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Usmle Students Notes


T h u r sda y , A pr i l 23, 2009

triplehelix notes
Notes by triplehelix. I did MKSAP 1 4 questions and m ade notes based on the key points, and I plan to rev iew this note before m y test. I thought to share this notes with y ou guy s. MKSAP 1 4 neurology notes: 1 . A spinal cord disorder should be considered in any patient with bilateral m otor and sensory dy sfunction in the extrem ities in the absence of signs or sy m ptom s of brain or brainstem dy sfunction. 2 . Spinal cord com pression due to epidural m etastasis is a neurologic em ergency for which urgent MRI of the entire spine is appropriate. 3 . Vertebral artery dissection ty pically presents with neck or head pain, Horner's sy ndrom e, dy sarthria, dy sphagia, decreased pain and tem perature sensation, dy sm etria, ataxia, and v ertigo. 4 . Magnetic resonance angiography is a sensitiv e diagnostic test for v ertebral artery dissection as a cause of stroke. 5. Juv enile m y oclonic epilepsy is a prim ary , genetic, generalized epilepsy that ty pically m anifests with m y oclonic jerks followed by a generalized tonicclonic seizure 6 . GuillainBarr sy ndrom e is characterized by proxim al and distal weakness, autonom ic sy m ptom s, cranial nerv e inv olv em ent, and respiratory failure. 7 . Treatm ent of GuillainBarr sy ndrom e with either intrav enous im m unoglobulin or plasm apheresis is indicated in patients who cannot walk independently or who hav e im paired respiratory function or rapidly progressiv e weakness. 8. Sm all, stable, asy m ptom atic m eningiom as can be followed with serial neuroim aging.

9 . In large, sy m ptom atic, or progressiv e m eningiom as, surgical resection offers an 80% chance of cure. 1 0. Personality change, lost initiativ e, and slowing of thought, with relativ e preserv ation of recent m em ory , suggest frontotem poral dem entia. 1 1 . Frontotem poral dem entia is usually associated with disproportionate atrophy of the anterior frontal and tem poral lobes, a finding that is usually clearly dem onstrated on MRI. 1 2 . Elev ation of the cerebrospinal fluid 1 4 -3 -3 protein in a patient with rapidly progressiv e dem entia and norm al structural im aging suggests CreutzfeldtJakob disease. 1 3 . Treatm ent with interferon-beta decreases the incidence of additional attacks in patients with m onosy m ptom atic dem y elination, including optic neuritis and m y elopathy . 1 4 . Propranolol and prim idone are first-line drugs in the treatm ent of essential trem or (postural and action trem or). 1 5. The diagnosis of Parkinson's disease requires the presence of at least two of the following: trem or at rest, brady kinesia, rigidity , and postural reflex abnorm ality . 1 6 . The characteristics of m igraine headache without aura include worsening of the headache with m ov em ent, lim itation of activ ities, and photo- and phonophobia 1 7 . Transv erse m y elitis is an acute or subacute dem y elinativ e or inflam m atory disorder of the spinal cord that causes m otor, sensory , and autonom ic dy sfunction below a spinal cord lev el. 1 8. High-dose intrav enous corticosteroids are indicated for initial treatm ent of acute transv erse m y elitis. 1 9 . Secondary prev ention of cardioem bolic stroke consists of warfarin with a target INR of 2 .0 to 3 .0. 2 0. Heparin has no established role in the acute treatm ent of stroke. 2 1 . The m anifestations of partial seizures depend on their neuroanatom ic location. 2 2 . Frontal seizures are brief and are usually not associated with aura or postictal confusion. 2 3 . Hereditary sensorim otor neuropathy is an autosom al dom inant disorder that usually presents with clum siness or difficulty running in the first decade of life. 2 4 . Hereditary sensorim otor neuropathy is characterized by distal m uscle atrophy , weakness, and sensory loss associated with high arches (pes cav us) and ham m ertoes

2 5. Cell ty pe and tum or grade are the m ost im portant determ inants of surv iv al in gliom a. 2 6 . Higher-grade gliom as are m ore aggressiv e than lower grade. 2 7 . Alzheim er's disease is characterized by prim ary dem entia with prom inent am nesia. 2 8. Dem entia with Lewy bodies, characterized by fluctuating cognition, parkinsonism , and/or v isual hallucinations, often coexists with Alzheim er's disease. 2 9 . All patients with relapsing m ultiple sclerosis should be considered for im m unom odulatory therapy with either a form of interferon-beta or glatiram er acetate. 3 0. Adult-onset idiopathic dy stonia is usually focal or segm ental and does not generalize to other parts of the body . 3 1 . Botulinum toxin injections can correct the abnorm al posture and allev iate the pain associated with cerv ical dy stonia. 3 2 . Approxim ately 2 0% of patients with m igraine hav e headache with aura, that is, neurologic problem s such as v isual hallucinations or num bness or tingling before or during headache. 3 3 . Lherm itte's sign, an electric shocklike sensation down the neck, back, or extrem ities occurring with neck flexion, is a helpful historical clue to a cerv ical spinal cord disorder. 3 4 . Cerv ical spondy losis is a chronic disorder of degenerativ e and hy pertrophic changes of the v ertebrae, ligam ents, and disks that m ay narrow the spinal canal and cause cerv ical spinal cord com pression. 3 5. In patients with stroke not eligible for throm boly tic therapy , aspirin m odestly reduces both the short-term risk of recurrent stroke and the long-term risk of stroke-related death and disability . 3 6 . In patients with acute stroke, throm boly tic therapy m ust be started within 3 hours of the onset of sy m ptom s or of the tim e the patient was last known to be well. 3 7 . Elderly patients m ay be particularly sensitiv e to the cognitiv e, m otor, and coordination side effects of pheny toin, ev en if the serum pheny toin lev el is in the therapeutic range. 3 8. Gabapentin, lam otrigine, and carbam azepine are equally effectiv e at controlling partial onset seizures in the elderly , but gabapentin and lam otrigine are better tolerated. 3 9 . Peripheral nerv ous sy stem v asculitis usually presents with asy m m etric weakness and sensory loss in specific nerv e distributions.

4 0. In an elderly patient with recurrent glioblastom a and poor perform ance status, referral for hospice care is preferable to additional antitum or treatm ent. 4 1 . The three specific criteria for dem entia with Lewy bodies are fluctuating encephalopathy , parkinsonism , and v isual hallucinations. 4 2 . A centrally acting anticholinesterase agent m ay allev iate the inattention, hallucinations, and fluctuating encephalopathy of dem entia with Lewy bodies. 4 3 . Wom en taking im m unom odulatory treatm ent for m ultiple sclerosis should use effectiv e contraception, or if they want to becom e pregnant, stop therapy sev eral m onths before attem pting to conceiv e. 4 4 . Inv oluntary brief, irregular, unpredictable m ov em ents fleeting from one body part to another are hallm arks of chorea. 4 5. Chorea can occur as a hereditary and degenerativ e disease or secondary to drugs, m etabolic disorders, infections, im m unem ediated diseases, and v ascular lesions. 4 6 . Tension-ty pe headache is distinguished from m igraine by the fact that patients with tension headache are not disabled and can carry out activ ities of daily liv ing in a norm al, expedient m anner. 4 7 . Vitam in B1 2 deficiency can cause dy sfunction of the posterior colum ns and corticospinal tracts of the spinal cord, causing paresthesias, loss of v ibration and position sense, sensory ataxia, weakness, and upper m otor neuron signs. 4 8. Neurologic signs of v itam in B1 2 deficiency m ay m anifest in the absence of hem atologic signs of v itam in B1 2 deficiency . 4 9 . In a patient with a transient ischem ic attack, carotid artery ultrasonography showing a > 50% stenosis of the internal carotid artery m ay be an indication for carotid endarterectom y . 50. A single antiepileptic drug should be used in pregnant wom en with epilepsy ; m ultiple drug therapy increases the risk for birth defects. 51 . Chronic inflam m atory dem y elinating poly neuropathy , the chronic form of GuillainBarr sy ndrom e, is characterized by proxim al and distal weakness, areflexia, and distal sensory loss. 52 . Chronic inflam m atory dem y elinating poly neuropathy 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 y oung patient with totally resected low-grade gliom a,

