus.
212. β-blockers should not be initiated in heart failure patients who are acutely decompensated or volume overloaded.
213. Patients with atrial fibrillation and minimal symptoms can usually be managed with rate control alone (without rhythm control).
214. Echocardiography is indicated when a new murmur, a systolic murmur ≥grade 3/6, or any diastolic murmur is heard.
215. Physiologic valvular regurgitation does not pose a risk of endocarditis and does not require antibiotic prophylaxis.
216. Antibiotic prophylaxis for endocarditis is tailored to the risk of the procedure and the risk of the patient.
217. Although pericardiectomy is the most effective treatment for constrictive pericarditis, it is unnecessary in patients with early disease.
218. Atrial flutter is characterized by saw-tooth pattern flutter waves most noticeable in the inferior leads.
219. The preferred treatment for recurrent atrial flutter is radiofrequency catheter ablation.
220. Aspirin-allergic patients with ST-elevation myocardial infarction can be treated with clopidogrel as part of postinfarction medical therapy.
221. Angiotensin-converting enzyme inhibitors are indicated for all patients with systolic heart failure, regardless of ejection fraction or functional status, barring contraindications.
222. Patients with STEMI should undergo coronary reperfusion in the most expeditious manner.
223. STEMI patients who cannot be reperfused by direct coronary intervention within 90 to 120 minutes should receive fibrinolytic therapy if there are no contraindications.
224. The decision to implant a pacemaker for sinus node dysfunction depends on the presence of symptoms rather than heart rate alone.
225. Subacute cardiac tamponade may be caused by acute viral pericarditis.
226. Echocardiography is a useful diagnostic modality for the delineation of pericardial hemodynamics.
227. • Papillary muscle dysfunction or rupture should be suspected in patients with clinical signs of acute mitral regurgitation in the setting of a myocardial infarction.
228. • An echocardiogram should be performed if papillary muscle dysfunction is suspected.
229. • Mitral regurgitation due to papillary muscle dysfunction often improves following coronary revascularization
230. Syncope in a patient with cardiomyopathy may be due to potentially fatal ventricular arrhythmia.
231. An ICD is indicated for patients with left ventricular dysfunction and hemodynamically significant ventricular arrhythmias.
232. Coronary artery bypass grafting improves survival in patients with obstructive left main and/or multivessel coronary artery disease.
233. Coronary artery bypass grafting improves survival in comparison to percutaneous intervention in diabetic patients with multivessel coronary artery disease.
234. Atrioventricular nodal re-entrant tachycardia is characterized by a narrow QRS complex and lack of visible P waves.
235. The first treatment of choice for atrioventricular tachycardia is carotid sinus massage.
236. If carotid sinus massage is unsuccessful, adenosine is the drug of choice for the termination of narrow-complex supraventricular tachycardias.
237. The murmur of hypertrophic cardiomyopathy increases after a Valsalva maneuver and decreases after a sit-to-squat maneuver, performing passive recumbent leg lifts, or performing handgripping exercises.
238. Ascending aortic dissection may involve the coronary arteries, most commonly the right coronary artery.
239. Ascending aortic dissection may lead to disruption of the aortic valve, leading to aortic regurgitation.
240. Noonan syndrome is characterized by short stature, intellectual impairment, unique facial features, neck webbing, and congenital heart defects.
241. Noonan syndrome should always be considered in a patient with pulmonary valve stenosis.
242. The recommended initial treatment for acute viral pericarditis is a high-dose nonsteroidal anti-inflammatory medication, such as indomethacin.
243. Anticoagulation therapy is contraindicated in pericarditis because of the risk of hemopericardium.
244. Perioperative β blockade decreases cardiovascular risk in patients undergoing noncardiac surgery.
245. Hypertension (blood pressure >180/110 mm Hg) is a relative contraindication to fibrinolysis in patients with STEMI.
246. Revascularization should proceed expeditiously with concomitant medical therapy for hypertension complicating STEMI.
247. Restrictive cardiomyopathy is a late complication of radiation therapy.
248. A normal left ventricular wall thickness in radiation-induced restrictive cardiomyopathy helps to differentiate this entity from other cardiomyopathies characterized by ventricular hypertrophy.
249. In asymptomatic patients with chronic aortic regurgitation, surgery should be considered when left ventricular ejection fraction drops below 60% or the left ventricular systolic dimension reaches 55 mm.
250. In asymptomatic patients with aortic regurgitation, nifedipine may delay the timing of surgical intervention.
251. Aortic coarctation is associated with a continuous murmur (often posterior thorax) and elevated but equal blood pressure in both upper extremities.
252. A bicuspid aortic valve is often seen in association with aortic coarctation, presenting with aortic regurgitation or aortic stenosis.
253. Physical findings of mitral regurgitation include holosystolic murmur at the apex radiating to the axilla, without respiratory variation.
254. In healthy adults, premature ventricular contractions are common and are not a cause for concern.
255. Suppression of premature ventricular contractions is indicated only in patients with severe and disabling symptoms.
256. Smoking, hypertension, advanced age, and male sex are risk factors for abdominal aortic aneurysm.
257. Most abdominal aortic aneurysms are asymptomatic, but abdominal pain is the most common symptom.
258. Patients at high risk for a subsequent coronary event after a myocardial infarction include those with multivessel coronary artery disease, anterior myocardial infarction, or a left ventricular ejection fraction 0.5 cm/year) increase in aneurysm size.
307. Severe hemolytic anemia in a patient with a mechanical valve suggests paravalvular leakage due to partial dehiscence of the valve or infection.
308. Prosthetic valve dehiscence or dysfunction should be suspected in patients that develop symptoms of congestive heart failure, particularly if these symptoms occur in the first 6 months following surgery.
309. Right ventricular infarction is a cause of hypotension following inferior infarction and typically requires appropriate volume infusion.
310. Right ventricular infarction should be suspected as a cause of hypotension when findings of right heart failure coincide with an absence of evidence of pulmonary congestion.
311. Implantation of a cardioverter-defibrillator is an important prophylactic treatment in patients with hypertrophic cardiomyopathy and high risk for sudden death.
312. Clinical features that predict high risk for sudden death in patients with hypertrophic cardiomyopathy include family history of sudden death, syncope, marked left ventricular septal hypertrophy, nonsustained ventricular tachycardia, and exertional hypotension.
313. Papillary muscle rupture and ventricular septal defect are recognized mechanical complications that occur early after myocardial infarction.
314. Both papillary muscle rupture and ventricular septal defect present with hypotension and acute dyspnea.
315. Annual echocardiography is appropriate in a patient with asymptomatic severe mitral regurgitation.
316. The timing of surgery for severe mitral regurgitation is based on symptoms and measures of left ventricular size and systolic function.
317. Classic features of Marfan's syndrome includes tall stature, high arched palate, joint hypermobility, scoliosis, and positive “wrist sign.”
318. Patients with Marfan's syndrome are at increased risk for asymptomatic thoracic aortic aneurysm and associated aortic valve incompetence.
319. Intravenous amiodarone is the drug of choice for shock-resistant ventricular fibrillation.
320. The risk of coronary artery disease in diabetic patients is 2 to 4 times higher than in nondiabetic patients.
321. The pretest likelihood of disease should be calculated using available algorithms in patients with coronary risk factors.
322. In patients with chest pain and intermediate risk of coronary artery disease, non-invasive testing is indicated.
323. Patients with chest pain and low coronary artery disease risk with a normal electrocardiogram and a normal exercise electrocardiogram can be discharged without coronary angiography.
324. Although uncommon, left atrial myxoma should be considered in young patients with embolic stroke.
325. Echocardiography is an important imaging modality for diagnosis of an intracardiac tumor.
326. Women with Marfan syndrome are at increased risk of aortic dissection during pregnancy.
327. Aortic dissection should be considered in the differential diagnosis of chest pain in pregnancy.
328. The tachycardia rate in atrioventricular nodal reentrant tachycardia is typically 160–180/min with the P wave buried in the QRS complex.
329. • If atrioventricular nodal reentrant tachycardia does not respond to vagal maneuvers, adenosine is the treatment of choice
330. Continuous effective anticoagulation is needed throughout pregnancy in women with mechanical heart valves.
331. Radiofrequency catheter ablation is the most effective treatment for atrioventricular nodal reentrant tachycardia.
332. Calcium-channel blockers may be used for prophylaxis of recurrent atrioventricular nodal reentrant tachycardia but are less effective than radiofrequency catheter ablation.
333. The cardiac output is low in primary cardiogenic shock, and inotropic agents may be needed to augment myocardial contractility and thus cardiac output.
334. Exercise (or pharmacologic) stress testing is the most sensitive noninvasive method to establish the diagnosis of coronary artery disease.
335. Exercise (or pharmacologic) stress cardiac imaging can be used to evaluate for coronary artery disease if the resting electrocardiogram is abnormal.
336. The role of electron-beam CT coronary calcium scores is not yet established in the assessment of coronary artery disease.
337. Prolonged immobility followed by a stroke or transient ischemic attack should raise the suspicion of a paradoxical embolism.
338. Transesophageal echocardiography is the test of choice to confirm the diagnosis of a suspected patent foramen ovale or cardiac source of embolus.
339. • Systemic lupus erythematosus is a cause of premature atherosclerotic coronary disease.
340. • Other causes of acute myocardial infarction in young persons include coronary spasm, embolic coronary occlusion, and Kawasaki's disease.
341. High risk patients that require a heparin anticoagulation bridge after stopping warfarin prior to surgery include those with a mitral mechanical valve, atrial fibrillation, or previous embolism.
342. Low risk patients do not require a heparin bridge after stopping warfarin prior to surgery and include patients with a bileaflet aortic valve and no other high risk features.
343. Aspirin alone is not a sufficient replacement for warfarin, and is used only as a chronic adjunct in patients who manifest systemic emboli despite therapeutic warfarin therapy.
344. Radial-femoral delay is a characteristic physical finding in aortic coarctation.
345. Bicuspid aortic valves are common in patients with aortic coarctation and are associated with a systolic ejection click and systolic murmur noted over the aortic area.
346. Elevated B-type natriuretic peptide levels occur with renal failure, acute coronary syndrome or myocardial infarction, and acute volume or pressure overload.
347. Adenosine is the treatment of choice for narrow-complex tachycardia.
348. Neither adenosine nor other atrioventricular nodal blocking agents should be given to patients with preexcited tachycardias.
349. Procainamide is the drug of choice for wide-complex tachycardia of unclear etiology.
350. Coronary angiography is indicated in patients with a history of unstable angina or non-ST-elevation myocardial infarction.
351. In patients with a high pretest probability of coronary artery disease, a negative stress test result is most likely to be false.
352. Spinal stenosis is characterized by pain with standing or walking that is relieved by sitting or bending forward and is further supported by a normal ABI.
353. Leg ischemia is characterized by pain with exertion and with a decrease in ABI of at least 20 % with exercise.
354. The use of angiotensin-converting enzyme inhibitors should be avoided during pregnancy.
355. Hydralazine and nitrates are the vasodilators of choice to treat heart failure during pregnancy.
356. Induction of mild hypothermia improves outcomes in comatose survivors of out-of-hospital cardiac arrest.
357. Aortic valve replacement is recommended once symptom onset occurs, regardless of patient age.
358. Symptom onset in aortic stenosis is often insidious and may include exertional dyspnea.
359. Alcoholic cardiomyopathy is a dilated cardiomyopathy.
360. Therapy for alcoholic cardiomyopathy must include total abstinence from alcohol.
361. In chronic angina, coronary artery bypass graft surgery is indicated for patients refractory to medical therapy; a large area of ischemic myocardium; high-risk coronary anatomy; and reduced left ventricular systolic function.
362. Atrial tachycardia with variable block is a classic electrocardiographic finding in digitalis toxicity.
363. The first-line treatment for life-threatening digitalis toxicity is administration of digoxin-specific antibody fragments.
364. Iron deficiency is a common cause for dyspnea and fatigue in patients with cyanotic heart disease.
365. The most common cause of iron deficiency in patients with cyanotic heart disease is recurrent phlebotomy.
366. Mitral valve surgery is indicated for symptomatic patients with chronic, severe mitral regurgitation.
367. In asymptomatic patients with chronic, severe mitral regurgitation, criteria for mitral valve surgery include an end-systolic dimension >45 mm, an end-diastolic dimension >60 mm, and an ejection fraction 5 mm of induration is considered a positive test.
654. Dengue fever is characterized by the abrupt onset of severe headache, high fever, myalgias, arthralgias, leukopenia, and thrombocytopenia.
655. Dengue hemorrhagic fever is associated with hemorrhage and capillary fragility.
656. Bronchiectasis is a risk factor for the development of Pseudomonas aeruginosa community-acquired pneumonia.
657. Administration of ganciclovir or valganciclovir has greatly reduced, but not eliminated, the occurrence of cytomegalovirus infections in transplant recipients.
658. Person-to-person transmission of meningococcal organisms occurs by the respiratory route.
659. Prophylaxis of health care workers exposed to a patient with a meningococcal infection is needed only after contact with the patient's respiratory secretions.
660. MRI and CT scans are the imaging procedures of choice in the diagnosis of patients with suspected osteomyelitis.
661. The most appropriate empiric therapy for Streptococcus pneumoniae meningitis is vancomycin plus ceftriaxone and dexamethasone.
662. African tick bite fever is the most common rickettsial infection in humans.
663. Symptoms of African tick bite fever are relatively mild and are characterized by a vesicular rash with an inoculation eschar.
664. Symptoms of Creutzfeldt–Jakob disease typically include cognitive changes (dementia), behavioral and personality changes, difficulty with movement and coordination, and visual and constitutional symptoms.
665. The course of Creutzfeldt–Jakob disease is rapid and progressive; 90% of patients die within 1 year of diagnosis.
666. The most appropriate therapy for a patient with Listeria meningitis and a severe allergy to penicillin is trimethoprim–sulfamethoxazole.
667. When initiating antituberculous therapy, a four-drug regimen must be used if the probability of resistance to isoniazid is greater than 4%.
668. The recommended empiric therapy for a patient with community-acquired pneumonia who is hospitalized on a general medical floor is either monotherapy with an intravenous fluoroquinolone or combination therapy with an intravenous β-lactam plus either an intravenous or oral macrolide or doxycycline.
669. The recommended empiric therapy for a patient with community-acquired pneumonia who is hospitalized in an intensive care unit is an intravenous β-lactam plus either an intravenous macrolide or an intravenous fluoroquinolone.
670. Penicillin is the treatment of choice for all forms of syphilis.
671. Treatment of a pregnant patient with newly diagnosed syphilis is essential in order to prevent congenital syphilis in the fetus.
672. A pregnant patient with newly diagnosed syphilis who may be allergic to penicillin should undergo skin testing for a penicillin allergy.
673. Immunosuppressed transplant recipients are at high risk for development of bacterial infections during the first month after surgery.
674. In patients with a contiguous foot ulcer and possible osteomyelitis, bone biopsy with cultures and histopathologic examination should be performed before initiating antimicrobial therapy.
675. Intravascular catheter–associated bloodstream infections are preventable if proper insertion procedures are used.
676. Chlorhexidine is superior to povidone-iodine for cleaning a catheter insertion site.
677. Vancomycin is the antimicrobial agent of choice for treatment of methicillin-resistant Staphylococcus aureus infections.
678. All β-lactam agents are inactive against methicillin-resistant Staphylococcus aureus infections.
679. HIV genotype resistance testing is indicated for patients with HIV infection who may have developed resistance to one or more antiretroviral agents.
680. No currently available test can differentiate true-positive from false-positive tuberculin skin test reactions in a person who previously received bacille Calmette–Guérin vaccine.
681. The recommended treatment for latent tuberculosis is isoniazid for 9 months.
682. Infection due to Pseudomonas aeruginosa, which is often found between layers of rubber soles in sneakers, may occur following puncture wounds of the foot.
683. Contacts of patients with possible smallpox should receive smallpox vaccine.
684. Contacts of patients with possible smallpox should take their temperature twice daily for 17 days; a contact who develops a temperature over 38 °C (100.4 °F) during this time should be isolated.
685. Acyclovir is effective in preventing reactivation of varicella zoster virus in stem-cell transplant recipients.
686. Noninfectious skin lesions can be differentiated from infectious disorders because the former are not associated with fever and other systemic signs and symptoms or abnormal laboratory studies and culture results.
687. The most appropriate empiric therapy for a patient with purulent meningitis following neurosurgery is vancomycin plus cefepime.
688. The finding of 14-3-3 protein in cerebrospinal fluid has a specificity and sensitivity of greater than 90% for diagnosing sporadic Creutzfeldt–Jakob disease.
689. Live attenuated influenza vaccine is contraindicated in an immunosuppressed patient.
690. All family members of an immunosuppressed patient should be immunized against influenza to decrease the patient's risk of exposure to this virus.
691. Doxycycline in a single dose is highly effective for preventing erythema migrans in patients from areas endemic for Lyme disease who present with an embedded, engorged tick.
692. Contact isolation is most effective for reducing spread of Clostridium difficile in hospitals.
693. The treatment of choice for patients with symptomatic babesiosis is atovaquone plus azithromycin.
694. A positive Western blot analysis confirms the diagnosis of HIV infection; a negative test rules out this diagnosis.
695. An indeterminate Western blot analysis may indicate either HIV seroconversion or the presence of cross-reactive antibodies.
696. Stained specimens of vaginal discharge from patients with candidal vaginitis show pseudohyphae and budding yeast.
697. Stained specimens of vaginal discharge from patients with bacterial vaginosis show gram-negative bacilli attached to squamous epithelial cells (clue cells).
698. In patients with catheter-associated bloodstream infections, the catheter should be removed whenever possible.
699. Echinocandins such as caspofungin, micafungin, and anidulafungin are effective in treating patients with candidemia.
700. Patients with Mycobacterium tuberculosis infection may be considered noninfectious after they are placed on effective antituberculous therapy, demonstrate clinical improvement, and have three different sputum smears that are negative for acid-fast bacilli.
701. Brain abscesses that result from contiguous spread of head and neck infections may contain multiple organisms.
702. Ceftriaxone plus metronidazole is the most appropriate empiric antimicrobial therapy for a brain abscess resulting from contiguous spread of an otitic focus of infection.
703. Vancomycin plus clindamycin is the most appropriate empiric antibiotic regimen for a patient with suspected streptococcal or staphylococcal toxic shock syndrome.
704. Gram-positive bacteria (staphylococci and streptococci) are the most common causes of nongonococcal septic arthritis in adults.
705. Because amantadine is excreted by the kidneys, dosage adjustment is required in patients with renal compromise.
706. Although oseltamivir and zanamivir are excreted by the kidneys, dosage adjustment is not required in a patient with renal compromise.
707. A highly effective vaccine is available for hepatitis A, which must be administered at least 2 weeks before a potential exposure.
708. Patients taking anti–tumor necrosis factor-α inhibitors are at increased risk for developing latent tuberculosis.
709. Patients about to begin therapy with anti–tumor necrosis factor-α inhibitors should undergo tuberculin skin test screening.
710. Transplant recipients are at risk for development of opportunistic infections such as fungal pneumonia.
711. Almost all patients with amebic abscesses will have high levels of antibodies directed against Entamoeba histolytica.
712. In a patient with sickle cell disease and osteomyelitis, potential causative organisms are staphylococci, streptococci, and Salmonella species.
713. Penicillin is the only antimicrobial agent approved for treatment of neurosyphilis.
714. Patients who are allergic to penicillin but for whom alternative antimicrobial agents cannot be prescribed require desensitization to penicillin.
715. Genital herpes simplex virus in a male patient is generally characterized by a limited number of genital vesiculoulcerative lesions without systemic symptoms.
716. Subdural empyema is a medical and surgical emergency.
717. Antimicrobial therapy and neurosurgical drainage are the most appropriate initial management for a patient with a subdural empyema.
718. Surgical site infections are a common complication of operations, especially coronary artery bypass graft surgery.
719. The appropriate dose, timing, and duration of prophylactic perioperative antibiotics help decrease the risk of surgical site infections.
720. Deep fungal infections such as histoplasmosis are a risk to travelers to endemic areas.
721. Reactivation of human herpesviruses 6 and 7 is being increasingly recognized in immunosuppressed patients.
722. Reactivation of human herpesviruses 6 and 7 may cause hepatitis and meningoencephalitis.
723. Treatment of latent tuberculosis is indicated for any person with a known tuberculin skin test conversion, regardless of the person's age.
724. Most cases of toxic shock syndrome are caused by Staphylococcus aureus or Streptococcus pyogenes.
725. Ceftriaxone provides effective empiric therapy for patients with possible disseminated gonococcal infection.
726. Health care workers in contact with a patient with possible smallpox require gown, gloves, and a personal respirator for protection.
727. A qualitative assay for hepatitis C virus RNA viral load is the most sensitive test for diagnosing hepatitis C infection.
728. Penicillin resistance is categorized as either intermediate-level resistance (minimal inhibitory concentration [MIC] between 0.1 and 1 μg/mL) or high-level resistance (MIC >1 μg/mL).
729. • Organisms that are resistant to penicillin generally remain sensitive to fluoroquinolones and are uniformly sensitive to vancomycin and linezolid
730. Polyomavirus BK is associated with nephropathy and deteriorating renal function in renal transplant recipients.
731. The presence of intranuclear inclusions in tubular epithelial cells or transitional cells is highly indicative of polyomavirus BK.
732. Acute retinal necrosis occurs most often in patients with HIV infection or AIDS.
733. Intravenous acyclovir is the preferred treatment for acute retinal necrosis.
734. In contrast to patients with sporadic, genetic, or iatrogenic Creutzfeldt–Jakob disease, patients with the variant form of the disorder tend to be younger and have psychiatric symptoms rather than dementia early in the disease, more prominent sensory findings, and MRI abnormalities in pulvinar area of the thalamus rather than in the basal ganglia and putamen.
735. Ninety percent of urinary tract infections are associated with indwelling catheters.
736. Administering prophylactic antibiotics, acidifying the urine, or using disinfecting washes have not been shown to prevent urinary tract infections.
737. Vancomycin plus cefepime is the most appropriate empiric antimicrobial therapy for a patient with an epidural abscess and a history of injection drug use.
738. The development of focal lymphadenitis in a patient with HIV infection is most commonly caused by mycobacteria, Streptococcus species, or Staphylococcus species.
739. Cryptococcal infection in transplant recipients is associated with high morbidity and mortality.
740. Flucytosine plus a lipid formulation of amphotericin B is usually effective for treating cryptococcal infections in transplant recipients.
741. Empiric antibiotic therapy while awaiting culture results is required for patients with an infected clenched-fist injury.
742. Oral valacyclovir is the most appropriate antiviral agent for a patient with genital herpes simplex virus infection without systemic complications.
743. The four “D's” that characterize botulism are diplopia, dysphonia, dysarthria, and dysphagia.
744. Fatal familial insomnia is the rarest of the prion diseases.
745. • Fatal familial insomnia is characterized by severe insomnia, confusion, other signs of dementia, and autonomic nervous system instability
746. Anaplasmosis (formerly human granulocytic ehrlichiosis) is characterized by fever, flu-like symptoms, leukopenia, thrombocytopenia, liver chemistry abnormalities, and a peripheral blood smear showing morulae.
747. Doxycycline is the treatment of choice for anaplasmosis.
748. A patient with suspected herpes simplex virus encephalitis requires polymerase chain reaction of the cerebrospinal fluid and MRI of the brain to confirm the diagnosis.
749. Acyclovir is the preferred initial therapy for a patient with herpes simplex virus encephalitis.
750. Keeping mechanically ventilated patients semi-recumbent (at a 45-degree angle) helps prevent development of ventilator-associated pneumonia.
751. Thrombocytopenia may occur in patients who take linezolid for 2 or more weeks.
752. The decision about whether admission to an intensive care unit is needed for patients with community-acquired pneumonia is based on the presence of specific major and minor criteria.
753. Because Legionella pneumonia is of particular concern in a patient with severe community-acquired pneumonia, testing for urinary Legionella antigen is indicated.
754. Whenever possible, outpatient parenteral therapy should use drugs that can be given once daily for convenience and patient comfort.
755. In patients with HIV infection and Kaposi's sarcoma, the sarcoma frequently regresses and sometimes resolves completely after successful treatment with highly active antiretroviral therapy.
756. Oral levofloxacin rather than intravenous levofloxacin is indicated for empiric treatment of a highly compliant patient with acute pyelonephritis who can eat and drink.
757. The most appropriate treatment for a cat bite in a patient with a penicillin allergy is trimethoprim–sulfamethoxazole plus clindamycin.
758. Patients with progressive massive fibrosis are at increased risk for developing tuberculosis.
759. The most appropriate diagnostic studies for suspected tuberculosis are tuberculin skin testing and sputum for acid-fast stain and culture.
760. Staphylococcus aureus and Pseudomonas aeruginosa are the most likely causes of septic arthritis in an injection drug user.
761. Enterotoxigenic Escherichia coli is the most common cause of diarrhea in travelers to developing countries.
762. Diarrhea due to enterotoxigenic E. coli is usually a mild and self-limited illness.
763. West Nile virus encephalitis is most likely to occur in patients 65 years of age and older.
764. Findings in patients with West Nile virus encephalitis include fever, severe headache, marked muscle weakness involving the lower motor neurons, mental status changes, and possibly seizures.
765. The need for isolation precautions is based on the route of transmission of the suspected pathogen or the clinical symptoms of the patient.
766. Because Francisella tularensis is not transmitted from person to person, only standard precautions, rather than isolation procedures, are required for patients with tularemia.
767. Esophagitis in an immunosuppressed patient is most often caused by Candida.
768. Echinocandins and triazoles are both effective for treating Candida esophagitis.
769. Shiga toxin–producing Escherichia coli is associated with development of the hemolytic uremic syndrome.
770. Administration of foscarnet is indicated for a patient with acyclovir-resistant herpes simplex virus infection.
771. Administration of foscarnet may be associated with significant electrolyte abnormalities.
772. Prophylaxis is not required for household contacts of patients with an invasive streptococcal infection.
773. If two or more cases of invasive streptococcal disease occur in postpartum or postsurgical patients hospitalized within 6 months in the same institution, an epidemiologic investigation is required to determine if a hospital worker is a carrier.
774. Immunosuppressed patients are at increased risk for developing nosocomial pneumonia even when mechanical ventilation is not required.
775. A “halo sign” (a nodular lesion with a surrounding ground-glass appearance) on chest radiographs is characteristic of Aspergillus pneumonia.
776. Bactericidal agents such as daptomycin are mandatory for treatment of endocarditis.
777. Emergence of resistance to daptomycin is rare, and daptomycin is not correlated with cross-resistance to any other drug class.
778. Current recommendations do not support use of tuberculin skin testing as a screening test in otherwise healthy persons with no personal or occupational exposure to persons with tuberculosis.
779. Pneumococcal strains are becoming increasingly resistant to penicillins and macrolides.
780. Most experts and guidelines support the use of a third-generation cephalosporin plus a macrolide for treatment of community-acquired pneumonia.
781. West Nile virus can be transmitted by blood transfusions.
782. West Nile virus can be transmitted to transplant recipients from organ donors.
783. he primary pathogens associated with bloodborne exposures in health care workers are HIV, hepatitis B, and hepatitis C.
784. • Two or three antiretroviral agents are recommended when a health care worker sustains a deep, penetrating injury from a source patient who is HIV seropositive.
785. Oral valganciclovir is as effective as intravenous ganciclovir for treating patients with cytomegalovirus retinitis.
786. A maculopapular rash, especially on the palms and soles, is characteristic of disseminated (secondary) syphilis.
787. A patient with possible neurosyphilis should receive intravenous aqueous crystal penicillin G for 14 days.
788. Patients with osteomyelitis and an epidural abscess who do not have focal neurologic deficits can usually be treated with antimicrobial therapy alone, but must be monitored carefully.
789. Aspiration and culture of joint fluid is the most appropriate test for determining whether a prosthetic joint is infected.
790. Patients with pneumonic plague typically present with high fever, headache, myalgias, dyspnea, hemoptysis, and watery sputum.
791. Patients with pneumonic plague have a mortality rate approaching 100% if not treated with streptomycin within 24 hours of development of symptoms.
792. Angiostrongylus cantonensis (the rat lungworm) is the most common cause of eosinophilic meningitis worldwide.
793. Prevention of nosocomial mycobacterial infections requires airborne isolation of the patient and personal respirators for health care workers.
794. The most common distribution of herpes zoster (shingles) is a unilateral rash in the thoracic region.
795. Famciclovir and valacyclovir have replaced acyclovir as the treatment of choice for patients with herpes zoster.
796. Cutaneous Mycobacterium marinum infection is most often associated with exposure to fish tanks.
797. The most appropriate diagnostic study is biopsy of a nodule for histopathologic examination, acid-fast stain, and culture.
798. Trimethoprim–sulfamethoxazole is the preferred antimicrobial therapy for a patient with a brain abscess caused by Nocardia species.
799. Patients with a presumptive diagnosis of Rocky Mountain spotted fever should receive treatment with doxycycline even before the diagnosis is confirmed.
800. Campylobacter jejuni is the most common cause of bacterial diarrheal disease in the United States.
801. C. jejuni often causes disease by cross-contamination of cooking utensils or surfaces such as countertops.
802. A complete history of antiretroviral drug use is essential for a patient with HIV infection who has been on many drugs and is not benefiting from the current treatment regimen.
803. Aspergillosis is the most common pulmonary mold infection in immunosuppressed patients in the United States.
804. Aspergillus infection cannot be distinguished from infection caused by Pseudallescheria before culture results are available
805. Nosocomial outbreaks of Clostridium difficile and norovirus have been well documented in recent years.
806. Nosocomial outbreaks of C. difficile and norovirus require contact isolation and increased cleaning of all patients' rooms.
807. Options for treatment of community-acquired pneumonia in an outpatient without additional risk factors include an advanced-generation macrolide or a ketolide or doxycycline.
808. Treatment of an outpatient with community-acquired pneumonia should be started without waiting for results of Gram stain and culture.
809. Patients with central nervous system Lyme disease who are allergic to β-lactam antibiotics should be given doxycycline.
810. Corticosteroids have been shown to significantly alleviate acute pain in patients with herpes zoster (shingles).
811. Corticosteroids are contraindicated in patients with poorly controlled plasma glucose levels, osteoporosis, or hypertension.
812. Hos

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812. Hospitalized patients with community-acquired pneumonia can usually be changed from an intravenous to an oral antibiotic regimen when fever, cough, and dyspnea have resolved; oral intake is satisfactory; and the leukocyte count is returning towards normal.
813. Asymmetric migratory joint pain and pustular lesions are characteristic of disseminated gonococcal infection.
814. Cultures of the pharynx, cervix, and anus should be obtained for a woman with suspected disseminated gonococcal infection.
815. Approximately 50% of patients with AIDS and progressive multifocal leukoencephalopathy will survive the latter disease if highly active antiretroviral therapy is administered.
816. Polymerase chain reaction of cerebrospinal fluid is the preferred test for diagnosing herpes simplex virus encephalitis.
817. Acute cellulitis in an immunosuppressed patient may be due to unusual pathogens, such as Cryptococcus neoformans.
818. Administration of zidovudine to a pregnant patient with HIV infection is believed to reduce the risk of maternal-to-child transmission of HIV.
819. Efavirenz is contraindicated in a pregnant patient with HIV infection.
820. Cyclosporiasis is associated with positive acid-fastâ€“stained stool specimens and copious diarrhea without fever.
821. The treatment of choice for cyclosporiasis is trimethoprimâ€“ sulfamethoxazole.
822. The incidence of fluoroquinolone-resistant N. gonorrhoeae has been increasing, especially on the West Coast of the United States and in Hawaii.
823. The most appropriate treatment for concurrent gonorrhea and a chlamydial infection is a single dose of intramuscular ceftriaxone plus oral azithromycin.
824. Patient-administered antibiotic therapy is usually appropriate for women with recurrent episodes of uncomplicated urinary tract infections.
825. Risk factors for aspiration pneumonia include difficulty swallowing, episodes of depressed consciousness, and mechanical factors such as esophageal obstruction.
826. Clindamycin provides effective treatment for anaerobic aspiration pneumonia.
827. Necrotizing fasciitis in an injection drug user may be due to many different organisms.
828. The most effective initial empiric antibiotic regimen for necrotizing fasciitis in an injection drug user is vancomycin plus piperacillinâ€“tazobactam plus clindamycin.
829. The most successful therapy for treating infected prosthetic joints involves removal of the prosthesis and a 6-week course of antimicrobial therapy followed by reimplantation of a new prosthesis.
830. Aztreonam can be used safely in patients who are allergic to penicillin.
831. The U.S. Centers for Disease Control and Prevention include aerosolized viruses that cause Ebola, Marburg, and Lassa fevers; Argentine hemorrhagic fever; and Bolivian hemorrhagic fever as most likely to be used as biochemical weapons.
832. Influenza virus resistance develops rapidly following exposure to rimantadine.
833. If one family member develops resistance after taking rimantadine for treatment of influenza, the resistant virus can be transmitted to other family members.
834. Hyponozoites of Plasmodium vivax malaria may remain in the liver for long periods and become reactivated at a later date.

here is the Gastroenterology and hepatology notes:

Gastroenterology and hepatology
839. Crohn's disease is more common in current smokers, whereas ulcerative colitis occurs more often in former smokers and nonsmokers.
840. Colonoscopic findings in Crohn's disease include deep ulcerations separated by areas of normal mucosa (skip lesions) and rectal sparing.
841. Colonoscopic findings in ulcerative colitis include continuous inflammation, typically including the rectum, but without deep ulcerations or skip lesions.
842. Approximately 70% of patients with gastric or duodenal ulcer disease also have Helicobacter pylori infection.
843. Patients with dyspepsia without alarm features (vomiting, weight loss, anemia) can usually be treated empirically for H. pylori infection.
844. Patients with acute gallstone pancreatitis present with elevated serum aminotransferase values and pancreatic enzyme values that rapidly return toward normal.
845. Patients with hepatitis C and cirrhosis are at increased risk for development of hepatocellular carcinoma.
846. The finding of a new mass with vascular enhancement in a patient with hepatitis C and cirrhosis almost certainly indicates hepatocellular carcinoma.
847. The most common cause of odynophagia (pain on swallowing) is pill-induced esophagitis.
848. Gastroparesis is a well-recognized complication of diabetes mellitus.
849. Patients with gastroparesis should be started on small, frequent feedings of a diet low in fiber, fat, and refined sugar.
850. Patients with choledocholithiasis typically have moderate to severe epigastric or right upper quadrant abdominal pain that is usually intermittent, inconsistently associated with nausea or vomiting, and occasionally nocturnal.
851. Symptomatic patients with choledocholithiasis almost always have elevated serum aminotransferase values.
852. Upper endoscopy with small bowel biopsies is the definitive test to confirm or exclude a diagnosis of celiac sprue.
853. Antimitochondrial antibody titers of more or equal to 1:40 occur in approximately 90% of patients with primary biliary cirrhosis.
854. Marked volume depletion is a poor prognostic sign in a patient with acute pancreatitis.
855. Vigorous hydration is critical in a patient with acute pancreatitis and marked volume depletion in order to maximize pancreatic perfusion and reduce subsequent complications.
856. Patients who have had pancolitis for 10 or more years should undergo colonoscopy with biopsies every 1 to 2 years for colorectal cancer surveillance.
857. Elevated serum aminotransferase values and a positive assay for antibody to hepatitis C virus (anti-HCV) in a patient with risk factors for HCV are highly suggestive of the presence of hepatitis C.
858. Patients with a positive assay for antibody to hepatitis C virus (anti-HCV) should be tested for HCV RNA to determine if viremia is present.
859. A Dieulafoy lesion is an abnormally large artery located just below the gastric mucosa that is prone to rupture and cause large-volume bleeding.
860. Proton pump inhibitors are most effective for treating an active nonsteroidal anti-inflammatory drug (NSAID)â€“induced ulcer when the NSAID cannot be discontinued.
861. Patients with oropharyngeal dysphagia typically have difficulty swallowing both solid foods and liquids, coughing and choking during meals, and changes in voice quality.
862. A videofluoroscopy study is the most appropriate initial test in patients with suspected oropharyngeal dysphagia.
863. Gastrointestinal bleeding, fever, abdominal pain, and leukocytosis in a patient with an abdominal prosthetic vascular graft should raise suspicion for an aortoenteric fistula.
864. Upper endoscopy is the initial diagnostic study for evaluation of a possible aortoenteric fistula.
865. If upper endoscopy is normal despite a strong clinical suspicion for an aortoenteric fistula, a contrast-enhanced CT scan of the abdomen should be done next.
866. Patients with severe cholangitis generally present with fever, jaundice, and altered mental status; abdominal pain is usually, but not invariably, present.
867. Patients with cholangitis require endoscopic retrograde cholangiopancreatography to determine the presence of common bile duct stones and provide endoscopic therapy, if indicated.
868. Endoscopic ultrasonography is the most sensitive test for diagnosing an insulinoma of the pancreas.
869. In patients with chronic ulcerative colitis, the finding of low-grade dysplasia on surveillance colonoscopy is associated with an increased risk of progression to high-grade dysplasia or cancer.
870. Patients with chronic ulcerative colitis and dysplasia of any grade detected on surveillance colonoscopy should be referred for colectomy.
871. Liver biopsy should be considered for selected patients with suspected nonalcoholic fatty liver disease.
872. Rosiglitazone or pioglitazone may be indicated for patients with nonalcoholic steatohepatitis and features of the metabolic syndrome in order to prevent progression of the liver disease.
873. Intraoperative endoscopy may be needed for a patient with unexplained severe recurrent gastrointestinal bleeding that cannot be diagnosed by less invasive studies.
874. Patients with short bowel syndrome associated with less than 115 cm of small intestine in the absence of a colon will most likely require continuous total parenteral nutrition.
875. A proton pump inhibitor or an H2-receptor antagonist may help reduce excessive gastric secretions and stomal fluid losses in patients with short bowel syndrome.
876. Bariatric surgery is effective for reducing morbidity associated with obesity-related disorders, such as type 2 diabetes mellitus, hypertension, obstructive sleep apnea, and hyperlipidemia.
877. â€¢ Development of gallstones is a common complication following bariatric surgery
878. The incidental finding of indirect (unconjugated) hyperbilirubinemia in an asymptomatic patient with a normal hemoglobin level and otherwise normal liver tests is indicative of Gilbert's syndrome.
879. Tenesmus (a sensation of incomplete evacuation of the bowels) indicates the presence of proctitis.
880. Neisseria gonorrhoeae infection should be considered as a cause of proctitis in sexually active patients.
881. A patient with acute pancreatitis should be evaluated for the presence of hypertriglyceridemia.
882. Patients with diabetes mellitus and associated neuropathy are at increased risk for development of small bowel bacterial overgrowth.
883. Patients with small bowel bacterial overgrowth often have secondary lactose intolerance
884. Patients with acute gastrointestinal bleeding associated with decreased consciousness, an absent gag reflex, and continued hematemesis require airway protection as the initial step in management.
885. Preoperative endoscopic retrograde cholangiopancreatography is indicated prior to laparoscopic cholecystectomy only for patients with gallstones and possible concomitant common bile duct stones.
886. Patients with a high-risk polypoid lesion detected and removed during screening colonoscopy should undergo surveillance colonoscopy in 3 years.
887. Symptoms of noncardiac chest pain frequently mimic those of cardiac chest pain.
888. The diagnosis of noncardiac chest pain can only be made after a thorough evaluation has ruled out cardiac causes for the pain.
889. Low-dose antidepressants may be helpful in treating patients with noncardiac chest pain.
890. Antinuclear antibody and antiâ€“smooth muscle antibody titers more or equal to 1:80 support a diagnosis of autoimmune hepatitis.
891. Antimitochondrial antibody is the serologic marker for primary biliary cirrhosis.
892. Gastrinoma (Zollinger-Ellison syndrome) and gastric distention related to gastric outlet obstruction are causes of hypergastrinemia.
893. A helical CT scan of the abdomen is a reasonable initial test when evaluating a patient for a possible gastrinoma.
894. Patients who have had two or more episodes of diverticulitis are more likely to develop complications such as abscesses, strictures, and perforation.
895. Patients who have had two or more episodes of diverticulitis should undergo surgical resection of the affected intestine.
896. An asymptomatic patient with a single positive fecal occult blood test on routine screening requires follow-up with colonoscopy.
897. Candidiasis is the most common esophageal disorder in patients with HIV infection.
898. Patients with HIV infection associated with dysphagia and odynophagia should receive an empiric trial of fluconazole.
899. Nonulcer dyspepsia is the most common cause of epigastric pain in a young, otherwise healthy patient.
900. A trial of a proton pump inhibitor is warranted in a young patient with a first episode of nonulcer dyspepsia and a negative serologic test for Helicobacter pylori.
901. Chronic intestinal pseudo-obstruction may be associated with a paraneoplastic syndrome.
902. The hallmark of mesenteric ischemia is the presence of pain that is out of proportion to the physical examination findings.
903. The most common cause of mesenteric ischemia is a prothrombotic state due to an inherited or acquired coagulation disorder or malignancy.
904. CT angiography is usually done to establish the diagnosis of mesenteric ischemia.
905. Patients with severe, acute pancreatitis require enteral, rather than parenteral, nutrition.
906. Fulminant hepatic failure is the clinical syndrome of severe acute liver failure and encephalopathy in a patient without pre-existing liver disease.
907. Patients with fulminant hepatic failure require immediate evaluation for liver transplantation.
908. Patients with inflammatory bowel disease have an increased risk for developing primary sclerosing cholangitis and superimposed cholangiocarcinoma.
909. A decreasing hemoglobin level in a stable patient with a recent episode of upper gastrointestinal bleeding may be due to redistribution of fluid into the vascular space rather than to continuing bleeding.
910. Ultrasonographic findings of gallstones, a thickened gallbladder wall, pericholecystic fluid, and a positive sonographic Murphy's sign are highly specific for a diagnosis of acute cholecystitis.
911. Initial management of a patient with acute cholecystitis includes pain medication, broad-spectrum antibiotics, and surgical consultation for elective cholecystectomy.
912. Artificial sweeteners that contain poorly absorbed carbohydrates (e.g., sorbitol, mannitol) may cause flatulence and diarrhea.
913. Anal fissures generally cause rectal outlet bleeding and pain with defecation.
914. Anal fissures may occur after a period of constipation.
915. Nutcracker esophagus is a spastic condition characterized by high-amplitude peristaltic waves on esophageal manometry.
916. Patients with nutcracker esophagus should be evaluated for the presence of gastroesophageal reflux disease.
917. A person who has a first-degree relative with colorectal cancer should initially undergo colorectal cancer screening 10 years before the age of diagnosis of the affected relative or at age 40 years, whichever comes first.
918. Patients with chronic pancreatitis often require narcotics for pain control.
919. Patients with acute hepatitis generally have more symptoms, are more likely to be jaundiced, and have higher serum aminotransferase values than those with chronic hepatitis.
920. Adults with hepatitis A are generally jaundiced, whereas many infants and children with this infection do not have jaundice.
921. A Mallory-Weiss tear is a laceration near the gastroesophageal junction that often results from forceful retching.
922. Bleeding from a Mallory-Weiss tear stops spontaneously in more than 90% of patients.
923. Mesalamine enemas are the most effective initial treatment for patients with ulcerative proctosigmoiditis.
924. The most common finding in patients with peptic ulcer disease is gnawing epigastric pain.
925. Pulmonary infiltrates, hepatomegaly, and a high alkaline phosphatase value are indicative of hepatic sarcoidosis.
926. Recurrent attacks of pancreatitis in a postcholecystectomy patient are most often caused by sphincter of Oddi dysfunction or pancreas divisum.
927. Fever, alcoholism, findings consistent with chronic liver disease, and a serum aspartate aminotransferase to serum alanine aminotransferase ratio (AST:ALT) more than 2 are associated with alcoholic hepatitis.
928. Self-limited hematochezia is a common cause of ischemic colitis in elderly patients.
929. Diagnostic studies, other than colonoscopy or flexible sigmoidoscopy, are usually not needed after an episode of ischemic colitis.
930. Patients with documented gallbladder stones and unexplained, nonspecific gastrointestinal symptoms should undergo diagnostic studies to identify other potential causes before cholecystectomy is performed.
931. Elderly patients with chronic hepatitis C virus infection who have other comorbid illnesses may not be candidates for treatment of hepatitis.
932. The age of a patient with obscure gastrointestinal bleeding helps guide the choice of diagnostic studies to be performed.
933. A young patient with obscure gastrointestinal bleeding should undergo diagnostic studies for Meckel's diverticulum.
934. An older patient with obscure gastrointestinal bleeding should undergo studies for angiectasias.
935. An intra-abdominal infection should be excluded before beginning immunosuppressive agents in a patient with a severe flare of Crohn's disease.
936. Hepatic adenomas are the most likely benign liver tumor to cause bleeding.
937. Hepatic adenomas should be resected whenever possible because of their potential for becoming malignant and their risk for bleeding.
938. Cameron's erosions are most often found in patients with large hiatal hernias and iron deficiency anemia.
939. Barrett's esophagus is a risk factor for the development of esophageal adenocarcinoma.
940. Patients with Barrett's esophagus without dysplasia should undergo surveillance upper endoscopy with esophageal biopsies every 3 years after the original diagnosis.
941. Patients with secretory diarrhea of unknown cause should be evaluated for the presence of microscopic colitis.
942. Biopsies of the colonic mucosa at the time of flexible sigmoidoscopy or colonoscopy are the definitive study for diagnosing microscopic colitis.
943. Cavernous hemangiomas are benign lesions that are found in 2% of the general population.
944. Cavernous hemangiomas are usually found incidentally when patients have imaging studies for other indications.
945. Patients who have diarrhea associated with fever, abdominal pain, and leukocytosis should be evaluated for the presence of an invasive or inflammatory bowel disease.
946. Visualization and biopsies of the colonic mucosa at the time of flexible sigmoidoscopy or colonoscopy are the definitive studies for diagnosing the cause of invasive or inflammatory diarrhea.
947. Upper endoscopy is the most appropriate initial diagnostic study for a patient with suspected peptic ulcer disease and one or more alarm features (vomiting, weight loss, anemia) suggestive of a possible ulcer-related complication.
948. Marked elevations in serum aspartate aminotransferase and alanine aminotransferase values may occur in patients with a skeletal muscle injury.
949. The least invasive palliative procedure for a patient with metastatic pancreatic adenocarcinoma and malignant obstructive jaundice is placement of an expandable metal stent during endoscopic retrograde cholangiopancreatography.
950. Cholangitis is the most common cause of liver abscesses.
951. Percutaneous aspiration is helpful for both diagnosis and treatment of pyogenic liver abscesses.
952. Patients with amyloidosis frequently have diarrhea and bleeding in addition to other signs and symptoms.
953. Patients with primary sclerosing cholangitis have a 10% to 30% lifetime risk of developing cholangiocarcinoma.
954. Eosinophilic esophagitis is occurring more often in adults, especially those with other atopic disorders.
955. Treatment of eosinophilic esophagitis includes an elemental diet and either oral or topical corticosteroids.
956. A patient with suspected AIDS cholangiopathy should undergo endoscopic retrograde cholangiopancreatography (ERCP) to confirm the diagnosis.
957. A patient with AIDS cholangiopathy associated with extrahepatic bile duct obstruction should undergo ERCP with sphincterotomy.
958. Hepatic ischemia is characterized by marked elevations in serum aminotransferase values that rapidly improve within several days.
959. Patients with nonulcer dyspepsia in whom H2-receptor antagonists have been ineffective should be treated with a proton pump inhibitor.
960. Common variable immunodeficiency should be suspected in a patient with recurrent gastrointestinal infections (especially giardiasis) and respiratory infections.
961. Pneumatic dilation is the initial treatment for patients with achalasia.
962. Patients with achalasia who do not respond to pneumatic dilation may require myotomy.
963. Patients with cirrhosis should undergo upper endoscopy to determine the presence of esophageal varices.
964. Patients with large esophageal varices should receive a nonselective Î²-blocker for prophylaxis against variceal bleeding.
965. Certain medications, including antidepressant agents and calcium channel blockers, increase colonic transit time and may cause constipation.
966. Triple therapy (a proton pump inhibitor and two antibiotics) is the most effective regimen for eradication of Helicobacter pylori.
967. Triple therapy for eradication of H. pylori should be given for 10 to 14 days.
968. Patients with hereditary hemochromatosis usually present with abnormal liver tests, arthropathy, fatigue, and impotence.
969. â€¢ The most appropriate initial diagnostic study for a patient with suspected hereditary hemochromatosis is determination of transferrin saturation
970. A low-dose antidepressant may be effective for treating patients with nonulcer dyspepsia.
971. CT enterography is the most appropriate study for a patient with possible Crohn's disease but with a normal colonoscopic examination.
972. Persons with one or more adenomatous colorectal polyps have an increased risk for developing colorectal cancer.
973. Persons with one or more adenomatous colorectal polyps should undergo periodic colonoscopic surveillance to detect colorectal cancer.
974. In patients with chronic hepatitis B and cirrhosis, one of the oral agents is preferred to pegylated interferon because interferon may be associated with more serious complications, such as hepatic decompensation and infection.
975. Patients with cirrhosis and gastrointestinal bleeding should receive a 7-day course of norfloxacin as prophylaxis against spontaneous bacterial peritonitis.
976. Patients with ischemic colitis may have a hypotensive episode followed by abdominal pain and subsequently by hematochezia.
977. Fundic gland polyps are the most common type of non-neoplastic polyp found in the stomach.
978. Fundic gland polyps are asymptomatic and do not present a risk for malignant transformation.
979. The treatment of choice for a patient with the HELLP syndrome (hemolysis, elevated liver enzymes, low platelets) is prompt delivery of the infant.
980. Administration of oral pancreatic enzyme supplements must be spaced out during a meal (one third at the start of the meal, one third during the meal, and one third directly after the meal) in order to be effective.
981. Either azathioprine or 6-mercaptopurine provides effective maintenance therapy following a corticosteroid-induced remission in patients with ulcerative colitis.
982. Early detection and surgical resection provide the only chance for cure in a patient with gastric cancer.
983. New-onset obstructive jaundice in an elderly patient is most often due to pancreatic or biliary tract cancer.
984. Pseudoachalasia may be associated with the presence of a malignant disorder.
985. Elderly patients with achalasia should undergo upper endoscopy to rule out pseudoachalasia.
986. The symptoms of pseudoachalasia may mimic those of idiopathic (benign) achalasia.
987. The most common causes of serum aminotransferase values more than 5000 U/L are acetaminophen hepatotoxicity, hepatic ischemia, and hepatitis due to unusual viruses.
988. Persons with alcoholism can develop acetaminophen hepatotoxicity when taking lower doses of acetaminophen than those necessary to cause liver damage in persons without alcoholism.
989. Endoscopic treatment of pancreatic duct strictures may reduce abdominal pain.
990. Radiation colitis typically occurs 9 months to 4 years after radiation therapy for prostate, gynecologic, or other pelvic malignancies.
991. Symptoms of radiation colitis include tenesmus, diarrhea, and hematochezia.
992. Acute colonic pseudo-obstruction is a frequent postoperative complication that is aggravated by electrolyte imbalances and administration of narcotics.
993. The major complications of acute colonic pseudo-obstruction are cecal ischemia and possible perforation of the cecum.
994. Patients over 40 years of age who have had chronic symptoms of gastroesophageal reflux disease for more than 5 years should undergo screening for Barrett's esophagus.
995. Upper endoscopy is the test of choice for patients with gastroesophageal reflux disease who are undergoing screening for Barrett's esophagus.
996. Budesonide is the drug of choice for treating a Crohn's disease flare that is limited to the ileum.
997. Colorectal cancer screening for average-risk persons should begin at 50 years of age.
998. Recommended colorectal cancer screening studies for average-risk persons include fecal occult blood testing, flexible sigmoidoscopy, barium enema examination, and colonoscopy.
999. Most patients with primary sclerosing cholangitis also have ulcerative colitis.
1000. The diagnosis of primary sclerosing cholangitis is established by imaging studies that show a â€œstring of beadsâ€� pattern in the biliary tree.
1001. Pancreaticoduodenectomy (Whipple procedure) offers the best chance of cure for a patient with cancer of the head of the pancreas.
1002. For immunosuppressed transplant recipients who develop odynophagia, upper endoscopy to establish the cause should be considered rather than empiric therapy.
1003. Bismuth subsalicylate is effective for inducing prolonged remissions in patients with collagenous colitis.
1004. The 14C-urea breath test is the most sensitive and specific noninvasive study for documenting active Helicobacter pylori infection.
1005. A positive serologic test for H. pylori indicates only past exposure to the organism; this test does not determine active infection.
1006. Findings of vasculitis and positive antibody to hepatitis C virus (anti-HCV) are consistent with cryoglobulinemia associated with hepatitis C.
1007. Angiectasias (vascular malformations) are most often diagnosed in elderly patients with chronic occult gastrointestinal bleeding.
1008. Angiectasias may occur anywhere in the gastrointestinal tract and may be beyond the reach of standard upper endoscopes and colonoscopes.
1009. A helical CT scan of the abdomen is the most sensitive and specific initial imaging study for a patient with possible pancreatic adenocarcinoma.
1010. The first step in evaluating a patient with recurrent nausea is to rule out common systemic disorders such as thyroid disease, diabetes mellitus, and electrolyte abnormalities.
1011. Spontaneous bacterial peritonitis is an ascitic fluid infection that is a common complication in patients with cirrhosis.
1012. Spontaneous bacterial peritonitis should be suspected in any patient with cirrhosis and new or worsening decompensation.
1013. The choice of diagnostic studies for a patient with obscure gastrointestinal bleeding should take into account the patient's age and the presence of significant comorbid conditions.
1014. Drugâ€“drug interactions are common in patients taking tacrolimus or cyclosporine plus other medications.
1015. Calcium channel blockers may interfere with the metabolism of tacrolimus.
1016. Dyssenergic defecation (pelvic floor dysfunction) refers to impaired defecation caused by inappropriate contraction or impaired relaxation of the puborectalis and external anal sphincter muscles.
1017. Anorectal manometry is the most appropriate study for diagnosing dyssenergic defecation.
1018. The most common symptoms of paraesophageal hernia are postprandial fullness, pain, and vomiting.
1019. A paraesophageal hernia may be associated with gastric ischemia as a result of torsion of the stomach.
1020. The recommended treatment for a symptomatic paraesophageal hernia is urgent repair of the hernia.
1021. Eradication of Helicobacter pylori is associated with a significant decrease in the risk of developing a recurrent ulcer.
1022. Eradication of H. pylori does not reduce the risk of developing gastric cancer.
1023. Because patients with celiac sprue are at increased risk for osteoporosis and osteomalacia, monitoring of serum vitamin D and calcium levels is required.
1024. The most appropriate treatment for primary biliary cirrhosis is ursodeoxycholic acid.
1025. Approximately 3% to 5% of patients found to have one colorectal cancer will have one or more synchronous cancers in other areas of the colon.
1026. A patient diagnosed with colorectal cancer requires evaluation of the entire colon either preoperatively or postoperatively to detect possible synchronous lesions.
1027. Patients with longstanding ulcerative colitis have an increased risk of developing colorectal cancer.
1028. â€¢ Proctocolectomy should be considered for patients with ulcerative colitis associated with colonic dysplasia
1029. The overall risk of maternalâ€“fetal transmission of hepatitis C is approximately 5%.
1030. Mothers infected with both hepatitis C and HIV have an increased risk of transmitting hepatitis C to their newborns.
1031. To determine the occurrence of maternalâ€“fetal transmission of hepatitis C, the newborn should be checked for HCV RNA at 2 to 6 months of age.
1032. Patients with postcholecystectomy bile leak usually present with diffuse abdominal pain, nausea, fever, and mild hyperbilirubinemia.
1033. â€¢ Postcholecystectomy bile leaks can be identified by endoscopic retrograde cholangiopancreatography
1034. The presence of a hypervascular hepatic mass in a patient with cirrhosis and a high serum Î±-fetoprotein level is diagnostic of hepatocellular carcinoma.
1035. Patients with advanced liver disease and hepatocellular carcinoma should usually be evaluated for liver transplantation.
1036. Patients with familial pancreatitis are at increased risk for developing pancreatic adenocarcinoma.
1037. The initial test in a patient with possible gastric outlet obstruction is upper endoscopy.
1038. A serumâ€“ascites albumin gradient (SAAG) more than or equal to 1.1 g/dL is consistent with portal hypertension.
1039. Portal hypertension is most often due to cirrhosis.
1040. Fundoplication should be considered for a patient with severe iron deficiency anemia associated with Cameron's erosions who cannot tolerate oral iron therapy.
1041. The great majority of recurrent colorectal cancers develop within 2 years postoperatively.
1042. A patient who has undergone resection for colorectal cancer requires surveillance colonoscopy 3 years postoperatively to detect the possible presence of metachronous lesions.
1044. Pill-induced esophagitis is characterized by the acute onset of painful swallowing (odynophagia) shortly after a patient begins taking a drug.
1045. Treatment of pill-induced esophagitis involves discontinuing the causative drug.
1046. Wilson's disease should be considered in a young patient with abnormal liver chemistry studies, cognitive changes, and hemolysis.
1047. A low serum ceruloplasmin value ( less than 20 mg/dL) is indicative of Wilson's disease.
1048. Patients with acute diverticulitis who are able to take liquids and are not dehydrated can usually be managed on an outpatient basis.
1049. The initial steps in managing outpatients with acute diverticulitis are administration of oral antibiotics and re-evaluation in several days.
1050. The preferred treatment of gastroparesis in the United States is administration of metoclopramide.
1051. Erythromycin should be considered for patients with gastroparesis who cannot tolerate metoclopramide.
1052. Obesity, hyperlipidemia, and hyperglycemia are risk factors for nonalcoholic fatty liver disease.
1053. Nearly 40% of patients with nonalcoholic fatty liver disease do not have obvious risk factors for this condition.
1054. A mucinous cystic neoplasm of the pancreas is often asymptomatic and is detected as an incidental finding during abdominal imaging studies for other causes.
1055. Because of its malignant potential, a mucinous cystic neoplasm of the pancreas should be surgically resected.
1056. Patients who have undergone gastrectomy may develop dumping syndrome, which is characterized by nausea, abdominal pain and distention, lightheadedness, and diaphoresis.
1057. Patients with dumping syndrome should initially be treated conservatively with a diet consisting of six small meals daily.
1058. A Dieulafoy lesion is an unusually large aberrant submucosal artery that can cause significant gastrointestinal bleeding.
1059. A Dieulafoy lesion may be missed on upper endoscopy unless active bleeding is occurring at the time of the endoscopic examination.
1060. A proton pump inhibitor is the agent of choice for healing a nonsteroidal anti-inflammatory drug (NSAID)â€“induced gastric ulcer after the NSAID has been discontinued.
1061. Prostaglandin analogues may prevent NSAID-induced lesions but do not treat an active ulcer.
1062. Patients with either chronic mesenteric ischemia or a malignancy may present with similar findings of postprandial pain, weight loss, and anorexia.
1063. The diagnosis of chronic mesenteric ischemia is established by the clinical history and findings of compromised mesenteric vessels on imaging studies.
1064. The treatment of chronic mesenteric ischemia is either a surgical or an interventional radiologic revascularization procedure.
1065. Patients with chronic hemolysis may develop secondary iron overload.

RHEUMATOLOGY

1066. Manifestations of systemic lupus erythematosus include arthralgias, photosensitive rash, malar rash, oral ulcers, pancytopenia, and serositis.
1067. The most common joints involved in osteoarthritis are the knee, hip, distal and proximal interphalangeal, and first carpometacarpal.
1068. Osteoarthritis is characterized by pain that worsens with activity and morning joint stiffness that lasts less than 30 minutes.
1069. Postmenopausal women who use diuretics have an increased risk for tophaceous gout of the distal interphalangeal joints.
1070. Patients with diffuse cutaneous systemic sclerosis are at increased risk for developing interstitial lung disease.
1071. Antiâ€“Scl-70 antibodies are most frequently associated with diffuse cutaneous systemic sclerosis and an increased risk for interstitial lung disease.
1072. Chest radiography frequently does not detect early interstitial fibrosis.
1073. The chronic inflammatory state of rheumatoid arthritis is associated with an increased risk for death from a coronary event.
1074. The erythrocyte sedimentation rate is useful for monitoring chronic inflammatory changes but may be elevated in the setting of advanced age, anemia, and other disease states.
1075. Takayasu's arteritis is a chronic, idiopathic, granulomatous inflammatory disease primarily of the aorta and its main branches that affects reproductive-age women.
1076. Constitutional symptoms and ischemic signs or symptoms in the territory of one or more large arteries in a woman 18 months of minocycline exposure.
1095. Liver involvement in minocycline-induced lupus often mimics autoimmune hepatitis.
1096. The clinical presentation of adult contacts of children with parvovirus B19 infection may mimic rheumatoid arthritis.
1097. Parvovirus B19â€“related arthritis is self-limited, may not have an associated rash, resolves within 1 to 2 months, and usually responds to nonsteroidal anti-inflammatory drugs.
1098. Polymyalgia rheumatica is characterized by pain or morning stiffness in the neck or torso, shoulders and upper arms, or hips and thighs in patients >50 years of age with an erythrocyte sedimentation rate >40 mm/h.
1099. Prednisone therapy rapidly alleviates symptoms of polymyalgia rheumatica.
1100. Olecranon bursitis may be infectious, crystalline, or traumatic.
1101. Bursa aspiration is indicated for patients with acute olecranon bursitis to guide therapy.
1102. Patients with fibromyalgia have widespread musculoskeletal pain and stiffness, paresthesias, nonrestorative sleep, fatigue, and multiple symmetrical painful tender points.
1103. Results of laboratory studies in patients with fibromyalgia are normal.
1104. Patients with a long history of Raynaud's phenomenon and diffuse or limited cutaneous scleroderma are at risk for pulmonary vascular disease.
1105. High-dose corticosteroid therapy in the setting of scleroderma may be associated with normotensive renal crisis.
1106. Invasive diagnostic studies or empirical treatment is not indicated in asymptomatic patients with an isolated elevated creatine kinase level.
1107. Antiâ€“cyclic citrullinated peptide antibody positivity is strongly associated with rheumatoid arthritis and may have the best predictive value when combined with rheumatoid factor measurement.
1108. Patients taking prednisone, equal or more than 5 mg/d, for more than 3 months may benefit from calcium and vitamin D supplements and a bisphosphonate.
1109. Allopurinol is equally effective in the setting of inefficient excretion and overproduction of urate.
1110. Allopurinol at a dose of more than 300 mg/d is necessary for approximately 50% of patients with hyperuricemia in order to achieve urate levels less than 6 mg/dL.
1111. Antibiotics, such as ampicillinâ€“sulbactam and others with broad-spectrum coverage, are indicated for animal bites.
1112. There is no treatment for scleroderma that is disease modifying.
1113. Therapy for scleroderma involves systematic management of end-organ involvement.
1114. In patients with scleroderma, high-dose corticosteroid therapy may be associated with normotensive renal crisis.
1115. Estrogen therapy is contraindicated in women with antiphospholipid antibodies.
1116. An unexplained prolonged activated partial thromboplastin time raises suspicion for the antiphospholipid antibody syndrome.
1117. Rheumatoid arthritis predisposes patients to secondary osteoarthritis.
1118. Immediate prednisone therapy is indicated for patients with clinical suspicion for giant cell arteritis before temporal artery biopsy to decrease the risk for visual loss.
1119. Low-dose aspirin may decrease visual loss and cerebrovascular incidents in the setting of giant cell arteritis.
1120. Left shoulder pain may be referred from the neck; chest; or subdiaphragmatic area, including the spleen.
1121. Intra-articular corticosteroid injections effectively relieve symptoms of knee osteoarthritis.
1122. Small-bowel bacterial overgrowth is a common cause of diarrhea in patients with scleroderma and is treated with intermittent broad-spectrum antibiotics.
1123. Opioid antidiarrheal therapy is not indicated for patients with scleroderma because it may worsen intestinal motility disorders.
1124. Psoriatic arthritis is associated with dactylitis and asymmetrical distal interphalangeal joint inflammation.
1125. The risk for malignant disease is increased in dermatomyositis and polymyositis and in inclusion body myositis.
1126. â€¢ Evaluation for an underlying malignancy is indicated in patients with refractory myositis
1127. Combination therapy with methotrexate and antiâ€“tumor necrosis factor agents is the most likely regimen to improve function, limit further damage, and control disease in severe rheumatoid arthritis.
1128. Immunosuppressed patients have increased risk for developing primary or reactivation tuberculosis.
1129. Prophylactic isoniazid therapy is beneficial in patients who use prednisone, equal or more than 15 mg/d, or any other immunosuppressive agent and who have equal or more than 5 mm of induration on tuberculin skin testing.
1130. Urate levels in patients with tophaceous gout should be reduced to 6.0 mg/dL (0.36 mmol/L) to dissolve tophi and other urate depositions in the tissue.
1131. Because decreasing the urate level in a patient with tophaceous gout may induce a gouty attack, continuation of prophylactic doses of colchicine is indicated until the tophi resolve and the urate level stabilizes.
1132. Acetaminophen is an effective, safe, and inexpensive treatment for osteoarthritis.
1133. Patients with osteoarthritis who have high risk for nonsteroidal anti-inflammatory drug complications may use alternate therapy with acetaminophen, often without compromising pain control.
1134. Patients with joint abnormalities have an increased risk for joint infection.
1135. Intra-articular corticosteroid therapy is contraindicated until infection is excluded.
1136. Alveolar hemorrhage may develop in systemic lupus erythematosus even without hemoptysis.
1137. Amyloidosis is an uncommon but potentially severe side effect of chronic inflammatory diseases, such as rheumatoid arthritis.
1138. Rheumatoid arthritisâ€“associated amyloidosis primarily involves the kidneys and may lead to the nephrotic syndrome and renal failure.
1139. Patients treated with cyclophosphamide have increased risk for transitional cell carcinoma of the bladder.
1140. Lifelong screening for bladder cancer is indicated for patients treated with cyclophosphamide.
1141. Adequate drainage and intravenous antibiotics are standard treatment for a â€œclosed-spaceâ€� joint infection.
1142. The malar rash of systemic lupus erythematosus is often photosensitive and spares the nasolabial folds and areas below the nares and lower lip.
1143. Rosacea is an inflammatory dermatitis characterized by erythema, telangiectasias, papules, pustules, and sebaceous hyperplasia that affects the central face, including the nasolabial folds.
1144. Antiâ€“tumor necrosis factor-Î± therapy is contraindicated in patients with infection.
1145. Corticosteroid-induced myopathy is characterized by continued or worsening proximal muscle weakness, particularly in the lower extremities, after a decrease in or normalization of muscle enzyme levels.
1146. Tramadol is as effective as ibuprofen in alleviating pain in osteoarthritis of the hip and knee in patients in whom nonsteroidal anti-inflammatory drugs are contraindicated or do not provide adequate pain relief.
1147. Upper- and lower-extremity weakness and gait abnormalities associated with rheumatoid arthritis strongly suggest cervical spine impingement.
1148. Immediate MRI scanning is indicated in patients with rheumatoid arthritis with suspected cervical spine impingement.
1149. Postexposure prophylaxis may benefit immunocompromised patients exposed to influenza virus.
1150. Administration of antiviral therapy does not affect the immune response to inactivated influenza vaccine.
1151. Intranasal trivalent live-attenuated influenza vaccination is contraindicated in immunosuppressed patients.
1152. Colchicine toxicity may cause acute vacuolar myopathy and axonal neuropathy.
1153. Use of colchicine with inhibitors of CYP3A4 and P-glycoprotein, which metabolize and transport this agent, respectively, may increase the likelihood of drug toxicity.
1154. Calcification of the cartilage, particularly the fibrocartilage of the knee meniscus, symphysis pubis, and glenoid and acetabular labrum and the triangular cartilage of the wrist, is pathognomic for calcium pyrophosphate deposition disease.
1155. An atypical distribution of osteoarthritis without a history of trauma suggests calcium pyrophosphate deposition disease.
1156. Prednisone and hydroxychloroquine are the preferred anti-inflammatory drugs during pregnancy.
1157. Upward titration of prednisone may be indicated if other immunosuppressant agents are discontinued during pregnancy.
1158. Hemorrhagic cystitis and bladder cancer are uncommon side effects of cyclophosphamide therapy.
1159. Follow-up cystoscopy is indicated for patients with hematuria and a history of treatment with cyclophosphamide.
1160. Methotrexate remains a vital drug in the treatment of rheumatoid arthritis.
1161. Combination therapy with methotrexate and antiâ€“tumor necrosis factor-Î± agents provides the best suppression of joint damage and leads to maximal clinical improvement in rheumatoid arthritis.
1162. Wegener's granulomatosis is a necrotizing granulomatous inflammation of small- to medium-sized vessels with a predilection for the upper and lower respiratory tracts and kidneys.
1163. LÃ¶fgren's syndrome, a variant of sarcoidosis, is characterized by the concomitant presence of acute erythema nodosum, hilar adenopathy, arthritis or periarthritis, and fever.
1164. Compared with physical examination, radiography of the hands is less sensitive and specific for symptomatic hand osteoarthritis.
1165. The most characteristic radiographic finding of osteoarthritis is osteophytes with joint-space narrowing.
1166. The most characteristic radiographic finding of psoriatic arthritis is the coexistence of erosive changes and new bone formation in the distal joints.
1167. Methotrexate is metabolized by the liver and excreted by the kidneys and should be reduced or discontinued in the setting of renal insufficiency.
1168. Inclusion body myositis is characterized by proximal and distal muscle involvement, asymmetrical muscle weakness and atrophy, falls, and mixed neuropathic and myopathic findings on electromyography.
1169. Muscle biopsy is the diagnostic study of choice for myositis.
1170. Characteristic radiographic changes of the hands associated with rheumatoid arthritis include juxta-articular osteoporosis and marginal erosions in the metacarpophalangeal joints.
1171. Propylthiouracil use is strongly associated with the development of antineutrophil cytoplasmic antibodies directed against myeloperoxidase and associated vasculitis.
1172. Antineutrophil cytoplasmic antibodyâ€“positive drug-induced vasculitis may continue to progress after discontinuation of the inciting medication.
1173. Whipple's disease is a chronic infection with multiorgan manifestations, including uveitis, diplopia, asymmetrical inflammatory arthritis, and weight loss.
1174. Corticosteroid therapy often resolves polymyalgia rheumatica symptoms within 24 hours.
1175. The mean duration of therapy for polymyalgia rheumatica is 2.4 years at an average prednisone dose of 9.6 mg/d.
1176. Hydroxychloroquine therapy is associated with retinal toxicity.
1177. Antinuclear antibody positivity may occur in 10% to 15% of healthy young women, in pregnancy, and with increasing age.
1178. An antinuclear antibody assay is indicated only if there is a high pretest probability of systemic lupus erythematosus or another connective tissue disease.
1179. Inflammatory changes in ankylosing spondylitis begin in the T12 to L1 region of the spine and eventually lead to ossification of the outer fibers of the annulus fibrosis and the development of syndesmophytes.
1180. Cryoglobulinemic vasculitis is characterized by palpable purpura, arthritis, weakness, neuropathy, and a membranoproliferative glomerulonephritis.
1181. Laboratory findings in cryoglobulinemic vasculitis include circulating cryoglobulins, rheumatoid factor positivity, hypocomplementemia, and an elevated erythrocyte sedimentation rate.
1182. Hepatitis C is a common cause of cryoglobulinemic vasculitis.
1183. Arthritis associated with hepatitis C infection may occur early or late in the disease course of this infection and may mimic rheumatoid arthritis.
1184. Even in the absence of arthritis, patients with hepatitis C infection often are rheumatoid factor positive.
1185. Primary Raynaud's phenomenon is not typically associated with damaging digital ischemia.
1186. The preferred initial treatment for primary Raynaud's phenomenon is nonpharmacologic.
1187. Concomitant use of sulfamethoxazole and methotrexate is contraindicated.
1188. Manifestations of inflammatory myositis may include elevated antinuclear antibody titers and creatine kinase levels, abnormal electromyography findings, proximal muscle weakness, interstitial lung disease, arthritis, and skin rashes.
1189. Reactive arthritis is a systemic inflammatory disorder triggered by a mucosal infection in the urethra or the bowel and is manifested by a nonseptic oligoarticular arthritis; enthesitis; and, occasionally, eye, skin, or mucosal inflammation.
1190. SjÃ¶gren's syndrome is characterized by oral and ocular dryness and anti-Ro/SSA and/or anti-La/SSB antibody positivity in women between 40 and 60 years of age.
1191. SjÃ¶gren's syndrome is associated with an increased risk for non-Hodgkin's lymphoma and other lymphoproliferative conditions.
1192. A complete response to appropriate antibiotic therapy for disseminated gonorrhea may take up to 72 hours.
1193. Patients with nongonococcal septic arthritis may have positive blood cultures and extra-articular sites of infection.
1194. Hemorrhagic cystitis is a possible complication of cyclophosphamide therapy.
1195. Mononeuritis multiplex is a common presenting feature of polyarteritis nodosa.
1196. Extra-articular manifestations of ankylosing spondylitis include aortitis with aortic insufficiency, upper-lobe pulmonary fibrocystic disease, amyloidosis, cardiac conduction disease, and recurrent uveitis.
1197. Relapsing polychondritis is characterized by inflammation and destruction of cartilaginous structures.
1198. The most common presenting feature associated with relapsing polychondritis is auricular pain and swelling.
1199. Reactive arthritis is characterized by large-joint oligoarthritis; enthesitis involving tendon insertion sites; and extra-articular manifestations, including uveitis.
1200. Reactive arthritis is triggered by infections in the intestines; urogenital tract; and, less commonly, throat or respiratory tract.
1201. Needle aspiration is the least invasive method for draining an easily accessible joint, such as the knee.
1202. In the setting of septic arthritis, a decrease of fluid volume and leukocyte and neutrophil counts in serial samples suggests adequate needle drainage, whereas persistence of inflammatory fluid after 7 days of therapy suggests treatment failure.
1203. Antiâ€“tumor necrosis factor-Î± therapy increases the risk for reactivation tuberculosis.
1204. Evaluation for possible septic arthritis is indicated for all patients with acute monoarticular arthritis.
1205. Patients with previously damaged joints and immunosuppression are at particularly high risk for septic arthritis.
1206. Peripheral joint disease in psoriatic arthritis responds to methotrexate and sulfasalazine, whereas related spinal inflammation does not.
1207. Psoriatic spinal inflammation responds to antiâ€“tumor necrosis factor therapy.
1208. BehÃ§et's disease is characterized by recurrent aphthous oral ulcers and at least two or more of the following features: recurrent genital ulceration, eye or cutaneous lesions, or positive findings on pathergy testing.
1209. Synovial fluid in osteoarthritis usually is clear, viscous, and noninflammatory with a leukocyte count less than 2000/ÂµL (2 Ã— 109/L).
1210. Gout and pseudogout are associated with inflammatory synovial fluid with a leukocyte count between 2000/ÂµL (2 Ã— 109/L) and 50,000/ÂµL (50 Ã— 109/L) but may be higher.
1211. Synovial fluid in septic arthritis is generally highly inflammatory with a leukocyte count between 10,000/ÂµL (10 Ã— 109/L) and 50,000/ÂµL (50 Ã— 109/L) and is often higher.
1212. Patients with the clinical triad of asthma, nasal polyps, and aspirin allergy also may have cross-reactivity to nonsteroidal anti-inflammatory drugs.
1213. Nonacetylated salicylate agents may be safely used in patients with aspirin sensitivity and asthma.
1214. Anteroposterior plain radiography of the pelvis is the initial imaging test of choice for suspected sacroiliitis.
1215. If findings on plain radiography are unequivocal or normal, MRI may detect subchondral osteitis and bone marrow edema associated with early sacroiliitis and enthesitis.
Here is the Hematology Oncology notes:

1211. Patients with acute venous thromboembolism and metastatic cancer are at higher risk for recurrent venous thrombosis than those without malignancy.
1212. Chronic low-molecular-weight heparin at therapeutic doses reduces the risk for thrombotic recurrence compared with standard-intensity warfarin in patients with venous thromboembolism and cancer.
1213. Hematologic findings in iron-deficiency anemia consist of microcytic, hypochromic red blood cells; abnormalities in erythrocyte size and shape; and occasional bizarre-shaped red blood cells.
1214. Iron-deficiency anemia is treated with iron therapy.
1215. Transfusion-related acute lung injury is an inflammatory infusion reaction in the pulmonary vasculature manifested primarily by hypoxemia.
1216. Major diagnostic criteria of polycythemia vera include an elevated red blood cell mass, a normal blood oxygen saturation, and the presence of splenomegaly.
1217. Low-dose aspirin reduces the risk of thrombotic complications in polycythemia vera.
1218. The electrophoretic gel in patients with hemoglobin SC disease is characterized by two bands of equal intensity that are slow-migrating.
1219. Monoclonal gammopathy of unknown significance (MGUS) is characterized by the presence of serum monoclonal gammaglobulin without the clinical features of multiple myeloma, a paraprotein level less than 3.5 g/dL (35 g/L), and less than 10% plasmacytosis in the bone marrow.
1220. Management of MGUS requires routine follow-up to identify signs of progression to multiple myeloma and periodic measurement of serum monoclonal protein concentration.
1221. Intraoperative acute normovolemic hemodilution ensures delivery of autologous blood with a hematocrit higher than the blood lost during surgery and has none of the clerical risks associated with blood banking.
1222. Peripheral neuropathy is a common side effect of bortezomib therapy, occurring in approximately 30% of patients who take this agent.
1223. A rapidly falling platelet count occurring within days of heparin administration is indicative of heparin-induced thrombocytopenia (HIT).
1224. In patients with HIT, heparin therapy must stopped and alternative anticoagulation with a direct thrombin inhibitor instituted immediately.
1225. Estrogen-containing oral contraceptives confer a fourfold increased relative risk for venous thromboembolism in women of childbearing age without heritable thrombophilia and a 35-fold increased risk in women who are heterozygous for the factor V Leiden mutation.
1226. Oral progestin-onlyâ€“containing contraceptives appear to confer little, if any, increased risk for venous thrombosis.
1227. No other intervention is required in handling a delayed hemolytic transfusion reaction except for avoidance of the incompatible antigen.
1228. Signs suggestive of disease transformation from myelodysplastic syndrome to acute myeloid leukemia (AML) include severe pancytopenia and circulating myeloid blasts on peripheral blood smear.
1229. Patients with transformed versus de novo AML have poorer response rates and disease-free survival, despite receiving the same chemotherapeutic regimen.
1230. Patients with the Î±-thalassemia trait have a two-gene defect ([Î±,--]/[Î±,--]) in the Î±-globin gene chain of chromosome 16.
1231. Patients who have Î±-thalassemia trait have mild microcytic anemia with prominent target cells on peripheral blood smear.
1232. Routine blood transfusion during pregnancy in patients with sickle cell disease is not necessary unless mandated by other high-risk conditions.
1233. The risk for recurrent venous thrombosis in patients with the factor V Leiden mutation is not greater than that in those without an underlying thrombophilic abnormality.
1234. Patients at high risk for recurrent thrombosis should receive long-term anticoagulation therapy with warfarin.
1235. Patients with delayed-onset heparin-induced thrombocytopenia (HIT) can present with typical manifestations of HIT as late as 3 to 4 weeks after heparin exposure.
1236. Patients with delayed-onset HIT require anticoagulation therapy with a direct thrombin inhibitor and no further exposure to heparin.
1237. Acute chest syndrome (ACS) is characterized by fever, chest pain, shortness of breath, hypoxia, and a chest infiltrate in a patient with a sickling disorder.
1238. Patients with ACS require erythrocyte transfusion to achieve a target hemoglobin of 10 g/dL (100 g/L).
1239. Erythropoietin therapy has been shown to improve anemia and reduce transfusion requirements in some patients with transfusion-dependent myelodysplastic syndrome.
1240. Patients with a drug-induced antibody reaction do not have indications of hemolysis or evidence of complement activation on direct antibody testing.
1241. Factor V Leiden and prothrombin G20210A mutations are the most common mutations predisposing to venous thrombosis in white populations, but are rare in Asian and black populations.
1242. Levels of protein S are reduced during pregnancy, making testing for deficiency of this protein unreliable.
1243. Bone marrow aspirate and biopsy should be performed in patients with suspected idiopathic thrombocytopenic purpura who do not respond to prednisone therapy.
1244. Immunosuppressive therapy with antithymocyte globulin and cyclosporine is effective in reducing transfusion requirements in more than 70% of patients with aplastic anemia.
1245. Inflammatory anemia is characterized by a low or normal serum iron concentration, reduced serum total iron-binding capacity, and serum ferritin that is not decreased.
1246. Hypercalcemia, bone pain, anemia, and clusters of large plasma cells on bone marrow aspirate smear are diagnostic of multiple myeloma.
1247. The risk for thrombosis in asymptomatic pregnant women who are heterozygous for the factor V Leiden mutation is low.
1248. Complete hematologic remission rates for patients with CML who received imatinib mesylate compared with interferon and low-dose cytarabine were 95% and 56%, respectively.
1249. Thrombotic thrombocytopenia purpura (TTP) is characterized by fever, neurologic abnormalities, thrombocytopenia, microangiopathic hemolytic anemia, and renal insufficiency.
1250. The treatment of choice for TTP is emergent plasma exchange, followed by plasma infusion when the former is not immediately available.
1251. Patients with heart failure and hemolysis require immediate transfusion, even when only incompatible blood is available, to avoid cardiovascular collapse.
1252. The initial treatment in patients with warm antibody autoimmune hemolytic anemia is corticosteroid therapy.
1253. Patients whose first thrombotic events are associated with transient risk factors are at relatively low risk for a spontaneous recurrent venous thrombotic episode.
1254. Incidental thrombocytopenia of pregnancy requires careful follow-up monitoring of the platelet count.
1255. Patients with incidental thrombocytopenia of pregnancy require further diagnostic evaluation when platelet values decrease to lower than 70,000/Î¼L (70Ã— 109/L).
1256. Drug-induced agranulocytosis is the most likely diagnosis in patients with sepsis, severe neutropenia, and relatively well-preserved hematocrit and platelet counts after ingestion of trimethoprimâ€“sulfamethoxazole
1257. A history of mucosal bleeding and a mildly prolonged activated partial thromboplastin time is consistent with a diagnosis of von Willebrand's disease.
1258. Factor V Leiden mutation is associated with venous, not arterial, thromboses.
1259. Erythropoietin failure in patients receiving dialysis can be caused by iron deficiency, folate deficiency, ongoing blood loss, or iron overload.
1260. Supplemental vitamin C can improve the response to erythropoietin in patients receiving dialysis.
1261. Patients with iron-deficiency anemia require iron-replacement therapy, not blood transfusion.
1262. Primary (AL) amyloidosis should be suspected in patients with nephrotic-range proteinuria in the presence of monoclonal gammaglobulin in serum or urine.
1263. A diagnosis of primary (AL) amyloidosis can be established by kidney biopsy.
1264. Bleeding symptoms and hematologic abnormalities in patients with autoimmune disorders, malignancy, or in the postpartum setting may be suggestive of an acquired factor VIII inhibitor.
1265. Fondaparinux administered for 28 days results in a low frequency of venous thromboembolism after hip-fracture repair and is FDA approved for extended thromboprophylaxis following this procedure.
1266. Patients with hereditary spherocytosis have predominantly spherocytic red cells on the peripheral blood smear; a mild, Coomb's-negative, hemolytic anemia; and an elevated mean cellular hemoglobin concentration.
1267. A new alloantibody is not always detectable in patients with sickle cell disease who have adverse transfusion reactions.
1268. Patients with sickle cell disease may experience infusion-related reactions that are manifested by lower, rather than higher, reticulocyte counts.
1269. Fatigue, weight loss, massive splenomegaly, and teardrop-shaped erythrocytes on peripheral blood are consistent with myelofibrosis.
1270. Chronic transfusion therapy is an appropriate management option for some patients with myelofibrosis.
1271. Isolated thrombocytopenia in an otherwise-healthy young patient is most commonly due to idiopathic thrombocytopenic purpura (ITP).
1272. Patients with ITP and low risk for bleeding as demonstrated by a platelet count >40,000 require only periodic monitoring of the platelet count.
1273. Patients with venous thromboembolism associated with oral contraceptives are generally at low risk for recurrent venous thromboembolism.
1274. Long-term oral anticoagulation is recommended in patients with unprovoked venous thrombotic events in association with antiphospholipid antibody syndrome.
1275. Patients with asymptomatic inflammatory anemia do not require additional diagnostic testing.
1276. Nonhemolytic transfusion reactions result in inflammatory-type symptoms without evidence of hemolysis.
1277. Stopping the blood transfusion is the only intervention required in the management of nonhemolytic transfusion reactions and should result in quick symptomatic resolution.
1278. A disease-free and overall survival benefit is observed in patients receiving high-dose chemotherapy and autologous stem cell transplantation during first remission from multiple myeloma.
1279. The HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets) usually resolves within several days after delivery of the fetus.
1280. An inherited thrombocytopenic disorder should be suspected in otherwise-healthy patients with a low platelet count, giant platelets on peripheral blood smear, a family history of thrombocytopenia, and who are refractory to corticosteroids
1281. Patients with vitamin B12 deficiency have elevated serum lactate dehydrogenase and unconjugated bilirubin and may have increased forgetfulness.
1282. Supplemental vitamin B12 does not always reverse the neurologic findings of B12 deficiency but may prevent further deterioration of mental status.
1283. Patients with pulmonary hemorrhage and those undergoing most types of major surgery need sustained platelet counts of 40,000 (40 Ã— 109/L) to 50,000/Î¼L (50 Ã— 109/L).
1284. The symptoms of serotonin syndrome may include tachycardia, hypertension, hyperthermia, mydriasis, hyperactive bowel sounds, diaphoresis, hyperreflexia, clonus, and changes in mental status.
1285. Warfarin with a target INR of 2 to 3 is adequate for preventing recurrent venous thrombosis in patients with antiphospholipid antibody syndrome.
1286. Patients with thalassemia may experience secondary iron overload due to increased iron absorption from the gut.
1287. Deferoxamine is a parenteral iron chelator that is used to decrease the tissue iron in patients with thalassemia.
1288. Leukoreduced blood should be used in pregnant patients in whom the cytomegalovirus infection status is not known.
1289. Imatinib mesylate can cause a mild, maculopapular rash that is most prominent over the extremities and trunk, and typically resolves within a week of interruption of therapy.
1290. For most patients who experience an imatinib-induced rash, the drug can be re-instituted after the rash resolves, without recurrence.
1291. Consumptive coagulopathy is often accompanied by thrombocytopenia and a prolonged prothrombin time.
1292. All stages of Hodgkin's lymphoma now are treated with systemic chemotherapy and no longer require invasive testing to identify the extent of disease.
1293. Mortality in patients with stage III colon cancer treated with surgical resection and adjuvant chemotherapy is decreased by as much as 33%.
1294. Patients with BRCA1/2 mutations have a higher risk for breast and ovarian cancer compared with the general population.
1295. Patients with a family history suggestive of germline-susceptibility cancer should be referred for genetic counseling.
1296. Gonadotropin-releasing hormone agonists such as leuprolide may result in bone loss in the lumbar spine in patients with prostate cancer.
1297. Î²-Carotene is associated with an increased risk for lung cancer in patie

Re: My NOTES: a small gift for you...
triplehelix - 01-12-09 23:55

1297. Î²-Carotene is associated with an increased risk for lung cancer in patients who already have an elevated risk for this disease because of smoking history.
1298. Serum Î±-fetoprotein has a half-life of 1 week and requires re-measurement at 14 to 21 days after surgery.
1299. Surgery alone is curative for patients with early-stage ovarian cancer in 90% of cases.
1300. Lymphadenopathy in the supraclavicular region almost always indicates an infectious or neoplastic cause and requires an immediate diagnostic procedure.
1301. A complete lymph node excision is always preferred over a percutaneous needle biopsy in patients with suspected Hodgkin's or non-Hodgkin's lymphoma.
1302. Patients with colon cancer and unresectable liver metastases require systemic treatment with chemotherapy.
1303. Additional diagnostic testing for extrahepatic metastases is necessary only when surgical resection of hepatic metastases is a consideration.
1304. A diet high in fruits and vegetables is associated with a lower risk for cardiovascular disease but not for cancer.
1305. Hyperviscosity syndrome must be considered in patients who have lymphoplasmacytic lymphoma (WaldenstrÃ¶m's macroglobulinemia) with an elevated serum IgM concentration and symptoms suggestive of congestive heart failure.
1306. Emergent plasmapheresis and immediate systemic chemotherapy is required in patients with lymphoplasmacytic lymphoma and a serum viscosity concentration more than 3.0 with suspicious symptoms, or a value of more than 4.0 without suspicious symptoms.
1307. Patients with prostate cancer are generally asymptomatic at diagnosis.
1308. Patients with recently diagnosed prostate cancer and a prostate-specific antigen concentration less than 10 ng/mL (10 Î¼g/L) have a low incidence of bony metastasis.
1309. Only women who are at high risk for ovarian cancer should consider prophylactic bilateral oophorectomy.
1310. Lung cancer screening does not decrease mortality and is not supported by evidence.
1311. In patients with adenocarcinoma of unknown primary site, the workup should be guided by the patient's history and physical and laboratory findings.
1312. Gemcitabine is Food and Drug Administration approved for the treatment of metastatic pancreatic cancer and results in improved clinical benefit and overall survival compared with 5-fluorouracil.
1313. Hodgkin's lymphoma survivors who receive extended-field radiation have a 1% risk/year for developing solid tumors.
1314. Tumor lysis syndrome is a consideration in patients who have bulky Burkitt's lymphoma and symptoms of vomiting and dehydration.
1315. Patients with symptomatic bulky lymphoma require hydration, urinary alkalinization, and administration of a xanthine oxidase inhibitor before chemotherapy to prevent tumor lysis syndrome.
1316. Breast-conserving surgery results in similar and sometimes superior survival in patients with early-stage breast cancer regardless of patient age compared with mastectomy.
1317. Re-excision is indicated in patients with positive tumor margins detected after breast-conserving surgery.
1318. Avoiding direct sunlight during peak hours and other sun-avoidance strategies are associated with a decreased risk for squamous cell carcinoma and malignant melanoma.
1319. Sunscreen may decrease the risk for developing squamous cell carcinoma but not malignant melanoma.
1320. Selenium has been associated with an increased risk for nonmelanomatous skin cancer compared with placebo.
1321. Treatment of patients with testicular cancer metastatic to the brain consists of whole-brain radiation therapy and combination chemotherapy.
1322. Preoperative radiation therapy plus chemotherapy can reduce tumor size and facilitates sphincter-preserving surgery in patients with distal rectal tumors.
1323. Gastric mucosa-associated lymphoid tissue (MALT) lymphoma is almost always associated with Helicobacter pylori infection.
1324. Disease in most patients with MALT lymphoma regresses after treatment with antibiotics alone within several months.
1325. Most patients with small-cell lung cancer respond dramatically to combination chemotherapy and whole-brain radiation therapy.
1326. Bisphosphonates such as pamidronate or zolendronate help reduce skeletal-related events in patients with metastatic lung cancer.
1327. Patients with abnormal breast findings on physical examination and normal mammogram should undergo further evaluation with breast ultrasonography and biopsy.
1328. Sensitivity of mammography ranges from 75% to 90%, with false-negative results most likely in women with dense breasts.
1329. Patients with stage T1c prostate cancer and a PSA less than 10 ng/mL (10 Î¼g/L) rarely have metastatic disease and don't need extensive staging
1330. Ovarian cancer screening does not result in decreased mortality in general or high-risk populations.
1331. The infrequency of ovarian cancer occurrence and invasiveness of the associated diagnostic procedures make routine ovarian cancer screening inappropriate.
1332. The risks of chemotherapy in bedbound patients with colorectal cancer who have a poor performance status outweigh its benefits because of poor likelihood for response and therapy-induced toxicity.
1333. Patients with histologically confirmed adenocarcinoma of the axillary lymph nodes but no clinically or radiologically detected breast abnormalities should be treated for stage II breast cancer.
1334. Watchful waiting is appropriate for patients with advanced-stage follicular lymphoma unless the disease progresses rapidly or poses an imminent threat to well-being.
1335. Although there is no current cure for patients with advanced-stage follicular lymphoma, the median survival ranges from 10 to 14 years.
1336. Tamoxifen decreases breast cancer risk by approximately 50% in pre- and postmenopausal women who have an elevated risk for this disease.
1337. Tamoxifen is the only Food and Drug Administrationâ€“approved medication for use in decreasing breast cancer risk.
1338. Infection with hepatitis B or C is associated with an increased risk for hepatocellular carcinoma.
1339. Hepatitis B and C are endemic to many parts of the developing world, especially Southeast Asia.
1340. In the Gleason histologic scoring system, grade 1 represents the most well-differentiated tumors, and grade 5 represents the most poorly differentiated tumors.
1341. Gleason scores consist of two scores derived from the most prevalent and second most prevalent differentiated tumors, which results in a combined score.
1342. The first of the two reported Gleason scores in the combined score may be most predictive of outcome.
1343. Mixed seminomatous and nonseminomatous germ cell tumors should be managed as though they were nonseminomatous tumors.
1344. Chemotherapy is indicated in the treatment of mixed seminomatous and nonseminomatous germ cell tumors.
1345. Flow cytometry of the peripheral blood is the best and least invasive way to establish a diagnosis in patients with suspicious lymphocytosis.
1346. Small-cell lung cancer is presumed to be a systemic disease with micrometastases, even when it appears to be isolated and resectable.
1347. Systemic chemotherapy is a required component of therapy in patients with small-cell lung cancer, even in those with limited-stage disease.
1348. The concomitant use of chemotherapy and radiation therapy confers a small survival benefit over sequential use of these modalities or chemotherapy alone.
1349. Finasteride reduces prostate cancer prevalence by 25%.
1350. Finasteride is associated with higher-grade tumors and more sexual side effects but fewer symptoms of urinary obstruction compared with placebo.
1351. Patients with squamous cell carcinoma (SCC) of unknown primary site and upper or midcervical lymph node involvement should be treated for locally advanced SCC of the head and neck.
1352. Aromatase inhibitors are more effective versus tamoxifen in preventing breast cancer recurrence in postmenopausal women.
1353. Marginal-zone B-cell lymphoma has been associated with hepatitis C virus in some patients; treatment of the underlying infection may result in remission of the lymphoma.
1354. Young, male patients with poorly differentiated midline carcinoma containing germ cell cancer markers and isochromosome 12p are likely to have extragonadal germ cell cancer and may respond to cisplatin-based chemotherapy.
1355. Docetaxel plus prednisone improves survival in men with metastatic prostate cancer refractory to hormonal ablation therapy when compared with mitoxantrone plus prednisone.
1356. Most patients become azoospermic shortly after chemotherapy for testicular germ cell cancer, but they may regain normalized sperm counts within 2 years; however, many remain infertile or subfertile.
1357. Sperm storage is offered to men with testicular cancer before they undergo chemotherapy.
1358. In patients with metastatic HER2-positive breast cancer, trastuzumab and chemotherapy result in prolonged survival compared with chemotherapy alone.
1359. In patients with early-stage resectable nonâ€“small-cell lung cancer, the use of adjuvant chemotherapy is a new standard of care replacing the former approach of providing no further therapy.
1360. Diffuse large B-cell lymphoma requires systemic therapy even when results of CT scans and positron emission tomography (PET) are negative.
1361. Rituximab and CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone), with or without radiation therapy, is curative for most patients with diffuse large B-cell lymphoma.
1362. Follow-up evaluation of postmenopausal women with breast cancer who undergo successful treatment consists of annual mammography.
1363. Smoking cessation is the most effective cancer prevention strategy for patients who are at high risk for lung cancer.
1364. Bronchioloalveolar cell carcinoma has a distinct pattern of presentation and responds uniquely to therapy with the new epidermal growth factor receptor inhibitors.
1365. Some patients with primary or recurrent bronchioloalveolar cell carcinoma who receive daily oral erlotinib or gefitinib have periods of disease reduction lasting from 1 to 2 years.
1366. Combination hormone replacement therapy has been shown to increase the risk for breast cancer.
1367. Follow-up examinations for patients with successfully treated testicular cancer should include studies focused only on new symptoms rather than an arbitrary schedule of imaging or workups.
1368. Patients with a poor performance status and widely metastatic nonâ€“small-cell lung cancer of squamous cell histology almost never respond to any type of therapy and require hospice care.
1369. Women with a history of ovarian cancer have a higher risk for breast cancer than that of the average population.
1370. Ovarian cancer metastasizes commonly to the pleura and peritoneum, rarely to bone or liver, and almost never to breast.
1371. Breast cancer metastasizes commonly to the pleura, peritoneum, liver and bone.

Endocrinology and metabolism

1372. The insulin sensitizing drugs metformin and the thiazolidinediones are contraindicated in patients with advanced heart failure.
1373. Thyroid hormone increases the metabolism of warfarin but increases the turnover of clotting proteins even more, resulting in a decreased dose requirement of warfarin.
1374. In an asymptomatic patient with mild hypercalcemia and an inappropriately normal parathyroid hormone level, the main differential includes primary hyperparathyroidism versus benign familial hypocalciuric hypercalcemia.
1375. Familial hypocalciuric hypercalcemia is diagnosed by a urinary calcium/creatinine clearance ratio less than 0.01 measured in a fasting morning urine spot collection.
1376. Severe hypogonadism in a young male with an elevated serum prolactin level strongly suggests pituitary macroadenoma and warrants evaluation of the entire pituitary.
1377. Patients with Cushing's syndrome produce three to four times the amount of urine free cortisol that unaffected persons produce.
1378. The three screening tests for Cushing's syndrome are measurement of urine free cortisol, the overnight dexamethasone suppression test, and the late-evening salivary cortisol test.
1379. Risk factors for hypopituitarism include previous macroadenoma, pituitary surgery, and brain radiation.
1380. Multiple endocrine neoplasia type 2A is characterized by pheochromocytoma, medullary thyroid carcinoma, and hyperparathyroidism due to parathyroid hyperplasia.
1381. The goal of preoperative blood pressure control in patients with pheochromocytoma is less than 140/90 mm Hg.
1382. Î±-Adrenergic blockade is used to reduce preoperative blood pressure in patients with pheochromocytoma.
1383. No pharmacologic therapy is more effective than diet and exercise in preventing the progression to type 2 diabetes in patients with prediabetes.
1384. The indications for parathyroidectomy in a patient with mild, asymptomatic hypercalcemia secondary to primary hyperparathyroidism are age less than 50 years, serum calcium level more than 1.0 mg/dL (0.25 mmol/L) above the upper limit of normal, 24-hour urine calcium excretion more than 400 mg (10 mmol), creatinine clearance reduced by more than 30%, and a bone mineral density T score less than 2.5 at any site.
1385. The cause of primary hyperparathyroidism in most cases is a single parathyroid adenoma.
1386. Substernal goiter results in a narrowed thoracic inlet, which is further compromised by extension of the arms over the head, resulting in compression of the great veins of the neck and the marked facial plethora known as Pemberton's sign.
1387. Pituitary apoplexy is the sudden onset of headache, visual disturbances, opthalmoplegia, and mental status changes caused by the acute hemorrhage or infarction of the pituitary gland.
1388. Urgent neurosurgical evacuation of the hemorrhage is generally indicated for patients with pituitary apoplexy and rapidly progressing visual disturbances and/or mental status changes.
1389. A noncontrast CT scan can distinguish between pituitary apoplexy and subarachnoid hemorrhage as patients with pituitary apoplexy will demonstrate acute hemorrhage in the region of the sella turcica.
1390. In a patient with androgen-dependent hirsutism who does not wish to become pregnant, antiandrogen and ovarian suppression therapy is usually effective.
1391. The 25-hydroxyvitamin D level is a marker of body stores of vitamin D and is measured as the initial step in the evaluation of suspected nutritional vitamin D deficiency.
1392. Coronary artery disease may be silent in patients with long-standing diabetes mellitus or present atypically.
1393. Dyspnea in a patient with an extensive history of complicated diabetes should be considered an anginal equivalent.
1394. Subclinical hypothyroidism is an elevated serum TSH level with a free T4 that is still within the population reference range.
1395. Patients with subclinical hypothyroidism who have a serum TSH value above 10 ÂµU/mL (10 mU/L) have been shown to have reductions in their LDL cholesterol concentrations when treated with levothyroxine.
1396. Hypomagnesemia in the patient with alcoholism can mimic hypoparathyroidism, including severe hypocalcemia and hyperphosphatemia.
1397. New-onset hirsutism with virilization, particularly in an older woman, and accompanied by a serum total testosterone level more than 200 ng/dL (6.9 nmol/L) is almost always due to a tumor.
1398. Excision of a cortisol-producing adrenal adenoma results in rapid clearance of cortisol within the first 24 hours after surgery and subsequent acute adrenal insufficiency; corticosteroid replacement is the appropriate therapy
1399. Growth hormone stimulation testing is more sensitive and specific for determining growth hormone deficiency than measuring basal hormone levels.
1400. Because of the potential nephrotoxicity of intravenous radiocontrast agents, metformin, which accumulates in renal insufficiency, should not be administered when any radiographic procedure using an intravenous contrast agent is performed.
1401. Inhibition of the renin-angiotensin axis reduces proteinuria and preserves renal function in patients with diabetes mellitus.
1402. A dominant thyroid nodule shown to be benign by fine-needle aspiration biopsy should be followed by serial monitoring with ultrasound to assess size stability.
1403. Pseudo-Cushing's syndrome consists of hypercortisolism in patients with such disorders as depression and alcohol use that alter hypothalamic - pituitary - adrenal function enough to perturb screening tests for Cushing's syndrome.
1404. If standard screening tests are equivocal in a patient with a strong pretest probability for Cushing's syndrome, the combined dexamethasone - CRH stimulation test may distinguish Cushing's syndrome from pseudo-Cushing's syndrome.
1405. The therapy of choice for uncomplicated Paget's disease is an oral bisphosphonate.
1406. In men, excessive production of glucocorticoids causes hypogonadotropic hypogonadism with diminished libido and loss of secondary sexual characteristics, in conjunction with commonly recognized manifestations of Cushing's syndrome.
1407. On CT scan of the adrenal glands, adenomas usually have smooth borders, are less than 4 cm in diameter, unilateral, homogenous in consistency, and less than 10 Hounsfield units in density.
1408. The serum TSH cannot be used to monitor thyroid hormone replacement therapy in patients with central hypothyroidism
1409. On patients with central hypothyroidism, the goal of thyroid hormone replacement is to titrate the dose to normalize the free T4 (or total T4 and free thyroxine index) not to normalize the TSH.
1410. Patients with type 2 diabetes taking monotherapy often require multidrug therapy as the duration of disease increases and beta-cell destruction progresses.
1411. The addition of one class of drug to another is the current favored approach in the patient with type 2 diabetes and progressive hyperglycemia despite monotherapy.
1412. Measurement of TSH-receptor autoantibodies, which are present in more than 90% of patients with Graves' disease but are not present in postpartum thyroiditis, can distinguish between the two disorders in a patient with postpregnancy thyrotoxicosis.
1413. Patients with gestational diabetes mellitus have a 50% risk of developing type 2 diabetes mellitus in the 5 to 10 years after the diagnosis of gestational diabetes.
1414. Nonâ€“parathyroid hormoneâ€“mediated hypercalcemia is characterized by suppressed parathyroid hormone levels.
1415. In most cases of malignancy-associated hypercalcemia, the tumor produces parathyroid hormoneâ€“related peptide, which shares significant homology with many of the metabolic actions of parathyroid hormone.
1416. A gradual decline in strength, cognitive and sexual function, and anhedonia in an elderly male suggests testosterone deficiency, and replacement therapy may be offered.
1417. Electrolyte abnormalities are generally not observed in patients with central adrenal insufficiency due to the fact that the aldosterone system is still functional.
1418. Multiple endocrine neoplasia (MEN) type 2A is an autosomal dominant syndrome in which adult carriers of the RET mutation are predisposed to medullary thyroid carcinoma, unilateral or bilateral pheochromocytomas, and hyperparathyroidism.
1419. Pendred's syndrome is an autosomal-recessive disorder of iodine organification characterized by congenital sensorineural hearing loss combined with goiter.
1420. Osteomalacia is a metabolic bone disease with failure of the organic matrix (osteoid) of bone to mineralize normally in adults.
1421. Looser's zones or Milkmans' fractures (pseudofractures) on radiography are pathognomonic of osteomalacia.
1422. In patients with type 1 diabetes and suboptimal glucose control, more complex regimens with more frequent injections of both short/rapid and long/intermediate acting insulins usually provide more effective control.
1423. The ADA recommended goals for management of adults with diabetes are hemoglobin A1C less than 7.0%, preprandial plasma glucose 90-130 mg/dL (5-7.22 mmol/L), peak (2 hour) postprandial plasma glucose less than 180 mg/dL (9.99 mmol/L), blood pressure less than 130/80 mm Hg, triglycerides less than 150 mg/dL (1.69 mmol/L), HDL cholesterol more than 40 mg/dL (1.03 mmol/L), and LDL cholesterol less than 100 mg/dL (2.59 mmol/L).
1424. Benign adrenal adenomas generally have smooth borders, attenuation values less than 10 Hounsfield units, and are homogenous in consistency.
1425. The size of an adrenal lesion is predictive of malignant potential; 25% of lesions more than 6 cm are carcinomas.
1426. In patients with malignancy-associated hypercalcemia, therapy with zoledronate, a long-acting intravenous nitrogen-containing bisphosphonate, induces rapid and long-lasting hypocalcemic response.
1427. Multiple endocrine neoplasia (MEN) 2a syndrome consists of medullary thyroid cancer, pheochromocytoma, and hyperparathyroidism due to four-gland hyperplasia.
1428. In patients with hyperglycemic hyperosmolar syndrome, the preservation of vascular volume is critical, and normal saline is the initial fluid of choice, even before intravenous insulin.
1429. The differential diagnosis in patients with apparently inappropriate TSH secretion includes a TSH-producing pituitary adenoma and congenital thyroid hormone resistance.
1430. he American Diabetes Association criteria for the diagnosis of diabetes mellitus are a fasting plasma glucose more or equal 126 mg/dL (6.99 mmol/L), a 2-hour plasma glucose more or equal 200 mg/dL (11.1 mmol/L) after a 75-g oral glucose load, or a random glucose more or equal 200 mg/dL (11.1 mmol/L) plus symptoms of diabetes.
1431. Thiazide diuretics stimulate renal tubular calcium reabsorption and in some patients lead to a mild hypercalcemia, which usually resolves when the diuretic therapy is discontinued.
1432. Primary hypothyroidism is a common secondary cause of hyperprolactinemia, likely caused by increased stimulation of the pituitary gland by thyrotropin-releasing hormone.
1433. Serum TSH should be measured with prolactin in the evaluation of a patient with galactorrhea and irregular menses.
1434. Causes of ACTH-dependent Cushing's syndrome can be distinguished by the dexamethasone 8-mg (high-dose) overnight suppression test and the corticotropin-releasing hormone (CRH) stimulation test.
1435. The average patient with type 1 diabetes mellitus who does not have coexisting insulin resistance requires a total daily dose of about 0.4 to 0.5 units of insulin per kg of body weight.
1436. In the water deprivation test, impaired ability to concentrate urine is consistent with either nephrogenic or central diabetes insipidus.
1437. In the water deprivation test, a large increase in urine osmolarity after the administration of desmopressin is indicative of central diabetes insipidus; no such increase occurs in nephrogenic diabetes insipidus.
1438. Hypocalcemia frequently occurs after removal of a hyperfunctioning parathyroid adenoma because of deficient secretion of parathyroid hormone by the remaining previously suppressed parathyroid tissue.
1439. Permanent hypoparathyroidism after an initial neck exploration for primary hyperparathyroidism is rare, but the incidence is greatly increased with repeated neck surgery for recurrent or persistent hyperparathyroidism and after subtotal parathyroidectomy for parathyroid hyperplasia
1440. In a patient with unstable coronary artery disease and hypothyroidism, therapy with thyroid hormone could increase myocardial metabolic demand and precipitate a myocardial infarction.
1441. Hyperprolactinemia can cause hypogonadism because prolactin directly suppresses gonadotropin-releasing hormone secretion and thus luteinizing hormone and testosterone production.
1442. The initial treatment for prolactin-producing macroadenomas is a dopamine agonist, such as bromocriptine or cabergoline, which decreases prolactin level, shrinks the tumor, and improves visual fields and pituitary function in most patients.
1443. Inferior petrosal sinus sampling is a confirmatory test for Cushing's syndrome in patients with ambiguous results in screening tests; the technique is very sensitive and specific, but extremely costly, technically difficult, and somewhat hazardous.
1444. Metformin should not be used in men with creatinine levels greater than 1.5 mg/dL (132.63 Âµmol/L) or in women with creatinine levels greater than 1.4 mg/dL (123.79 Âµmol/L).
1445. A thiazolidinedione should not be used in patients with class III congestive heart failure and will often cause worsening edema even in patients with less severe congestive heart failure.
1446. In euthyroid patients, amiodarone therapy results in high free and total T4, low-normal T3, and high-normal TSH.
1447. Osteoporosis is diagnosed by the presence of fragility fractures or by a bone mineral density value less than âˆ’2.5 in patients who have not experienced a fragility fracture.
1448. The classic characteristics of prolactinoma are amenorrhea and galactorrhea.
1449. Serum prolactin levels greater than 200 ng/mL (200 mg/L) in a nonpregnant woman usually suggest a tumor instead of another cause of hyperprolactinemia.
1450. Secondary diabetes mellitus may be the direct result of such underlying disease states as other endocrinopathies, islet cell neoplasms, and disorders of the exocrine pancreas such as pancreatitis, pancreatic malignancies, and cystic fibrosis.
1451. Localizing the ectopic source of ACTH in a patient with evidence of ACTH-dependent Cushing's syndrome may require combination CT/MRI/octreotide imaging of chest/abdomen/pelvis.
1452. In patients with severe primary hypothyroidism, decreased negative feedback of thyroid hormone at the level of the hypothalamus leads to release of thyrotropin-releasing hormone, which stimulates expansion of TSH-producing pituitary cells, causing pituitary hyperplasia.
1453. Exenatide, an incretin mimetic that increases insulin secretion, is an alternative to insulin therapy in patients who have not achieved optimal glycemic control with multi-agent oral therapy.
1454. Tertiary hyperparathyroidism is a rare disorder that usually occurs after many years of chronic renal insufficiency and secondary hyperparathyroidism.
1455. Cinacalcet hydrochloride is a calcimimetic agent that has been shown to significantly parathyroid hormone levels in patients with chronic kidney disease and uncontrolled secondary hyperparathyroidism.
1456. The classic presentation of hereditary hemochromatosis includes hypogonadism, diabetes mellitus, liver dysfunction, and skin hyperpigmentation.
1457. The most commonly affected organs in hereditary hemochromatosis are the pituitary gland, pancreas, liver, and heart.
1458. Postprandial glucose excursions in patients with diabetes should ideally be 30 to 50 mg/dL (1.67 to 2.78 mmol/L) above premeal glucose values.
1459. Significant postprandial hyperglycemia can be managed by using a bolus of short-acting insulin (lispro or aspart) just before or with each meal.
1460. The absence of menses for several months after dilation and curretage raises the possibility of endometrial damage or formation of scar tissue causing an outflow tract obstruction (Asherman's syndrome).
1461. Pheochromocytomas usually occur within the adrenal medulla, are rarely bilateral, occur more commonly in the right adrenal, are rarely metastatic to the local lymphatic vessels and /or liver, and are usually more or equal to 2 cm in diameter and heterogeneous in consistency.
1462. Computed tomography of the abdomen with thin sections through the adrenals is the preferred initial localizing study for pheochromocytoma.
1463. Patients with Hashimoto's thyroiditis are at risk for other autoimmune endocrine disorders, including adrenal insufficiency, pernicious anemia, type 1 diabetes mellitus, vitiligo, and premature ovarian failure.
1464. The classic symptoms of renal osteodystrophy are vague bone pain localized to the lower back, hips, or legs; muscle weakness often occurs with normal muscle enzymes and nonspecific electromyography changes.
1465. The main radiographic feature of renal osteodystrophy is increased bone resorption, most commonly in the subperiosteal surfaces of the hands, neck of femur, and clavicle.
1466. The presence of three or more pituitary hormone deficiencies has a positive predictive value for growth hormone deficiency of 95%.
1467. Replacement of growth hormone in hormone-deficient adults has been shown to improve body composition, lipid parameters, and bone mineral density.
1468. Therapy with an angiotensin II receptor blocker delays the progression of nephropathy in diabetic patients with hypertension, macroalbuminuria, and renal insufficiency.
1469. Î²-Blocker therapy to reduce thyrotoxic symptoms is the most appropriate therapy during the hyperthyroid phase of postpartum thyroiditis.
1470. Approximately 75% of patients with postpartum thyroiditis recover, whereas 25% develop permanent hypothyroidism.
1471. Hemochromatosis can result in various endocrinopathies, including hypogonadism, adrenal insufficiency, and diabetes mellitus.
1472. Growth hormone replacement is started at a low dose and titrated up based on the patient's insulin-like growth factor 1 level, symptom control, and side effects of therapy.
1473. The goal of growth hormone replacement is to normalize the insulin-like growth factor 1 level and alleviate symptoms without causing adverse side effects.
1474. Adverse effects of growth hormone replacement therapy include parasthesias, myalgias, edema, and joint pain.
1475. In patients with bilateral adrenal hyperplasia, spironolactone therapy reduces blood pressure and eliminates the requirement for potassium supplementation.
1476. In men with bilateral adrenal hyperplasia in whom spironolactone therapy causes painful gynecomastia, epleronone may be substituted for spironolactone.
1477. Paget's disease is a focal disorder of bone remodeling that leads to greatly accelerated rates of bone turnover, disruption of the normal architecture of bone, and sometimes to gross deformities of bone (enlargement of the skull, bowing of the femur or tibia).
1478. Osteomalacia usually presents with an elevation of alkaline phosphatase in association with hypocalcemia and hypophosphatemia.
1479. In patients with the empty sella syndrome, the pituitary gland is not usually damaged and pituitary function is usually normal.
1480. Fasting blood glucose levels, which are due primarily to excessive hepatic glucose production, are controlled mainly by the basal insulin dose.
1481. Patients on basal bolus insulin therapy often take 40% to 50% of their total daily dose as basal insulin (glargine) and 50% to 60% as meal boluses (lispro or aspart).
1482. Postmenopausal women with subclinical hyperthyroidism and an undetectable TSH have an increased risk of developing osteoporosis.
1483. Hypoglycemia unawareness, a dangerous sequela of long-standing insulin-treated diabetes mellitus, is an adaptive central nervous system response and is exacerbated by recurrent episodes of hypoglycemia.
1484. In patients with type 1 diabetes mellitus and hypoglycemic unawareness, insulin dose should be reduced and treatment goals relaxed.
1485. The classic triad of symptoms for pheochromocytoma consists of headaches, palpitation and diaphoresis.
1486. The sensitivity of fractionated plasma metanephrines for catecholamine-producing tumors is nearly 97%; however, the specificity is 85%.
1487. The first step in the evaluation of a thyroid nodule is measurement of serum TSH; if TSH is normal, the nodule is most likely nonfunctioning or â€œcoldâ€�; if TSH is low, the nodule is more likely to be hyperfunctioning or â€œhot.â€�
1488. Measurement of serum thyroglobulin is useful for following thyroid cancers in response to treatment, but a serum thyroglobulin level is not useful in distinguishing benign from malignant nodules.
1489. Very high levels of human chorionic gonadotropin (hCG) are sufficient to stimulate the thyroid gland to release excess thyroid hormone.
1490. Risk factors for osteoporosis in men include a BMI less than 18, a history of smoking or excessive alcohol consumption, family history of osteoporotic fractures, hypogonadism, history of corticosteroid use, vitamin D deficiency, and medications causing osteomalacia or hypogonadism.
1491. Hypogonadism increases the skeletal sensitivity to parathyroid hormone and decreases intestinal calcium absorption, predisposing to osteoporosis.
1492. The objectives in evaluating pituitary incidentalomas are to determine whether they are secreting pituitary hormones, causing deficiencies of pituitary hormones, and growing.
1493. Close observation of the tumor to detect growth and pituitary hormone deficiency is the treatment choice for clinically silent small adenomas.
1494. DEXA scanning has the best correlation of procedures for measuring bone loss with fracture risk, requires a short scanning time, and measures the bone mineral density of all areas of the skeleton with high accuracy and reproducibility and low exposure to radiation.
1495. Features of the euthyroid sick syndrome include a precipitous drop in serum total and free T3 levels, and a concomitant increase in reverse T3.
1496. The changes in thyroid hormone levels during an acute illness are likely adaptive, as a means of protecting the body from catabolic illness; thyroid hormone therapy in patients with euthyroid sick syndrome has not been shown to be beneficial.
1497. Hyperglycemia after cardiac surgery and during critical illness is a strong predictor of adverse outcomes, including infectious complications and death.
1498. Intravenous insulin infusion in hyperglycemic patients in the intensive care unit reduces mortality.
1499. Potential complications of Paget's disease of the bone include osteogenic sarcoma in affected bone, hypercalcemia, high-output congestive heart failure, deafness, and excessive bleeding during surgery as a result of hypervascular bone.
1500. Non-tumor causes of elevated prolactin levels are typically associated with levels less than 100 ng/dL (100 mg/L).
1501. â€¢ Psychotropic medications may raise serum prolactin levels modestly; patients with hyperprolactinemia and severe psychiatric illnesses requiring continued therapy with psychotropic agents can be treated with estrogen- and progesterone-containing oral contraceptives to restore normal menses and prevent bone loss
1502. Primary hypogonadism in a young male may be due to Klinefelter's syndrome; therefore, any young male with a high serum FSH level should have a karyotype study.
1503. The most sensitive screening test for primary aldosteronism is the plasma aldosterone-plasma renin activity ratio.
1504. Secondary causes of hypertension include primary aldosteronism, acromegaly, pheochromocytoma, and Cushing's syndrome.
1505. During a normal pregnancy, thyroid hormone production must be increased to provide thyroid hormone to the developing fetus; most women who are taking thyroid hormone replacement require a 30% to 50% increase in their thyroid hormone dose during their pregnancy.
1506. Risk factors for gestational diabetes mellitus include obesity, a family history of type 2 diabetes, and a history of gestational diabetes in previous pregnancies.
1507. The diagnosis of gestational diabetes mellitus requires any two of the following four values in a 3-h, 100-g oral glucose tolerance test: fasting equal or more than 95 mg/dL (5.27 mmol/L); 1-h equal or more than 180 mg/dL (9.99 mmol/L); 2-h equal or more than 55 mg/dL (3.05 mmol/L); 3-h equal or more than 140 mg/dL (7.77 mmol/L).
1508. Therapy for gestational diabetes mellitus consists of restricted diet, with insulin if glycemic target values are not achieved.
1509. In hypercalcemia secondary to production of parathyroid hormone-related peptide by a carcinoid, the serum parathyroid hormone level is suppressed.
1510. In patients with Graves' ophthalmopathy and blurry vision, the presence of an afferent pupillary defect (Marcus Gunn pupil) and greatly diminished unilateral visual acuity suggest optic nerve impingement by enlarged extraocular muscles.
1511. Parathyroidectomy causes rapid improvement in the bone mineral density in patients with osteoporosis associated with primary hyperparathyroidism.
1512. The use of antiresorptive agents is not recommended in osteoporosis secondary to primary hyperparathyroidism.
1513. Obese, insulin-resistant men generally have a reduced serum total testosterone concentration, primarily as a result of a low sex-hormone binding globulin concentration.
1514. Orthostatic hypotension is a common manifestation of diabetic autonomic neuropathy, reflecting loss of normal vasoconstrictor tone, with deranged compensation to upright posture.
1515. Fludrocortisone therapy expands the plasma volume, thereby raising blood pressure and improving symptoms in diabetic autonomic neuropathy.
1516. After biochemical confirmation of primary aldosteronism, localization procedures differentiate aldosterone-producing adenomas from bilateral adrenal hyperplasia; aldosteronism-producing adenomas are amenable to laparoscopic resection, whereas bilateral adrenal hyperplasia is medically treated.
1517. Radiographic imaging rarely differentiates aldosterone-producing adenomas from bilateral adrenal hyperplasia in patients with primary aldosteronism.
1518. Intestinal calcium absorption is reduced and osteoclastic activity is increased in hyperthyroidism, and the high levels of free T4 and free T3 likely produce hypercalcemia through excessive osteoclastic activity.
1519. Hypercalcemia associated with thyrotoxicosis usually resolves when the patient becomes euthyroid.
1520. Exogenous testosterone suppresses sperm production, resulting in infertility.
1521. Treatment with exogenous testosterone at normal doses does not normally cause permanent infertility, but restoration of sperm production requires gonadotropins.
1522. Silent thyroiditis is an autoimmune disorder characterized by high levels of antithyroid peroxidase antibodies, painless enlargement of the thyroid gland, and a triphasic course with early thyrotoxicosis followed by hypothyroidism and then a return to euthyroidism in most patients.
1523. Most patients with interferon alfaâ€“associated thyroid dysfunction recover after the drug is discontinued.
1524. Hypopituitarism is a frequent outcome of patients treated with irradiation of the thyroid gland.
1525. In a patient with hypopituitarism, documentation and therapy of adrenal insufficiency takes priority over other anterior pituitary hormonal deficiencies.
1526. Infection is a common precipitant of myxedema coma, and pan-culture and empiric antibiotic therapy with broad-spectrum antibiotics is recommended for all affected patients.
1527. Signs of androgen excess (increased muscle mass, irritability, and pustular acne) with small testes and low serum testosterone and gonadotropins in a young male suggest androgenic anabolic steroid abuse.
1528. In patients with macroprolactinoma and normal visual fields, dopamine agonist therapy effectively reduces prolactin secretion and tumor size.
1529. ACE inhibitors reduce albuminuria and retard the progression of renal disease in diabetic patients with and without hypertension.
1530. Angiotensin II receptor blockers prevent progression of nephropathy in patients with type 2 diabetes and macroalbuminuria and hypertension.
1531. Breast enlargement in a young man occurs most commonly with drugs or substances or alterations in the androgen/estrogen ratioâ€”either androgen deficiency or estrogen excess
1532. High concentrations of hCG in a man suggest the diagnosis of choriocarcinoma, an aggressive germ cell tumor.
1533. The measurement of insulin-like growth factor 1 is more sensitive than serum growth hormone measurements for acromegaly in patients with a high pretest probability for acromegaly.
1534. Corticosteroid therapy results in a decrease in intestinal calcium absorption and an increase in urinary calcium excretion; secondary hyperparathyroidism occurs.
1535. The prevention and treatment of corticosteroid-induced osteoporosis includes calcium and vitamin D supplementation, a DEXA scan at the initiation of therapy, and bisphosphonates in patients taking prednisone equal or more than 5 mg/d (or its equivalent) for more than 3 months.
1536. As many as 3% of patients with poorly controlled diabetes mellitus (hemoglobin A1c more than 8.0%) have Cushing's syndrome.
1537. The treatment of choice for a nonfunctioning pituitary adenoma is transsphenoidal tumor resection.
1538. Benign adrenal adenomas are homogenous and have smooth borders and attenuation values of less than 10 Hounsfield units on unenhanced CT.
1539. The classic presentation of thyroid lymphoma is an elderly woman with autoimmune thyroiditis and a rapidly expanding thyroid mass.
1540. Latent autoimmune diabetes of adulthood (LADA) occurs in lean patients with initially apparent type 2 diabetes who become insulin-dependent later in life and exhibit the labile glycemic tendencies and many of the autoimmune markers of patients with type 1 diabetes.
1541. Latent autoimmune diabetes of adulthood (LADA) is characterized by slowly progressive loss of beta-cell function, leading to severe insulin deficiency and labile glycemic control.
1542. Patients with latent autoimmune diabetes of adulthood (LADA) become refractory to oral agents and as insulin-dependent and ketosis-prone as patients with type 1 diabetes.
1543. Pericardial effusion is a consequence of moderate to severe hypothyroidism and is indicated by diminished heart sounds, low voltage on electrocardiography, and an enlarged cardiac silhouette.
1544. The â€œhypothyroid heartâ€� refers to decreased contractility and pulse rateâ€”both contributing to a decreased cardiac output at a time when peripheral vascular resistance is increased.
1545. In a patient with acromegaly based on elevated serum insulin-like growth factor 1 and growth hormone levels, MRI of the head is indicated to identify and characterize the causative pituitary tumor.
1546. Multiple endocrine neoplasia type 1 is characterized by pituitary tumors, pancreatic islet tumors, and hyperparathyroidism due to parathyroid hyperplasia.
1547. Familial hyperparathyroidism, which is almost always due to parathyroid hyperplasia, is treated with subtotal parathyroidectomy in which 3Â½ parathyroid glands are removed.
1548. Chemotherapy with alkylating agents often induces irreversible damage to sperm production in young men.
1549. Subacute thyroiditis is characterized by a prodrome of arthralgias, malaise, and anorexia followed by pain in the thyroid bed and thyrotoxicosis.
1550. Teriparatide (recombinant human parathyroid hormone [1-34]) stimulates osteoblastic bone formation; it significantly increases bone mass in patients with osteoporosis and can decrease the incidence of both vertebral and nonvertebral fractures.
1551. Kallman's syndrome is X-linked hypothalamic hypogonadism accompanied by anosmia.
1552. In patients with diabetes and severely impaired beta-cell secretory capacity, basal insulin is effective on fasting glucose but cannot adequately control post-prandial glucose.
1553. The overall goal of therapy for acromegaly is normalization of the serum growth hormone and insulin-like growth factor 1 levels.
1554. An increased dose requirement for levothyroxine may occur as due to malabsorption (for example, celiac disease), accelerated metabolism, or an increased occupancy of binding proteins
1555. Most adrenal nodules are hormonally silent and have no malignant potential.
1556. Patients with an incidentally detected adrenal mass should be screened for pheochromocytoma, Cushing's syndrome, and primary aldosteronism.
1557. In a patient with normal ovulation but autoimmune disease and repeated fetal loss, evaluation for a hypercoagulable state is indicated.
1558. In patients with concomitant autoimmune adrenal and thyroid failure (Schmidt's syndrome), adrenal failure is often unrecognized initially; as thyroxine deficiency is corrected, the patient develops clinical adrenal insufficiency, requiring glucocorticoid supplementation.
1559. Testosterone therapy does not cause prostate cancer but can stimulate the growth of occult tumors.
1560. In patients beginning testosterone therapy, a rectal examination of the prostate gland before the first dose and the serum prostate-specific antigen should be measured at 3, 6, and 12 months after the start of therapy.
1561. Vitamin D deficiency must be corrected before starting other active osteoporosis therapy because the response to the therapy will be impaired by the defective mineralization associated with vitamin D deficiency and osteomalacia.
1562. Prediabetes glycemic states consist of impaired glucose tolerance, defined as a 2-hour glucose level of 140-199 mg/dL (7.77-11.04 mmol/L) during an oral glucose tolerance test, and impaired fasting glucose, defined as a fasting glucose level of 100-125 mg/dL (5.55-6.94 mmol/L).
1563. Narcotics suppress gonadotropins and testosterone production.
1564. The major storage form of vitamin D in the body is 25-dihydroxyvitamin D, and therefore this is the best test to assess for vitamin D deficiency.
1565. In a short young woman with primary amenorrhea, even in the absence of associated stigmata and comorbidities, Turner's syndrome (or mosaic) is the most likely diagnosis.
1566. High-risk patients with obesity and metabolic syndrome can most effectively reduce their risk of developing type 2 diabetes with a conscientious lifestyle modification program consisting of diet, exercise, and weight loss.
1567. The two causes of central hyperthyroidism are a TSH-producing adenoma and the resistance to thyroid hormone syndrome.
1568. The two causes of central hyperthyroidism, TSH-producing adenoma and the resistance to thyroid hormone syndrome, can be distinguished by measuring TSH Î± subunit.
1569. Testosterone stimulates production of erythropoietin, and the hematocrit and erythrocyte indices rise significantly during testosterone replacement therapy.
1570. The somatostatin analogue, octreotide, reduces growth hormone production and shrinks tumor in patients with acromegaly and is first-line therapy for patients not cured by surgery alone or surgery combined with radiation
1571. The humoral mediator of hypercalcemia of malignancy in most cases, especially in lung cancer, is parathyroid hormoneâ€“related peptide (PTHrp), which is secreted by the tumor.
1572. In gonadotropinoma, the gonadotropins are often detected on immunostaining of the surgical specimen but are rarely secreted into the bloodstream in meaningful amounts.

Pulmonology and critical care

1573. In a patient taking high-dose inhaled corticosteroids as part of therapy for persistent asthma whose disease is stable, reducing the dose of corticosteroids should be considered to prevent therapy-related side effects.
1574. High-resolution computed tomographic scanning (HRCT) is more sensitive than plain chest radiography for detecting interstitial lung disease and more specific for the potential diagnoses.
1575. In hepatic hydrothorax, underlying cirrhosis results in usually right-sided pleural effusion that is transudative as a result of hypoalbuminemia and reduced serum oncotic pressure.
1576. In patients with severe sepsis from nosocomial pneumonia, the ventilator should be adjusted by using a â€œprotective lung strategyâ€� with 6 mL/kg of ideal body weight and a plateau pressure less than 30 cm H2O.
1577. Low-dose dopamine has been shown to be of no benefit in critically ill patients with early renal dysfunction.
1578. Intermittent pneumatic compression is effective prophylaxis in patients at moderate to high risk for venous thrombosis in whom heparin and low-molecular-weight heparin are contraindicated.
1579. Inadequate amount of sleep is the most common cause of daytime somnolence in young adults; improved sleep hygiene and increased amount of sleep are the initial management.
1580. Noninvasive positive pressure ventilation in selected patients with moderate respiratory distress has been shown to improve heart and respiration rates, gas exchange; and to reduce morbidity and mortality rates, the need for intubation, and the length of hospital stay.
1581. Contraindications to noninvasive positive pressure ventilation in patients with moderate respiratory distress include excessive secretions, uncooperativeness, and acute ischemic changes on electrocardiography.
1582. The diagnosis of rhabdomyolysis is based on clinical findings and a history of a predisposing factor(s) and confirmed by the presence of myoglobinuria, an increased serum creatine kinase, and hyperkalemia.
1583. Early aggressive fluid therapy is essential in rhabdomyolysis to counteract fluid loss from sequestration into damaged muscle and to increase renal perfusion.
1584. The diagnostic yield of current imaging and biopsy methods in very small incidentally detected pulmonary lesions is very small.
1585. Incidentally detected very small pulmonary lesions should be monitored periodically to detect signs of growth compatible with lung cancer.
1586. The clinical presentation of hypersensitivity pneumonitis is typically recurrent acute episodes of fever, cough, and dyspnea that begin 4 to 6 hours after antigen exposure and resolve spontaneously 24 to 48 hours after antigen avoidance.
1587. Reversible airflow obstruction is a nonspecific finding that can occur with asthma, postinfectious bronchial hyperreactivity, endotoxin inhalation, or hypersensitivity pneumonitis
1588. In patients with persistent asthma not adequately controlled with daily low- or moderate-dose inhaled corticosteroids, adding a long-acting Î²-agonist improves asthma control and quality of life.
1589. In idiopathic pulmonary fibrosis, a characteristic HRCT pattern is seen in approximately 50% of patients and the extent of disease on HRCT is a predictor of survival.
1590. Patients with severe sepsis and refractory shock despite adequate fluid resuscitation should be treated with replacement-dose corticosteroids.
1591. High-dose corticosteroid therapy is ineffective and may be harmful in patients with severe septic shock and relative adrenal insufficiency.
1592. Pleural effusion in tuberculosis is usually associated with a lymphocytic pleocytosis.
1593. Tuberculous pleural effusion most often develops from a cell-mediated immune response to tuberculosis antigens.
1594. In patients with potentially operable non-small-cell lung cancer, pulmonary function tests are indicated to assess pulmonary reserve.
1595. Brain scan and bone scan are needed in patients with potentially operable non-small-cell lung cancer.
1596. Unfractionated and low-molecular-weight heparins reduce the risk of clinically important venous thromboembolism in critically ill patients by up to 60%.
1597. Aspirin has not been shown to reduce the incidence of thromboembolism in most populations at risk.
1598. In patients with cardiogenic pulmonary edema, continuous positive airway pressure (CPAP) and noninvasive positive pressure ventilation (NPPV) more rapidly improve dyspnea, vital signs and gas exchange, and avoid intubation more effectively than oxygen supplementation plus standard therapy.
1599. The standard of practice to determine the optimal continuous positive airway pressure level to manage obstructive sleep apnea is an attended laboratory polysomnography with CPAP pressure titration.
1600. The goal of therapy for hypertensive crisis is not to decrease the blood pressure to normal levels but to prevent further end-organ damage; precipitous reduction of blood pressure increases the risk for cerebral, cardiac, and renal ischemia.
1601. In prospectively evaluation by HRCT, up to 60% of patients with rheumatoid arthritis have radiographic abnormalities consistent with interstitial lung disease.
1602. In drug-induced interstitial lung disease, there are not specific pathologic patterns that would provide a definitive diagnosis.
1603. In patients with vocal cord dysfunction, oxygen saturation is normal during an acute exacerbation; laryngoscopy during an exacerbation shows adduction of the vocal cords during inspiration.
1604. Treatment of hepatic hydrothorax is directed to management of cirrhosis and ascites with salt restriction and diuretic therapy.
1605. Symptoms of anaphylaxis include flushing, urticaria, conjunctival pruritus, bronchospasm, nausea, and vomiting which develop within 30 minutes to 1 hour after the offending antigen is injected or up to 2 hours after the antigen is ingested.
1606. Patients with moderate to severe anaphylaxis should be monitored for at least 12 hours for a possible late recurrence (biphasic anaphylaxis)
1607. Risk factors for noninvasive ventilatory failure include the acute respiratory distress syndrome (ARDS) or severe community-acquired pneumonia, PaO2/FiO2 ratio less than 146, and age greater than 40 years.
1608. The CAM-ICU, a clinical instrument for use in evaluating a patient in the intensive care unit for delirium, takes less than a minute and is recommended for all mechanically ventilated patients.
1609. Pregnant women with deep venous thromboembolism or pulmonary embolism are treated with either unfractionated heparin or a low-molecular-weight heparin during the pregnancy and for 6 weeks post partum.
1610. Silicosis with small nodules in the lungs on radiographs is not associated with symptoms or physiologic abnormalities, but continued exposure and development of progressive massive fibrosis causes disabling symptoms.
1611. Screening for lung cancer with chest radiography or sputum cytology does not lower lung cancer mortality in the screened population and is not indicated.
1612. The anti-Xa test is a sensitive marker for anticoagulant activity of low-molecular-weight heparins and fondaparinux.
1613. More than 90% of patients with sarcoidosis have pulmonary involvement that is manifest radiographically as hilar and mediastinal lymphadenopathy, with or without parenchymal disease.
1614. Treatment of sarcoidosis is generally reserved for those with disabling symptoms, evidence for progressive lung disease, extrapulmonary disease, or complications such as hypercalcemia.
1615. Patients with radiographic stage 1 sarcoidosis (hilar and/or mediastinal lymphadenopathy without infiltrates) and no systemic symptoms have spontaneous remission rates of 50% to 90%.
1616. Exposure to nerve agents causes a cholinergic crisis by inhibiting cholinesterase and causing muscarinic, nicotinic, and central nervous system effects.
1617. Pralidoxime (2-PAM) reactivates acetylcholinesterase, and can reverse the muscle weakness, paralysis, and respiratory depression caused by exposure to nerve agents.
1618. Predictors of failure of noninvasive ventilation in patients with an exacerbation of COPD include a respiration rate more than 35/min, APACHE score more than 29, pH less than 7.25, and Glasgow coma score less than 11.
1619. Patients with predominant supine-dependent sleep apnea can be managed initially with a trial of restricting sleep to lateral recumbency.
1620. The advanced cardiac life support guidelines state that a single dose of vasopressin can be administered as a one-time alternative to epinephrine in patients with ventricular fibrillation or pulseless ventricular tachycardia.
1621. In patients with ventricular fibrillation or pulseless ventricular tachycardia, the guidelines for advanced cardiac life support recommend the following sequence of interventions: defibrillation, COTE [cardiopulmonary resuscitation, oxygen, tubes (endotracheal and intravenous), epinephrine (or vasopressin)], and more defibrillation.
1622. D-dimer reflects the presence of thrombosis (or inflammation), but does not reflect the activity of thrombosis.
1623. Hypocapnia is the cause of central sleep apnea in patients with Cheyne-Stokes respiration.
1624. A short course of oral corticosteroids may help restore asthma control in previously well-controlled patients who have developed unstable disease as a result of a respiratory tract infection
1625. Daily hemodialysis has been shown to significantly reduce in-hospital deaths in patients with acute renal failure in surgical and medical intensive care units.
1626. Inhaled corticosteroids with as-needed albuterol is the cornerstone of therapy for persistent asthma.
1627. In a patient with severe COPD and respiratory failure with severe carbon dioxide retention, inappropriately high rate and tidal volume of mechanical ventilation can cause 1) excessively rapid reduction in PaCO2 potentially causing severe alkalemia and 2) the induction of dynamic hyperinflation leading to a severe elevation of intrinsic positive end-expiratory pressure (auto-PEEP).
1628. Helical CT scanning without contrast enhancement is not sensitive for diagnosing pulmonary embolism.
1629. In a patient presenting with likely advanced metastatic lung cancer, a biopsy of an accessible site should be done to confirm the diagnosis of metastatic disease with a minimum of discomfort, risk, and expense.
1630. Lung disease is the most common cause of morbidity and mortality in systemic sclerosis.
1631. In scleroderma, both interstitial lung disease and pulmonary hypertension can develop (both independently or together) and have an adverse effect on outcome.
1632. Pulmonary disease can be the initial clinical manifestation of scleroderma.
1633. In a patient with potential smoke inhalation injury, the presence of facial burns, soot in the mouth, carbonaceous sputum, or singed nasal hairs may correlate with upper airway injury and a high risk of delayed airway compromise from edema.
1634. Approximately one fifth of adult patients with cystic fibrosis develop pneumothorax at some time in their lives.
1635. Tube thoracostomy is the preferred treatment for secondary pneumothorax.
1636. Patients with cystic fibrosis have a high rate of recurrent pneumothorax; therefore, parietal pleurectomy, pleural abrasion, and thoracoscopy with talc pleurodesis are reasonable interventions after initial management of the pneumothorax with tube thoracostomy.
1637. Placement of a pulmonary artery catheter in critically ill ICU patients has not been shown to have a benefit on mortality or other outcomes.
1638. The diagnosis of the acute respiratory distress syndrome (ARDS) requires a PaO2/FiO2 less than 200 in combination with bilateral infiltrates and the absence of other evidence for congestive heart failure.
1639. The â€œlung protective strategyâ€� for intubation in patients with ARDS consists of the tidal volume at 6 mL/kg ideal body weight and plateau pressure kept less than 30 cm H2O.
1640. Nocturnal pulse oximetry can document nocturnal hypoxemia causing pulmonary hypertension in patients with obstructive lung disease.
1641. Intravenous heparin has immediate onset of action and has a half-life of under an hour after discontinuation.
1642. Low-molecular-weight heparins and fondaparinux have onset of action within about a half hour of subcutaneous administration, and the effect lasts throughout much of the subsequent day.
1643. The characteristic features of allergic bronchopulmonary aspergillosis include moderate to severe persistent asthma, bronchiectasis and chest radiographic abnormalities, elevated serum IgE, eosinophilia, and a positive skin test to Aspergillus fumigatus.
1644. The pathologic pattern nonspecific interstitial pneumonitis (NSIP) can occur in various clinical disorders, including infections, drug reactions, hypersensitivity pneumonitis, and connective tissue diseases.
1645. Patients in the intensive care unit generally require 25 to 30 nonprotein kcal/kg/d and 1.0 to 1.5 protein kcal/kg/d to meet the energy expenditures associated with critical illness
1646. In patients with advanced neuromuscular disease, inspiratory capacity is too small for an adequate cough, and cough assistance may be required in such patients with upper respiratory tract infection.
1647. Clinical findings of cocaine toxicity include tachycardia, hypertension, hyperthermia, mydriasis, agitation, and psychosis.
1648. Hypertension in cocaine toxicity usually responds to control of agitation.
1649. The Churg-Strauss syndrome is a small-vessel vasculitis typically associated with significant eosinophilia, pulmonary infiltrates in the setting of asthma, the use of a leukotriene receptor antagonist, and withdrawing oral corticosteroids.
1650. Extubation to noninvasive ventilation has been shown to improve outcomes in carefully selected intubated COPD patients who fail spontaneous breathing trials.
1651. Exercise-induced asthma is confirmed by exercise challenge (to more than 85% of maximal predicted heart rate) with post-exercise spirometry showing a 20% fall in FEV1.
1652. Treatment with short-acting inhaled Î²-agonists 5 to 10 minutes before exercise prevents exercise-induced asthma in >80% of patients.
1653. Metabolic signs of salicylate toxicity include respiratory alkalosis, anion gap metabolic acidosis, and hyperthermia; other signs and symptoms include depressed level of consciousness, noncardiogenic pulmonary edema, prolonged prothrombin time, hepatic toxicity, and hypoglycemia.
1654. Management of salicylate toxicity includes alkalinization of urine to enhance excretion of salicylates and hemodialysis for severe toxicity.
1655. Enoxaparin is cleared by the kidney, and if used in patients with chronic kidney disease, therapeutic drug monitoring is required for possible dosage adjustment.
1656. Malignant pleural effusions are typically lymphocytic and are usually exudative.
1657. Pleural fluid erythrocyte counts more than 100,000/Î¼L (100 Ã— 109/L), when not associated with trauma or pulmonary infarction, are suggestive of pleural malignancy.
1658. In patients with neuromuscular disease and chronic hypoventilation, noninvasive mechanical ventilation is required to maintain ventilation during sleep.
1659. Metastasectomy is indicated in patients with multiple lung metastases who have a resectable primary tumor, a low likelihood of other metastases, and normal pulmonary function.
1660. No medical therapy has been shown to clearly alter the natural history of idiopathic pulmonary fibrosis.
1661. Lung transplantation has been shown to improve survival, quality of life, and functional status in patients with end-stage fibrotic lung disease.
1662. Administration of type A equine antitoxin within 12 hours of diagnosis of wound botulism may significant shorten the duration of mechanical ventilation.
1663. In a patient with acute severe asthma, prompt administration of aerosolized bronchodilators is indicated after systemic corticosteroid therapy is started.
1664. Approximately 80% of effusions associated with pulmonary emboli are exudative, usually small and unilateral, and tend not to be progressive or to persist beyond 7 days after formation.
1665. In most patients treated with heparin for pulmonary embolism, a substantial portion of their perfusion defects resolve within the first week.
1666. CT scanning to follow the resolution of pulmonary embolism is not well standardized.
1667. No specific therapy is indicated for asymptomatic bronchial hyperresponsiveness.
1668. The co-presence of focal areas of fat and calcium are virtually pathognomonic of hamartoma.
1669. Malignant lung lesions tend to have a doubling time of between 30 and 400 days; benign lesions double in less than 30 days or over very long periods of slow growth.
1670. Patients with anaerobic bacterial infection involving the pleural space usually have subacute presentations with weight loss and a history of alcoholism, unresponsiveness, possible aspiration, and poor oral hygiene.
1671. Fibrinolytic therapy may be considered in patients with empyema who are poor surgical candidates.
1672. Organizing pneumonia is a pathologic pattern of lung injury that can occur in various settings, including infections, connective tissue diseases, and as a complication of treatments, such as amiodarone or radiation therapy.
1673. Urinary Legionella pneumophila antigen test should be done in patients with suspected Legionella pneumonia.
1674. Early therapy with azithromycin plus ceftriaxone is considered adequate initial coverage for a severe community-acquired pneumonia.
1675. A history of orthopnea, abdominal paradox, and a decrease in forced vital capacity more than 25% when the patient goes from the upright to supine position are diagnostic of diaphragm paralysis.
1676. Patients with hypoventilation secondary to diaphragm paralysis should be treated with nocturnal noninvasive positive airway pressure to augment their ventilation during sleep.
1677. Clinical findings in hydrogen cyanide toxic

Re: My NOTES: a small gift for you...
triplehelix - 01-12-09 23:56

1677. Clinical findings in hydrogen cyanide toxicity include coma, hypotension, cardiac irritability, and profound anion gap metabolic acidosis in the setting of adequate volume resuscitation and oxygen administration.
1678. The treatment for cyanide poisoning is intravenous sodium thiosulfate.
1679. In patients with severe sepsis, early goal-directed therapy within the first 6 hours to maintain a central venous oxygen saturation of more than 70% and to resolve lactic acidosis improves survival over more delayed resuscitation attempts.
1680. Acute mountain sickness is characterized by poor sleep, anorexia, fatigue, nausea, and vomiting.
1681. Acetazolamide taken for 2 days before ascent to high altitude is effective prophylaxis for acute mountain sickness.
1682. Diffuse alveolar hemorrhage is characterized by dyspnea and diffuse alveolar infiltrates; it can be the initial manifestation of primary or secondary pulmonary vasculitis, drug reactions, coagulation disorders, and infection.
1683. The diagnosis of diffuse alveolar hemorrhage is made with bronchoalveolar lavage, with serial samplings showing a persistently bloody fluid.
1684. Malignant hyperthermia is a life-threatening inherited skeletal muscle disorder characterized by a hypermetabolic state precipitated by exposure to volatile inhalational anesthetics and depolarizing muscle relaxants.
1685. Heparin, low-molecular-weight heparins, and fondaparinux all catalyze antithrombin to neutralize clotting enzymes, and these drugs can be assayed by incubation of the patient's plasma with activated factor Xa.
1686. The reactive airway dysfunction syndrome follows a single, accidental inhalation of high levels of a nonspecific respiratory irritant in patients who typically do not have a history of asthma.
1687. The diagnosis of the reactive airways dysfunction syndrome is based on history and confirmed by positive methacholine challenge.
1688. The most common causes of chylothorax are cancer and trauma; other causes are pulmonary tuberculosis, chronic mediastinal infections, sarcoidosis, lymphangioleiomyomatosis, and radiation fibrosis.
1689. In a competent, severely ill patient in the ICU with a treatable condition but a clearly expressed preference for comfort measures rather than more aggressive intervention, comfort measures to provide good end-of-life care should be provided
1690. Although a fixed therapeutic dose of subcutaneous heparin may be appropriate for treatment of deep venous thrombosis and pulmonary embolism, aPTT monitoring and dose adjustment are required for patients at high risk of bleeding.
1691. Renal ultrasound with renal artery Doppler examination provides anatomic and functional assessment of the renal arteries, and has a sensitivity of 72% to 92% for renovascular hypertension.
1692. Idiopathic pulmonary fibrosis (IPF) is the most common of the idiopathic interstitial pneumonias, and by far more common than other members of the group.
1693. Sarcoidosis, the most common interstitial lung disease, is a systemic disorder and its radiographic presentation is generally dominated by mediastinal and hilar adenopathy with or without parenchymal changes.
1694. For ventilator-associated pneumonia manifesting clinical resolution of symptoms and signs of infection, radiologic improvement, and requirement for less ventilatory support with improving oxygenation, courses of no more than 8 days of antibiotic therapy are associated with as good outcomes as longer courses.
1695. Activated protein C has anticoagulant properties, and evidence of active bleeding is a contraindication to its use in patients with sepsis.
1696. Patients with COPD may experience a fall in PaO2 of as much as 25 to 30 mm Hg during air travel, and pre-flight assessment is useful to determine the need for in-flight oxygen supplementation with the goal of maintaining PaO2 either at equal or more than 50 mm Hg or, in high risk patients, at the PaO2 with which the patient is clinically stable at sea level.
1697. The neuroleptic malignant syndrome is a rare, but potentially fatal, complication of the administration of neuroleptic (antipsychotic) drugs such as haloperidol.
1698. Acute hypoxemia and systemic hypotension in combination with an increase in peak airway pressure and asymmetric chest wall expansion are cardinal features of an acute tension pneumothorax
1699. In patients taking theophylline as part of asthma therapy, concomitant ciprofloxacin therapy can decrease theophylline clearance in the liver, increasing theophylline blood levels and leading to potential theophylline toxicity.
1700. Theophylline clearance is decreased by various drugs as well as in the elderly and patients with congestive heart failure.
1701. Insertion of an inferior vena cava filter reduces the short-term incidence of pulmonary embolism in patients being anticoagulated for deep venous thrombosis.
1702. Lung transplant-related bronchiolitis obliterans, which is probably a form of chronic rejection, occurs in up to 50% of long-term survivors of transplantation.
1703. The typical findings of lung transplant-related bronchiolitis obliterans include cough, dyspnea, early inspiratory crackles, and severe airflow obstruction.
1704. Obstructive sleep apnea can exacerbate nocturnal asthma; CPAP therapy for sleep apnea can improve asthma control.
1705. Prompt intubation is indicated in patients with severe pneumonia whose condition is deteriorating on conventional therapy.
1706. Intubation rates are high in non-COPD patients with severe community-acquired pneumonia treated with noninvasive ventilation.
1707. Hyperglycemia should be treated in critically ill patients with aggressive insulin therapy to maintain tight glycemic control.
1708. Intermittent bolus dosing of sedatives titrated via a validated sedation scale is consistent with the guidelines for the use of sedation in critically ill patients.
1709. Antipsychotic agents may cause torsades de pointes in patients with prolonged QTc intervals.
1710. Patients with evidence of a physiologically severe and progressive fibrosing lung disease should be referred early for evaluation for lung transplantation.
1711. In patients with acute lung injury/ARDS on mechanical ventilation with a lung protective strategy, PEEP should be increased in 2- to 3-cm H2O increments to lower FiO2 to 60%, if possible, and to maintain an arterial oxygen saturation of â‰¥88% and â‰¤ 95%
1712. Vocal cord dysfunction mimics asthma, but unlike asthma, it begins and ends abruptly, does not respond to Î²-agonists, and airflow limitation is mainly during inspiration.
1713. The ultrasound may be abnormal for several months after a deep venous thrombosis, and the venous wall does not return to normal compressibility at all in some patients.
1714. The most common form of delirium in the ICU is hypoactive or â€œquietâ€� delirium.
1715. Delirium is a form of acute brain dysfunction that occurs in 50% to 80% of ventilated patients in the intensive care unit; it is associated with higher mortality rates, longer hospital and ICU stay, higher costs, and chronic cognitive deficits.
1716. The cardinal features of delirium are 1) acute onset or fluctuations in mental status over a 24 hour period, 2) inattention, 3) disorganization of thinking, and 4) an altered level of consciousness at the time of the evaluation.
1717. Patients with potential healthcare-acquired pneumonia (HCAP) require initial coverage for resistant organisms including methicillin-resistant Staphylococcus aureus and Pseudomonas.
1718. Segmental perfusion defects in patients with right heart failure and right ventricular hypertrophy strongly suggests the diagnosis of chronic thromboembolic pulmonary hypertension (CTEPH).
1719. Surgical pulmonary thromboendarterectomy can improve cardiac output, reduce mortality, and enhance quality of life in patients with thromboembolic pulmonary hypertension (CTEPH)
1720. Crytogenic organizing pneumonia is an idiopathic interstitial pneumonia that clinically resembles a flulike syndrome, and is characterized by crackles and patchy persistent infiltrates on chest radiograph, and restrictive lung defect with decrease in carbon monoxide diffusing capacity.
1721. Inability to protect the airway because of impaired swallowing or cough function is a contraindication to the use noninvasive positive pressure ventilation.
1722. In a neuromuscular disease patient who cannot manage airway secretions, severe restriction with a vital capacity of less than 15-20 mL/kg is an indicator of the need for intubation.
1723. No drug is FDA-approved for the treatment of delirium, but clinical practice guidelines recommend antipsychotic agents, such as haloperidol.
1724. All antipsychotics, and especially â€œtypicalâ€� agents, pose a risk of torsades de pointes and extrapyramidal side-effects as well as the more rare neuroleptic malignant syndrome.
1725. Patient education and encouragement in the use of CPAP and management of associated adverse effects improves compliance with CPAP in severe sleep apnea.
1726. A highly elevated peak pulmonary artery pressure is consistent with pulmonary hypertension, but not necessary to confirm the diagnosis and may be inaccurate for evaluating severity.
1727. In patients in status asthmaticus, pulse oximetry is a good monitoring tool but is not a substitute for determining actual oxygenation by measuring arterial blood gases.
1728. The characteristic clinical features of interstitial lung disease are progressive dyspnea, diffuse radiographic pulmonary infiltrates, restrictive pulmonary physiology, and oxygen desaturation with exertion.
1729. In the correct clinical setting, bronchoscopy with bronchoalveolar lavage can provide a specific diagnosis in interstitial lung disease.
1730. Epoprostenol is first-line therapy for patients with severe pulmonary hypertension, and may be life-saving for patients in cor pulmonale.
1731. Bosentan causes pulmonary artery vasodilation and is associated with a reduction in mortality in patients with pulmonary artery hypertension
1732. Intubated patients should receive a tracheostomy as soon as it is deemed unlikely that they will wean from mechanical ventilation within 21 days.
1733. In patients with asthma who have increased nocturnal symptoms despite adequate daytime control, a trial of gastric acid suppression therapy is warranted.
1734. In selected immunosuppressed patients with respiratory failure, noninvasive positive pressure ventilation is associated with a lower mortality rate than conventional oxygen therapy and intubation.
1735. Hereditary hemorrhagic telangiectasia (HHT) is diagnosed clinically by the presence of three of the following four criteria: (1) recurrent epistaxis; (2) telangiectasias in the lips, oral cavity, fingers, or nose; (3) visceral lesions such as gastrointestinal telangiectasias, or arteriovenous malformations in the lung, liver, or brain; and (4) first-degree relatives with the syndrome.
1736. The propofol infusion syndrome in adults occurs primarily in patients with acute neurologic or acute inflammatory diseases complicated by severe infection or sepsis, and receiving catecholamines and/or corticosteroids in addition to propofol.
1737. The main features of the propofol infusion syndrome are cardiac failure, rhabdomyolysis, severe metabolic acidosis, and renal failure associated with hyperkalemia.
1738. Noninvasive positive pressure ventilation can reverse hypoventilation and alleviate cor pulmonale in patients with obesity hypoventilation syndrome.
1739. Methacholine challenge testing is most useful in evaluating patients with suspected asthma but who has episodic symptoms and normal baseline spirometry.
1740. The diagnosis of cough-variant asthma is suggested by the presence of airway hyperresponsiveness and confirmed when cough resolves with asthma therapy.
1741. A trial of inhaled albuterol can help control symptoms and confirm the diagnosis of cough-variant asthma.
1742. Poor technique in the use of a metered-dose inhaler (MDI) or other inhalation devices is a major reason patients do not respond well to medications.
1743. All patients with COPD who have intermittent symptoms should receive a short-acting bronchodilator.
1744. For patients with stage 3 COPD, especially those with frequent exacerbations, inhaled corticosteroids should be part of their regular therapy.
1745. In the staging of patients with dyspnea for therapy, the post-bronchodilator FEV1 is most relevant finding.
1746. A postbronchodilator FEV1/FVC ratio greater than 70% indicates stage 0 (at risk) chronic obstructive pulmonary disease.
1747. Chronic obstructive pulmonary disease is corticosteroid-insensitive, and inhaled corticosteroids do not change the rate of FEV1 decline in affected patients.
1748. In patients with COPD, cor pulmonale usually occurs in GOLD stage 3 or 4 in patients with an FEV1 equal or less than 1 L.
1749. In patients with end-stage chronic obstructive pulmonary disease, pulmonary rehabilitation improves symptoms, exercise endurance, and quality of life.
1750. Patients with GOLD stage 4 chronic obstructive pulmonary disease who have an acute exacerbation should be treated like patients with community-acquired pneumonia.

Last part of the notes, now it is COMPLETE !!