postsurgical m anagem ent consists of observ ation with serial neuroim aging. 54 . Vascular dem entia is suggested by a history of v ascular risk factors, abrupt onset with subsequent im prov em ent, periv entricular white m atter ischem ia on im aging, and focal neurologic findings. 55. Intrav enous m ethy lprednisolone therapy followed by an oral prednisone taper speeds recov ery of v isual acuity in optic neuritis 56 . The restless legs sy ndrom e consists of abnorm al sensations in the legs and restlessness reliev ed by m ov em ent. 57 . Patients are at risk for dev eloping analgesic ov eruse headache if they use prescription or ov er-the-counter m edication for headache m ore than 2 day s a week. 58. Pseudotum or cerebri is characterized by papilledem a, postural change with headache, v isual changes, recent report of rapid weight gain, or introduction of oral contraceptiv es or tetracy cline. 59 . Infarction of the spinal cord ty pically presents as sudden spinal cord dy sfunction. 6 0. Spinal cord infarction usually affects the territory of the anterior spinal artery , causing weakness and pinprick loss of sensation with sparing of v ibration and position sense. 6 1 . CT scan m ay m iss subarachnoid hem orrhage, especially when there is a delay in presentation after the initial hem orrhage. 6 2 . Focal neurologic sy m ptom s 3 to 7 day s after a subarachnoid hem orrhage m ay be due to v asospasm with cerebral ischem ia. 6 3 . Patients with epilepsy who are m ost likely to rem ain seizure free after m edication withdrawal are those with no structural brain lesion, no epileptiform or focal abnorm alities on electroencephalogram , a sustained seizure-free period, and no abnorm alities on neurologic exam ination. 6 4 . Patients with epilepsy who discontinue antiepileptic m edication should stop driv ing for at least 3 m onths and preferably 6 m onths from the start of the taper. 6 5. Critical illness poly neuropathy is a com m on cause of failure to wean from a v entilator in a patient with associated m ultiorgan failure and sepsis. 6 6 . Critical illness poly neuropathy is characterized by generalized or distal flaccid paraly sis, depressed or absent reflexes, and distal sensory loss with sparing of cranial nerv e function. 6 7 . Patients with prim ary central nerv ous sy stem ly m phom a

should be ev aluated for v itreal or uv eal inv olv em ent before therapy is begun. 6 8. Aggressiv e resection is not recom m ended in prim ary central nerv ous sy stem ly m phom a; m ethotrexate chem otherapy is prim ary therapy . 6 9 . Donepezil, an acety lcholinesterase inhibitor, m ay cause m ild peripheral cholinergic side effects, including increased v agal tone, with brady cardia, and occasionally atriov entricular block. 7 0. In at least 50% of patients with relapsingrem itting m ultiple sclerosis, disease will ev olv e to a secondary progressiv e course. 7 1 . In at least 50% of patients with relapsingrem itting m ultiple sclerosis, disease will ev olv e to a secondary progressiv e course. 7 2 . Metoclopram ide, which blocks dopam ine receptors both in the periphery and inside the central nerv ous sy stem , can induce parkinsonism . 7 3 . Prednisone is the m ost appropriate treatm ent for episodic cluster headache. 7 4 . Acute cerv ical spinal cord com pression due to hy perextension injury is com m on in elderly patients. 7 5. Em ergent MRI of the cerv ical spinal cord is indicated in any patient with quadriparesis after a fall. 7 6 . The classic sy m ptom s of cerebellar stroke are headache, v ertigo, and ataxia. 7 7 . Patients with epilepsy who fail to respond to three trials of antiepileptic drugs are unlikely to ev er becom e seizure free with drug therapy . 7 8. Treatm ent-resistant patients with epilepsy should be ev aluated for a surgically rem ediable epilepsy sy ndrom e. 7 9 . My asthenia grav is is an autoim m une disease caused by antibodies against the acety lcholine receptor, which results in im paired neurom uscular transm ission. 80. My asthenia grav is is characterized by fatigable weakness with a predilection for ocular, bulbar, proxim al-extrem ity , neck, and respiratory m uscles. 81 . Leptom eningeal spread of sy stem ic carcinom a m anifests as a cranial neuropathy or spinal poly radiculopathy , or as encephalopathy , diffuse brain infiltration, or com m unicating hy drocephalus. 82 . CreutzfeldtJakob disease is suggested by subacute progression of dem entia with m y oclonus and other m otor signs and a norm al

brain MRI. 83 . In the setting of subacutely progressiv e dem entia, the presence of 1 4 -3 -3 protein in cerebrospinal fluid, or electroencephalography showing periodic sharp wav es, can be diagnostic of CreutzfeldtJakob disease. 84 . Mitoxantrone therapy is of m odest benefit in slowing progression of secondary progressiv e or sev ere relapsingrem itting m ultiple sclerosis. 85. The prim ary concern about m itoxantrone therapy is the risk for cardiotoxicity . 86 . Progressiv e supranuclear palsy is characterized by parkinsonism with early gait and balance inv olv em ent, v ertical gaze palsy , sev ere dy sarthria, and dy sphagia. 87 . Norm al pressure hy drocephalus is characterized by the classic triad of gait im pairm ent, cognitiv e decline, and urinary incontinence. 88. Patients with idiopathic intracranial hy pertension present with signs and sy m ptom s of increased intracranial pressure without a m ass lesion on brain im aging. 89 . In patients with possible idiopathic intracranial hy pertension, a diagnostic and potentially therapeutic lum bar puncture is indicated after brain im aging excludes a m ass lesion. 9 0. Sev ere cerebral anoxia from cardiac arrest can cause sev ere diffuse cerebral hem ispheric cortical injury with relativ e preserv ation of brainstem function, leading to the dev elopm ent of a v egetativ e state. 9 1 . A v egetativ e state is a condition of com plete unawareness of self or the env ironm ent, accom panied by sleepwake cy cles and preserv ation of brainstem and hy pothalam ic functions. 9 2 . Intracerebral hem orrhage with extensiv e subarachnoid hem orrhage is the hallm ark of a ruptured arteriov enous m alform ation. 9 3 . Conv entional angiography is the definitiv e diagnostic procedure for detecting arteriov enous m alform ations and berry aneury sm s. 9 4 . In a patient with status epilepticus, after the airway is stabilized and plasm a glucose determ ined to be norm al, parenteral antiepileptic m edications should be started. 9 5. Lorazepam is the preferred benzodiazepine for initial therapy for a patient in status epilepticus. 9 6 . My asthenia grav is crisis is characterized by dy sphagia

requiring nasogastric feeding and/or sev ere respiratory m uscle weakness necessitating v entilation. 9 7 . My asthenia grav is crisis is treated with either plasm apheresis or intrav enous im m unoglobulin. 9 8. Radiation-induced leukoencephalopathy is a subcortical process affecting white m atter and characterized by the triad of gait apraxia, dem entia, and urinary incontinence. 9 9 . Radiation-induced leukoencephalopathy m ay occur m onths to y ears after radiation and is m ore com m on after whole-brain com pared with focal brain irradiation. 1 00. Mild cognitiv e im pairm ent consists of isolated m ild am nesia with no im pairm ent of interpersonal, occupational, or daily liv ing activ ities. 1 01 . The conv ersion rate from m ild cognitiv e im pairm ent to m ild dem entia is 1 0% to 1 5% per y ear. 1 02 . Am antadine is the first-line pharm acologic agent for treatm ent of m ultiple sclerosis-related fatigue. 1 03 . Multiple sy stem atrophy is characterized by orthostatic hy potension, neurogenic bladder, constipation, and im potence, with gait-predom inant parkinsonism and corticospinal tract signs. 1 04 . Carbam azepine is the appropriate treatm ent for trigem inal neuralgia. 1 05. Patients with the locked-in sy ndrom e are quadriplegic, hav e paraly sis of horizontal ey e m ov em ents and bulbar m uscles, and can com m unicate only by m ov ing their ey es v ertically or blinking. 1 06 . The locked-in state is due to a lesion of the base of the pons, usually from pontine infarction due to basilar artery occlusion. 1 07 . Antiplatelet therapy , statins, and ACE inhibitors each reduce the risk of recurrent stroke ev en in the absence of chronic hy pertension or a lipid disorder. 1 08. Headache m ay be a lim iting factor in the use of the com bination of aspirin and extended-release dipy ridam ole for secondary stroke prev ention. 1 09 . Nonepileptic seizures of psy chogenic origin can be differentiated from epilepsy by their longer duration, norm al electroencephalogram findings, and m aintenance of consciousness. 1 1 0. Nonepileptic psy chogenic seizures are often associated with m oaning, cry ing, and arrhy thm ic shaking of the body . 1 1 1 . Absence seizures are characterized by a brief loss of awareness with no m ov em ent or v ery subtle m ov em ents of the lips and fingers.

1 1 2 . Juv enile m y oclonic epilepsy is characterized by m y oclonic seizures and often accom panied by absence and generalized tonic clonic seizures. 1 1 3 . Am y otrophic lateral sclerosis is characterized by pathologic hy perreflexia, spasticity , extensor plantar responses, along with atrophy , fasciculations, and weakness. 1 1 4 . Muscle weakness in am y otrophic lateral sclerosis usually begins distally and asy m m etrically in the upper or lower extrem ities or m ay be lim ited initially to the bulbar m uscles, resulting in dy sarthria and dy sphagia. 1 1 5. Surgical resection is indicated for an accessible solitary brain m etastasis in patients with lim ited or no sy stem ic tum or. 1 1 6 . Cholinesterase inhibitors hav e m odest efficacy on cognitiv e and global function in m ild to m oderate Alzheim er's disease. 1 1 7 . Vitam in E and selegiline m ay delay the progression of Alzheim er's disease, but do not allev iate cognitiv e or psy chiatric sy m ptom s. 1 1 8. In patients with possible m ultiple sclerosis, new MRI whitem atter lesions or new gadolinium -enhancing lesions on serial brain or spinal cord MRI at least 3 m onths after an initial scan, indicate dissem ination of dem y elination, ev en without a new clinically ev ident attack. 1 1 9 . Carbidopa-lev odopa is the first-line treatm ent for patients older than 7 0 y ears with new-onset Parkinson's disease. 1 2 0. Com plications associated with the use of dopam ine agonists, such as som nolence, drug-induced psy chosis, and dizziness, are m ore com m on in patients older than 7 0 y ears. 1 2 1 . The risk of rupture of a sm all intracranial aneury sm is less than the risk of com plications with clipping or endov ascular coiling of the aneury sm . 1 2 2 . Incidentally discov ered sm all aneury sm s should be re-ev aluated periodically for enlargem ent. 1 2 3 . Oxcarbazepine is effectiv e m onotherapy for partial onset seizures. 1 2 4 . Risk factors for recurrent seizures include m ultiple prev ious seizures, a history of significant head traum a, focal electroencephalogram abnorm alities, and structural abnorm ality on MRI. 1 2 5. Am y otrophic lateral sclerosis causes progressiv e respiratory m uscle weakness that m ay present with supine dy spnea, frequent

arousals, day tim e fatigue, or m orning headache. 1 2 6 . Noninv asiv e positiv e-pressure v entilation should be started in patients with am y otrophic lateral sclerosis whose forced v ital capacity is less than 50% or who has sy m ptom s of nocturnal hy pov entilation. 1 2 7 . Neurologic sy m ptom s in conjunction with norm al brain im aging and the detection of a sy stem ic cancer are m ost likely due to an im m une-m ediated paraneoplastic neurologic sy ndrom e. 1 2 8. Mem antine m ay allev iate cognitiv e sy m ptom s and im prov e global function in m oderate to sev ere Alzheim er's disease when added to cholinesterase inhibitor therapy . 1 2 9 . Estrogen replacem ent in post-m enopausal wom en with Alzheim er's dem entia has not been shown to allev iate cognitiv e sy m ptom s or delay disease progression. 1 3 0. Drug-induced psy chosis in Parkinson's disease consists prim arily of v isual hallucinations, ev olv ing at tim es into paranoid-ty pe delusions. 1 3 1 . Infection with fev er can tem porarily exacerbate a chronic neurologic defect in a patient with a prev ious stroke. 1 3 2 . Partial com plex epilepsy consists of stereoty ped nonconv ulsiv e seizures with loss of awareness and am nesia for ev ents. 1 3 3 . My otonic dy strophy is an autosom al dom inant disorder that presents with distal weakness and m uscle stiffness and is characterized by cataracts, frontal balding, tem poral m uscle atrophy , and cognitiv e dy sfunction. 1 3 4 . Cardiac disease resulting in arrhy thm ias and respiratory failure due to diaphragm atic weakness are com m on features of m y otonic dy strophy . 1 3 5. Lam bert-Eaton m y asthenic sy ndrom e is characterized by sy m m etrical proxim al m uscle weakness and autonom ic dy sfunction. 1 3 6 . Lam bert-Eaton m y asthenic sy ndrom e is diagnosed by m otor nerv e conduction studies with repetitiv e stim ulation. 1 3 7 . Cognitiv e im pairm ent accom panied by fluctuating lethargy and inattention, hallucinations, and asterixis is likely the result of a toxic encephalopathy . 1 3 8. Drugs that block dopam ine receptors can induce acute dy stonic reactions. 1 3 9 . In acute ischem ic stroke, tissue plasm inogen activ ator is indicated if therapy is started within 3 hours of onset of sy m ptom s,