Nephrology:

1751. Sleep apnea is associated with resistant hypertension and is particularly prevalent in obese patients.
1752. Hypertension associated with sleep apnea may be related to insulin resistance, increased activity of the sympathetic nervous system, and increased sodium retention.
1753. Referral to a nephrologist for education and evaluation for consideration of preemptive kidney transplantation is indicated for patients with chronic kidney disease when the glomerular filtration rate reaches the 30 mL/min range
1754. Minimal change disease is the most common cause of the nephrotic syndrome in children and young adults.
1755. The presence of numerous oval fat bodies on urinalysis is a hallmark of a proteinuric state.
1756. Decreased thresholds for arginine vasopressin in normal pregnancy cause relatively lower sodium levels.
1757. Increased vasodilation in pregnancy is associated with a decreased blood pressure measurement and an increased heart rate.
1758. In normal pregnancy, increases in the glomerular filtration rate and renal blood flow result in decreased creatinine and blood urea nitrogen levels.
1759. The sudden development of hyperkalemia in a patient on dialysis may be a sign of tissue necrosis.
1760. Abdominal pain, hematochezia, and lactic acidosis are suggestive of bowel infarction.
1761. Henochâ€“SchÃ¶nlein purpura is a renalâ€“dermal vasculitis syndrome that may present with intermittent episodes of mild abdominal pain.
1762. Patients with chronic kidney disease have increased risk for acute renal failure because of their use of osmotic agents such as dextran 40, mannitol, and sucrose-containing preparations of intravenous immune globulin.
1763. Reduction in blood pressure has been shown to influence the progression of renal disease and the development of cardiovascular disease in patients with diabetes.
1764. Dialysis should be considered early in the course of tumor lysis syndrome in patients with oliguric acute renal failure.
1765. Measurement of urine microalbumin is the screening test of choice for diabetic nephropathy.
1766. A 24-hour urine collection is no longer recommended to assess kidney function or quantify proteinuria.
1767. Combination therapy with angiotensin-converting enzyme inhibitors and angiotensin receptor blockers may be more renoprotective than single-agent therapy with either drug in patients with diabetic nephropathy.
1768. An antiâ€“glomerular basement membrane antibody assay is indicated to diagnose Goodpasture's syndrome.
1769. In selected patients, ambulatory blood pressure monitoring should be used to diagnose white coat hypertension.
1770. The syndrome of inappropriate antidiuretic hormone secretion (SIADH) is defined as hypotonic hyponatremia with a urine osmolality more than 100 mosm/kg H2O in the absence of volume depletion, adrenal insufficiency, congestive heart failure, hypothyroidism, cirrhosis, and/or renal impairment.
1771. The classical triad of acute interstitial nephritis (fever, skin rash, and arthralgias) in the setting of acute or subacute renal failure is present in only a minority of affected patients.
1772. The presence of a slowly progressive nephrotic syndrome suggests the possibility of solid tumorâ€“associated membranous nephropathy
1773. Nonsteroidal anti-inflammatory drugs can cause acute interstitial nephritis as well as prerenal acute renal failure through changes in local glomerular hemodynamics.
1774. Abdominal CT or ultrasonography are the recommended imaging modalities for uric acid stones.
1775. Patients with progressive chronic kidney disease should be referred for creation of a permanent vascular dialysis access when the glomerular filtration rate decreases below 30 mL/min.
1776. Blood pressure measurements in elderly patients who tolerate medication poorly may be higher in the office than at home.
1777. In selected patients, ambulatory blood pressure monitoring can exclude white coat hypertension.
1778. Ambulatory blood pressure monitoring can detect symptoms that may be related to excessive reduction of blood pressure.
1779. Elevated blood pressure in early pregnancy is most likely caused by a chronic condition.
1780. Glomerulonephritis, not preeclampsia, is the most likely diagnosis in patients with elevated creatinine levels and proteinuria early in pregnancy.
1781. Patients with membranous nephropathy are at increased risk for renal vein thrombosis.
1782. CT, MRI, or venography is indicated to definitively diagnose renal vein thrombosis.
1783. Hypertonic saline is not indicated for asymptomatic hyponatremia.
1784. Focal segmental glomerulosclerosis is the most common cause of the nephrotic syndrome in black patients, particularly those of younger age.
1785. Antiretroviral therapy and plasmapheresis are indicated for patients with HIV infection and thrombotic thrombocytopenic purpura.
1786. Listeria is a common cause of meningitis in renal transplant recipients.
1787. Increasing dietary calcium intake to 1 g/d to 4 g/d decreases the risk for recurrent calcium oxalate stones.
1788. High-protein and -sodium diets can worsen kidney stone disease by causing hypercalciuria and hyperuricosuria.
1789. A decrease in the bicarbonate level accompanied by an elevated anion gap is consistent with a primary metabolic acidosis.
1790. In a patient with a primary metabolic acidosis, a PCO2 that is much higher than would be expected based on the degree of acidemia indicates a condition that is secondary to inadequate ventilation.
1791. Compared with hemodialysis therapy, renal transplantation offers a survival advantage in patients with diabetic nephropathy and end-stage renal disease.
1792. Renal transplantation is most beneficial in young people and in patients with diabetes mellitus.
1793. Hyperaldosteronism should be considered in patients with difficult-to-control hypertension and hypokalemia in the absence of diuretic use.
1794. Hyperaldosteronism should be considered in patients with difficult-to-control hypertension even in the absence of hypokalemia.
1795. The aldosteroneâ€“renin ratio is a reasonable screening study for primary hyperaldosteronism.
1796. Rhabdomyolysis-associated acute renal failure presents with dipstick-positive hematuria but no intact erythrocytes on microscopic analysis of the urine sediment.
1797. Heparin therapy inhibits aldosterone synthesis and therefore may cause hyperkalemia.
1798. The development of the nephrotic syndrome in the setting of urinary reflux is most likely caused by focal segmental glomerulosclerosis.
1799. The fractional excretion of sodium may be more than 4% in patients with prerenal acute renal failure who use diuretics.
1800. Patients with the nephrotic syndrome are predisposed to develop deep venous and renal vein thrombosis.
1801. Staghorn calculi form as a result of chronic infections with urease-splitting organisms such as Proteus or Klebsiella.
1802. Stone removal in struvite stone disease often is indicated to prevent recurrence of infection and stone growth.
1803. Angiotensin-converting enzyme inhibitor therapy has been shown to prevent the development of microalbuminuria in patients who have diabetes and normoalbuminuria.
1804. Microalbuminuria is the first clinical sign of diabetic nephropathy and a major risk factor for the development of clinical proteinuria, chronic kidney disease progression, and cardiovascular death.
1805. The most common causes of primary hyperaldosteronism are aldosterone-producing adenoma (Conn's syndrome) and bilateral adrenal hyperplasia.
1806. Hypotonic fluids should not be used postoperatively.
1807. Normal saline (0.9%) is the most appropriate intravenous fluid when fluid therapy is indicated in the postoperative setting.
1808. SjÃ¶gren's syndrome is a common cause of interstitial nephritis.
1809. A collapsing form of focal segmental glomerulosclerosis is the most likely diagnosis in black patients with HIV infection who have the nephrotic syndrome.
1810. Postinfectious glomerulonephritis associated with hepatitis C typically presents with hematuria, proteinuria, and low C3 and C4 levels.
1811. Albumin infusions decrease the risk for acute renal failure in patients undergoing paracentesis with more than 5 L of volume removed and in patients with spontaneous bacterial peritonitis.
1812. Octogenarians with poor functional status are unlikely to experience improvement or benefit from dialysis.
1813. Increasing calcium intake decreases the risk for calcium oxalate stones because calcium binds to gastrointestinal sources of oxalate and therefore prevents absorption.
1814. Dietary modifications such as decreasing animal protein intake, decreasing sodium intake, and increasing citrate can reduce the risk for recurrent kidney stones without additional medical therapy.
1815. Clinical manifestations of autosomal dominant polycystic kidney disease include renal, hepatic, and pancreatic cysts; intracranial, thoracic, and abdominal aortic aneurysms; and colonic diverticulae.
1816. Certain manifestations of autosomal dominant polycystic kidney disease, such as intracranial aneurysms, tend to cluster in families.
1817. Patients with pheochromocytoma should receive an Î±-blocker 2 weeks before surgery.
1818. Î²-Blockade in the absence of Î±-blockade is contraindicated in patients with pheochromocytoma and may lead to hypertensive crisis.
1819. The combination of upper and/or lower respiratory tract disease and proteinase-3 antinuclear cytoplasmic antibody positivity at the time of diagnosis is associated with the highest likelihood of relapsing disease in antinuclear cytoplasmic antibodyâ€“associated small-vessel vasculitis.
1820. Hydrochlorothiazide can cause severe hyponatremia.
1821. Cryoglobulinemia is characterized by Raynaud's phenomenon, a purpuric rash, abnormal findings on liver function studies, and the presence of glomerulonephritis.
1822. Cryoglobulinemia typically decreases the C4 level, which indicates activation of the classical pathway of complement activation, more than the C3 level.
1823. Renal biopsy is indicated for patients with acute glomerulonephritis of unknown cause.
1824. Pulmonary hemorrhage associated with acute glomerulonephritis is associated with substantial morbidity and mortality.
1825. Atheroembolic disease can mimic vasculitis.
1826. The presence of livedo reticularis, Hollenhorst plaque, cyanotic toe, low C3 levels, and peripheral eosinophilia suggests a diagnosis of atheroembolic disease.
1827. Atheroembolic disease should be suspected in patients with erosive atherosclerosis presenting with acute renal failure.
1828. Asymptomatic hypercalcemia in a patient with a history of calcium stones warrants evaluation for primary hyperparathyroidism.
1829. Parathyroidectomy should be considered for patients with calcium-containing stones secondary to primary hyperparathyroidism.
1830. Alport's syndrome causes persistent microscopic hematuria, progressive nephritis with proteinuria, and progressive decline in renal function to end-stage renal disease.
1831. Alport's syndrome is an inherited condition that may present with high-frequency sensorineural hearing loss and/or ocular abnormalities.
1832. Isotonic saline is preferred over bicarbonate-containing solutions for resuscitation of patients with rhabdomyolysis.
1833. In the absence of renal failure or flash pulmonary edema, medical rather than invasive therapy is preferred for blood pressure control, even when renovascular hypertension is suspected.
1834. Solute diuresis secondary to a high urea load is a common cause of hypernatremia in the critical care setting.
1835. Simple cysts discovered on renal imaging studies require no therapy.
1836. Complex renal cysts on ultrasonography require follow-up imaging with CT or MRI.
1837. Kidney biopsy is contraindicated in patients with complex renal masses suspicious for malignancy.
1838. A paraprotein associated with systemic amyloidosis or multiple myeloma is a likely cause of the nephrotic syndrome in older patients.
1839. Angiotensin-converting enzyme inhibitor therapy is warranted in patients with stage III and stage IV chronic kidney disease unless the creatinine level rises >30% after initiation of therapy.
1840. Once-daily dosing of angiotensin-converting enzyme inhibitors can decrease the risk for hyperkalemia.
1841. Sarcoidosis may cause nephrolithiasis, nephrocalcinosis, and interstitial nephritis.
1842. Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers are the agents of choice for the treatment of hypertension in chronic kidney disease.
1843. An anion gap metabolic acidosis may be present in a patient with severe hypoalbuminemia and a â€œnormalâ€� anion gap.
1844. Renal ultrasonography can be normal early in the course of acute urinary tract obstruction.
1845. Urinary tract obstruction should be suspected in elderly men with acute renal failure.
1846. IgA glomerulonephritis is manifested by the nephritic syndrome and is associated with dysmorphic erythrocytes and erythrocyte casts.
1847. Diabetic ketoacidosis can lead to an anion gap metabolic acidosis and metabolic alkalosis simultaneously.
1848. Iatrogenic respiratory alkalosis may develop after initiation of mechanical ventilation.
1849. Antihypertensive agents such as diuretics and Î²-blockers have been associated with an increased risk for type 2 diabetes mellitus, whereas angiotensin-converting enzyme inhibitors and angiotensin receptor blockers may improve insulin sensitivity.
1850. Risk factors for contrast nephropathy include diabetic nephropathy, dehydration, heart failure, age more than 70 years, impaired kidney function, and concurrent use of nephrotoxic drugs and high-osmolar or high doses of radiocontrast medium.
1851. Prevention of contrast nephropathy in patients at increased risk for this condition involves discontinuing nephrotoxic drugs, using the lowest possible dose of low-osmolality contrast medium for the study, and administering intravenous therapy with 0.9% saline at 1 mL/kg/h for 24 hours beginning 12 hours before administration of contrast medium.
1852. Myeloma-related kidney disorders should be suspected in patients with anemia, a low serum anion gap, and renal failure.
1853. A low serum anion gap warrants evaluation for myeloma due to an increase in unmeasured cations such as calcium and immunoglobulins.
1854. Myeloma kidney is associated with a discrepancy in proteinuria detection between the dipstick urinalysis and a spot urine collection.
1855. Mathematical equations such as Cockcroftâ€“Gault or Modification of Diet in Renal Disease are recommended for the assessment of glomerular filtration rate rather than 24-hour urine collections or radioimaging studies.
1856. Individuals with uncontrolled hypertension and recurrent episodes of flash pulmonary edema should be screened for renovascular disease.
1857. In patients with suspected renovascular disease and a glomerular filtration rate more than 60 mL/min, magnetic resonance angiography is the imaging study of choice to avoid the risk for contrast-induced acute renal failure.
1858. A low glomerular filtration rate is the main cause of phosphate retention and hyperphosphatemia in patients with chronic kidney disease.
1859. Diuretics are effective antihypertensive agents in elderly patients but may cause electrolyte abnormalities.
1860. The presentation of anion gap metabolic acidosis and respiratory alkalosis suggests salicylate toxicity.
1861. Immobilization in the exaggerated lithotomy position can result in rhabdomyolysis.
1862. An extremely elevated creatine kinase level and elevated urine myoglobin level suggest a diagnosis of pigment nephropathy.
1863. Combination therapy with an angiotensin-converting enzyme inhibitor and an angiotensin receptor blocker is associated with decreasing proteinuria in patients with nondiabetic renal disease.
1864. Thin basement membrane disease (benign familial hematuria) is characterized by glomerular hematuria with dysmorphic erythrocytes on microscopic analysis of the urine and no evidence of proteinuria.
1865. Patients with ethylene glycol poisoning presenting with both an increased anion and osmolar gap metabolic acidosis require dialysis in addition to either fomepizole or ethanol.
1866. Amyloidosis is a common cause of the nephrotic syndrome in nondiabetic patients >50 years of age.
1867. Phosphate binders may help to treat hyperphosphatemia in patients with chronic kidney disease.
1868. Black patients with kidney disease and hypertension have better renal outcomes after treatment with angiotensin-converting enzyme inhibitor therapy compared with amlodipine or Î²-blockers.
1869. In pregnancy, labetalol is preferable to pure Î²-blockers, which may be associated with low birthweight.
1870. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are contraindicated in pregnancy.
1871. A highly negative urine anion gap suggests that the kidney is appropriately excreting acid during metabolic acidosis.
1872. Alport's syndrome is associated with a glomerulonephritis with dysmorphic erythrocytes, mild proteinuria, and a high-frequency hearing loss.
1873. Wegener's granulomatosis is characterized by upper and lower airway disease, glomerulonephritis, and positive findings on a proteinase-3 antineutrophil cytoplasmic antibody assay.
1874. A disparity between the dipstick protein level and quantified urinary protein excretion, a low anion gap, and an increase in the globulin fraction of the total protein level suggests multiple myeloma.
1875. Microscopic polyangiitis is a nongranulomatous or small-vessel vasculitis occasionally accompanied by medium-sized vessel involvement that causes a pulmonaryâ€“renal syndrome.
1876. Renal transplant recipients who are Epsteinâ€“Barr virusâ€“negative are at increased risk for post-transplant lymphoproliferative disorder, especially after receiving an organ from an Epsteinâ€“Barr virusâ€“positive donor.
1877. One of the most important initial steps in the evaluation of microscopic hematuria is urine microscopy to assess erythrocyte morphology.
1878. Glomerular hematuria is associated with dysmorphic erythrocytes and erythrocyte casts on urinalysis.
1879. Obesity may lead to proteinuria and chronic kidney disease.
1880. Lowering blood pressure to appropriate targets is particularly important in patients with diabetes who have increased risk for cardiovascular and renal complications.
1881. Diuretics potentiate the blood pressureâ€“lowering effects of angiotensin-converting enzyme inhibitors and Î²-blockers.
1882. Postinfectious glomerulonephritis may present 3 weeks after onset of the inciting infection and is associated with low C3 levels and normal C4 levels.
1883. Respiratory alkalosis commonly develops in end-stage liver disease.
1884. The refeeding syndrome is a potential complication in malnourished patients who suddenly receive a large calorie load.
1885. Rhabdomyolysis is a potentially severe complication of the refeeding syndrome.
1886. The antiphospholipid antibody syndrome is characterized by thrombosis in association with a lupus anticoagulant or persistently elevated levels of anticardiolipin antibodies.
1887. A peritoneal fluid cell count more than 100 total nucleated cells/ÂµL is abnormal and consistent with the diagnosis of peritonitis.
1888. Antibiotic therapy covering both gram-negative and gram-positive pathogens should be started immediately in a patient with suspected peritoneal dialysisâ€“related peritonitis.
1889. Acute tubular necrosis is the most common cause of acute renal failure after acetaminophen poisoning.
1890. Patients with chronic kidney disease should be educated to avoid venipuncture and intravenous catheters in veins above the level of the wrist in both arms to preserve veins for future creation of arteriovenous fistulas.
1891. Subclavian vein lines should be strictly avoided in patients with chronic kidney disease.
1892. Creation of an arteriovenous fistula is indicated months before initiation of dialysis.
1893. Patients more than 50 years of age with persistent hematuria should be evaluated for genitourinary tract malignancy.
1894. Nonsteroidal anti-inflammatory drug use is a common cause of resistance to antihypertensive therapy.
1895. Acetazolamide may cause nonâ€“anion gap metabolic acidosis.
1896. In addition to corticosteroids, the most appropriate treatment for lupus nephritis is intravenous cyclophosphamide followed by maintenance mycophenolate mofetil once remission is achieved.
1897. Infusion of normal saline before and after exposure to radiocontrast is the most effective method to decrease the risk for radiocontrast nephropathy.
1898. Calcific uremic arteriolopathy typically presents with painful violaceous nodules on the trunk, proximal extremities, and buttocks in patients with chronic kidney disease.
1899. Quantification of urinary protein in upright and recumbent positions to evaluate for orthostatic proteinuria is indicated for young adults with proteinuria and no other evidence of kidney disease.
1900. Acute glomerulonephritis is uncommon without hematuria and a bland urine sediment.
1901. Hospitalization and delivery are indicated for women with preeclampsia at term.
1902. The manifestations of the HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets) are features of severe preeclampsia.

Zaco's Hematology Notes

2009-01-20T08:01:00.000-08:00

Hematology

Anemia, General Principles
• Definition à Hb < 13.5 g/dL (Hct < 40) in men or Hb < 12 g/dL (Hct < 37) in women • Most useful classification of anemia (based on MCV or mean corpuscular volume): 1. Microcytic (MCV < 80) à Iron-deficiency anemia, sideroblastic anemia, anemia of chronic disease, lead poisoning, thalassemia 2. Normocytic (MCV 80-100) à aplastic anemia, anemia of chronic disease, myelofibrosis/bone marrow infiltration, chronic renal failure, hemolytic anemia, early stages of iron-deficiency anemia, hemorrhage 3. Macrocytic (MCV > 100) à megaloblastic anemia (vitamin B12 and/or folate
deficiency; drug-induced), liver disease, myelodysplasia, reticulocytosis