there is no hem orrhage on CT scan, and all other eligibility criteria are m et. 1 4 0. All states require that an episode of loss of awareness be reported to gov ernm ent authorities, either to the Departm ent of Health or to the Departm ent of Motor Vehicles. 1 4 1 . Hy pothy roid m y opathy is characterized by m uscle pain, cram ps, stiffness, fatigue, and paresthesias. 1 4 2 . In hy pothy roid m y opathy , creatine kinase lev els m ay be 1 0 to 1 00 tim es norm al, but thy roid function tests should be perform ed before electrom y ography or m uscle biopsy . 1 4 3 . Paraneoplastic lim bic encephalitis is m ost com m only associated with sm all-cell lung cancer. 1 4 4 . Paraneoplastic lim bic encephalitis is characterized by rapidly progressiv e decline in short-term m em ory and seizures. 1 4 5. The m ost com m on heritable form of Alzheim er's disease results from a m utation in presenilin-1 . 1 4 6 . Testing for presenilin-1 m ay be useful when a heritable form of Alzheim er's disease is suspected. 1 4 7 . CT scan of the brain is indicated to diagnose suspected intracerebral hem orrhage. 1 4 8. Head traum a increases the relativ e risk for epilepsy by 1 0 only if there is penetration of the dura or loss of consciousness for m ore than 3 0 m inutes. 1 4 9 . Critical illness m y opathy is com m on in v entilator-dependent patients who hav e been treated with corticosteroids and neurom uscular blocking agents. 1 50. Critical illness m y opathy is characterized by v entilator dependence, generalized or proxim al flaccid paraly sis, m uscle atrophy , and high creatine kinase lev els. 1 51 . Prim ary im pairm ent of concentration and attention, as opposed to m em ory , is likely the result of depression rather than a neurodegenerativ e condition. 1 52 . Carotid endarterectom y is the appropriate interv ention in patients with sy m ptom atic carotid artery stenosis, especially within the first few weeks after initial sy m ptom s. 1 53 . Depression is a possible side effect of m any antiepileptic drugs, including phenobarbital, pheny toin, v alproate, lev etiracetam , and topiram ate. 1 54 . Selectiv e serotonin reuptake inhibitors, m oclobem ide, v enlafaxine, and nefazodone do not increase the seizure threshold in

patients with epilepsy and therefore are the preferred pharm acologic agents in depression. 1 55. Poly m y ositis is characterized by proxim al m uscle weakness, elev ated creatine kinase lev els, and needle electrom y ography showing diffuse fibrillations and m y opathic m otor unit potentials. 1 56 . Results of creatine kinase m easurem ent and needle electrom y ography are inv ariably norm al in steroid m y opathy but abnorm al in inflam m atory m y opathy . 1 57 . Antiplatelet therapy is the m ainstay of secondary stroke prev ention in patients with cry ptogenic stroke. 1 58. Clopidogrel is the preferred antiplatelet therapy for aspirinallergic patients with a history of stroke. My Cardiology Note: 1 6 0. Right v entricular infarction should be suspected in patients with inferior m y ocardial infarction who present with hy potension, clear lung fields, and elev ated jugular v enous pressure. 1 6 1 . An echocardiogram establishes the diagnosis of right v entricular infarction by dem onstrating right v entricular enlargem ent and hy pokinesis. 1 6 2 . Im plantable cardiov erter-defibrillator therapy reduces risk of sudden death in surv iv ors of cardiac arrest due to v entricular tachy cardia or v entricular fibrillation without a rev ersible cause. 1 6 3 . Spontaneous coronary dissection m ay occur during pregnancy . 1 6 4 . In patients with ST-elev ation m y ocardial infarction, successful fibrinoly sis is suggested by resolution of chest pain and ST-segm ent elev ation and/or transient v entricular arrhy thm ias early after reperfusion. 1 6 5. In patients with ST-elev ation m y ocardial infarction, reperfusion arrhy thm ias, ty pically m anifested as a transient accelerated idiov entricular arrhy thm ia, usually do not require additional antiarrhy thm ic therapy . 1 6 6 . Throm bosis of m echanical v alv es m ay present with v alv e dy sfunction rather than em bolic ev ents. 1 6 7 . Intrav enous heparin should be started im m ediately while diagnostic ev aluation is in progress. 1 6 8. Chest CT scan with contrast is indicated to detect acute aortic dissection. 1 6 9 . In patients at risk for radiocontrast nephropathy and contraindication to MRI, transesophageal echocardiography is the test of choice for possible aortic dissection.

1 7 0. Breast and lung carcinom a are the m ost com m on causes of m alignant pericardial disease. 1 7 1 . The epicardium is the m ost com m on location of m etastatic cardiac neoplasm . 1 7 2 . An ACE inhibitor and a -blocker are indicated in all patients with sy stolic heart failure, including asy m ptom atic patients. 1 7 3 . Spironolactone and digoxin are not indicated in patients with asy m ptom atic sy stolic heart failure. 1 7 4 . Fixed splitting of the S2 is the auscultatory hallm ark of atrial septal defect. 1 7 5. A div ergence between electrocardiography showing low-v oltage and echocardiography dem onstrating a substantial increase in left v entricular wall thickness is a useful diagnostic clue for cardiac am y loidosis. 1 7 6 . Abdom inal fat aspiration biopsy is a safe and reasonably sensitiv e test for the diagnosis of am y loidosis. 1 7 7 . Phy sical exam ination is helpful is identify ing the presence, but not the sev erity , of v alv e disease. 1 7 8. The m ost sensitiv e sign on phy sical exam ination to exclude the diagnosis of sev ere aortic stenosis is a phy siologically split S2 . 1 7 9 . Most patients with peripheral v ascular disease hav e an ABI grade 3 /6 in intensity , continuous m urm urs, or any diastolic m urm ur. 1 9 2 . Surgery for nativ e v alv e endocarditis is indicated if there is significant hem ody nam ic instability or ev idence of parav alv ular extension. 1 9 3 . Factors fav oring earlier tim ing of surgery include significant congestiv e heart failure, resistant infections, and large m obile v egetations. 1 9 4 . Ev en if activ e bacterem ia is still present or if the antibiotic treatm ent course is ongoing, surgery for endocarditis should not be delay ed if surgical criteria are m et. 1 9 5. Medical therapy for acute, recent m y ocardial infarction includes -blockers, aspirin, angiotensin-conv erting enzy m e inhibitors, and statins. 1 9 6 . Sm oking cessation is the single m ost effectiv e interv ention for patients with peripheral v ascular disease. 1 9 7 . blockade does not prom ote clinical claudication. 1 9 8. Cilostazol is relativ ely contraindicated in patients with congestiv e heart failure.

1 9 9 . Patients with heart failure who hav e sev ere sy m ptom s and ev idence for v entricular dy ssy nchrony benefit from im plantation of a biv entricular pacem aker. 2 00. Biv entricular pacing im prov es cardiac perform ance and quality of life and m ay also im prov e surv iv al. 2 01 . Gly coprotein receptor blockade is indicated for patients with acute coronary sy ndrom e who will undergo coronary angiography and interv ention. 2 02 . Patients with ST-elev ation m y ocardial infarction treated with stents require aspirin and clopidogrel at discharge. 2 03 . Patients with ST-elev ation m y ocardial infarction treated without stents m ay be m anaged with aspirin alone or with warfarin if indicated for atrial fibrillation or anterior akinesis or aneury sm . 2 04 . In low-risk patients with lone atrial fibrillation, warfarin anticoagulation is not required. Aspirin or no therapy is recom m ended. 2 05. A sy stolic m urm ur, an S3 gallop, and m ild peripheral edem a are norm al findings during pregnancy . 2 06 . In the absence of significant m itral regurgitation, prim ary m itral v alv e prolapse has a benign prognosis. 2 07 . Antibiotic prophy laxis for endocarditis is indicated in m itral v alv e prolapse if there is m ore than m ild m itral regurgitation, if a m urm ur is heard on auscultation, or if the patient has high-risk echocardiographic features. 2 08. Initial m anagem ent of acute coronary sy ndrom e related to a sy stem ic process, such as anem ia, is treatm ent of the precipitating factor. 2 09 . Medical therapy for NSTEMI in patients with TIMI low-risk status has acceptable outcom es. 2 1 0. Patients with atrial fibrillation and risk factors for stroke require anticoagulation with warfarin. 2 1 1 . Risk factors for stroke in nonrheum atic atrial fibrillation include prior em bolic ev ent or stroke, hy pertension, adv anced age, congestiv e heart failure, coronary artery disease, and diabetes m ellitus. 2 1 2 . -blockers should not be initiated in heart failure patients who are acutely decom pensated or v olum e ov erloaded. 2 1 3 . Patients with atrial fibrillation and m inim al sy m ptom s can usually be m anaged with rate control alone (without rhy thm control).

2 1 4 . Echocardiography is indicated when a new m urm ur, a sy stolic m urm ur grade 3 /6 , or any diastolic m urm ur is heard. 2 1 5. Phy siologic v alv ular regurgitation does not pose a risk of endocarditis and does not require antibiotic prophy laxis. 2 1 6 . Antibiotic prophy laxis for endocarditis is tailored to the risk of the procedure and the risk of the patient. 2 1 7 . Although pericardiectom y is the m ost effectiv e treatm ent for constrictiv e pericarditis, it is unnecessary in patients with early disease. 2 1 8. Atrial flutter is characterized by saw-tooth pattern flutter wav es m ost noticeable in the inferior leads. 2 1 9 . The preferred treatm ent for recurrent atrial flutter is radiofrequency catheter ablation. 2 2 0. Aspirin-allergic patients with ST-elev ation m y ocardial infarction can be treated with clopidogrel as part of postinfarction m edical therapy . 2 2 1 . Angiotensin-conv erting enzy m e inhibitors are indicated for all patients with sy stolic heart failure, regardless of ejection fraction or functional status, barring contraindications. 2 2 2 . Patients with STEMI should undergo coronary reperfusion in the m ost expeditious m anner. 2 2 3 . STEMI patients who cannot be reperfused by direct coronary interv ention within 9 0 to 1 2 0 m inutes should receiv e fibrinoly tic therapy if there are no contraindications. 2 2 4 . The decision to im plant a pacem aker for sinus node dy sfunction depends on the presence of sy m ptom s rather than heart rate alone. 2 2 5. Subacute cardiac tam ponade m ay be caused by acute v iral pericarditis. 2 2 6 . Echocardiography is a useful diagnostic m odality for the delineation of pericardial hem ody nam ics. 2 2 7 . Papillary m uscle dy sfunction or rupture should be suspected in patients with clinical signs of acute m itral regurgitation in the setting of a m y ocardial infarction. 2 2 8. An echocardiogram should be perform ed if papillary m uscle dy sfunction is suspected. 2 2 9 . Mitral regurgitation due to papillary m uscle dy sfunction often im prov es following coronary rev ascularization 2 3 0. Sy ncope in a patient with cardiom y opathy m ay be due to potentially fatal v entricular arrhy thm ia. 2 3 1 . An ICD is indicated for patients with left v entricular

dy sfunction and hem ody nam ically significant v entricular arrhy thm ias. 2 3 2 . Coronary artery by pass grafting im prov es surv iv al in patients with obstructiv e left m ain and/or m ultiv essel coronary artery disease. 2 3 3 . Coronary artery by pass grafting im prov es surv iv al in com parison to percutaneous interv ention in diabetic patients with m ultiv essel coronary artery disease. 2 3 4 . Atriov entricular nodal re-entrant tachy cardia is characterized by a narrow QRS com plex and lack of v isible P wav es. 2 3 5. The first treatm ent of choice for atriov entricular tachy cardia is carotid sinus m assage. 2 3 6 . If carotid sinus m assage is unsuccessful, adenosine is the drug of choice for the term ination of narrow-com plex suprav entricular tachy cardias. 2 3 7 . The m urm ur of hy pertrophic cardiom y opathy increases after a Valsalv a m aneuv er and decreases after a sit-to-squat m aneuv er, perform ing passiv e recum bent leg lifts, or perform ing handgripping exercises. 2 3 8. Ascending aortic dissection m ay inv olv e the coronary arteries, m ost com m only the right coronary artery . 2 3 9 . Ascending aortic dissection m ay lead to disruption of the aortic v alv e, leading to aortic regurgitation. 2 4 0. Noonan sy ndrom e is characterized by short stature, intellectual im pairm ent, unique facial features, neck webbing, and congenital heart defects. 2 4 1 . Noonan sy ndrom e should alway s be considered in a patient with pulm onary v alv e stenosis. 2 4 2 . The recom m ended initial treatm ent for acute v iral pericarditis is a high-dose nonsteroidal anti-inflam m atory m edication, such as indom ethacin. 2 4 3 . Anticoagulation therapy is contraindicated in pericarditis because of the risk of hem opericardium . 2 4 4 . Perioperativ e blockade decreases cardiov ascular risk in patients undergoing noncardiac surgery . 2 4 5. Hy pertension (blood pressure > 1 80/1 1 0 m m Hg) is a relativ e contraindication to fibrinoly sis in patients with STEMI. 2 4 6 . Rev ascularization should proceed expeditiously with concom itant m edical therapy for hy pertension com plicating STEMI. 2 4 7 . Restrictiv e cardiom y opathy is a late com plication of radiation