• Clinical features à fatigue, malaise, weakness, poor exercise tolerance,
tachycardia/palpitations, dyspnea on exertion, dizziness/syncope, chest pain, pallor,
systolic ejection murmur, wide pulse pressure, orthostatic hypotension
• Presentation depends on:
1. Degree of anemia
2. Rapidity of onset of anemia
3. Age/health status
• Best initial diagnostic tests à CBC with RBC indices (e.g. MCV), reticulocyte count,
blood smear
• Management à etiology-dependent ± packed RBC transfusion
• Indications for RBC transfusion à
1. Acute blood loss > 30% (> 1500-2000 ml)
2. Hb < 7 g/dL 3. Hb <> 65, cardiovascular/pulmonary disease and/or
acute bleed
4. Overtly symptomatic (e.g. chest pain, respiratory distress, CNS symptoms/signs)
Microcytic Anemia
Iron-deficiency Anemia
• Most common cause of anemia
• Females > Males
• Etiology:
1. Chronic blood loss à most common cause; e.g. GI cancer, PUD, menorrhagia
2. ↓ dietary intake/malabsorption à e.g. celiac disease, post-gastrectomy, cow’s
milk diet in infants, achlorhydria
3. ↑ requirements à e.g. pregnancy, growth spurt
4. Chronic intravascular hemolysis à hemoglobinuria, hemosiderinuria
• Promoters of iron absorption à ↓ gastric pH and ascorbic acid
• Clinical features specific for iron-deficiency anemia à
1. brittle nails/koilonychia (spoon-shaped nails)
2
2. glossitis/angular cheilitis
3. pica (craving for non-nutritive substances)
4. dysphagia (Plummer-Vinson syndrome)
• Initial lab results (CBC, reticulocyte count, etc.) à low Hb and/or Hct, low MCV, ↑
RDW (red blood cell distribution width), ↓ reticulocyte count, possible thrombocytosis
• Blood smear à hypochromic, microcytic RBCs ± poikilocytosis (abnormal shapes)
• Best next step à perform iron studies:
1. ↓ serum ferritin à most specific laboratory test; lacks sensitivity (falsely
elevated in inflammatory conditions, liver disease and/or malignancies)
2. ↓ serum iron
3. ↑ TIBC (total iron binding capacity)
4. ↓ transferrin saturation (serum iron/TIBC ratio, expressed as %)
• Most accurate diagnostic test à bone marrow biopsy + Prussian blue stain
• Best next step in men > 50 and/or postmenopausal women à colonoscopy to rule out
colon cancer
• Management:
1. Treatment/correction of any underlying abnormality
2. Packed RBC transfusion, when indicated (see above)
3. PO ferrous sulfate (or ferrous gluconate) replacement à continued until serum
ferritin becomes normal, indicating replenishment of iron stores (~ 3-12 months)
4. Parenteral iron replacement, if malabsorption/intolerance to oral medications
• Adequate iron replacement indicated by à
1. Reticulocytosis after ~ 1 week
2. Rise in Hb of ~ 1g/week
3. Normalization of Hb after ~ 1 month
Anemia of Chronic Disease
• Anemia that accompanies any chronic inflammatory (e.g. RA, IBD, etc.), infectious
(e.g. TB, bacterial endocarditis, etc.) and/or malignant condition
• Pathophysiology à
1. ↓ sensitivity to erythropoietin
2. Impaired utilization of stored iron à due to ↑ levels of TNF-α and IL-6
• Clinical features à symptoms/signs of anemia + that of the underlying disease
• Initial lab results à low Hb and/or Hct, low or normal MCV, ↓ reticulocyte count,
normal RDW
• Blood smear à hypochromic, microcytic or normochromic, normocytic RBCs
• Best next step à perform iron studies:
1. ↓ serum iron
2. ↓ TIBC
3. Normal transferring saturation
4. Normal or ↑ serum ferritin
• Bone marrow biopsy + Prussian blue stain à ↑ stainable iron
• Management à treatment/correction of any underlying abnormality ± large doses of
exogenous erythropoietin ± iron replacement
3
Sideroblastic Anemia
• A group of disorders of heme (protoporphyrin) synthetic pathway characterized by iron
accumulation in the perinuclear mitochondria of nucleated RBCs à “ringed”
sideroblasts
• May be hereditary (e.g. X-linked; defective δ-aminolevulinic acid (ALA) synthase) or
acquired (e.g. alcohol, isoniazid, lead poisoning, myelodysplastic syndrome)
• Sideroblastic anemia associated with myelodysplasia may progress to acute
myelogenous leukemia (AML)
• Clinical features of lead poisoning à abdominal colicky pain, peripheral neuropathy
(e.g. wrist drop, foot drop), encephalopathy, gingival lead lines, developmental delay +
symptoms/signs of anemia
• Initial lab results à low Hb and/or Hct, low MCV, ↓ reticulocyte count
• Blood smear à dimorphic (both normocytic and microcytic) population of RBCs ±
basophilic stippling (with lead poisoning)
• Best next step à perform iron studies:
1. ↑ serum iron
2. ↑ serum ferritin
3. Normal TIBC
4. ↑ transferrin saturation
• Most accurate diagnostic test (required for diagnosis) à bone marrow biopsy +
Prussian blue stain showing ↑ iron stores and ringed sideroblasts
• Management à removal of any underlying drug/toxin + trial of vitamin B6/pyridoxine
(successful in some forms of hereditary sideroblastic anemia) ± lead chelation (e.g.
EDTA, dimercaprol)
• Packed RBC transfusion, as indicated
Thalassemia
• A group of hereditary (autosomal recessive) disorders characterized by decreased to
absent globin chain (α and/or β) synthesis à hypochromic, microcytic anemia
• α-thalassemia (common in Asians and African-Americans) à
Silent α-thalassemia (carrier
state)
Deletion of one gene Asymptomatic
Normal CBC, Hb and MCV
α-thalassemia trait (minor α-
thalassemia)
Deletion of two genes:
Asian variant à - - / α α
African variant à α - / α -
Mild anemia
↓Hb, ↓MCV, normal RDW
Smear à hypochromic,
microcytic RBCs ± target
cells
HbH (tetrads of β-chains)
Disease
Deletion of three genes
More common in Asians
Severe anemia with
splenomegaly
↓Hb, ↓MCV, normal RDW
Smear à hypochromic,
microcytic RBCs with HbH
(children/adults) or Hb
Barts (neonates/infants)
inclusions ± target cells
Hb Barts (tetrads of γ-chains)
Disease
Deletion of all four genes
More common in Asians
Hydrops fetalis
In utero fetal demise
4
• β-thalassemia (common in people of Mediterranean origin; also seen in Asians and/or
African-Americans) à unbalanced production of α-chains leads to ineffective
erythropoiesis, chronic hemolysis and extramedullary hematopoiesis
β-thalassemia minor Mutations involving one gene Asymptomatic to mild anemia
± splenomegaly
↓Hb, ↓MCV, normal RDW
Smear à hypochromic,
microcytic RBCs with
basophilic stippling ± target
cells ± poikilocytosis
β-thalassemia major
(Cooley’s anemia)
Mutations involving both
genes
Presentation at ~ 3-6 months
of age (switch from γ to β
chain synthesis) with severe
anemia, growth retardation,
hepatosplenomegaly,
jaundice, bone deformities
(principally involving the face
and skull, e.g. frontal bossing,
maxillary hyperplasia),
possible gallstones, leg ulcers
and/or pathologic fractures
↓Hb, ↓MCV, normal RDW
Smear à hypochromic,
microcytic RBCs with
basophilic stippling ± target
cells ± poikilocytosis
Skull X-ray à “crew-cut”
appearance
• Best initial step à perform iron studies to rule out iron-deficiency (should be normal
in both forms of thalassemia)
• Best next and the most sensitive test à hemoglobin electrophoresis:
1. α-thalassemia à normal levels of HbA2 and HbF
2. β-thalassemia minor à ↑ HbA2 ± ↑ HbF
3. β-thalassemia major à ↑ HbA2 and HbF
• Most accurate diagnostic test à Genetic analysis
• Management:
1. α-thalassemia trait/ β-thalassemia minor à genetic counseling ± folate
supplementation
2. β-thalassemia major/HbH disease à daily folate supplementation + chronic
blood transfusions + iron-chelation to prevent secondary hemochromatosis
(e.g. deferoxamine and/or deferasirox) + splenectomy (improves anemia,
decreases transfusion requirements) ± bone marrow transplantation (possibly
curative)
3. Experimental therapy à hydroxyurea, cytarabine and/or butyrates (↑ HbF
production)
• Major cause of death à secondary hemochromatosis
* Note à Thalassemia may present with ↑ Hct
5
Normocytic Anemia
Hemolytic Anemia, General Principles
• Anemia resulting from ↑ premature destruction of RBCs
• May be classified according to:
1. time-course à acute vs. chronic
2. site of hemolysis à intravascular vs. extravascular
3. causative factor à intrinsic vs. extrinsic (intracorpuscular vs. extracorpuscular)
• Clinical features suggestive of hemolysis à acute onset, jaundice with dark urine,
gallstone disease, chronic leg ulcers, hepatosplenomegaly + symptoms/signs of anemia
• Lab findings à ↓ Hb, ↓ Hct, normal MCV (possible ↑ MCV due to reticulocytosis), ↑
reticulocyte count, ↑ serum LDH, ↑ serum indirect bilirubin, ↓ serum haptoglobin
(binds free hemoglobin; more prominent with intravascular hemolysis)
• Lab findings consistent with intravascular hemolysis à ↓ haptoglobin, presence of
serum free hemoglobin, hemoglobinuria, possible hemosiderinuria
• Management à etiology-dependent + adequate hydration (with intravascular
hemolysis to prevent renal tubular damage à acute renal failure) ± packed RBC
transfusion, as indicated
Hereditary Spherocytosis
• Most common hereditary hemolytic anemia
• Autosomal dominant (more common, less severe) or autosomal recessive inheritance
• Etiology à spectrin deficiency resulting from various genetic defects, with mutations
involving the ankyrin gene being most common
• Pathophysiology: RBC membrane defects/instability à assumption of a spherical
shape à ↓ elasticity à inability to traverse splenic cords à extravascular (principally
splenic) hemolysis
• Clinical features à family history + triad of mild/moderate anemia + splenomegaly +
jaundice/gallstone disease (e.g. biliary colic, acute cholecystitis)
• Aplastic crisis à worsening of anemia characterized by ↓ reticulocyte count,
secondary to parvovirus B19 infection and/or concurrent folate deficiency
• Lab findings à consistent with extravascular hemolysis (see above) + ↑ MCHC (mean
corpuscular hemoglobin concentration)
• Blood smear à normochromic, normocytic RBCs + presence of spherocytes (small,
hyperchromic RBCs with loss of normal central pallor)
• Most accurate diagnostic test à osmotic fragility test (RBC susceptibility to hemolysis
when placed in hypotonic solutions)
• Management:
1. Mild anemia à daily folate supplementation
2. Severe anemia à splenectomy (symptomatic improvement; persistence of
spherocytosis) + daily folate supplementation
* Remember à administer Pneumococcal vaccine before performing splenectomy
* Remember à Never perform cholecystectomy in suspected/confirmed hereditary
spherocytosis before removing the spleen (↑ risk of intahepatic stone formation)
6
Sickle Cell Anemia
• Autosomal recessive chronic hemolytic anemia resulting from substitution of valine for
glutamic acid at position 6 of the β-globin gene à HbS
• Most common in people of African descent (8% of African-Americans are
heterozygous for HbS à sickle cell trait)
• Both sickle cell trait and anemia (homozygous for HbS) protect against falciparum
malaria
• Pathophysiology: deoxygentated HbS tends to polymerize forming rigid crystals à
“sickling” of RBCs (irreversible with time) + membrane damage à abnormally sticky
and non-deformable RBCs à principally extravascular hemolysis + vaso-occlusion of
small arterioles and/or larger arteries
• Factors that promote/precipitate sickling à
1. ↓ pO2
2. acidosis (both metabolic and respiratory)
3. dehydration
4. ↑ temperature
5. ↑ Hb concentration
• Inhibitor of HbS polymerization à HbF (no clinical manifestations until 6-12
months of age)
• Clinical manifestations:
1. chronic hemolytic anemia
2. jaundice
3. bilirubin gallstones/acute cholecystitis
4. chronic leg ulcers
5. avascular necrosis of the femur/humerus
6. growth and/or developmental delay
7. splenomegaly followed by autosplenectomy
8. susceptibility to infections with encapsulated bacteria (e.g. Streptococcus
pneumonia, Heamophilus influenzae, Neisseria meningitidis)
9. osteomyelitis caused by Salmonella (most common) and/or S. aureus
10. hyposthenuria (renal concentrating defects) à nocturia, enuresis
11. renal papillary necrosis à hematuria and/or acute renal failure
12. retinopathy (non-proliferative or proliferative)
13. acute painful crisis (vaso-occlusive crisis):
• dactylitis (painful, swollen digits) à common in children
• pain involving the ribs, back, elbows and/or knees
14. acute chest syndrome:
• chest pain, tachypnea/dyspnea, ↑ temperature, ↑ WBC count, hypoxia
• infiltrates on chest X-ray
• indistinguishable from pneumonia
• most common cause of mortality
15. priapism (painful, prolonged erection)
16. transient ischemic attacks (TIA) and/or stroke
17. myocardial infarction, cardiomyopathy
18. aplastic crisis:
• secondary to Parvovirus B19 infection and/or folate deficiency
• worsening anemia with ↓ reticulocyte count
19. hemolytic crisis:
• in patients with concurrent G6PD deficiency
• worsening anemia with ↑ reticulocytosis
7
20. splenic sequestration crisis:
• massive splenomegaly, hemodynamic instability
• develops only in children < 5 years of age (before autosplenectomy) 21. ↑ rate of spontaneous abortion and/or preterm delivery • Lab findings à ↓ Hb, ↓ Hct, ↑ reticulocyte count (unless in aplastic crisis), ↑ indirect bilirubin, ↑ LDH, ↑ WBC count (in the absence of infection) with eosinophilia • Blood smear à normochromic, normocytic RBCs, “sickled” RBCs, target cells, Howell-Jolly bodies (post-splenectomy) • Urinalysis à microscopic hematuria • X-ray à “fish-mouth” vertebrae • Best initial (screening) test à sickle solubility test or sickle cell prep or Sickledex (cannot differentiate between trait and disease) • Most accurate diagnostic test à Hb electrophoresis with HbS > 80%
• Management:
1. chronic management à daily folate supplementation, vaccination against
Pneumococcus and Haemophilus; possible daily penicillin V prophylaxis
2. acute vaso-occlusive crisis à adequate hydration, analgesia and oxygen
supplementation; antibiotics if ↑ temperature (e.g. 3rd-generation
cephalosporins, newer fluoroquinolones)
3. acute chest syndrome à as above + RBC exchange transfusion (goal HbS
level of < 30%) 4. indications for exchange transfusion (other than acute chest syndrome) à stroke/TIA, priapism, retinopathy, cardiac involvement 5. splenic sequestration crisis à hemodynamic stabilization followed by splenectomy 6. recurrent vaso-occlusive crisis and/or single episode of acute chest syndrome à hydroxyurea (increases HbF à ↓ HbS polymerization à ↓ frequency of vaso-occlusion à ↓ mortality) 7. recurrent acute chest syndrome and/or stroke à consider bone marrow transplantation (possibly curative) • Top 3 causes of mortality: 1. acute chest syndrome 2. stroke 3. infections * Sickle Cell Trait à asymptomatic to hyposthenuria with nocturia/enuresis, hematuria from renal papillary necrosis, asymptomatic bacteriuria/↑ risk of pyelonephritis (especially during pregnancy), possible PE and/or glaucoma ± acute vaso-occlusive crises in periods of extreme hypoxia and/or acidosis; Lab findings à normal; Blood smear à normal; most accurate diagnostic test à Hb electrophoresis with HbS > 35% but < 50%; treatment not required 8 Glucose-6-Phosphate Dehydrogenase (G6PD) Deficiency • X-linked recessive • Most common in African-Americans • G6PD deficiency protects against malaria • Pathophysiology: G6PD deficiency à ↓ NADPH à ↓ reduced glutathione à susceptibility to oxidant stress à self-limited acute intravascular hemolysis (reticulocytes have normal G6PD activity) • Oxidant stress à infections (e.g. pneumonia, hepatitis, typhoid fever), drugs (e.g. primaquine, sulfonamides, nitrofurantoin, dapsone, quinidine, aspirin) and/or fava beans (“favism” à limited to patients with the Mediterranean variant of G6PD deficiency) • Clinical features à previously asymptomatic (Mediterranean variant à mild/moderate chronic hemolytic anemia) + sudden onset of fever/chills, backache, tachycardia/palpitations, weakness, dizziness, jaundice and/or dark urine within several days of oxidant exposure • Lab findings à suggestive of intravascular hemolysis (see above) • Blood Smear à normochromic, normocytic RBCs with Heinz bodies (denatured, oxidized Hb) + bite cells (remnants of RBCs after removal of Heinz bodies by splenic macrophages) ± spherocytes • Most accurate diagnostic test à G6PD assay (not performed until acute episode subsides à ↑ reticulocyte count à false-positive results) • Management à Adequate hydration ± alkalinization of urine, removal of oxidant stress (e.g. treatment of infections, stopping offending medications, etc.), transfusion, as indicated • Prevention of future attacks (most important) Paroxysmal Nocturnal Hemoglobinuria (PNH) • Acquired stem cell disorder characterized by the triad of chronic hemolytic anemia with superimposed attacks of intravascular hemolysis, hypercoagulability and ineffective hematopoiesis • Pathophysiology: stem cell somatic mutation à ↓ synthesis of the GPI (glycosylphosphatidylinositol) anchor à absence of CD55/DAF (decay-accelerating factor) and CD59 on RBC plasma membranes à ↑ complement binding/activation à hemolytic anemia • PNH may progress to aplastic anemia and/or leukemia • Clinical features à 1. Asymptomatic to chronic hemolytic anemia 2. Intermittent attacks of intravascular hemolysis à dark urine (e.g. in the morning, during infection, etc.) 3. Intra-abdominal venous thrombosis (hepatic, portal, etc.) à Budd-Chiari syndrome (hepatic vein thrombosis) 4. Possible cerebral venous sinus thrombosis • Lab findings à suggestive of intravascular hemolysis (see above) + ↓ WBC count and/or thrombocytopenia + ↓LAP (leukocyte alkaline phosphatase) • Most accurate diagnostic test à flow-cytometric demonstration of the absence of CD55/DAF and/or CD59 9 • Previously used diagnostic tests (commonly tested on exams) à sucrose lysis and/or acidified serum lysis/Ham test • Standard Management à 1. Periodic washed RBC transfusions and/or steroids ± iron replacement (chronic hemoglobinuria/hemosiderinuria à iron-deficiency) 2. Treatment of thrombotic complications (e.g. thrombolysis, chronic anticoagulation, etc.) 3. Bone marrow transplantation (possibly curative) • Most common cause of mortality à intra-abdominal and/or cerebral thrombosis * Recently updated test Qs may offer eculizumab (Soliris) as the treatment of choice for PNH; monoclonal antibody directed against C5 complement protein à ↓ hemolysis, ↓ transfusion requirements, ↓ thrombotic complications, improved quality of life; DO NOT STOP anticoagulation in patients on eculizumab; vaccinate against meningococcus before initiating therapy Immunohemolytic Anemia, Warm-Antibody Type • Autoimmune-mediated hemolytic anemia secondary to production of “warm” antibodies of the IgG type (react at body temperature) • Most commonly seen in adult females • Usually idiopathic • Secondary causes include à 1. Drugs: • α-methyldopa (production of anti-Rh autoantibodies) • penicillins/cephalosporins (stable hapten) • quinidine, sulfonamides/other sulfa derivatives (unstable hapten) 2. NHL (non-Hodgkin lymphoma), Hodgkin’s lymphoma 3. CLL (chronic lymphocytic leukemia) 4. SLE/other collagen-vascular disorders 5. Viral infection (usually transient; predominantly in children) • Pathophysiology: IgG and/or complement coating of RBCs à Fc fragment and/or complement-mediated adherence to splenic macrophages à extravascular (principally splenic) hemolysis ± intravascular hemolysis (from complement activation) • Clinical features à 1. Mild/moderate anemia + splenomegaly and/or 2. Sudden onset of fever/chills, dark urine, weakness, tachycardia, dizziness/syncope, acute CHF à shock (with massive intravascular hemolysis) • Lab findings à consistent with hemolysis (see above) • Blood Smear à normochromic, normocytic RBCs + spherocytes • Most accurate diagnostic test à direct Coombs’ test showing reaction with anti- IgG ± anti-C3 antibodies: 1. Both reactive à consider SLE 2. Only anti-C3 reactive à consider quinidine-type drug-induced hemolysis • Management: 1. Mild hemolysis à treatment not required 2. Severe hemolysis à IVIG (intravenous immunoglobulin) + steroids 10 3. Moderate hemolysis à systemic steroids with gradual taper (after normalization of Hb levels) 4. No response to steroids à splenectomy 5. Intolerance to steroids à splenectomy 6. Relapse à splenectomy 7. No response to splenectomy à cyclophosphamide, azathioprine or rituximab (anti-CD20 antibodies) * Evans Syndrome à Autoimmune hemolytic anemia + ITP Immunohemolytic Anemia, Cold-Antibody Type (Cold Agglutinin Disease) • Autoimmune-mediated hemolytic anemia secondary to production of “cold” antibodies of the IgM type (react at temperatures < 37ºC) • Classification: 1. Chronic à idiopathic, CLL, lymphoma, Waldenstrom’s macroglobulinemia 2. Acute/transient à Mycoplasma pneumoniae, infectious mononucleosis, adenovirus • Pathophysiology: IgM coating of RBCs + activation of complement cascade à agglutination of RBCs ± hemolysis (usually intravascular and/or intra-hepatic) • Clinical features à acrocyanosis (ears, nose, fingers) on cold exposure that disappears with re-warming ± symptoms/signs of anemia • Lab findings à consistent with hemolysis (see above) • Blood Smear à normochromic, normocytic RBCs ± agglutination • Most accurate diagnostic test à direct Coombs’ test showing reaction with anti-C3 antibodies • Management: 1. Associated with infections à treatment not required 2. Mild disease à avoidance of cold exposure + treatment of underlying disease 3. Severe disease à immunosuppressive medications (e.g. cyclophosphamide, azathioprine) and/or rituximab + treatment of underlying disease * Paroxysmal Cold Hemoglobinuria (PCH) à due to the presence of anti - P antigen IgG antibodies (Donath-Landsteiner antibodies); secondary to à tertiary syphilis, postviral (e.g. measles, mumps) or autoimmune; asymptomatic with episodes of intravascular hemolysis on cold exposure (fever/chills, backache, weakness, dark urine, etc.); management à steroids and/or immunosuppressive medications * Schistocytes or fragmented RBCs (e.g. helmet cells, triangle cells) on blood smear à look for traumatic causes of hemolysis (macro- and/or microangiopathic), such as DIC, TTP/HUS, malignant hypertension, HELLP syndrome, prosthetic heart valves, disseminated cancer, renal graft rejection * Anemia due to chronic renal failure à treat with erythropoietin (side effects à ↑BP (most common), flu-like symptoms, skin irritation/rash, and headache) 11 Aplastic Anemia • Pancytopenia associated with bone marrow hypocellularity secondary to failure of hematopoietic stem cells • Etiology à 1. Idiopathic (most common) 2. Radiation 3. Drug- and/or chemical-related • Anticipated reaction à chemotherapeutic agents, benzene, etc. • Idiosyncratic reaction à chloramphenicol. NSAIDs, phenytoin, carbamazepine, cimetidine, gold, etc. 4. Infectious à hepatitis virus (so called non-A, non-B, non-C), HIV, infectious mononucleosis, parvovirus B19 5. Congenital (Fanconi’s anemia) 6. Other à PNH, eosinophilic fasciitis, transfusion-related GVH disease • Clinical features à symptoms/signs of thrombocytopenia (e.g. easy bruising, nosebleeds, petechiae, etc.) + anemia (e.g. pallor, weakness, dyspnea, etc.) ± neutropenia (e.g. ↑ fever, pharyngitis, sepsis, etc.) in the absence of systemic manifestation, splenomegaly/lymphadenopathy and/or weight loss • Lab findings à ↓ Hb (and Hct), ↓ reticulocyte count, ↓ WBC count, ↓ platelet count • Most accurate diagnostic test à bone marrow biopsy showing ↓ and/or absent hematopoietic precursors with marked fatty replacement and some residual stromal and/or lymphoid cells (note à remaining precursor cells should be morphologically normal) • Management à 1. removal of any offending drug/toxin 2. supportive measures (e.g. antibiotics for infection/↑ fever (see neutropenic fever), single donor, leuko-depleted platelet transfusions, packed RBC transfusion) 3. bone marrow transplantation (BMT) à curative; suitable for otherwise healthy young adults with a histocompatible donor 4. BMT not possible à immunosuppression using a combination of ATG (antithymocyte globulin) and cyclosporine; future risks à high relapse rate, MDS (myelodysplastic syndrome), possible leukemia and/or PNH 12 * Neutropenic Fever requiring treatment à Temperature > 38.3 ºC (single reading) or >
38.0 ºC (> 1 hour) in the presence of ANC (absolute neutrophil count) < 500 • Low risk (outpatient, no comorbidities, serum creatinine < 2 mg/dL, normalslightly increased LFTs, neutropenia of short duration, normal BP) à PO ciprofloxacin + PO amoxicillin-clavulanate or IV ceftazidime (usually not tested on exams) • High risk: 1. Step 1 à evaluate for indications for vancomycin (e.g. catheter-related infection, ↓ BP, previous known colonization with MRSA (methicillinresistant S. aureus) and/or penicillin-resistant pneumococcus) 2. Vancomycin not needed à IV ceftazidime (or cefepime or imipenem) (most common test Q answer) or combination of IV aminoglycosides with piperacillin/tazobactam (or ceftazidime, cefepime or imipenem) 3. Vancomycin needed à IV vancomycin + IV ceftazidime (or any of the above mentioned drugs/combinations) • Afebrile within 3 days à switch to PO antibiotics (e.g. cefixime or fluoroquinolones) if low-risk (otherwise continue the same antibiotics) • Febrile on days 5-7 à add antifungal agents (possible Candida, Aspergillus) à posaconazole, voriconazole, echinocandins (e.g. caspofungin) or amphotericin B Macrocytic Anemia Megaloblastic Anemia • Pathophysiology: Vitamin B12 and/or folate deficiency à ↓ DNA synthesis à arrested nuclear maturation + normal cytoplasmic maturation à large, nucleated RBC precursors (megaloblasts) • Etiology: 1. Vitamin B12 deficiency à pernicious anemia (most common), total gastrectomy, atrophic gastritis, malabsorption syndromes (e.g. Crohn’s disease, celiac disease, chronic pancreatitis, bacterial overgrowth), resection of the ileum, fish tapeworm (Diphillobothrium latum), strict vegetarianism, chronic N2O inhalation 2. Folate deficiency à ↓ dietary intake (most common; seen in alcoholism, poverty and/or infancy), ↑ requirements (e.g. pregnancy, rapid growth, chronic hemolysis, hemodialysis, psoriasis, dermatitis), malabsorption syndromes (especially celiac disease), drug/chemical induced (e.g. phenytoin, barbiturates, methotrexate, trimethoprim, pyrimethamine, alcohol) • Clinical features (common to both forms of disease) à symptoms/signs of anemia, mild jaundice (due to ineffective hematopoiesis à intramedullary hemolysis), atrophic glossitis, diarrhea, abdominal pain, ± symptoms/signs of thrombocytopenia • Clinical features suggestive of vitamin B12 deficiency à neurologic manifestations: 1. Distal, symmetric, predominantly sensory, peripheral neuropathy (prominent paresthesias, pain, etc. predominantly affecting the lower limbs) 13 2. Subacute combined degeneration (involvement of posterior columns and corticospinal tracts) à ↓ proprioception (ataxia with positive Romberg’s sign) and vibratory sense ± spastic paralysis 3. CNS involvement à confusion, delirium, dementia (commonly reversible) 4. Other à cranial nerve involvement, sexual dysfunction, loss of bladder/bowel control, autonomic neuropathy • Lab findings à ↓ Hb, ↓ Hct, ↓ reticulocyte count, ↑ MCV, ↓ WBC and/or platelet count, ↑ LDH, ↑ indirect bilirubin • Blood smear à macrocytic RBCs (oval macrocytes), hypersegmented neutrophils (>50% with 4 lobes, or >5% with 5 lobes, or at least one with 6 lobes)
• Bone marrow biopsy à hypercellularity + prominent arrest in nuclear maturation
• Most accurate diagnostic test à serum vitamin B12 and RBC folate levels, respectively
• Suspected vitamin B12 deficiency with normal vitamin B12 levels à order serum
methylmalonic acid (MMA), which should be high
• Best next step in confirmed B12 deficiency à anti-intrinsic factor and/or anti-parietal
cell autoantibodies (to confirm the diagnosis of pernicious anemia)
• Best next step if antibodies negative (or not offered as one of the answer choices) à
Schilling test
• Management:
1. vitamin B12 deficiency à usually lifelong IM vitamin B12 replacement (clinical
improvement within hours, brisk reticulocytosis within 5-7 days, normalization of
hematologic picture within 2 months, neurologic manifestations ± reversible)
2. folate deficiency à PO folate replacement
* Macrocytic anemia due to liver disease à ↓ LCAT (lecithin-cholesterol acetyl
transferase) activity à ↑ plasma cholesterol à cholesterol deposition on RBC
membranes à ↑ membrane surface area à round macrocytosis (liver disease may also
be associated with spur cell anemia (spur cells/acanthocytes à large RBCs covered
with irregularly-spaced spike-like projections of variable shapes and/or lengths) Note:
Burr cells/echinocytes à large RBCs covered with uniformly spaced spike-like
projection of similar shapes and/or lengths
14
Myelodysplasia (MDS)
• A group of stem cell disorders characterized by anemia ± other cytopenias, dysmorphic
and frequently hypercellular bone marrow and ineffective hematopoiesis
• > 50% of cases progress to acute myelogenous leukemia (AML)
• Etiology à radiation, benzene, post-chemotherapy (latent period of 2-7 years;
commonly implicated agents include à busulfan, procarbazine, nitrosureas,
topoisomerase II inhibitors, such as etoposide, irinotecan), aplastic anemia
• Most common in persons > 60 years of age
• Common cytogenetic abnormalities à del (5q), del 7, trisomy 8, del (20q)
• FAB classification of MDS:
1. Refractory Anemia à < 5% blasts, <15% ringed sideroblasts 2. Refractory Anemia with ringed sideroblasts à <> 15% ringed
sideroblasts
3. Refractory Anemia with excess blasts à > 5% but < 20% blasts 4. Refractory Anemia with excess blasts in transformation à > 20% blasts
and/or Auer rods
5. Chronic Myelomonocytic leukemia
• Clinical features à Symptoms/signs of anemia ± thrombocytopenia and/or
neutropenia; possible hepatosplenomegaly
• Fever and/or weight loss à consider CML or other myeloproliferative disorders
• Lab findings à ↓ Hb, ↓ Hct, ↑ MCV, ↓ reticulocyte count, ↓ WBC and/or ↓ platelet
count
• Blood smear à macrocytic and/or dimorphic population of RBCs, large platelets and
hypogranulated PMNs with hyposegmented nuclei
• Most accurate diagnostic test à bone marrow examination showing:
1. hypercellularity
2. ringed sideroblasts
3. PAS-positive erythroblasts
4. asynchronous nuclear/cytoplasmic maturation
5. micromegakaryocytes ± giant platelets
6. pseudo-Pelger-Huet cells (hypogranulated, two-lobed PMNs/precursors)
• Management à supportive measures (blood transfusion, antibiotics, etc.), G-CSF
and/or erythropoietin, azacytidine (inhibits DNA methylation), amifostine (inhibits
apoptosis)
• BMT à possible curative; suitable for younger and otherwise healthy patients with
high-risk MDS
15
Myeloid Malignancies
Acute Myelogenous Leukemia (AML)
• Hematopoietic stem cell disorder characterized by clonal proliferation of immature
myeloid precursors (myeloblasts) secondary to loss of ability to differentiate à bone
marrow failure + peripheral myeloblasts
• Risk factors à benzene, petroleum products, radiation, post-chemotherapy
(alkylating agents à del 5q and/or del7q; topoisomerase II inhibitors à 11q
abnormalities; faster onset), Down syndrome, Klinefelter syndrome, ataxiatelangiectasia,
Fanconi’s anemia, Bloom syndrome
• Incidence increases with age
• FAB classification of AML:
M0: minimally differentiated CD13 and CD33
M1: myeloblastic without maturation
M2: myeloblastic with maturation Most common AML; t(8;21); mass lesions
(granulocytoc sarcoma, also called chloroma)
M3: promyelocytic t(15;17) involving the retinoic acid receptor-
α gene; Auer rods most prominent; DIC
M4: myelomonocytic inv(16) à M4Eo (subtype of M4 AML with
abnormal marrow eosinophils); tissue
infiltration (gums, skin à leukemia cutis,
meninges, soft tissues, etc.)
M5: monocytic t(9;11); tissue infiltration
M6: erythroleukemia (DiGuglielmo’s disease) Glycophorin A and/or ferritin receptor
expression
M7: megakaryoblastic Prominent myelofibrosis; CD41 and CD61
• Clinical features à symptoms/signs of anemia, thrombocytopenia and/or neutropenia
(e.g. weakness, fatigue, pallor, shortness of breath, easy bruising, bleeding gums,
pharyngitis, skin infections, etc.), anorexia, weight loss, fever, hepatosplenomegaly,
lymphadenopathy, sternal tenderness and/or diffuse bone pain, ± symptoms/signs of
tissue infiltration and/or mass lesions
• Symptoms/signs of leucostasis if ↑↑WBC count à headache, dyspnea, visual
disturbances, retinal and/or CNS hemorrhage
• Lab findings à normochromic, normocytic anemia with ↓ reticulocyte count, ↓ platelet
count, ↓, normal or ↑ WBC count, circulating blasts, ↑ LDH, ↑ uric acid
• Most accurate diagnostic test (for leukemia in general)à bone marrow biopsy
showing > 20% blast forms
• Most accurate diagnostic test to differentiate among AML and ALL and between
subtypes of AML à Cytogenetic/molecular and immunophenotypic analysis
• Characteristics of myeloblasts:
1. fine, reticular nuclear chromatin
2. large, multiple nucleoli
3. larger cytoplasm
4. presence of granules and/or Auer rods
5. positive for meyloperoxidase, sudan black and/or nonspecific esterase (seen
with monocytic and/or myelomonocytic AML)
16
• Management:
1. Induction therapy à combination of cytarabine (cytosine arabinoside) and
daunorubicin (anthracycline) ± etoposide
2. Complete remission achieved (< 5% marrow blasts, no peripheral blasts, no Auer rods, > 20% bone marrow tri-linage cellularity, etc.) à high-dose
cytarabine consolidation therapy or BMT (preferred if available/suitable)
3. Complete remission not achieved à repeat induction therapy
4. Failure to achieve complete remission after two cycles of induction therapy à
BMT
5. Relapse after complete remission à BMT
6. BMT not available or age > 65-70 à consider newer investigational agents (e.g.
gentuzumab à anti-CD33 monoclonal antibody linked to calicheamicin, an
anti-cancer antibiotic)
7. Supportive measures à leukodepleted and irradiated RBC and/or platelet
transfusions (keep Hb > 8 g/dL, and platelets > 10,000), antibiotics if ↑
temperature (see neutropenic fever), possible use of G-CSF and/or GM-CSF
8. IV/PO hydration and allopurinol (xanthine oxidase inhibitor) ± urine
alkalinization before initiating chemotherapy to prevent ↑ serum uric acid à
precipitation of uric acid crystals à acute renal failure (uric acid nephropathy)
9. Induction therapy for M3 AML à ATRA (tretinoin) in combination with
daunorubicin
10. Consolidation therapy for M3 AML à cytarabine and daunorubicin
11. Maintenance therapy for M3 AML à ATRA (tretinoin) ± chemotherapy
12. Refractory to ATRA à consider arsenic trioxide
* ATRA associated with retinoic acid syndrome à fever, dyspnea, pulmonary
infiltrates on chest X-ray, pleural/pericardial effusion, hypoxia; treatment à steroids ±
supportive measures
* symptoms/signs of leucostasis à IV hydration, allopurinol, platelet transfusion,
leukaphresis, standard chemotherapy ± hydroxyurea
* Alternative to allopurinol in the management of AML à rasburicase (recombinant
uric oxidase)
* Tumor lysis syndrome à hyperuricemia, hyperkalemia, hyperphosphatemia,
hypocalcemia, hyperuricosuria, leading to acute renal failure and/or arrhythmias;
prevention à IV hydration + allopurinol (or rasburicase); treatment à IV hydration,
loop diuretics, rasburicase ± hemodialysis; correction/management of electrolyte
abnormalities
17
Chronic Myelogenous Leukemia
• Myeloproliferative disorder characterized by clonal proliferation of a myeloid stem
cell harboring the pathognomic t(9;22) translocation (Philadelphia chromosome)
• Risk factors à high-dose radiation (e.g. atomic bomb survivor)
• Incidence increases with age
• Pathophysiology: t(9;22) à BCR/ABL fusion protein with tyrosine kinase activity à
↓ apoptosis à transformation of myeloid stem cells à CML, characterized by ↑↑
production of mature myeloid cells
• Clinical features à asymptomatic (e.g. detected on routine CBC) to night sweats,
fatigue, weakness, fever, weight loss, splenomegaly (e.g. LUQ abdominal pain, early
satiety), hepatomegaly, ± symptoms/signs of thrombocytopenia and/or neutropenia
(uncommon), ± “leucostasis” (e.g. priapism, dyspnea, visual disturbances, ±
arterial/venous thrombosis and/or hemorrhages)
• Possible manifestations of ↑ histamine release (secondary to peripheral basophilia) à
pruritus, diarrhea, PUD, flushing, hypotension/tachycardia
• Possible manifestations of hyperuricemia à gouty arthritis, gouty nephropathy
• Lab findings à ↑↑ WBC count with prominent left shift, blasts < 5%, ↑ basophils and/or eosinophils, ↑ platelet count, normochromic normocytic anemia, ↑ vitamin B12 level, ↓ LAP activity (differentiates from other myeloproliferative disorders and/or reactive leukocytosis (“leukemoid reaction”) • Best initial diagnostic test in suspected CML à LAP score • Bone marrow biopsy à ↑ cellularity (predominantly myeloid and megakaryocytic), altered myeloid-to erythroid ratio, ↑ marrow basophils and/or eosinophils, ↑ fibrosis • Most accurate diagnostic test (mandatory for diagnosis) à demonstration of Philadelphia chromosome (e.g. PCR, FISH, etc.) • Natural course of CML: chronic phase à disease acceleration à blast crisis • Acceleration/blast crisis à worsening symptoms/signs, significant weight loss, bone and/or joint pain, bleeding, ↑ infections * Definition of disease acceleration à blasts 10-20%, worsening anemia, thrombocytopenia, and/or basophils > 20%
* Definition of blast crisis à blasts > 20%; most common variant is AML (with ALL
in second)
* Definition of complete response à WBC count < 10,000/μL, normal RBC and platelet counts, normal spleen size, 0% bone marrow cells with t(9;22), undetectable BCR/ABL (using RT-PCR) • Management: 1. Best initial therapy à standard-dose imatinib mesylate/Gleevec (inhibitor of BCR/ABL tyrosine kinase) 2. Complete response à continue same-dose imatinib 3. Partial/minor response à ↑ imatinib dose 4. No response à switch to dasatinib or linotinib; consider BMT 5. Accelerated phase à imatinib (or dasatinib) followed by BMT 6. AML blast crisis à cytarabine + daunorubicin + imatinib (or dasatinib) followed by BMT 18 7. ALL blast crisis à daunorubicin + L-asparaginase + vincristine + prednisone + imatinib (or dasatinib) followed by BMT (consider CNS prophylaxis using intrathecal methotrexate) 8. Symptomatic treatment à antihistamines, IV hydration, allopurinol * Interferon-α ± cytarabine and/or hydroxyurea ± busulfan à never a correct answer in test Qs (not only in test Qs) * Management of thrombocytosis à anagrelide (inhibition of phosphodiesterase III à ↓ platelet production); second-line therapy (inferior to imatinib and/or hydroxyurea + aspirin for CML and ET, respectively) Polycythemia Vera • Most common myeloproliferative disorder characterized by autonomous overproduction of eryhtroid cells, secondary to ↑ JAK2 kinase activity • Males > females; incidence increases with age
• Clinical features à
1. ↑ blood viscosity à headache, dizziness, blurry vision, tinnitus, hypertension
2. ↑ histamine release (secondary to ↑ basophilia) à pruritus (especially postbathing),
PUD, flushing, etc.
3. hyperuricemia à gouty arthritis
4. splenomegaly
5. plethoric appearance
6. fatigue, weakness, weight loss
7. ↑ risk of thrombosis (e.g. stroke, MI, dural venous sinus thrombosis, etc.)
8. ↑ risk of hemorrhage (secondary to platelet dysfunction)
9. erythromelalgia à dysesthesias, erythema and/or swelling of the lower
extremities, brought about by exposure to heat, exertion and/or alcohol
consumption
• Lab findings à ↑↑ Hct, ↑ WBC count, ↑ platelet count, ↑ basophils and/or eosinophils,
↑ vitamin B12 levels, ↑ LAP score
• Bone marrow biopsy à trilineage hyperplasia, ± marrow fibrosis
• Diagnosis à exclusion of secondary causes of erythrocytosis:
1. undetectable erythropoietin levels
2. oxygen saturation > 92%
• Management:
1. symptomatic therapy à anti-histamines, allopurinol, IV hydration
2. phlebotomy (goal Hct of < 45%) à mainstay of therapy 3. low-dose aspirin 4. indications for hydroxyurea therapy à age > 60, history of thrombosis,
extreme thrombocytosis, intractable pruritus (use interferon for younger
patients)
• Complications à myelofibrosis, AML, thrombotic complications
19
* Gaisböck syndrome (stress erythrocytosis) à obese, sedentary males with
hypertension and ↓ blood volume à relative erythrocytosis
* Erythropoietin-secreting tumors à cerebellar/retinal hemangioblastomas, renal
cell carcinomas, hepatomas, uterine fibroids
Essential Thrombocythemia (Essential Thrombocytosis)
• Chronic myeloproliferative disorder characterized by autonomous platelet
overproduction à ↑↑ platelet count in the absence of secondary causes of
thrombocytosis (e.g. iron-deficiency, infection, asplenia, etc.)
• Clinical features à asymptomatic (most common presentation) to ↑ risk of thrombotic
and/or hemorrhagic complications; possible symptoms/signs of histamine excess
and/or hyperuricemia
• Diagnosis à platelet count > 600,000, bone marrow megakaryocytic hyperplasia,
absence of t(9;22) + exclusion of secondary causes of thrombocytosis ± ↑ JAK2 kinase
activity
• Complications à myelofibrosis, AML
• Management à
1. Symptomatic therapy + low-dose aspirin
2. Asymptomatic, young à treatment not required
3. Age > 60 and/or history of thrombosis à hydroxyurea
4. Intolerance to hydroxyurea à anagrelide
5. Young + history of thrombosis à interferon-α
6. Pregnant or contemplating pregnancy à interferon-α
Primary Myelofibrosis (Idiopathic Myelofibrosis)
• Chronic myeloproliferative disorder characterized by marrow fibrosis, extramedullary
hematopoiesis and varying degrees of pancytopenia
• Incidence increases with age
• Pathophysiology: abnormal megakaryocytes à ↑ TGF-β secretion à
recruitment/activation of fibroblasts à collagen deposition
• Clinical features à asymptomatic to massive splenomegaly, hepatomegaly,
lymphadenopathy, symptoms/signs of anemia, possible gouty arthritis
• Difficult to differentiate from other myeloproliferative disorders complicated with
myelofibrosis
• Clues à older age, hepatosplenomegaly, ↓ Hct, teardrop-shaped RBCs (dacryocytes),
leukoerythroblastosis (blood smear showing immature RBCs and WBCs à nucleated
RBCs and myelocytes, promyelocytes and/or myeloblasts), “dry-tap” on attempted
marrow aspiration, bone marrow biopsy showing ↑ collagen deposition ± ↑
megakaryocytes, absence of t(9;22)
• Complications à AML
• Management à symptomatic therapy, possible hydroxyurea and/or interferon, ±
splenectomy; consider BMT
20
Lymphoid Malignancies
Acute Lymphoblastic Leukemia/Lymphoma (ALL)
• Most common leukemia in children
• Boys > girls
• Whites > African-Americans
• 85% of cases are of B-cell origin
• Risk factors à radiation, benzene, genetic syndromes (e.g. Down syndrome, Bloom
syndrome, etc.)
• Clinical features à symptoms/signs of anemia, thrombocytopenia and/or neutropenia,
↑ temperature, severe bone pain, arthralgias, lymphadenopathy, splenomegaly ±
hepatomegaly, mediastinal mass (especially with T-cell ALL) ± respiratory distress,
possible CNS disease, testicular enlargement and/or tissue infiltration
• Lab findings à pancytopenia with ↓ reticulocyte count, circulating lymphoblasts, ↑
LDH, ↑ uric acid
• Most accurate diagnostic test in general à bore marrow biopsy showing > 20%
marrow blasts
• Most accurate diagnostic test to differentiate between AML and ALL and/or different
forms of ALL à immunophenotypic and/or cytogenetic analysis
• Characteristics of a lymphoblast à
1. scant cytoplasm
2. few, small nucleoli
3. no granules and/or Auer rods
4. positive for PAS and/or TdT (terminal deoxynucelotidyl transferase)
• Immunophenotypic classification of ALL à
1. Pro-B-cell ALL à TdT +, CD 19 +, CD 10 (CALLA) –
2. Pre-B-cell ALL à TdT +, CD 19 +, CD 10 +, cytoplasmic Ig +
3. Mature B-cell (Burkitt) ALL à TdT -, CD 19 +, surface Ig +
4. Pre-T-cell ALL à TdT +, CD 3 -, CD4+/CD8+ or CD4-/CD8-
5. Mature T-cell ALL à CD 3 +. CD4+/CD8 – or CD4+/CD8+
• Common genetic abnormalities (associated with poor prognosis) à t(4;11), t(9;22),
t(8;14), t(1;19)
• Management:
1. Induction therapy à vincristine, prednisone, daunorubicin and Lasparaginase
2. Consolidation therapy à cytarabine + daunorubicin
3. Maintenance therapy à 2-3 years of methotrexate and/or 6-
marcaptopurine (most commonly used agents)
4. CNS prophylaxis à intrathecal methotrexate
5. Relapse after complete remission à intensive chemotherapy + BMT
6. Relapse at “sanctuary” sites (e.g. CNS, testes) à radiation
7. Complete remission in ALL with t(9;22) or t(4;11) à BMT
8. Initial therapy of ALL with t(9;22) à Hyper-CVAD regimen
(cyclophosphamide, vincristine, Adriamycin, dexamethasone) ± imatinib
9. Supportive measures
• Poor prognostic factors à age <> 10, male sex, black race, ↑ WBC count,
mature phenotype, mediastinal mass, T-cell origin, chromosomal translocations
21
Chronic Lymphocytic Leukemia/Small Cell Lymphoma (CLL/SCL)
• Clonal proliferation of mature B lymphocytes
• Most common form of leukemia
• Age > 50
• Males > Females
• Clinical features à asymptomatic (most common; e.g. detected on routine CBC, etc.)
to fatigue, splenomegaly, lymphadenopathy, ↑ risk of infections, ± symptoms/signs of
anemia and/or thrombocytopenia
• Complications à autoimmune hemolytic anemia, immune-mediated
thrombocytopenia, hypogammaglobulinemia, Richter syndrome (transformation to
high-grade large-cell lymphoma)
• Lab findings à ↑ WBC count with absolute lymphocytosis (lymphocyte count >
5000/μL) ± ↓ RBC and/or platelet counts
• Blood smear à small, mature lymphocytes + “smudge” cells
• Bone marrow biopsy à > 30% lymphocytes
• Most accurate diagnostic test à flow-cytometry (CD5+, CD19+, CD20+ and CD23+)
• Staging:
1. Stage 0 à lymphocytosis
2. Stage 1 à lymphocytosis + lymphadenopathy
3. Stage 2 à lymphocytosis + lymphadenopathy + splenomegaly
4. Stage 3 à lymphocytosis + anemia (excluding autoimmune etiology)
5. Stage 4 à lymphocytosis + thrombocytopenia
• Management:
1. Stages 0-2 + asymptomatic à observation
2. Symptomatic and/or Stages 3-4 à fludarabine ± rituximab (side effects à
myelosuppression and immunosuppression, requiring PCP prophylaxis)
3. Alternative for older individuals à chlorambucil ± prednisone
4. Relapse/failure à pentostatin, alemtuzumab (anti-CD52 monoclonal antibody)
or bendamustine
5. immune-mediated hemolytic anemia and/or thrombocytopenia à steroids
Hairy Cell Leukemia
• A mature B-cell neoplasm
• Males > Females; middle age
• Clinical features à asymptomatic to splenomegaly, progressive fatigue,
symptoms/signs of anemia, thrombocytopenia and/or neutropenia
• In summary à triad of middle age, splenomegaly and pancytopenia
• Lab findings à consistent with pancytopenia
• Blood smear à WBCs with “hair-like” cytoplasmic projections
• Bone marrow aspirate à “dry tap”
• Most accurate diagnostic test à bone marrow biopsy positive for TRAP (tartrateresistant
acid phosphatase) stain
• Flow Cytometry à CD19+, CD20+, CD11+, CD25+
• Management:
1. Asymptomatic + normal/mildly decreased CBC à observation
2. Best initial therapy à cladribine or pentostatin
3. Relapse/failure à rituximab (or alemtuzumab)
• Most common cause of mortality à infections
22
Hodgkin Lymphoma (Hodgkin Disease)
• A germinal center B-cell neoplasm characterized by contiguous spread and presence of
Reed-Stenberg cells
• Less common than NHLs
• Males > Females
• Bimodal age distribution à 15-25 and > 50
• Risk factors à EBV infection, ↑ SES, family history
• Histologic Subtypes:
Nodular Sclerosis Most common variant; females > males;
frequent mediastinal involvement
Lymphocyte Predominant Best prognosis
Lymphocyte Depleted Worst prognosis
Mixed-Cellularity Intermediate prognosis
• Clinical features à painless, rubbery lymphadenopathy (cervical, axillary and/or
supraclavicular), possible mediastinal lymphadenopathy, splenomegaly (30% of cases
at diagnosis), B symptoms (night sweats, fever, weight loss), generalized pruritus, pain
on alcohol consumption, cyclic fever (Pel-Epstein fever), cutaneous anergy, possible
immune-mediated hemolytic anemia and/or thrombocytopenia
• Spread à contiguous from one lymph node region to another
• Lab findings à anemia (of chronic disease), ↑ WBC count, ↑ platelet count,
eosinophilia, lymphocytopenia, ↑ ESR, ↑ LDH
• Best initial and most accurate diagnostic test à excisional lymph node biopsy
showing Reed-Stenberg cells (large, bi-nucleated cells with prominent nucleoli à
“owl’s eye” appearance; CD15+, CD30+) admixed with eosinophils, lymphocytes
and/or plasma cells
• Best next step à Staging (history and physical examination, chest X-ray, CT of the
chest, abdomen and pelvis, blood tests, including CBC, ESR, LFTs, ± PET or gallium
scan and/or bilateral bone marrow aspiration/biopsy)
• Staging System (simplified) à
Stage I (IA or IB) Single lymph node region ± B symptoms
Stage II (IIA or IIB) ≥ 2 lymph node regions on the same side of
the diaphragm ± B symptoms
Stage III (IIIA or IIIB) Lymph node regions on both sides of the
diaphragm, including the spleen ± B
symptoms
Stage IV (IVA or IVB) Diffuse involvement of extralymphatic sites
(e.g. bone marrow, liver, etc.) ± B symptoms
• Poor prognostic factors à age > 45, stage IV disease, male gender, B symptoms,
mediastinal involvement, ↑ ESR
• Management:
1. Stages IA and IIA (limited disease) à brief course of chemotherapy (ABVD
regimen) + localized radiation
2. Stages IA and IIA documented by laparotomy à radiation
3. Stages III-IV (extensive disease) and/or any Stage B à full course of
combination chemotherapy:
• ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine)
• MOPP (mechlorethamine, vincristine, prednisone, procarbazine)
• Stanford V à inferior to ABVD
23
• BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide,
vincristine, procarbazine and prednisone) à superior to ABVD
4. Best initial therapy in extensive disease à ABVD
5. Relapse after radiotherapy à standard chemotherapy
6. Relapse after chemotherapy à high-dose chemotherapy + BMT
7. Acute, life-threatening complications (e.g. SVC, spinal cord compression,
airway obstruction, etc.) à radiation
• Late complications of therapy (more common with MOPP and BEACOPP) à
1. infertility/amenorrhea
2. radiation-induced hypothyroidism
3. radiation-induced pneumonitis and/or constrictive pericarditis
4. doxorubicin-induced cardiomyopathy
5. bleomycin-induced pulmonary fibrosis
6. secondary AML and/or MDS
7. aplastic anemia
8. radiation-induced solid tumors (e.g. breast cancer)
Non-Hodgkin Lymphomas (NHLs)
• Most common hematologic malignancy
• B-cell origin > 85% of cases
• Males > Females
• Whites > African-Americans
• Age > 50 (exceptions à Lymphoblastic and/or Burkitt lymphomas; common in
children/young adults)
• Risk factors à EBV infection (e.g. endemic Burkitt lymphomas), HIV infection (e.g.
immunoblastic lymphomas, primary CNS lymphomas, Burkitt lymphomas), HTLV-1
infection (e.g. adult T-cell leukemia/lymphoma), H. pylori infection (e.g. gastric
MALTomas), HHV-8 infection (e.g. body cavity-based lymphomas), Hashimoto’s
thyroiditis, Sjogren syndrome
• Clinically divided into low-grade (indolent), intermediate-grade and high-grade
(aggressive) lymphomas
• Characteristics of NHLs à
1. Non-contiguous spread
2. Diffuse lymphadenopathy (including retroperitoneal) on presentation
3. Common extralymphatic involvement, including the CNS and/or Waldeyer ring
4. Common bone marrow involvement à cytopenias
5. No pruritus
6. No alcohol-induced pain
7. No cyclic fever
• Best initial and most accurate diagnostic test à excisional lymph node biopsy ±
immunophenotyping
• Best next step à staging (including bilateral bone marrow aspiration/biopsy ±
lumbar puncture)
• Best initial therapy à CHOP regimen (cyclophosphamide, doxorubicin, vincristine,
prednisone) or R-CHOP (rituximab + CHOP; high-grade large-cell lymphomas)
24
Low-Grade NHLs High-Grade NHLs
Follicular lymphoma, small cell lymphoma Diffuse large-cell lymphoma, immunoblastic
lymphoma, Burkitt lymphoma
Non-curable Curable
Longer survival Shorter survival if treatment-resistant
* Endemic Burkitt Lymphoma à EBV infection; African child with mandibular
enlargement
* Sporadic Burkitt Lymphoma à most common form in USA; possible HIV infection;
abdominal mass ± bowel obstruction
* Lymphoblastic Lymphoma à commonly of T-cell origin; mediastinal adenopathy ±
respiratory compromise and/or SVC in a young adult
* ↑ risk of tumor lysis syndrome upon initiation of chemotherapy à prevent with IV
hydration, urine alkalinization and allopurinol
* Bexxar (tositumomab) à anti-CD20 conjugated to I¹³¹ and/or Zavalin
(ibritumomab)à anti-CD20 conjugated to yttrium 90; low-grade refractory NHL
Plasma Cell Disorders
Monoclonal Gammopathy of Undetermined Significance (MGUS)
• Most common monoclonal gammopathy
• Incidence increases with age (3-5% > 70 years of age)
• Asymptomatic to MGUS-associated peripheral neuropathy
• Detected as ↑ total serum protein on routine blood tests
• Best initial diagnostic test à serum protein electrophoresis (SPEP) showing Mprotein
spike < 3g/dL (usually of IgG type) • Most accurate diagnostic test à bone marrow biopsy showing < 10% plasma cells • Lab findings à normal serum creatinine, normal Hb, normal serum Ca • Skeletal survey à no evidence of lytic lesions • Management à SPEP every 12 months (initially every 6 months for a total of one year) • 1-2% annual risk of progression to multiple myeloma 25 Multiple Myeloma • Clonal proliferation of abnormal plasma cells (CD19-, CD56+) characterized by bone marrow infiltration with varying degrees of pancytopenia, bone destruction and ↑ paraprotein production (monoclonal or “M” protein) • Incidence increases with age • More common in African-Americans • Second most common hematologic malignancy • Most common primary bone tumor (more common than osteosarcoma) • Clinical features: 1. bone pain (especially back and/or ribs) à most common manifestation 2. pathologic fractures (e.g. vertebral, femoral neck) ± deformities 3. symptoms/signs of anemia 4. symptoms/signs of thrombocytopenia 5. ↑ risk of infections (especially secondary to Pneumococcus and Haemophilus) 6. spinal cord compression (severe back pain ± neurologic deficits) 7. symptoms/signs of hypercalcemia à Nephrogenic DI (polyuria, polydipsia) 8. carpal tunnel syndrome (secondary amyloidosis) 9. slowly progressive renal failure (secondary to hypercalcemia, hyperuricemia, Bence-Jones proteinuria, and/or secondary amyloidosis) 10. hyperviscosity syndrome à blurry vision, headache, confusion, dyspnea, etc. • In summary à older patient with back/chest pain exacerbated by movement + anemia + ↑ ESR ± renal failure and/or hypercalcemia • Lab findings à ↓ Hb, ↓ Hct, ± thrombocytopenia and/or leukopenia, ↑ ESR, ↑ serum Ca, ↑ serum creatinine, ↑ total serum protein, ↑ serum β2-microglobulin • Blood smear à “Rouleaux” formation • Best initial diagnostic test à skeletal survey (not bone scan) looking for “punchedout” osteolytic lesions • Best next step (or best initial step if skeletal survey not one of the answer choices) à SPEP showing M-protein spike > 3g/dL (usually of IgG type)
• Most accurate diagnostic test à bone marrow biopsy showing > 10% plasma cells
• Best initial step in suspected cord compression à IV dexamethasone
• Best next step in suspected cord compression à spinal MRI
• Best initial therapy in confirmed cord compression à radiation
• Management:
1. Young, healthy à thalidomide (or lenalidomide) + dexamethasone followed
by BMT
2. Older, asymptomatic, normal skeletal survey and/or lab findings à treatment
not indicated
3. Older, symptomatic or abnormal skeletal survey and/or lab findings à
melphalan + prednisone ± thalidomide
4. Relapse à VAD regimen (vincristine, doxorubicin, dexamethasone)
5. Hypercalcemia à IV hydration + furosemide + bisphosphonates
6. Hyperviscosity à plasmapheresis
7. Light-chain nephropathy à plasmapheresis
8. Vaccination against pneumococcus and haemophilus
26
Waldenström Macroglobulinemia
• Synonyms à lymphoplasmocytic lymphoma
• Clinical features à age > 60, hepatosplenomegaly, generalized lymphadenopathy,
fatigue, nasal/oral bleeding, peripheral neuropathy, recurrent infections,
symptoms/signs of hyperviscosity syndrome (e.g. headache, blurry vision, dyspnea,
retinal/cerebral hemorrhages, etc.); renal involvement uncommon
• Associations à cold agglutinin hemolytic anemia, cryoglobulinemia, Raynaud’s
phenomenon
• Diagnosis à serum protein electrophoresis showing IgM spike > 3 g/dL
• Management à plasmapheresis for hyperviscosity syndrome; rituximab + fludarabine
or cladribine
* POEMS syndrome à polyneuropathy + organomegaly (e.g. hepatosplenomegaly,
lymphadenopathy) + endocrinopathy (e.g. amenorrhea, gynecomastia/impotence, DM
type 2) + multiple myeloma + skin changes (e.g. hyperpigmentation, hypertrichosis)
* Light Chain Disease à prominent renal involvement, normal serum protein
electrophoresis; diagnosis à urine protein electrophoresis
Platelet/Coagulation Disorders
Idiopathic Thrombocytopenic Purpura (ITP)
• Most common cause of thrombocytopenia
• Pathophysiology: anti-platelet IgG production à coating of platelets à destruction by
splenic macrophages
• ITP is a diagnosis of exclusion
• ITP is frequently associated with SLE, HIV infection and hematologic malignancies,
e.g. CLL (known as autoimmune thrombocytopenic purpura; not ITP)
• Females > Males; 20-40 years of age
• Clinical features à epistaxis, menorrhagia, easy bruising, petechiae, purpura,
ecchymoses, possible hematuria and/or GI bleeding (so called “platelet-type” bleeding);
intracranial hemorrhages in severe cases; NO splenomegaly
• Best initial diagnostic test à CBC showing ↓ platelets with normal RBC and WBC
counts
• Other Lab findings à normal PT, PTT, blood smear and serum creatinine; ↑ bleeding
time; presence of antibodies against IIb/IIIa receptor complex (not helpful)
• Next step à exclusion of secondary/known causes of thrombocytopenia:
1. Drug-induced (e.g. quinidine, rifampin, heparin, alcohol)
2. SLE/connective tissue disorders
3. HIV infection
• Bone marrow examination (for definite diagnosis) indicated:
1. If age > 60
2. Before splenectomy
27
• Bone marrow findings à ↑ megakaryocytes
• Management:
1. Best initial therapy à prednisone
2. Refractory disease à splenectomy (vaccinate against Pneumococcus and
Haemophilus)
3. No response to steroids/splenectomy à immunosuppressive medications (e.g.
cyclophosphamide, azathioprine) and/or rituximab
4. Platelet count < 10,000 and/or severe, life-threatening bleeding à IVIG (intravenous immunoglobulin) or RhoGAM + high-dose steroids and/or platelet transfusions * Who needs steroids? 1. patients with platelet counts < 30,000 2. patients with platelet counts < 50,000 + superficial mucocutaneous bleeding 3. patients with platelet counts < 50,000 + ↑ risk of bleeding (e.g. hypertension, PUD) * Acute ITP à common in children 2-6 years of age; usually follows a viral URI and/or vaccinations; abrupt onset of “platelet-type” bleeding; lab findings à ↓ platelet count + ↑ bleeding time; spontaneous remission within 6 months; average duration 6-8 weeks; treatment à supportive Type II Heparin-Induced Thrombocytopenia (HIT) • Syndrome characterized by thrombocytopenia and ↑ incidence of venous and/or arterial thrombosis • More common with UFH (unfractionated heparin) • Pathophysiology: anti - platelet factor 4–heparin complex IgG production à platelet aggregation and activation à activation of coagulation cascade à thrombocytopenia with thrombosis • Clinical features à thrombocytopenia and/or venous/arterial thrombosis developing within 4-21 days of heparin use • Risk factors à previous, high-dose and/or unfractionated heparin use • Clue to the presence of HIT à dropping platelet counts (do not order any other diagnostic test; proceed to treatment) • Most accurate diagnostic test à serotonin release assay (antibody assay may also be used as a confirmatory test) • Management: 1. Step 1 à stop heparin administration 2. Step 2 à administer direct thrombin inhibitors (lepirudin, bivalirudin, argatroban); monitor with aPTT 3. Step 3 à never use heparin in the future (even LMWH à ↑ risk of crossreactivity) 28 * Bernard-Soulier syndrome à autosomal recessive deficiency of glycoprotein IB/IX receptor complex; characterized by thrombocytopenia, giant platelets on blood smear, superficial mucocutaneous bleeding, ↑ bleeding time and no aggregation in response to ristocetin administration (not corrected by normal plasma); management à ε- aminocaproic acid (anti-fibrinolytic) and/or platelet transfusions * Glanzmann thrombasthenia à autosomal recessive deficiency of glycoprotein IIB/IIIA receptor complex; characterized by normal CBC, superficial mucocutaneous bleeding, ↑ bleeding time, normal response to ristocetin, no aggregation in response to ADP, epinephrine and/or collagen; management à platelet transfusions and/or recombinant factor VIIa Thrombotic Thrombocytopenic Purpura/Hemolytic-Uremic Syndrome (TTP/HUS) TTP HUS More common in adults; females > males More common in children
Etiology à idiopathic, associated with HIV
infection, ticlopidine, cyclosporine,
pregnancy
Etiology à associated with E.coli O157:H7
infection (e.g. hamburgers at fast-food
restaurants, apple cider), Shigella infection,
pregnancy
Pentad of thrombocytopenia (with possible
mucocutaneous bleeding), microangiopathic
hemolytic anemia (e.g. helmet cells, triangle
cells), acute renal failure/active sediment,
fever and neurologic manifestations (e.g.
headache, altered LOC, seizure, delirium)
Triad of thrombocytopenia,
microangiopathic hemolytic anemia and acute
renal failure/active sediment; possible
antecedent hemorrhagic gastroenteritis
Pathology à widespread hyaline thrombi
(platelets + fibrin without inflammation)
Pathology à hyaline thrombi limited to the
kidneys
Lab findings à ↓ Hb and Hct, ↓ platelet
count, ↑ indirect bilirubin, ↑ LDH, ↑ serum
creatinine and BUN, normal PT and aPTT
Lab findings à same as with TTP
Pathophysiology à ↓ ADAMTS13 activity
(protease that cleaves large vWF multimers)
secondary to IgG autoantibody production
Normal ADAMTS13 activity
Management à plasma exchange
(plasmapheresis + fresh frozen plasma
infusion) + steroids ± dipyridamole/aspirin
Management à supportive (e.g. dialysis) ±
steroids ± anti-platelet agents; plasma
exchange reserved for severe cases
• DO NOT (may worsen the disease) à
1. Transfuse platelets
2. Administer antibiotics
29
Von Willebrand’s Disease (vWD)
• Most common inherited form of coagulopathy
• Autosomal dominant (most common) or autosomal recessive
• Secondary to quantitative or qualitative defects in vWF
• Pathophysiology: ↓ vWF à ↓ platelet adherence ± secondary factor VIII deficiency
• Clinical features à positive family history + “platelet type” bleeding (epistaxis,
menorrhagia, petechiae, easy bruising, etc.), especially after aspirin administration;
possible hematuria and/or GI bleed; soft tissue and/or intra-articular bleeding
uncommon
• Best initial diagnostic test à CBC showing normal platelet counts (already performed
in most test Qs)
• Best next diagnostic test (or best initial, if platelet count already known) à bleeding
time, which should be prolonged
* Normal platelet count + ↑ bleeding time à consider vWD, uremia-associated platelet
dysfunction, anti-platelet agent (e.g. aspirin) use and/or Glanzmann thrombasthenia.
• Other lab findings à ↑ aPTT (↑ aPTT + ↑ bleeding time = vWD)
• Most accurate diagnostic test à vWF assay (also known as factor VIIIag assay)
showing ↓ vWF levels
• Suspected vWD + normal vWF levels à order ristocetin cofactor assay:
1. ↓ platelet aggregation in response to ristocetin
2. Corrected by mixing with normal plasma
• Management:
1. Best initial therapy à desmopressin/DDAVP (releases subendothelial stores of
vWF and factor VIII)
2. Desmopressin not effective and/or contraindicated à vWF concentrates
3. Avoid anti-platelet agents
Hemophilia A
• X-linked recessive (hence males > females)
• Deficiency of factor VIII (also known as factor VIIIpro)
• Categorized as mild/subclinical (> 5%), moderate (1-5%) and severe (<1%) based on factor VIII activity • Clinical features à positive family history + asymptomatic with unexpected bleeding following major trauma and/or surgical procedures to hemarthrosis, deep tissue hematomas, GI and/or urinary bleeding, intracranial hemorrhage with minor head trauma • Repeated hemarthrosis à disabling arthropathy • Lab findings à ↑ aPTT with normal PT, bleeding time, platelet count, etc. • Best next diagnostic test à mixing studies (patient’s plasma mixed with normal plasma) to differentiate between factor deficiency (aPTT should normalize) and factor inhibitor (e.g. antibodies against factor VIII, lupus anticoagulant) • Normal aPTT after mixing with normal plasma à clotting factor assay, showing ↓ factor VIII levels 30 • Management à desmopressin for mild disease; otherwise recombinant factor VIII concentrates • Treatment complications à transfusion-related infections (e.g. HBV, HIV), production of anti-factor VIII antibodies (resistant to standard therapy; use factor VIIa and/or prothrombin-complex concentrates) * Hemophilia B (Christmas Disease)à X-linked recessive deficiency of factor IX; otherwise similar to hemophilia A; treat with factor IX concentrates * Factor VII deficiency à prolonged PT with normal aPTT; asymptomatic to manifestations similar to hemophilia A; management à factor VIIa concentrates (alternative à fresh frozen plasma) * Hemophilia C à autosomal recessive deficiency of factor XI; prolonged aPTT with normal PT; management à fresh frozen plasma * Factor XIII deficiency à autosomal recessive; normal aPTT, PT and bleeding time; umbilical cord bleeding, delayed wound healing, delayed bleeding with trauma; management à cryoprecipitate * Factor XII, prekallikrein and/or HMWK deficiencies à no risk of bleeding; prolonged aPTT * Factor II, V, X deficiencies à ↑ aPTT + ↑ PT Vitamin K deficiency • Etiology à malabsorption syndromes, prolonged antibiotic use, dietary deficiency, warfarin therapy, liver disease (see below) • Asymptomatic to bleeding similar to hemophilia • Lab findings à ↑↑ PT, ↑ aPTT, normal bleeding time • Management à 1. vitamin K supplementation (PT should normalize within 24 hours) 2. active bleeding à fresh frozen plasma + vitamin K Liver Disease • Bleeding tendency secondary to ↓ production of all clotting factors, except factor VIII and vWF ± thrombocytopenia and/or thrombocytopathia • Most common site of bleeding à GI tract • Lab findings à ↓ factor V, ↑↑ PT, ↑ aPTT (advanced disease), ± thrombocytopenia and/or ↑ bleeding time • Management à fresh frozen plasma ± platelet transfusions 31 Disseminated Intravascular Coagulation (DIC) • Acquired consumptive coagulopathy that manifests as bleeding and/or thrombosis • Etiology à 1. Gram-negative sepsis (most common) 2. Meningococcemia 3. Massive trauma 4. Burns 5. Obstetric complications (abruptio placenta, amniotic fluid embolism) 6. Severe pancreatitis 7. Adenocarcinomas of the GI tract, pancreas 8. Acute promyelocytic leukemia (M3) 9. Transfusion reaction 10. Rhabdomyolysis 11. Large aortic aneurysms and/or giant hemangiomas (localized DIC) 12. Snakebites • DIC may be classified as acute (most causes of DIC) or chronic (e.g. solid malignancies, retained products of conception) • Pathophysiology: activation of coagulation cascade à generation of thrombin à diffuse microthrombi formation à consumption of platelets and coagulation factors + microangiopathic hemolytic anemia + activation of fibrinolysic system à diffuse combined-type bleeding ± thrombosis • Clinical features à symptoms/signs of underlying disease + bleeding from venipuncture sites and/or surgical wounds, petechiae, purpura, ecchymoses, GI tract and/or GU tract bleeding, hematomas ± evidence of thrombosis (e.g. skin necrosis, gangrene, stroke, MI, DVT/PE) ± manifestations of acute hemolysis (e.g. acute renal failure, jaundice) • Lab findings à ↓ platelet count, ↑ PT and aPTT, ↓ Hb and Hct, ↓ fibrinogen and ↑ Ddimer levels (fibrin-split products) • Blood smear à evidence of traumatic hemolysis (schistocytes à helmet cells, triangle cells, etc.) • Management: 1. Treatment/correction of underlying disease (most important) 2. FFP (fresh frozen plasma) for ↑ PT/aPTT 3. Cryoprecipitate for ↓ fibrinogen 4. Platelet transfusions for thrombocytopenia 5. Heparin only for chronic DIC with evidence of thrombosis 32 Transfusion Reactions Acute Hemolytic Transfusion Reaction • Most life-threatening of all transfusion reactions (but pretty uncommon) • Secondary to ABO incompatibility (80% of cases) • Clerical errors being the most common cause • Females > Males
• Pathophysiology: preformed IgM antibodies against donor RBCs à coating of RBCs
and activation of complement cascade à complement-mediated intravascular
hemolysis
• Clinical features à sudden onset of fever/chills, abdominal and/or back pain,
hypotension, chest pain, shortness of breath, bleeding/pain/discomfort at the
venipuncture site, and/or flushing, developing within minutes to hours after initiation
of transfusion
• Complications à acute renal failure, DIC
• Diagnosis à positive direct Coombs test
• Management:
1. Step 1 à stop transfusion
2. Step 2 à IV fluids and furosemide ± urine alkalinization
3. Step 3 à do not resume transfusion
Delayed Hemolytic Transfusion Reaction
• More common than acute hemolysis
• Secondary to Rh and/or Kidd antigen incompatibility
• Females > Males
• More common in patients with sickle cell disease
• Develops 1-4 weeks after transfusion
• Pathophysiology: preformed antibodies at low titers à exposure to antigen à
anamnestic response à rise in antibody titer à mild/moderate hemolysis
• Clinical features à asymptomatic (detected as unexplained fall in Hb and/or Hct) to
symptoms/signs of acute intravascular hemolysis
• Management:
1. Mild reaction à identify the cause; avoid future exposure to the offending
antigen
2. Severe reaction à as above + IV fluids and furosemide ± urine alkalinization
33
Febrile Non-hemolytic Transfusion Reaction
• Most common transfusion reaction (3% of cases)
• Secondary to preformed antibodies against donor WBC HLA molecules ± release of
cytokines from stored WBCs
• Clinical features à ↑ fever/chills ± headache, arthralgias, myalgias, developing ~ 1 hour
after initiation of transfusion
• Management:
1. Step 1 à stop transfusion
2. Step 2 à administration of acetaminophen
3. Step 3 à resumption of transfusion
• Prevention à acetaminophen prophylaxis before transfusion ± leukoreduction
(leukodepleted blood products)
Allergic (Urticarial) Transfusion Reaction
• Most common transfusion reaction (3% of cases)
• Secondary to preformed antibodies against donor serum proteins
• Clinical features à urticaria (not generalized), edema developing during and/or
immediately after transfusion
• Management:
1. Step 1 à stop transfusion
2. Step 2 à administer diphenhydramine
3. Step 3 à resumption of transfusion
• Prevention à diphenhydramine immediately before transfusion
Anaphylactic Transfusion Reaction
• Develops in persons with IgA deficiency
• Pathophysiology: presence of anti-IgA antibodies of IgG type à complement
activation à generation of anaphylatoxins
• Clinical features à similar to acute hemolytic transfusion reaction ± sudden onset of
severe bronchospasm, generalized urticaria, hypotension/shock
• Management:
1. Step 1 à stop transfusion
2. Step 2 à administer epinephrine, IV fluids, diphenhydramine and steroids
3. Step 3 à do not resume transfusion
• Prevention à use of washed blood products and IgA-deficient plasma
34
Other Transfusion Reactions
• Volume overload à
1. Common in patients with existing CHF
2. Asymptomatic to symptoms/signs of acute pulmonary edema
3. Management à Slow/stop transfusion + IV furosemide
• Acute lung injury à
1. Second most common cause of mortality
2. Acute onset of respiratory distress + noncardiogenic pulmonary edema
3. Management à supportive (oxygen, mechanical ventilation, etc.)
• Post-transfusion purpura à
1. Severe thrombocytopenia developing 5-12 days after transfusion
2. Secondary to preformed anti-HPA1a (anti-platelet) antibodies
3. Sudden onset of widespread purpura ± GI and/or GU bleeding
4. Management à IVIG ± steroids
• Graft-versus-Host Disease à
1. Secondary to transfusion of non-irradiated blood products to
immunocompromised patients
2. Bullous skin rash + fever + watery/bloody diarrhea + pancytopenia
3. Prevention à use of irradiated blood products
• Infectious complications (e.g. HBV, HCV, HIV, HTLV-1, etc.)
• Dilutional thrombocytopenia à
1. Secondary to massive blood transfusion
2. Bleeding from cut surfaces and/or venipuncture sites
3. Management à platelet transfusion
• Hypocalcemia à secondary to ↑ citrate content
• Hypothermia à prevent using the heat-exchange device to warm blood
35
Anticoagulation, General Principles
Heparin
• Mechanism of action à ↓ thrombin and factor Xa activity secondary to ↑ inhibitory
action of antithrombin III
• Side effects à ↑ risk of hemorrhage, thrombocytopenia, ↑ LFTs, hyperkalemia,
alopecia, osteoporosis
• Contraindications à active bleeding and/or bleeding tendency, history of HIT
• Overdose (usually manifested as bleeding) à protamine sulfate (side effects include
hypotension, bradycardia, anaphylactic reaction)
• Monitoring à aPTT (target 1.5-2.5 times normal)
• Resistance à consider antithrombin III deficiency
Warfarin
• Mechanism of action à ↓ γ-carboxylation of vitamin K – dependent clotting factors
(II, VII, IX and X) and anticoagulants (proteins C and S) secondary to functional
deficiency of vitamin K (warfarin à inhibition of vitamin K epoxide reductase)
• Side effects à ↑ risk of hemorrhage, skin necrosis (especially in patients with protein
C deficiency), teratogenic (e.g. epiphyseal stippling)
• Contraindications à active bleeding and/or bleeding tendency, pregnancy
• Overdose à vitamin K ± fresh-frozen plasma (see below)
• Monitoring à INR or PT (see below)
• Resistance à consider vitamin K supplementation
Target INR
Target INR value/range Medical Condition
INR 2 (range 1.5 – 2.5) Primary prophylaxis
INR 2.5 (range 2 – 3) Most warfarin indications
INR 3 (range 2.5 – 3.5) Mechanical heart valves
prophylaxis of recurrent MI
Supratherapeutic INR (warfarin overdose)
• INR < 5 à lower/omit next warfarin dose ± PO vitamin K • INR > 5 but < 9 à omit next 1-2 warfarin doses + resume warfarin at a lower dose • INR > 9 à stop warfarin + PO vitamin K + resume warfarin at a lower dose
• Any INR + active bleeding à stop warfarin + fresh-frozen plasma + IV vitamin K
• Any INR + life-threatening bleeding à as above ± recombinant VIIa concentrates