therapy . 2 4 8. A norm al left v entricular wall thickness in radiation-induced restrictiv e cardiom y opathy helps to differentiate this entity from other cardiom y opathies characterized by v entricular hy pertrophy . 2 4 9 . In asy m ptom atic patients with chronic aortic regurgitation, surgery should be considered when left v entricular ejection fraction drops below 60% or the left v entricular sy stolic dim ension reaches 55 m m . 2 50. In asy m ptom atic patients with aortic regurgitation, nifedipine m ay delay the tim ing of surgical interv ention. 2 51 . Aortic coarctation is associated with a continuous m urm ur (often posterior thorax) and elev ated but equal blood pressure in both upper extrem ities. 2 52 . A bicuspid aortic v alv e is often seen in association with aortic coarctation, presenting with aortic regurgitation or aortic stenosis. 2 53 . Phy sical findings of m itral regurgitation include holosy stolic m urm ur at the apex radiating to the axilla, without respiratory v ariation. 2 54 . In healthy adults, prem ature v entricular contractions are com m on and are not a cause for concern. 2 55. Suppression of prem ature v entricular contractions is indicated only in patients with sev ere and disabling sy m ptom s. 2 56 . Sm oking, hy pertension, adv anced age, and m ale sex are risk factors for abdom inal aortic aneury sm . 2 57 . Most abdom inal aortic aneury sm s are asy m ptom atic, but abdom inal pain is the m ost com m on sy m ptom . 2 58. Patients at high risk for a subsequent coronary ev ent after a m y ocardial infarction include those with m ultiv essel coronary artery disease, anterior m y ocardial infarction, or a left v entricular ejection fraction 0.5 cm /y ear) increase in aneury sm size. 3 07 . Sev ere hem oly tic anem ia in a patient with a m echanical v alv e suggests parav alv ular leakage due to partial dehiscence of the v alv e or infection. 3 08. Prosthetic v alv e dehiscence or dy sfunction should be suspected in patients that dev elop sy m ptom s of congestiv e heart failure, particularly if these sy m ptom s occur in the first 6 m onths following surgery . 3 09 . Right v entricular infarction is a cause of hy potension following inferior infarction and ty pically requires appropriate v olum e infusion.

3 1 0. Right v entricular infarction should be suspected as a cause of hy potension when findings of right heart failure coincide with an absence of ev idence of pulm onary congestion. 3 1 1 . Im plantation of a cardiov erter-defibrillator is an im portant prophy lactic treatm ent in patients with hy pertrophic cardiom y opathy and high risk for sudden death. 3 1 2 . Clinical features that predict high risk for sudden death in patients with hy pertrophic cardiom y opathy include fam ily history of sudden death, sy ncope, m arked left v entricular septal hy pertrophy , nonsustained v entricular tachy cardia, and exertional hy potension. 3 1 3 . Papillary m uscle rupture and v entricular septal defect are recognized m echanical com plications that occur early after m y ocardial infarction. 3 1 4 . Both papillary m uscle rupture and v entricular septal defect present with hy potension and acute dy spnea. 3 1 5. Annual echocardiography is appropriate in a patient with asy m ptom atic sev ere m itral regurgitation. 3 1 6 . The tim ing of surgery for sev ere m itral regurgitation is based on sy m ptom s and m easures of left v entricular size and sy stolic function. 3 1 7 . Classic features of Marfan's sy ndrom e includes tall stature, high arched palate, joint hy perm obility , scoliosis, and positiv e wrist sign. 3 1 8. Patients with Marfan's sy ndrom e are at increased risk for asy m ptom atic thoracic aortic aneury sm and associated aortic v alv e incom petence. 3 1 9 . Intrav enous am iodarone is the drug of choice for shockresistant v entricular fibrillation. 3 2 0. The risk of coronary artery disease in diabetic patients is 2 to 4 tim es higher than in nondiabetic patients. 3 2 1 . The pretest likelihood of disease should be calculated using av ailable algorithm s in patients with coronary risk factors. 3 2 2 . In patients with chest pain and interm ediate risk of coronary artery disease, non-inv asiv e testing is indicated. 3 2 3 . Patients with chest pain and low coronary artery disease risk with a norm al electrocardiogram and a norm al exercise electrocardiogram can be discharged without coronary angiography . 3 2 4 . Although uncom m on, left atrial m y xom a should be considered

in y oung patients with em bolic stroke. 3 2 5. Echocardiography is an im portant im aging m odality for diagnosis of an intracardiac tum or. 3 2 6 . Wom en with Marfan sy ndrom e are at increased risk of aortic dissection during pregnancy . 3 2 7 . Aortic dissection should be considered in the differential diagnosis of chest pain in pregnancy . 3 2 8. The tachy cardia rate in atriov entricular nodal reentrant tachy cardia is ty pically 1 6 01 80/m in with the P wav e buried in the QRS com plex. 3 2 9 . If atriov entricular nodal reentrant tachy cardia does not respond to v agal m aneuv ers, adenosine is the treatm ent of choice 3 3 0. Continuous effectiv e anticoagulation is needed throughout pregnancy in wom en with m echanical heart v alv es. 3 3 1 . Radiofrequency catheter ablation is the m ost effectiv e treatm ent for atriov entricular nodal reentrant tachy cardia. 3 3 2 . Calcium -channel blockers m ay be used for prophy laxis of recurrent atriov entricular nodal reentrant tachy cardia but are less effectiv e than radiofrequency catheter ablation. 3 3 3 . The cardiac output is low in prim ary cardiogenic shock, and inotropic agents m ay be needed to augm ent m y ocardial contractility and thus cardiac output. 3 3 4 . Exercise (or pharm acologic) stress testing is the m ost sensitiv e noninv asiv e m ethod to establish the diagnosis of coronary artery disease. 3 3 5. Exercise (or pharm acologic) stress cardiac im aging can be used to ev aluate for coronary artery disease if the resting electrocardiogram is abnorm al. 3 3 6 . The role of electron-beam CT coronary calcium scores is not y et established in the assessm ent of coronary artery disease. 3 3 7 . Prolonged im m obility followed by a stroke or transient ischem ic attack should raise the suspicion of a paradoxical em bolism . 3 3 8. Transesophageal echocardiography is the test of choice to confirm the diagnosis of a suspected patent foram en ov ale or cardiac source of em bolus. 3 3 9 . Sy stem ic lupus ery them atosus is a cause of prem ature atherosclerotic coronary disease. 3 4 0. Other causes of acute m y ocardial infarction in y oung persons include coronary spasm , em bolic coronary occlusion, and Kawasaki's

disease. 3 4 1 . High risk patients that require a heparin anticoagulation bridge after stopping warfarin prior to surgery include those with a m itral m echanical v alv e, atrial fibrillation, or prev ious em bolism . 3 4 2 . Low risk patients do not require a heparin bridge after stopping warfarin prior to surgery and include patients with a bileaflet aortic v alv e and no other high risk features. 3 4 3 . Aspirin alone is not a sufficient replacem ent for warfarin, and is used only as a chronic adjunct in patients who m anifest sy stem ic em boli despite therapeutic warfarin therapy . 3 4 4 . Radial-fem oral delay is a characteristic phy sical finding in aortic coarctation. 3 4 5. Bicuspid aortic v alv es are com m on in patients with aortic coarctation and are associated with a sy stolic ejection click and sy stolic m urm ur noted ov er the aortic area. 3 4 6 . Elev ated B-ty pe natriuretic peptide lev els occur with renal failure, acute coronary sy ndrom e or m y ocardial infarction, and acute v olum e or pressure ov erload. 3 4 7 . Adenosine is the treatm ent of choice for narrow-com plex tachy cardia. 3 4 8. Neither adenosine nor other atriov entricular nodal blocking agents should be giv en to patients with preexcited tachy cardias. 3 4 9 . Procainam ide is the drug of choice for wide-com plex tachy cardia of unclear etiology . 3 50. Coronary angiography is indicated in patients with a history of unstable angina or non-ST-elev ation m y ocardial infarction. 3 51 . In patients with a high pretest probability of coronary artery disease, a negativ e stress test result is m ost likely to be false. 3 52 . Spinal stenosis is characterized by pain with standing or walking that is reliev ed by sitting or bending forward and is further supported by a norm al ABI. 3 53 . Leg ischem ia is characterized by pain with exertion and with a decrease in ABI of at least 2 0 % with exercise. 3 54 . The use of angiotensin-conv erting enzy m e inhibitors should be av oided during pregnancy . 3 55. Hy dralazine and nitrates are the v asodilators of choice to treat heart failure during pregnancy . 3 56 . Induction of m ild hy potherm ia im prov es outcom es in com atose surv iv ors of out-of-hospital cardiac arrest. 3 57 . Aortic v alv e replacem ent is recom m ended once sy m ptom onset

occurs, regardless of patient age. 3 58. Sy m ptom onset in aortic stenosis is often insidious and m ay include exertional dy spnea. 3 59 . Alcoholic cardiom y opathy is a dilated cardiom y opathy . 3 6 0. Therapy for alcoholic cardiom y opathy m ust include total abstinence from alcohol. 3 6 1 . In chronic angina, coronary artery by pass graft surgery is indicated for patients refractory to m edical therapy ; a large area of ischem ic m y ocardium ; high-risk coronary anatom y ; and reduced left v entricular sy stolic function. 3 6 2 . Atrial tachy cardia with v ariable block is a classic electrocardiographic finding in digitalis toxicity . 3 6 3 . The first-line treatm ent for life-threatening digitalis toxicity is adm inistration of digoxin-specific antibody fragm ents. 3 6 4 . Iron deficiency is a com m on cause for dy spnea and fatigue in patients with cy anotic heart disease. 3 6 5. The m ost com m on cause of iron deficiency in patients with cy anotic heart disease is recurrent phlebotom y . 3 6 6 . Mitral v alv e surgery is indicated for sy m ptom atic patients with chronic, sev ere m itral regurgitation. 3 6 7 . In asy m ptom atic patients with chronic, sev ere m itral regurgitation, criteria for m itral v alv e surgery include an end-sy stolic dim ension > 4 5 m m , an end-diastolic dim ension > 6 0 m m , and an ejection fraction 5 m m of induration is considered a positiv e test. 6 54 . Dengue fev er is characterized by the abrupt onset of sev ere headache, high fev er, m y algias, arthralgias, leukopenia, and throm bocy topenia. 6 55. Dengue hem orrhagic fev er is associated with hem orrhage and capillary fragility . 6 56 . Bronchiectasis is a risk factor for the dev elopm ent of Pseudom onas aeruginosa com m unity -acquired pneum onia. 6 57 . Adm inistration of ganciclov ir or v alganciclov ir has greatly reduced, but not elim inated, the occurrence of cy tom egalov irus infections in transplant recipients. 6 58. Person-to-person transm ission of m eningococcal organism s occurs by the respiratory route. 6 59 . Prophy laxis of health care workers exposed to a patient with a m eningococcal infection is needed only after contact with the patient's respiratory secretions.

6 6 0. MRI and CT scans are the im aging procedures of choice in the diagnosis of patients with suspected osteom y elitis. 6 6 1 . The m ost appropriate em piric therapy for Streptococcus pneum oniae m eningitis is v ancom y cin plus ceftriaxone and dexam ethasone. 6 6 2 . African tick bite fev er is the m ost com m on rickettsial infection in hum ans. 6 6 3 . Sy m ptom s of African tick bite fev er are relativ ely m ild and are characterized by a v esicular rash with an inoculation eschar. 6 6 4 . Sy m ptom s of CreutzfeldtJakob disease ty pically include cognitiv e changes (dem entia), behav ioral and personality changes, difficulty with m ov em ent and coordination, and v isual and constitutional sy m ptom s. 6 6 5. The course of CreutzfeldtJakob disease is rapid and progressiv e; 9 0% of patients die within 1 y ear of diagnosis. 6 6 6 . The m ost appropriate therapy for a patient with Listeria m eningitis and a sev ere allergy to penicillin is trim ethoprim sulfam ethoxazole. 6 6 7 . When initiating antituberculous therapy , a four-drug regim en m ust be used if the probability of resistance to isoniazid is greater than 4 %. 6 6 8. The recom m ended em piric therapy for a patient with com m unity -acquired pneum onia who is hospitalized on a general m edical floor is either m onotherapy with an intrav enous fluoroquinolone or com bination therapy with an intrav enous -lactam plus either an intrav enous or oral m acrolide or doxy cy cline. 6 6 9 . The recom m ended em piric therapy for a patient with com m unity -acquired pneum onia who is hospitalized in an intensiv e care unit is an intrav enous -lactam plus either an intrav enous m acrolide or an intrav enous fluoroquinolone. 6 7 0. Penicillin is the treatm ent of choice for all form s of sy philis. 6 7 1 . Treatm ent of a pregnant patient with newly diagnosed sy philis is essential in order to prev ent congenital sy philis in the fetus. 6 7 2 . A pregnant patient with newly diagnosed sy philis who m ay be allergic to penicillin should undergo skin testing for a penicillin allergy . 6 7 3 . Im m unosuppressed transplant recipients are at high risk for dev elopm ent of bacterial infections during the first m onth after surgery .

6 7 4 . In patients with a contiguous foot ulcer and possible osteom y elitis, bone biopsy with cultures and histopathologic exam ination should be perform ed before initiating antim icrobial therapy . 6 7 5. Intrav ascular catheterassociated bloodstream infections are prev entable if proper insertion procedures are used. 6 7 6 . Chlorhexidine is superior to pov idone-iodine for cleaning a catheter insertion site. 6 7 7 . Vancom y cin is the antim icrobial agent of choice for treatm ent of m ethicillin-resistant Staphy lococcus aureus infections. 6 7 8. All -lactam agents are inactiv e against m ethicillin-resistant Staphy lococcus aureus infections. 6 7 9 . HIV genoty pe resistance testing is indicated for patients with HIV infection who m ay hav e dev eloped resistance to one or m ore antiretrov iral agents. 6 80. No currently av ailable test can differentiate true-positiv e from false-positiv e tuberculin skin test reactions in a person who prev iously receiv ed bacille Calm etteGurin v accine. 6 81 . The recom m ended treatm ent for latent tuberculosis is isoniazid for 9 m onths. 6 82 . Infection due to Pseudom onas aeruginosa, which is often found between lay ers of rubber soles in sneakers, m ay occur following puncture wounds of the foot. 6 83 . Contacts of patients with possible sm allpox should receiv e sm allpox v accine. 6 84 . Contacts of patients with possible sm allpox should take their tem perature twice daily for 1 7 day s; a contact who dev elops a tem perature ov er 3 8 C (1 00.4 F) during this tim e should be isolated. 6 85. Acy clov ir is effectiv e in prev enting reactiv ation of v aricella zoster v irus in stem -cell transplant recipients. 6 86 . Noninfectious skin lesions can be differentiated from infectious disorders because the form er are not associated with fev er and other sy stem ic signs and sy m ptom s or abnorm al laboratory studies and culture results. 6 87 . The m ost appropriate em piric therapy for a patient with purulent m eningitis following neurosurgery is v ancom y cin plus cefepim e. 6 88. The finding of 1 4 -3 -3 protein in cerebrospinal fluid has a specificity and sensitiv ity of greater than 90% for diagnosing