MASTER DOC UW NOTES for USMLE Step2 CK

2008-12-28T12:13:00.000-08:00

MASTER DOC UW NOTES for USMLE Step2 CK

propranolol=drug of choice for HTN+beningn essential tremor

)Reccurent chalazion=> do histopathologic examination because of risk of Squamous cellular carcinoma (SCC)

)PH=7.23, HCO3=16, PCO2=40-what is it?
=mixed metabolic+respiratory acidosis, because if it were simple metabolic acidosis, then PCO2 would have been=1.5*HCO3+8=1.5*16+8=32mmHg and in this case it is 40mmHg, so there is also a respiratory acidosis

Know the formula for calculating the compensation in acidosis: PC02= 1.5*HCO3+8
Ex.: a diabetic suffering from COPD treated with metformin may have mixed acidosis, metabolic from metformin, respiratory from COPD.

)NSAID can give SIADH (innapropriate secreation of ADH)

)Quinsy=peritonssilar abcess

)Tamsulosin=blocks alpha1-receptors only in prostate and bladder=>no side effects like hypoTN, headache, rhinitis as other alpha 1 blockers

)Sideroblastic anemia-high Fe, high TIBS, may be hypocromic and normocromic anemia in the same time=HIGH YIELD

)Streptoccocus bovis endocarditis-asoc. with colorectal cancer=>do colonoscopy

)Treatment of MG crisis=intubation+withdrawl of anticholinesterasic drugs for many days, then do plasmapheresis and iv IG

)Foreign body in the eye=>first pen light exam=>fluoresceine exam, if still (-)=>CT or US, never MRI (it can dislocate the foreign body)
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
)patient with XYY karyotype=severe acne, but not precocious puberty
21-hydroxylase deficiency=precocious pseudo-puberty, independent of the hypotalamic-hypophyseal-gonadal axe

)Black widow spider bite=>treat with narcotics, muscle relaxants and Ca gluconate

)Women with CIN (cervical intraepithelial neoplasia):
a) imunocpmpromized
b) in utero exposure to DES
c) hystory of CIN II/III
will have annual PAP smear done, regardless the normal previous ones.

)In severly depressed patient, even suffering from terminal illness with suicidal thoughts=>start antidepressant therapy

)Systemic steroids=drug of choice in sarcoidosis with disabling symptoms, if not responding=>cyclosporine
if asymptomatic sarcoidosis=>no treatment

)Lachman test is more sensitive than anterior drawer test in ACL rupture (anterior cruciate ligament)

)Primary polydipsia=increased thrist first, can be given by antipsyhotic medication (phenotiazines) because they give a dry mouth. Look for a patient in the psychiatric ward on antipsychotics who gets diarhhea, polyuria and thrist
Insipid diabetes=increased polyuria first

)HTN+peripheral vascular disease=>give Ca channel blocker

)BCC (basal cell carcinoma)=most common tumor of the eyelid
=pearly, indurated
=>treat by chemosurgery of frozen section control excision

)Respiratory alkalosis-in liver insufficiency because of increased levels of progesterone (not metabolized anymore)

)Hashimoto thyroiditis-can be eu/hypo/hyper thyroid
-anti preoxidase Antibodies are diagnostic
-risk (6 times) of thyroid lymphoma
)Nasopharingeal carcinoma-appears in all age groups

)Colonic villous adenoma, sessile adenoma or size>2.5 cm=> increased risk of malignancy=HIGH YIELD
No further work-up for hyperplastic polyps

)US of KUB (kidney, ureter, bladder)=first step in evaluating BPH (benign proastate hypertrophy) with elevated Creatinine and normal urinalysis

)MALT gastric lymphoma and no metastasis=>eradicate H.pylori infection, if this fails, then give chemotherapy (CHOP)

)Athlete's foot (in swimmers too)=fungal infection, treat with tolnaftate

)Excessive bleeding (like abruptio placenta) in pregnant woman Rh (-)=>give higher dose of anti-D globulin

)If HDL>60mg%=>it removes one risk factor for CV disease

)Alcohol withdrawl=>first-line give chlordiazepoxide (librium), then lorazepam=second-line

)Sjogen syndrome=>diagnosis confirmed by lip biopsy (lymphoid foci in accessory salivary glands)=most specific

)Allergic contact dermatitis=erythema, edema, pruritus, tiny vesicles, weepy&crusted lesions 24-48h after contact with the allergen-cell mediated hypersensitivity

)Psammoma bodies=thyroid papillary cancer
Invasion of tumor capsule and blood vessels=folicular cancer
Hurtle cells-appears in both the above types (rarely)

)Carcinoid syndrome=>develop deficiency of niacine (dermatitis, diarhea dementia) because Trp is mainly converted to serotonine and 5HIAA
Hyper Ca crisis=vomiting, oliguria/anuria, dizziness, coma

)Invasive aspergillosis="halo sign" on CT scan of lung
=in imunocompromized people
=on CXR-cavitary nodule

)Miastenia gravis=>thymectomy if:
-between age of puberty and 60
-if <12 age="">frecquent spontaneous remissions
-if>60 years of age=>give corticosteroids
-if only ocular disease=>no thymectomy

)Defect in Le adhesion=reccurent bacterial infections
-characteristic are: delayed separation of umbilical stump
necrotic periodontal infections

)Defect in opsonisation=asplenia (infections with S. Pneumoniae are frecq)

)Acute ingestion of masssive alcohol=> reduces the toxic effect of acetaminophen by inhibiting CYP2E1 like in suicide attemps with alcohol and acetaminophen together, but
Chronic ingestion of alcohol reduces glutathion=>increases the toxicity of acetaminophen like in an alcoholic patient with some kind of fever due to common cold

)Egg allergy=>contraindication to influenza vaccine and Q fever vaccine, and relative c.i. to MMR (which is however still recommended)-HIGH YIELD

)ACE inhibitors=>increase renin and kinin derivates=>cough

)Dermatomiositis=Gottron's sign=scaly patches on MCP and IP joints
=heliotrop rash (periorbital edema+purplish suffusion)
=proximal muscle weakness
)Vertebral osteomyelitis-lumber area frecq.=>back pain
- low fever, high ESR, local tenderness, spasm
Do MRI=of choice for diagnosis
-Complications=epidural abcess, spinal cord compression
)Pale lesions, velvet-pink or whitish that do not tan and are not scaly=tinea versicolor (Malassezia furfur)
-thick budding spores, large blunt hyphae="spaghetti and meatballs"
-treat=>Se sulfid shampoo and ketoconazole

)Loss of gastric fluid by NG suction in intestinal obstruction=>metabolic alkalosis (contraction alkalosis) even if initially it was a metabolic acidosis from the obstruction
)Hypophosphatemic rickets-only P is low, the rest are normal (PTH, Ca)
)Migratory trombophlebitis-due to cancer=> do CT of chest abdomen and pelvis; can be pancreatic, lung, prostate, stomach cancer

)Acyclovir=nephrotoxic=>renal tubular obstruction, gives crystalluria
)Deficiency of Iron=most common anemia in the elderly=HIGH YIELD
)Anemia of chronic disease is given by inflamatory joint disease not degenerative joint disease

)Pseudomonas osteomyelitis (punctures through snikers in the foot)=>give quinolones+surgical debridement
) Anemia of prematurity-normocitic, normochromic, low reticulocytes, few precursors of red line, normal WBC, T, normal Bilirubin, , no other abnormalities

)Isoniazide=>lowers the levels of GABA in the brain=>seizures in 1h after administration, treat by Vit. B6
)For screening use=total cholesterole+HDL
For treament use=LDL+Risk assessment

)Undiagnosed pleural effusion=best evaluated by thoracocentesis, except in CHF (here give diretics and see what happens-it will disappear)-HIGH YIELD
Varicose veins with incompetent perforating veins- can give:
-non-pitting edema
-medial leg ulcer
-fatigue
-brown discoloration of the ankles

)Warfarin induces skin necrosis=>mostly in patients with deficiencies of prot C or S or when it is started in high doses without prior heparin coverage (like in Atrial fibrillation)

)Larger Confidence interval (CI)=wider range of possible effects for a tested drug (efficient drug in some patients, non efficient in others)
If CI of 2 groups overlap=>no statistical significance
If they don't overlap=> statistical significant differences

)Niacine treatment=> raises HDL, but gives pruritus and flushing (release of Prostaglandines)=>prevent this by giving aspirin 30 min. prior to taking niacine

)Pulmonary embolism (PE)-post surgery in pacients with JVD and new RBBB; also dilated pupils=ominous sign

)Post-ictal (after seizures) lactic acidosis is transient=> no treatment, it resolves by itself in 60-90 min.
HCO3 is given in acidosis only if PH<7.2 )In primary hyper aldosteronism, there's no edema, but hyper Na )Retinal vein occlusion=disk swelling, venous dilation and tortuosity, retinal hemorrhages, cottol-wool spots )Retinal artery occlusion=pale disk, cherry-red fovea, boxcar segmentation of blood in the retinal veins )Celiac disease-diarrhea, pallor (anemia), bone pain (osteomalacia), easy buising (low vit.K), hyperkeratosis (low vit. A), Ig A Antib. to gliadine, to endomissium and to tissue transglutaminase =malabsortion+Iron def. anemia )Overflow incontinence-can be given by: TCA, antichol., antipsychotics, sedative-hypnotics )Spinal cord compression=>first give STEROIDS, then do MRI of the spine, if not available do=>CT myelogram=> give radiotherapy for malignancies=HIGH YIELD

) Diagnosis of Bartonella Henselae is clinical, confirm by Warthin-Starry stain of tissue specimen or Antib.
treat by azytromycin for 5 days and only in regional lymphadenopathy or systemic symptoms (also can give claritromycin, rifampin, TMP/SMX, cipro or Doxi)

)Shy-Dragger syndrome=Parkinson +autonomic instability (HypoTN...)
-can have bulbar dysfunction or laringeal stridor
-treat by iv expansion (fludrocortisone), salt, alpha agonists
Riley-Day Syndrome-AR disease, in Askenazi Jews
=autonomic dysfunction +severe hypoTN

)Prepubertal vulvo-vaginitis=>pruritus mainly in the night=>do scotch tape test to detect pinworm (do not answer stool examination)
)Treatment for low HDL=>Choice=fibrates, the niacine
)Treatment of choice for anorexia=hospitalisation

)Subcutaneous emphysema in patients on 100% O2 on mask=> do first CXR to rule out pneumotorax; if (-) this is a benign condition=>no furthet treatment

)Thoracic outlet syndrome-after MVA, playing with musicalinstruments, chronic illnesses, cervical ribs, congenital muscle band...=has signs of neuro-muscular bundle compression
-do EAST test for screening (elevated arm stress test), and CXR, MRI or angiography for confirming the diagnosis

)Medial meniscus tear-C shaped meniscus (the lateral is O-shaped)
by twisting the leg, effusion forms in 24h and is not as bloody as in ACL tear, tenderness on the medial part on the knee
=characteristic=bucket handle tear and locking of the knee joint in extension
(+)McMurray sigh=snapping felt with tibial torsion, knee flexed at 90 degrees
-trea by immobilization+bracing

ACL tear=hystory of hyperextension
(+) Lachman test, ant. drawer test, pivot shift test

)CI=1.02-2.15
RR=1.6 What does it mean? Well, the CI does not include value of where RR=1, then it means that the result is statistical significant
RR=1=> no effect or association

)Low cardiac output + high PCWP+high SVR=left ventricular failure (cardiogenic shock)=HIGH YIELD, I got some similar questions on actual exam, know this type of Q for cardilogy very well!!!

)Eczema herpeticum=HSV infection associated with atopic dermatitis, there are vesicles over the areas of atopic dermatitis
treat by acyclovir in infants

)Causes of altered mental status in the elderly patients:
low+high Na, Ca, low Mg, low P, low glucose, stroke, cardaic events, infections
-risk of dehydration by:WATER ACCESS IS DENIED=main mechanism in:
a)nursing homes
b)post-surgery
c)intubation in ICU

)To slow down the progression of Diabetic nephropathy=>restrict proteins and give ACE inhibitors (even if normal TN, but not if Clearance of Creatinine>2)

) Treat of both acute and chronic anal fissures=> starts with dietary modifications+stool softner+local anesthetics; in refractory cases do lateral sphincterotomy or gradual dilatation=>risk of incontinence and disruption of sphincter

)Paroxismal nocturnal hemoglobinuria-may cause pancitopenia
-like hemolytic anemia (High reticulocytes)
-intravascular process (high LDH, total billirubin, low haptoglobin)
-splenomegaly, Cooms (-)
-loss of iron in the urine=>microcytes, hyprocromia
-bone marrow=hypocellular
-flow cytometry=absence of CD59 -used for confirmation of disease

)Screen for hepatitis C if blood transfusion was before 1992 and for hep. B is before 1986

)To supress lactation=>tight-feeting bra+ice packs, no longer bromcriptine

)First step in organo-phosphoric poisoning=remove clothes and wash patient, then atropine
)Use CA-125+vaginal US for screening the intermediate risk of ovarian cancer in women with family hystory of ovarian cancer (not other type of cancer); otherwise, there's no screening done for ovarian cancer

)Avascular hip necrosis-given by steroids, scikle cell disease, alcoholism, SLE, Gaucher's disease
=hip pain with normal range of motion and normal X-rays. Do MRI=GOLD STANDARD for diagnosis
)Intraperitoneal rupture of bladder in MVA=previous full baldder in a patient who drank water (2l) and didn't urinated for 8h
Extraperitoneal rupture=more common

)Treat Ig A deficeincy:-prophilactic TMP/SMX, donor erytrocytes washed five times or bloodfrom other IgA def.patients

)HTA+osteoporosis=first choice are THIAZIDIC DIURETICS

)Vitiligo=pale macules with pigmented borders-acral or peri-orificial areas, autoimmune distrcution of melanocytes
Piebaldism=absence pf melanocyes, obvious from birth
Infection with M. Leprae=areas of hypopigmentation+anesthesia

)Metabolic alkalosis:
a) Cl sensitive (Urinary Cl<20mEq/l)-causes;vomiting,diurectics...=ECF contraction; treatable by NaCl infusion b) Cl resistant (U Cl>20mEq/l)=ECF expansion, not correctede by Na Cl infusion; causesersistent mineralocorticoid stimulation

)Nerve IX neuralgia-associated with Multiple Sclerosis (MS)

)Nephrotic syndrome-associated with arterial+venous thrombosis (freq. renal vein thrombosis and even PE
-anemia microcytes, hypocromia, resistant to iron therapy (loss of transferine)
-vit D deficiency, low Thyroxine levels

)Angiofibroma in the nose-can give bony erosions
Chondroma of nasal cartillage-is very rare in young patients

)Lyme disease in pregnancy and in children<9 age="">give AMOXI, not Doxi; also can give Azytromycin or cefuroxime

)Sympathetic ophtalmia-ant. uveitis, panuveitis, papillary edema, blindness
-by uncovering of "hidden antigens" (auto-Antib, cell-mediated reaction)

)Diphenilhydramine toxicity-seizures+cholinergic effects
Mercury overdose=vomitting, abdom. pains, bloddy diarrhea, renal insufficiency

)Best prevention of osteoporosis=HRT, c.i. if hystory of endometrial/breast cancer, but not if only family hystory

)Pulmonary nodule with cartillage in it=hamartoma=>observe
Radiotherapy-use it emergently in Superior Cava Vein syndrome

)Dupuytren contracture-associated with alcoholism, epilepsy, DM, TB, Peyronnie disease, Riedel thyroiditis; over 50 years of age

)Perforated retro-cecal appendix, edematous cecum, pus behind the ascending colon=>do right hemicolectomy+ileo-transverse anastomosis=best post-surgical results

)Excruciating pain from femur fracture=>give iv. Morphine (even in patients with hystory of drug abuse), then give PCA (patient controlled analgezia)
Give methadone in chronic severe pain syndromes

) If a test is (-)=> probability of the disease is =1-NPV

)HCO3 if given in lactic acidosis can depress the myocardium and increase the production of lactic acid by stimulating the phosphofructokinase enzyme

)Most common location of ischemic colitis is splenic flexure, than recto-sigmoid area

)MCC of bleeding in patients with renal failure is platelet dysfunction; treat by DDAVP

)Bacterial meningitis-treat empirically with ceftriaxone+vancomycine
Give iv dexamethasone in intracranial HTN and bacterial meningitis in infants

)The decision of using N-acetyl-cysteine for acetaminophen overdose is based on the drug levels taken at 4h post-ingestion. But if taken>7.5g acetaminophen or levels are not available at 8h of ingestion=>start treatment

)COPD exacerbation with: ph=7.32, pco2=52, po2=60=> give NIPPV (non-invasive positive pressure ventilation)-the indications are:
ph<7.35 pc02>45mmHg
Resp. rate>25/min.

)Adult Still's disease-variant of RA
-at 20-30 years of age
-high spiking fever
-salmon colored rash along with thye fever
-arthralgias, lymphadenopathy, high Le

)Any gunshot under the 4th i.c. space=>do laparotomy of the abdomen

)Latex allergy-associated with spina bifida
-gives anaphilactic reaction to "sex and surgery" (because of condoms and surgical gloves)

)Selection bias=loss of follow-up in a prospective study

)Reccurent myocardial infarction-detect by serial CK-MB levels

)RTA 1-assoc. with Sjogren syndrome
-urine ph>5.5
low HCO3
low K+

RTA 2-osteomalacia
-urinary ph<5.5 low HCO3 levels -low K+ )Corrected Ca=measured Ca+0.8 (4.5-measured albumin) For each 1g of lost albumin, Ca goes down by 0.8-1mg% )Cavernous sinus thrombosis-like orbital cellulitis but with cranial nerves involvement (III,IV,V, VI) and bilateral -treat by Antibiotics, then anticoagulation and corticosteroids )Acute pancreatitis and non-alcoholic=>suspect gall-stones=>do US=first step; do CT only if Le>20000/ml and suspect necrotising pancreatitis

)DM foot ulcer-treat by cephalosporine, ampi/sulbactam, clidamycine+fluoroquinolone

)Syringomyelia=areflexic weakness + dissociated anesthesia in a "cape" distribution in the upper extremities

)Emergent contraception=estradiol+norgestrol, 2 tb taken in no later than 72h, 12h apart

)HIV individuals-give Td vaccine

)Aspirin sensitivity syndrome=pseudo-allergic reaction; treat with leukotriene inhibitors=drug of choice

)To confirm Ankilosing spondilitis=>do X-ray of the sacro-iliac joint, if not conclusive=>do CT
)Splenic rupture- the need of surgery determined by:
a)vital sighns+hemodynamic stability
b)change in hematocrit over time
c)need for blood transfusion

)NTG-dilates the capacity vessels not the resistance vessels=>reduces preload

)Molluscum contagiosum-poxvirus
-diseminated in HIV patients
-central umbilicated, dome shaped
resolves spontaneous in 1 year

)Bullous myringitis-painful vesicles on the timpanic membrane
-mycoplasma or viral infection

)Drug-induced pancreatitis: valproic acid, diuretics (loop and thiazidic), 5-ASA, sulfasalazine, imunosuppressive (L-asparaginase, azathioprine), AIDS-patient (didanosine, pentamidine), metronidazole, tetracycline

)Cystinuria-reccurent stones since childhood
-family hystory
-hexagonal crystals, hard stones which are radio-opaque
-screening test=urinary cyanide nitroprusside test

)Antiphospholipid syndrome-reccurent fetal losses, reccurent artery+vein thrombosis
-types-I has false (+) VDRL
-II has lupic anticoagulant=>false + APTT
-III-has anticardiolipin antibody
treat in pregnancy by: heparin+aspirin and measure factor X activity and not APTT for treatment

)Gilbert syndrome-associated with fasting, alcohol, stress, complete reversal with phenobarbital
Crygler Naijar 1-billirubin=8-30mg%, kernicterus, no response to phenobarbital
Crygler Naijar 2-billirubin<20mg%, no kernicterus, 25% response to phenobarbital )In gonochoccal arthritis=>do urethral culture to identify the gonococcus

)Common variable imunodeficiency=15-35 years of age
-normal B and T cells
-frecq. sino-pulmonary infections
-low IgG, Ig M, Ig A
Wiskot-Aldrigh=has low IgM, but high Ig A, IgE

)Acute appendicitis-can perforate and give pelvic abcess with diarrhea, fever, tender mass on rectal exam, low abdom pain and not the usual sighns of appendicitis

)PTCA=has better outocme than thrombolysis

)NPV is high and PPV is low if the pre-test probability of the disease is low

)Microalbuminuria in DM=>start ACE inihibitors even if no HTN

)Motility disorder of the oesophagus=>do contrast study=>then oesophagoscopy to exclude mecanic causes (strictures,cancer)=>only then manometry

)Chronic headaches+painless hematuria=>think analgesic nephropathy due to papillary necrosis

)Terminal patients with severe pain=>give short-acting morphine, then long-acting narcotics

)Campylobacter jejuni-MCC of diarrhea
-in undercooked poultry
-diarrhea is watery or hemorrhagic

)Craniopharingiomas-bimodal distribution:
-children (gives growth problems)
-55-65 age group (gives sexual dysfunction, bitemporal hemianopsia-think of a truck driver who has to turn his head all over when looking sideways

)Chlamydia screening-do it in all women under 25 years of age if sexually active

)Nonseminomatous tumor-may give ant.mediastinal mass, high AFP, HCG; treat by cysplatinum for 6 weeks; use the above two markers to monitor the therapy

)Signs of high ICP: dilated pupils, anisocoria
flaccidity, decerebrate or decorticate posturing
papilledema
NOT Glasgow coma scale=it assesses the severity of head injury only

)Matching=tool that makes cases and controls have similar distribution of some important confounding variables; it's an efficient mean to control confounding

)Warfarin induced skin necrosis-pain, bullae, skin necrosis; use heparin until they heal

)Furosemid-is ototoxic

)SLE-has-low T supressor cells, high T helper cells>B-cell hyperactivity>high serum Antib and Ig G auto-anitbodies which form the immune complexes

)Hyperlipidemia 1 and 5=associated with pancreatitis

)In PCP in HIV patients give steroids, besides TMP/SMX if:
-Pa O2<70mmHg -A-a gradient>35=150-(1.25*PCO2)-PO2
sat O2<75% )Amantadine-dual drug=anti-viral+anti-Parkinson )Granulosa cell tumors-precocious puberty -postmenopausal bleeding )Trachoma-given by chlamydia trachomatis (A-C) -cause of blindness by neovascularisation=pannus -follicular conjunctivitis -treat by oral erytro or tetracycline )Anserine bursitis-medial knww pain below the joint line, hystory of trauma -valgus stess test is (-), it's (+) in medial collateral ligament strain -X-ray of tibia is normal Patellofemural syndrome-in females <45 years -ant. knee pain aggravated by flexion -retropatellar tenderness and crepitation )A narrower CI=>the study is more precise

)If DM type II is not controlled by one hypoglicemic agent, add another one from another class; give insulin only if BUN and Cr are abnormal

)In acute bacterial prostatitis=>get urnie sample for culture before starting empirical antibiotics

)Acute variceal bleeding-give octreotid; beta-blockers are for prophylaxis

)Mucormicosis-treat by surgical debridement and amphotericin B

)Labetalol=drug of choice in pregnancy if HTN+DM nephropathy

)Open-angle gluacoma-cupping of optic disk
-loss of peripheral vision=tunnel vision
-more frecq. in African-Americans
Macular degeneration=central vision loss

)Give MMR to all HIV patients (except those severly compromized)

)Patients with impaired consciousness, advanced dementia=>predisposed to aspiration pnemonia due to impaired epiglotic function

)In patients with frecq. attacks of gout=>first step is to measure 24h urinary uric acid level
-<800mg/day=>under-secretion (probenecid)
->800mg/day=>over-production (allopurinol)

)Ulnar nerve syndrome=MC site of entrapment is: medial epicondilar groove; think of counter clerks who sit with their elbows on the table all day

)In CHF-improved survival by: aspirin, beta-blockers, ACE inhib., spironolactone
-don't improve survibal: digoxin and loop diuretics

)What acid-base disorder is this?
ph=7.53
pco2=30mmHg
HCO3=24
Cl=85
Na=138
Well, tough one: we have alkalosis and is respiratory because Pco2 is low;
AG=Na-(Cl+HCO3)=29=>metabolic acidosis;
But a change in the AG (increase) is accompanied by a similar change in the levels of HCO3 (decrease). Here HCO3 is normal=> metabolic alkalosis.
Scenario (all three together): pneumonia=>respiratory alkalosis
vomiting=>metabolic alkalosis
DKA (from ketones)=>metabolic acidosis

)Any patient with bone pains, renal failure and hypercalcemia has Multiple Mieloma until proven otherwise

)Sudden RUQ pain+rise in hematocrit levels with hepatomegaly, splenomegaly and ascites=>think Budd-Chiari syndrome (from polycitemia vera)=>first step=hepatic venogram or liver biopsy

)Carotid stenosis of >60%-99%=> do CEA even if asymptomatic; complete occlusion= c.i. to surgery

)Lichenus sclerosis-dryness, severe itch, vaginal soreness
-may give vaginal cancer
-do biopsy to rule out cancer
-treat by topical steroids

)Retinal artery occlusion-treat with occular massage+high flow O2
-give thrombolytics within 4-6 hours of visual loss

)TCA- cardiotoxic potential=>because they inhibit fast Na channels
-to asses the severity of the toxicity=>get QRS duration

)Pneumovax-has capsular polysacharrides and gives T-cell independent B cell response; live vaccines give T-cell dependent......

)All uncouncious patients, even those breathing need airway established by:
-intubation in the ICU
-cricothyroidectomy in the field

)In unstable angina=> no thrombolytics; give aspirin, heparin, NTG, beta-blockers

)In MI, give thrombolytics after sublingual NTG to rule out vasospasm.

)VF=is a reentrant ventricular arrythmia

)Superficial spreading melanoma=MC
-increased intraepithelial atypical melanocytes
Acral lentiginous melanoma-on palms, soles, beneath nail plate
Lentigo melanoma-head, neck, arms of fair skinned older people

)Diuretic use (also thiazidic)=>gives metabolic alkalosis

)Euthyroid sick syndrome: low T3, Normal T4, normal TSH; in severe disease: low T4+T3, normal TSH

)Cholesterol embolism-follows surgical or intervention on arterial tree
-livedo reticularis, gangrene, ulcer or mottling of toes
-systemic eosinophilia, low complement levels
-renal failure (eosinophiluria)

)If an ulcer is seen on colonoscopy=>do biopsy to rule out cancer

)Subconjunctival hemorrhage-benign condition, observe only; think of a person with a red eye on awakening in the morning

)Parvovirus infection=>arthralgias of small joints with 5-10 min morning stiffness, normal ESR, no signs of inflamation locally
-joint involvement is symmetrical+-rash

)Intermitent claudication-give aspirin and exercise program
-do angiogram only pre-op,otherwise do duplex arterial study if you want imaging

)Acantosis nigricans-insulin resistance (DM)-in young people
-gastro-intestinal malignancy in the older
-symmetrical, hyperpigmented, velvety palques in axilla, groin, neck

)Drug-induced acute allergic interstitial nephropathy:
a)antibiotics (meticilline, cephalosporine, sulfonamides...)
b)NSAID
c)thiazides
d)phenytoin
e)allopurinol

)Epiglotitis-given MC by H.influenzae type B and strep. group A

)Food droolong out of the mouth and nose during meals=Zenker diverticulum=> can give aspiration pneumonia
-diagnose by oesopphagography

)Chronic diarrhea=>oxalate stones (due to malabs. of fatty acids, they bind Ca and oxalate is free for absortion)

)Gardner syndrome:colonic polyps+lipoma, nasal angiofibroma, gastric polyps, osteomas, epidermoid cysts, more teeth

)Amebic hepatic abcess-"anchovy paste" in the liver
-treat by oral metronidazole (not percutaneous drainage)
-in the tropics acquired

)Cluster headache=>treat by 100%O2 and s.c. sumatriptan; prophilaxis: verapamil, Li, ergotamine

)Vaginal delivery in breech:
-frank or complete breech
->36 weeks of gestation
-weight:2500-3800g
-adequate maternal pelvis
External cephalic version-converts breech into cephalic presentation=>use over 37 weeks until the onset of labor
Internal podalic version-in twin delivery (from transverse/oblique to breech)

)Friedrich ataxia-ataxia, dysarthria, skeletal deformities (scoliosis, hammer toes, pes cavus), cardiomyopathy; three words: neurologic, cardiac and skeletal problems

)Pseudogout-can be triggered by surgery or trauma
-may have 100000 Le/ml in joint fluid

)Nosocomial infections-UTI
-surgical wound infection
-pneumonia

)Know the X-ray appearance of descented aorta aneurysm-well circumscribed lesion=>due to aterosclerosis

)For acute aortic dissection=>use first TEE or CT(only if hemodynamically stable)

)Herpetic withlow-HSV 1 and 2
-in health care workers
-pain in the finger pulp with vesicles and systemic symptoms
-treat by acyclovir+topical bacitracin (to prevent secondary infection)
Felon-appears in tailors
-from needle injuries
-it's a bacterial abcess (tense abcess)=>do drainage+cephalosporine

)Urinary diversion procedure (ureter implanted in the ileum for example)=>gives Hyper Cl metabolic acidosis because the colon absorbs NH4+ derived from ureea under the action of intestinal bacteria
-also the pum Cl/HCO3 functions like this: absorbs Cl, lets HCO3 go!

)Tinitus-by aspirin, quinine
-also in Meniere disease, acoustic neuroma and ...depressed patients=>give TCA

)Chronic myelogenous leukemia=>give IMATINIB (Gleevec)=Tyrosine kinase inhibitor; side effects are: nausea, diarrhea, cramps, rash, face swelling, temporary reduction in blood cell production

)Post-herpetic neuralgia=>give acyclovir
-follows acute herpetic-zoster infection

)Intra-uterine fetal demise (IUFD)-death in utero>20weeks
-Beta-HCG remaind eleveted
-confirm with US
-first do a coagulation profile to assess the risk of DIC
<=>between 13-28 weeks, no DIC=>watchful expectancy
<=>between 13-28 weeks, with DIC=>induction of labor with PG suppositories
<=>after 28weeks, with/out DIC=>induction of labor with oxytocin and laminaria tents
-can use vaginal delivery
So, in case of DIC=>deliver immediately by induction of labor

)Acute retinal necrosis in HIV patients
-pain, keratitis, uveitis
-peripheral pale lesions+central retinal necrosis
-given by HSV or VZV
CMV retinitis=hemorrhages+granular lesions around the retinal vessels

)Pneumonia after upper GI endoscopy=>suspect anaerobic bacteria=> give clindamycine or ampi+metronidazole
Ampi+genta=used almost NEVER for pneumonia, they are used for abdominal infections+-metronidazole

)Cyclophosphamide=> can give bladder cancer
-prevent by lots of fluids and mesna

)Stress fracture (March fracture) or insufficiency fracture:
-young adults who exercise a lot
-X-ray=normal, dignose it with CT or MRI
-dull pain increased by exercise
-point tenderness
-at metatarsal, navicular, neck of femur/tibia

)Hypothyroidism-consider in patients with unexplained high CK levels

)Bicuspid aortic valves=>can give aortic stenosis later in life (4-5th decade)=MCC of aortic stenosis in middle-aged adults

)Seborrheic keratosis-in the elderly
-0.3-2cm large
-slow enlargement
-greasy surface, stuck on appearance-HIGH YIELD these words
-varies in color
-anywhere on the body, except palms and soles
-can itch or rub
-do shave biopsy (DON'T DO IT FOR MELANOMA)
)Aspirin toxicity-gives metabolic acidosis and respiratory alkalosis (not normal compensation, but two distinct processes)

)Gastroparesis-treat in order by: metoclopramide, bethanecol, erythromycine; also cysapride-but it gives cardiac arrythmias
-confirm study=Nuclear Medicine Scintigraphy

)To determine the type of jaundice (conjugated or unconjugated) do:
-check urnary excretion of billirubin
-Van der Bergh test

)Lyme disease prophylaxis-do it only in pregnant women with hystory of tick bite in order to RELIEVE ANXIETY by Amoxi
-give vaccine to people living in moderate/high risk areas
-to the rest of the population=NO PROPHYLAXIS

)MCC of SAH (subarahnoid hemorrhage) syndrome in children is AVM rupture
-may have a case with hystory of seizures and migraine-like headaches

)Screen patients for lipid abnormalities:
-men>35 years
-women>45 years, if in good health or
between 20-35 (M) and 20-45 (W) if they suffer from:
a)DM
b)family hystory of hyperlipidemia
c)personal risks of CAD
d)family hystory of cardiac disease<50 years (M) or <60 years (W) )Gout attacks-give: -low-purine diet -no alcohol=>metabolises to lactic acid=>impairs renal excretion of uric acid by acidifying the ph
-avoid diuretics, pyrazinamide=>they compete with uric acid for renal excretion

)Penile fracture=emergency
-penis deviated to one side due to the rupture of albugineea of a cavernous body
-first do retrograde urethrogram, then surgical exploration of the penis

)Hypercarotinemia-in anorexia, DM, hypothyroidism

)A confounder (ex.smoking), to be considered so, needs to be linked to the:
-exposure (ex.people who drink alcohol are more likely to smoke)
-outcome (ex. smoking is associated with oral cavity cancer)
So smoking can be a confounder if a study concludes that alcohol alone is responsable for oral or oesophageal cancer!!!

)Effect modification=the effect of exposure (ex.drugs) on outcome (a disease) is modified by another variable ( ex.family hystory). This effect is not BIAS!!!

)Amiodarone=> don't give it if low BP
)Lesion suspicious of melanoma=>do excisional biopsy with narrow margins

)Radioactive iodine=treat of choice for Grave's disease
Antithyroid drugs-give in pregnancy+Grave's
-pre-op for surgery on Grave's
Iodinated contrast agents=>treat thyrotoxicosis
-give them if intolerant to anthytiroid drugs
Surgery-if:
-very large goiters
-antithyroid drugs do not control thyrotoxicosis in pregnancy
-increased risk of malignancy
-if next year scheduled pregnancy

)Petrous apicitis-triad=retro-orbital pain, paralysia of lateral rectus, otorrhea

)Anoscopy/proctoscopy=first step for blood per rectum in patients <50 years of age, without risk factors for colon cancer (here's not included blood mixed with stool=this is a risk factor) )Sickle cell disease-aplastic crisis-prevent by folic acid administartion and NOT by vaccination against parvovirus (which is a nother cause) )Exercise level in pregnancy=keep it at the same level as before preganancy )Phenothiazine-gives hypothermia, inhibit shivering-think of a schizo wandering in the streets in winter and is found lying in a park )If someone exposed to HBV is vaccinated already and HAS a documented response to HBV (by prior adequate titer of antibodies)=>do nothingm, just reassure!!!

)If in 2 weeks from the beginning of a pneumonia, the CXR is still pathologic=> do bronchoscopy and CT scan to rule out abcess or tumor and to take cultures, to drain...

)A reliable test gives similar results on repeat measurements
A valid (accurate) test gives results that can be compared with a gold standard test!!!

)Graft versus host disease=> affects skin (rash), intestin (blood+diarrhea), liver (abnormal LFT)
-by activation of donor T-cells, so it's cell-mediated immune response
)In DKA there's a paradoxycal hyper K+ from acisosis, because the reserves of K+ are actually depleted=> so give K+ in your treatment plan

)FIRST sign of colo-rectal cancer under 40 years of age=Rectal Bleeding

)Removal of K+ from the body=cation-exchange resin (kayexalate), diuretics, dialysis; NOT Ca gluconate, NOT insulin (these create only a shift intracellularly)

)Roth spots and Osler nodulesm in IE are from immune complex deposition (immune vasculitis)
Janeway lesions=septic embolism

)Optic neuritis=rapid vision decrease
-marked changes in color perception
-pain on eye movements
-central scotoma
-afferent pupillary defect
-swollen disk

)Myotonic muscular dystrophy
-begins in childhood (~13 years)
-AD disease
-muscle weakness, wasting in distal hands, post. forearms, ant. compartment of legs
-myotonia=delayed relaxation
-associated with testicular atrophy, DM, frontal balldness, hypothyroidism

)Matitis-in nursing
-treat by anti-Staph penicillin
-continue nursing to decrease breast engorgement and observe
-drainage only if there'sa fluctuating mass (=abcess)

)Atracurium-metabolized in plasma, by serum esterases
-use it safe in renal and liver dysfunctions
Pancuronium+mivacuronium=>not good in renal disease
Rocuronium=>not good in liver disease
Succinylcholine-in renal disease gives Hyper K+ and apneea

)Randomization=similarities in the baseline characteristics of patients in both placebo and treated groups. It controls known/unknown confounders!!!

)Mild acne=>topical retinoids; if reactivation occurs, give topical antibiotics
Moderate to severe acne (papular or inflamatory acne)=>oral antibiotics
Nodulocystic, scarring acne=>oral isotretinoin

)IMPORTANT!!!
In any metabolic acidosis=>first step=get AG (Na-Cl-HCO3); normal is 6-12 (or 8-14 depends on the author)
a)Normal AG metabolic acidosis-usually hyper Cl-2 causes:
-renal loss of HCO3 by RTA, moderate renal failure (GFR>20ml/min), carbonic anhidrase inhibitors
-GI loss of HCO3 by diarrhea, pancreatic fistula, ureterosigmoidostomy
To differentiate between them, get next step=urine AG(Na+K-Cl); normal is from -50 to 0.
If (+)=> defective urine acidification, lower urinary Cl, like RTA 1,2 and 4
If (-)=> higher urinary Cl=>adecquate NH4+ production=> GI causes
Then, urine PH differentiates different types of RENAL causes of acidosis!!!
b)High AG metabolic acidosis:
-lactic acidosis
-ketoacids (DM, starvation, alcohol ingestion)
-methanol ingestion
-ethjylen glycol ingestion
salycilate poisoning
uremia (GFR<20ml/min) Here, next step is to calculate the osmolar gap (especially if toxicity is suspected) )Paget disease=disordered skeletal remodelling Osteoporosis=low bone mass with normal mineralization Rickets=defective mineralization of bone and cartillage of the growth plate )Malignant otitis externa-by pseudomonas (in DM, imunocompromized) -granulations of the ear canal -involvement of CN VII, IX to XII -erosion of bone -foul smelling discharge -deep otalgia Rhizopus+Aspergillus are fungal infections that give external otitis, (not malignant), but don't make granulations )Suspect Zollinger-Elisson syndrome if refractory ulcers are associated with renal stones and there's a + family hystory of PUD )HIGH-YIELD: Erythopoietin in dialysed patients-side effects: -raises BP, even HTN encephalopathy -headaches -flu-like syndromes -red-cell aplasia (rare) Start treatment at Hematocrit<30% or Hb<10g% )Gall-bladder pathology-First use US HIDA scan-for diagnosis of acalculous cholecystitis or suspected on US )Trichinosis-2 phases: a)GI upsetsain, nausea, vomit, diarrhea
b)splinter hemorrhages, retinal&conjunctival hemorrhages, periorbital edema, chemosis, muscle pain, tenderness, swelling, weakness

)Eato-Lamber syndrome-earliest manifestation is hip-girdle weakness, later shoulder girdle involvement

)Thioridazine toxicity-cardiac arrythmias, prolonged QRS, low BP, tahicardia; treat by NaHCO3

)Sputum gram stain of pneumonia-purulent specimen if >25 neutrophils and <10 epithelial cells/field )Respondent bias=when outcome is obtained by patient's response (ex.migraine) and not by objective means of diagnosis (ex.biopsy) )Tinea corporis infection-itching -ring-shaped scaly patches with centralclearing and distinct borders -caused most frecq. by Trichophyton rubrum -treat by topical terbinafine -use griseofulvine if only extensive disease (this drug is usually not used today) )Salivary glands inflamation-from drugs such as: tioureea, iodine, cholinergic drugs )Hepatitis B-associated with membranous GN Carrierrs of Hep. B virus-associated with membrano-proliferative GN )Vit.K deficiency: -NPO patient -receiving antibiotics -high PT, then high PTT (prolongation of PT>> prolongation of PTT)

)Primary sclerosing cholangitis-in Ulcerative Colitis
-complication of it is cholangiocarcinoma=contraindication to transplant
So any severe stricture of the biliary tree MUST BE BIOPSIED!!!

)Mitral regurgitation=MC valvular abnormality in patients with IE

)Hollenhorst bodies=cholesterol particles, signs of impending stroke

)Benzodiazepines-can cause paradoxycal agitation in the elderly

)Congenital cataract=MCC of white reflex in pediatric population

)Any nocturnal, newly diagnosed asthma in middle-aged patients=>suspicion of GERD if associated laryngitis; to differentiate between asthma and GERD give a trial of proton pump inhibitors which can be both dignostic anf therapeutic

)CREST syndrome-may have pulmonary HTN (loud P2 sound)
)Mechanical symptoms in patients with meniscal problems=>evaluate by arthroscopy or MRI, then correct by surgery (arthroscopic or open)

)Latent period-in chronic disease epidemiology; is NOT BIAS
=extended time of continuous exposure is needed to affect the outcome (ex. 2 years of continuous multivitamins administration is needed to give a protective effect against cancer)

)Nitrates are c.i. for at least 24h after taking sildenafil (viagra)

)SCC-scaly plaque, central ulceration, 1.5cm, on the forearm
-polygonal cells, atypical nuclei at all levels of epidermis, zones of keratinization; sometimes is difficult to tell it apart from BCC

)Hypo K+ metabolic alkalosis:
-vomiting=>low urine Cl
-S. Bartter
-S. Gitelmann
-diuretic abuse; all three have high urine Cl

)Otosclerosis-AD disease
-Women>>men
-more in Caucasian race
-treat by NaF

)Lactose intolerance-diagnose with Lactose Breath H+ Test or (+) Clinitest for stool reducing substances
-high osmotic stool gap=290-2(stool Na+stool K)>50mosm/kg

)Goodpasture's syndrome-give emergent plamapheresis!!!

)Metastatic bleeding brain mass=> FIRST think MELANOMA
Tumors that don't metastisize to the brain are:
a) non-melanomatous skin cancer
b) oropharingeal cancer
c) oesophageal cancer
d) prostate cancer

)Parkinson's tremor=>gibe benztropine
Choreea Huntington=>give haloperidol

)Vitreous hemorrhage-sudden, acute loss of vision
-sudden onset of floaters
-fundus is hard to visualize, floating debris, dark red glow
-treat conservatively-sleep in upright position

)Prematurity-cause of intraventricular hemorrhage

)Mamography-do it annually between 50-75 years
FOBT-anually; 50-80 years
sigmoidoscopy-every 5 years between 50-80 years
Pap smear-until the age of 65 years, not after
Lipid screening-men>35y
-women>45y
-not >75y
-??unknown recommendations between 65-75y

)Alpha-1 antitrypsine deficiency in non-smoker, 3rd decade of life, lower lobe emphysema, neonatal jaundice in hystory

)Relapsing polychondritis
-recurrent inflamation of cartillaginous structures: ear=MC,spares the lobules; eye (conjunctivitis, episcleritis); joints (diffuse joint pains); skin; CNS.

)Fracture of calcaneum due to fall=> evaluate for other potetial fractures by X-ray of head, chest, abdomen, lumber area and pelvis
It's a very painful fracture and prior taken narcotics may alter pain perception
-so give morphine in severe pain, but after investigating for potential injuries (head and neck first)!!!

)Li-can cause seizures, opisthotonus, hyperreflexia, coma

)Attributable risk percent (ARP)=risk in exposed-risk in unexposed/risk in exposed=1-risk in unexposed/risk in exposed=1-1/RR=RR-1/RR
-it's the excess risk in the exposed population attributable to the risk factor!!!

)Impaired NH4+ excretion=main mechanism of metabolic acidosis in renal failure

)Hypo K+ periodic paralysis-by stress or medication
-sudden drop in K+ levels
-renin=normal, BP=normal
-familial condition or thyrotoxicosis

)Bartter syndrome=hypoK+ metabolic alkalosis
-impaired Na absortion in Henle ascending loop=hypovolemia=>activate RAA syste
-polyuria, polydipsia, growth abnormalities
-high urine Cl

)Serous otitis media=>air bubbles seen in the middle ear
Cholesteatoma-marginal tympanic membrane perforation, ear canal filled with mucus, pus, granulation tissue, destroys bone; remove surgically

)All patients suspencted of Zollinger-Elisson syndrome should have checked:
-first: serum gastrin levels (if>1000pg/ml are diagnostic); if not diagnostic,
-then:secretin stimulation test, if (-),
-then: Ca infusion study
Also measure gastric PH once to exclude hypergastrinemia from achlorhydria

)Chlamydial urethritis-dysuria, urinary frecquency
-mucopurulent urethral discharge
-sexual hystory of multiple partners
-pyuria+absence of bacteria on urialysis (colonies<100/ml) In gonochoccal, the discharge is purulent!!! )Differentiate CML from leukemoid reaction by measuring Leukocyte Alkaline Phosphatase (LAP); low in CML, high in leukemoid reaction!!! )Lewy body dementia-fluctuating cognitive impairement -reccurent visual halucinations -motor features of Parkinson Pick's disease-fronto-temporal -personality changes (euphoria, dezinhibition,apathy) compulsive behaviour -peculiar eating habits, hyperorality -impaired memory -visuo-spatial function=intact )Transient synovitis of the hip: -X-ray=normal -2 weeks after URI -high ESR -pain of joint movements -treat by bed rest and hip joint in the position of comfort )Beta-blockers intoxication-treat by: -atropine, if fails -isoproterenol, if fails -glucagon )Gold standard for osteoporosis is DEXA scan )Increased ventilatory rates onmechanical ventilation=>can lead to auto-PEEP=>lowers BP
-treat by decreasing the ventilator rate

)Erythema nodosum-may be the first sign of sarcoidosis
-goes with flare-ups of IBD
-appears in TB too

)Osgood-Schaltter disease-treat with rest, NSAID, brief casting

)Beta-blockers-selective beta 1 are agents of choice for perioperative MI risk decrease

)Cocaine abuse-young, venous trace marks, EKC with ischemia (ST depression), tahicardia, HTN
-treat-first line: Benzodiazepine, then nitrates, aspirin
-do catheterisation only if MI is obvious!!!

)Use aspirin in children only in:
a)Kawasaki disease
b)Juvenile rheumatoid arthritis

)Patients on both Mg(OH)2 and Kayexalate can get metabolic alkalosis due to the fact that Kayexalate bind Mg, so HCO3 remains in access and can be reabsorbed from GI tract!!!

)Treatment of hypo Na (SIADH):
-mild, asymptomatic, Na=120-130: fluid restriction
-moderate, asymptomatic, Na=110-120: normal saline+loop diuretic
-severe, symptomatic: hypertonic saline (3%)+loop diuretic

)Laxative abuse-10-20 evacuations/day and night,cramps=cause of factitious diarrhea
-on colonoscopy you see melanosis coli, because of the use of anthraquinone-laxatives (bisacodyl) and is dark-brown discoloration of the colon with shining limph follicles as pale patches

)Cyclosporine side effects=HIGH YIELD:
a)nephrotoxicity, high K+
b)HTN-tret with Ca channel blocker
c)neurotoxicity-tremors
d)glucose intolerance
e)infections
f)malignancy
g)gingival hypertrophy, hirsutism
h)GI complaints
Tacrolimus-same side effects except no gingival hypertr. and no hirsut.
Mycophenolate=>bone marrow suppression
Azathioprine=>bone marrow suppression,hapatotoxicity, diarrhea, leukopenia

)Pernicious anemia=>has high levels of LDH

)Nosocomial pneumonia in intubated patients=>think Pseudomonas=>give cefepime or ceftazidime (4th generation)

)A definite diagnosis for Alzheimer's disease can be made only post-mortem by brain biopsy!!!

)Chronic fatigue syndrome-like fibromialgia,but no trigger-points+symptoms of at least 6 months duration

)Barton's fracture-intraarticular, carp+distal margi of radius
Chauffeur's fracture-of radial styloid
Galeazzi's fracture-anywhere on the radius+radio-ulnar junction
Smith's fracture-reverse Colles fracture

)Null-hypothesis for cross-sectional study:
There's no association between elevated ESR level and colon cancer!
Null-hypothesis for cohort study:
The risk of colon cancer is the same for the subjects with and without elevated ESR level

)Descending aortic aneurysm in a young male is frecq. due to blunt trauma to the chest!!!
HIGH-YIELD:

)Bullous penphigoid=IgG+C3 deposits at the dermal-epidermal junction
-no oral lesions
-tense blisters in flexural areas
->60 years of age
-pruritus precipitated by UV, NSAID, antibiotics

Pemphigus vulgaris-intraepidermal blistering disease with auto-antibodies to adhesion molecules
-Ig G deposits intracellularly in the epidermis

Cicatricial pemphigoid-affectsmucous membrames
-Ig G deposits in linear band at the deromo-epidermal junction

Herpes gestationis-2nd trimester
-sub-epidermal blisters
-deposits of C3 at the basement membrane zone

)Amphotericine=>can give hypoK+

)Hshimoto thyroiditis:
-low TSH, high T4, T3, high T3 resin uptake
-low radioactive iodine uptake
-high thyroglobilin level
-non-tender goiter
-dry mouth&eyes

)Leukoplakia:
-increased risk of SCC
-from tabacco, vit. A, B deficiencies, syphilis
-do incisional biopsy or exfoliative citology examination!!!

)Soemtimes UC can involve the terminal ileum=>backwash ileitis

)Adult PKD complications:
-hepatic cysts
-valvualr heart disease (MVP, AR)
-colonic diverticula
-abdominal wall and inguinal hernia

)Thrombastenia Glanzmann-RA disease
-defect in GP IIb-IIIa
-increased BT
-trombocytes=normal, vWF=normal
-clot retraction is decreased
-epinephrine, colagen, thrombin and ADP fails to induce aggrgation
-normal response to ristocetin test
Bernar-Soulier syndrome-giant trombocytes, bleeding tendencies
-lack of aggrgation to vWF and ristocetin
-normal responde to ADP
-abnormality in GP Ib

)Acalculous cholecytitis:
-extensive burns
-severe trauma
-prolonged TPN
-prolonged fasting
-mechanical ventilation

)HIV patients with esophagitis-give fluconazole against Candida; if it donesn't cure, then and only then do esophagoscopy, cytology, biopsy, culture!!!

)In alkali ingestion(ex. lye)=>do contrast study with gastrografin+endoscopy as easrly as possible
-don't give charcoal=ineffective!!!

)Bupropion-can be given with nicotin patches, monitor BP=>risk of HTN
-causes weight loss
-risk of seizures=>don't give to anorexic patients as antidepressant

)In tumor lysis syndrome=>give allopurinol+hydration!!! If on allopurinol, give only 25% of purine antagonists (mercaptopurine, azathioprine)!

)In heat stroke=>rapid cooling with evaporating cooling=choice,then gastrci lavage or imersion in cold water

)Dermatitis herpetiformis=>dapsone

)In metab acidosis=>look for compensation (PaCo2)=>look at AG=>look at variation of AG and HCO3; one goes up and the other should go down, if this is the only acid-base problem, so the divisation of their variations is equal to 1!!!

)Prevalence high=>high PPV, low NPV

)Nickel jewelry, poison ivy=allergic contact dermatitis (type IV reaction)

)Do thyroid function tests if:
-hyperlipidemia
-unexplained low Na
-high CK levels

)Treat strep.pharingitis with one shot of benzatin-penicilline G i.m.

)MC complication of PUD=hemorrhage

)MC drug causing priapism=prazosin

)Asymptomatic lymphocytosis in older=>suspect CLL=> lymphadenopathy=>hypogamaglobulinemia=infections!
-Smudge cells are characteristic
-lymph node biopsy is not required for diagnosis, but it confirms it!

)In primary billiary cirrhosis-give ursodeoxycolic acid=first line, second-line=cholestiramine; ultimate cure=liver transplant

)Actinomycosis-anaerobic gram (+) branching bacteria
-draining infection, indurated area
-sulfur granules
-treat by high dose penicilline or erythromycine 6-12 weeks!!!
Another cause of draining face/neck infection=scrofula!

)Scoliosis-Cobb's angle
-mild curve<20degrees=>careful follow-up to assess the rate of progression
-20-30 degrees=>choice between observation and bracing is made on the presence of rotational deformity and + family hystory
->30 degrees=>bracing
->40degrees=> surgery

)Unacceptability bias=participants' response with desirable answers which leads to underestimation of the risk factors-ex. medical students are asked to complete a survey about whether they smoke or not...some may say that they don't smoke just because they know that smoke is bad for health!!!

)Hystory of normal skin at birth+gradual progression to dry scaly skin=ichthyosis
-dry skin with horny plates over the extensor surfaces of the limbs
-worsens in winter due to increased dryness=lizard skin!

)Markers of adrenal tissue: DHEA, DHEA-Sulfate
Testosterone+androstendione coem equally from ovaries and adrenal glands

)Symple renal cyst on CT=>reassurance (know the CT appearance), but investigate if:
-multilocular mass
-thcikened irregular walls and septae within the mass
-contrast enhancement

)In mononucleosis, patients can play sports only when physical exam is normal (no splenomegaly)

)TIA-give anticoagulation if embolic
-in the rest, give aspirin; if fails, give clopidogrel, if fails, give ticlopidine
-aspirine+dipiridamole-if there's a hystory of TIA on aspirin alone

)Zellweger's syndrome-defect in peroxisomes
-neonatal seizures
-facial dysmorphism
-hypotonia, wide open sutures, cloudy cornea, glaucoma
-they live only a few months

Neonatal adrenoleukodystrophy-no dysmorphic features
-enlarged liver, abnormal LFT, pigmentary degeneration of retina, impaired hearing

X-linked adrenoleukodystrophy
-accumulation of fatty acids (log chain ones)=>pregressive adrenal cortex dysfunction and CNS white matter

Infantile Refsum disease
-gait problems, hearing loss, pigmentary degen. of retina, dysmorphic features

Classic Refsum disease-young adulthood
-visual problems (night blindness), ataxia, cardiac arrythmia, ichthyosis, peripheral neuropathy

)Osteoporosis-acute backpain with noobvious preceding trauma in the elderly women=compression fractures of the vertebrae

)More than 5 days of symptoms of appendicitis with RLQ findings=>give iv. hydration, antibiotics (cover gram (-)), bowel rest

)Chronic therapy with Vit. D=>hyper Ca
-stop vit.D, low Ca diet, acidify urine, give corticosteroids!

)To control confounding-means:
-matching
-randomization
-restriction
Selection bias=>controlled by selecting a representative sample of the population for the study+high rates of follow-up
Ascertainment bias=>avoided by a strict protocol of case ascertainment
Observer's bias=>controlloed by blinding

)Patients with dyspepsia and <45>first step=Non-invasive test for H.pylori (breath test or serologic test)
-if +=>eradication therapy of H.pylori
-if -=>empirical trial of H2 blockers or PPI or prokinetics
If >45 years or with alarming symptoms=>do endospcopy+H.pylori testing

)Hematuria+irritative or voiding symptoms=>suspect bladder cancer, even in a patient with large, firm prostate
-associated factors: cigarette smoking, suprapubic pain, long hystory of analgezic use

)Chronic ITP-can be a feature of SLE; that's why in chronic cases of ITP=> do BM biopsy

)In conjugated hyper bilirubinemia=> first do LFT, then US of CT scan

)Dubin-Jonhsons+Rotor syndromes=> have normal ALP

)Hawthorne effect=tendency of the studied population to affect the outcome due to the fact that they are being studied!!!
Sample distorsion bias=when the sample is not representative for the whole population in "exposure" and "outcome"
Information bias=imperfect assessment of association between exposure and outcome as a result of errors in the measurement of exposure and outcome-it's minimized by standard techniques for surveillance and measurement+trained observers

)HIGH-YIELD:
Left ventricle dysfunction: high RA and PCWP pressure
Septic shock: low PCWP and RA pressure, low SVR, high debit
In pericarditis, tamponade=>RA pressure=PCWP and both are high
RV infarct=> low PCWP, low BP

)Post-prandial worsening pain+avoidance of food+risk factors for atherosclerosis=abdominal angina

)Hydatid cysts-Echinococcus granulosus
-asymptomatic
-mostly in the liver, but also lung
-comes from sheep
=fluid-filled cyst with numerous secondary daughter cysts
Pig farmers=> get neurocysticercosis
Commercial sex-worker=>can get perihepatitis from STD (gonorrhea)

)Congenital adrenal hyperplasia-hirsutism, virilization+very high levels of 17-HO-progesteron, normal Testosteron and DHEA
Idiopatic hirsutism-from excessive peripheral conversion of testosteron=>dihidro-testosteron

)If bleeding >25-30% of blood volume (or 1500ml)=>give blood transfusion
In trauma, usually give 2l of crystalloid solution in 10 min=>if still hypovolemic=>give blood
Give blood also if:
-Ht<25% -Ht<30%+ COPD, Ischemic Heart, chronic renal failure -unexplained acidosis in anemic patients )Epiglotitis=>first do fiberoptic laryngoscopy to establish a diagnosis, then do nasotraheal intubation (alternative=traheostomy)

)HIGH-YIEDL-Know this thouroughly!!!
low PCWP, normal MV02 (mixed venous O2 concentration)=>is septic shock; also: low RA pressure, high debit, low SVR
low PCWP, low MVO2=>is volume depletion or neurogenic shock
)Atopic dermatitis-infants<6 months -pruritus -symmetrical-scalp, cheeks, trunk, extensor areas -unknowun etiology -in acute attacks give low-moderate potency corticosteroids -spares diaper area (contact dermatitis does not) Exfoliative dermatitis-over 40 years of age -prior dermatological condition, systemic illness, new medication )Dehydration in diabetes insipidus=>give normal saline; once the volume deficit is replaced, can switch to 0.45% saline to restore water deficit

)HIGH-YIELD
CT scan=>use it to evaluate the extent of newly diagnosed gastric cancer; treat by surgery

)In dialysis-persist or worsen the followings: anemia, HTN, bone disease, autonomic neuropathy

)Intrahepatic cholestasis of pregnancy
-3rd trimester with jaundice
-marked pruritus, high AST, ALT(<200), very high bile acid levels, ALP<200, PT=normal )If suspect IUFD=>GET US, then coagulation profile

)Spontaneous hemarthrosis=>think hemophilia

)Osteogenesis imperfecta=>get type 1 collagen assay

)If one parent gives consent for the treatment of a minor is sufficient 9even if the other one disagrees)=>go ahead with the treatment!!!
If both parents refuse treatment=>get a court order if the situation is not emergent!!! If it's emergent=>treat as you see fit; you are protected by the law that you act in the best interest of the child!!!

)Inhaled steroids=> can give dysphonia, thrush

)In a ureteral colic, one can have intestinal ileus=>do CT scan or IVP; treat by ureterolithiasis
Enteroclysis=used to diagnose small bowel tumors or other pathology which cause intestinal obstruction

)In case-control studies, if prevalence of the disease is low=>odd ratio=~RR (this is rare disease assumption). They love these questions, try to understand them, though they are difficult!!!

)Study of choice for abdominal aortic aneurysm=abdominal US

)Malignant melanoma-MC as a changing mole
-hystory of sun exposure
3 major crteria:
change in-color
-shape
-size
4 minor criteria:
inflamation
bleeding/crusting
>7mm
sensory changes

)In metabolic alkalosis from vomitting=> give K, not Ca which is normal in total, only ionized is decreased

)In acute respiratory alkalosis=>PH raisis the afinity of Ca for albumin=>decreased ionized Ca, increased albumin-bound Ca, normal total Ca and normal Ca bound to inorganic anions

)Chronic pancreatitits with central duct>1cm and severe pain=>do lateral pancreatico-jejunostomy

)Alcoholism=>can cause rhabdomyolysis (drunk man lying in a park)=> urine dipstick is + for blood but (-) for RBC=>from myoglobinuria

)IE of drug users: give vanco+genta because of high incidence of meticillin-resistant Staph
-if not drug abuser=>give naph+genta

)Acarbose (alpha glucosidase inhibitor)=> don't allow carbohydrate breakdown in the intestin=>high carbohydrates in the stool!
-indicated in late onset type II DM

)Dysphagia to both solids&liquids=>achalasia=>domanometry, but alsoendoscopy to rule out cancer

)Acute monicitic leukemia- M5A in young (~16 years)
- M5B-middle age(~49 years)
-(+) alpha-naftyl esterase
-numerous promonocytes and monocytes
M3 leukemia-assoc. with DIC

)Post-op benign intrahepatic cholestasis
-after major sugery
-low BP
-extensive blood loss
-or after massive blood replacement

Halothane toxicity-type 1-mild elevation of LFT, no jaundice
-type 2-acute liver failure

)Kaposi sarcoma-on the trunk, face, extremities
-papules>plaques/nodules
Bacillary angiomatosis-like Kaposi sarcoma, but with systemic signs (malaise, headaches, fever)

)Prolactin is (+) by TRH, serotonin and (-) by dopamine
Hyperprolactinemia=>(-)GnRH=>amenorrhea
=>galactorrhea
Both of them appear in hypothyroidism due to high TRH

)Idiopathic pulmonary fobrosis-treat by steroids; lung transplant is not an option since it must be bilateral and there's a shortage a donors!

)In fibromyalgia=>check thyroid tests and CK levels
Diffuse axonal injuries-from deceleration
-at the gray-white matter junction
-looses consciousness on the spot=>then persistent vegetative state
MRI is more sensitive than CT for detecting the axonal injuries

)Lumbosacral strain-pain after exertion
-absence of radiation
-(+) paravertebral tenderness
-(-) straight-leg raising test
-normal neurologic exam

)Situational syncope: middle-aged, old male, losses counsciousness immediately after urination or during coughing fits

)Hypocalcemia-after major surgery, extensive transfusions
-due to volume expansion, hypoalbuminemia
Mypo Mg-alcoholism
-diarrhea, diuretic abuse
-prolonged NG suction
)Management of DM foot ulcer from mild to severe forms:
-off-loading
-debridement
-wound dressing
-antibiotics
-revascularization
-amputation

)In refractory ascites=>do tapping of up to 2l/day+give 10g albumin/liter taped as a last resort before any surgical procedure you may think!!!
Spleno-renal shunt-will worsen ascites
Side to side porto-caval shunt-improves ascites, worsens encephalopathy
Peritoneo-jugular shunt-for the treatment of ascites only; risksIC, sepsis, peritonitis
iv furosemide therapy=>worsens encephalopathy, precipitates hepato-renal syndrome

)Treat Ca-oxalate stone lithiasis by:
a)increased fluid intake>3l
b)normal or increased Ca intake-yes!!! you read fine!!! (1000mg)
c)low Na diet
d)low oxalate diet (no chocolate, vit C)
e) low dietary proteins (meat, eggs)

)Soap-bubble appearance in the distal femur on x-ray with knee pain, some mass, in 20-40 years old=>think giant-cell tumor of the bone=>refer to orthopedic surgeon; don't do bone scan=this is for solid tumor metastasis identification

)Choledocal cyst=congenital anomaly of the biliary tree
-dilatation of the intra/extra hepatic ducts
-jaundice, acholic stools
-reccurent attacks of pancreatitis
-can degenerate into cholangiocarcinoma
-First do US, then CT or MRI
Caroli'ssyndrome=congenital
-intrahepatic dilation of bile ducts

)In transplant patients=> give TMP/SMX to prevent PCP pneumonia; alternatives:dapsone or aerosolized pentamidine

)Lumbar pain in the 3rd trimester=> due to lumbar lordosis and relaxation of the ligaments of the sacro-iliac joints

)Dystonia-treat by benztropine or diphenilhydramine

)90% of PE come from emboli in the ileo-femoral veins

)Pseudogout under 50 years=>think any of:
hypo Mg, hypo P, hyper PTH, hypothyroidism, hemochromatosis

)Treat fractures of the humeral shaft by: closed reduction and immobilization of the arm in a hanging cast

)Cystic fibrosis-may develop Cl sensitive metabolic alkalosis
Barter'syndrome-Cl resistant metab. alkalosis

)In GERD=> give empirical treatm. with PPI or H2 blockers=>if it fails or there are features of complicated disease=>esophagoscopy=>if (-)=>PH monitoring

)HIGH-YIELD
Acute tubular necrosis-muddy-brown cast
GN-RBC cast
Pyelonephritis, interstitial nephritis-WBC cast
Nephrotic syndrome-fatty cast
Chronic renal failure-broad, waxy cast