sporadic CreutzfeldtJakob disease. 6 89 . Liv e attenuated influenza v accine is contraindicated in an im m unosuppressed patient. 6 9 0. All fam ily m em bers of an im m unosuppressed patient should be im m unized against influenza to decrease the patient's risk of exposure to this v irus. 6 9 1 . Doxy cy cline in a single dose is highly effectiv e for prev enting ery them a m igrans in patients from areas endem ic for Ly m e disease who present with an em bedded, engorged tick. 6 9 2 . Contact isolation is m ost effectiv e for reducing spread of Clostridium difficile in hospitals. 6 9 3 . The treatm ent of choice for patients with sy m ptom atic babesiosis is atov aquone plus azithrom y cin. 6 9 4 . A positiv e Western blot analy sis confirm s the diagnosis of HIV infection; a negativ e test rules out this diagnosis. 6 9 5. An indeterm inate Western blot analy sis m ay indicate either HIV seroconv ersion or the presence of cross-reactiv e antibodies. 6 9 6 . Stained specim ens of v aginal discharge from patients with candidal v aginitis show pseudohy phae and budding y east. 6 9 7 . Stained specim ens of v aginal discharge from patients with bacterial v aginosis show gram -negativ e bacilli attached to squam ous epithelial cells (clue cells). 6 9 8. In patients with catheter-associated bloodstream infections, the catheter should be rem ov ed whenev er possible. 6 9 9 . Echinocandins such as caspofungin, m icafungin, and anidulafungin are effectiv e in treating patients with candidem ia. 7 00. Patients with My cobacterium tuberculosis infection m ay be considered noninfectious after they are placed on effectiv e antituberculous therapy , dem onstrate clinical im prov em ent, and hav e three different sputum sm ears that are negativ e for acid-fast bacilli. 7 01 . Brain abscesses that result from contiguous spread of head and neck infections m ay contain m ultiple organism s. 7 02 . Ceftriaxone plus m etronidazole is the m ost appropriate em piric antim icrobial therapy for a brain abscess resulting from contiguous spread of an otitic focus of infection. 7 03 . Vancom y cin plus clindam y cin is the m ost appropriate em piric antibiotic regim en for a patient with suspected streptococcal or staphy lococcal toxic shock sy ndrom e. 7 04 . Gram -positiv e bacteria (staphy lococci and streptococci) are the

m ost com m on causes of nongonococcal septic arthritis in adults. 7 05. Because am antadine is excreted by the kidney s, dosage adjustm ent is required in patients with renal com prom ise. 7 06 . Although oseltam iv ir and zanam iv ir are excreted by the kidney s, dosage adjustm ent is not required in a patient with renal com prom ise. 7 07 . A highly effectiv e v accine is av ailable for hepatitis A, which m ust be adm inistered at least 2 weeks before a potential exposure. 7 08. Patients taking antitum or necrosis factor- inhibitors are at increased risk for dev eloping latent tuberculosis. 7 09 . Patients about to begin therapy with antitum or necrosis factor- inhibitors should undergo tuberculin skin test screening. 7 1 0. Transplant recipients are at risk for dev elopm ent of opportunistic infections such as fungal pneum onia. 7 1 1 . Alm ost all patients with am ebic abscesses will hav e high lev els of antibodies directed against Entam oeba histoly tica. 7 1 2 . In a patient with sickle cell disease and osteom y elitis, potential causativ e organism s are staphy lococci, streptococci, and Salm onella species. 7 1 3 . Penicillin is the only antim icrobial agent approv ed for treatm ent of neurosy philis. 7 1 4 . Patients who are allergic to penicillin but for whom alternativ e antim icrobial agents cannot be prescribed require desensitization to penicillin. 7 1 5. Genital herpes sim plex v irus in a m ale patient is generally characterized by a lim ited num ber of genital v esiculoulcerativ e lesions without sy stem ic sy m ptom s. 7 1 6 . Subdural em py em a is a m edical and surgical em ergency . 7 1 7 . Antim icrobial therapy and neurosurgical drainage are the m ost appropriate initial m anagem ent for a patient with a subdural em py em a. 7 1 8. Surgical site infections are a com m on com plication of operations, especially coronary artery by pass graft surgery . 7 1 9 . The appropriate dose, tim ing, and duration of prophy lactic perioperativ e antibiotics help decrease the risk of surgical site infections. 7 2 0. Deep fungal infections such as histoplasm osis are a risk to trav elers to endem ic areas. 7 2 1 . Reactiv ation of hum an herpesv iruses 6 and 7 is being increasingly recognized in im m unosuppressed patients.

7 2 2 . Reactiv ation of hum an herpesv iruses 6 and 7 m ay cause hepatitis and m eningoencephalitis. 7 2 3 . Treatm ent of latent tuberculosis is indicated for any person with a known tuberculin skin test conv ersion, regardless of the person's age. 7 2 4 . Most cases of toxic shock sy ndrom e are caused by Staphy lococcus aureus or Streptococcus py ogenes. 7 2 5. Ceftriaxone prov ides effectiv e em piric therapy for patients with possible dissem inated gonococcal infection. 7 2 6 . Health care workers in contact with a patient with possible sm allpox require gown, glov es, and a personal respirator for protection. 7 2 7 . A qualitativ e assay for hepatitis C v irus RNA v iral load is the m ost sensitiv e test for diagnosing hepatitis C infection. 7 2 8. Penicillin resistance is categorized as either interm ediate-lev el resistance (m inim al inhibitory concentration [MIC] between 0.1 and 1 g/m L) or high-lev el resistance (MIC > 1 g/m L). 7 2 9 . Organism s that are resistant to penicillin generally rem ain sensitiv e to fluoroquinolones and are uniform ly sensitiv e to v ancom y cin and linezolid 7 3 0. Poly om av irus BK is associated with nephropathy and deteriorating renal function in renal transplant recipients. 7 3 1 . The presence of intranuclear inclusions in tubular epithelial cells or transitional cells is highly indicativ e of poly om av irus BK. 7 3 2 . Acute retinal necrosis occurs m ost often in patients with HIV infection or AIDS. 7 3 3 . Intrav enous acy clov ir is the preferred treatm ent for acute retinal necrosis. 7 3 4 . In contrast to patients with sporadic, genetic, or iatrogenic CreutzfeldtJakob disease, patients with the v ariant form of the disorder tend to be y ounger and hav e psy chiatric sy m ptom s rather than dem entia early in the disease, m ore prom inent sensory findings, and MRI abnorm alities in pulv inar area of the thalam us rather than in the basal ganglia and putam en. 7 3 5. Ninety percent of urinary tract infections are associated with indwelling catheters. 7 3 6 . Adm inistering prophy lactic antibiotics, acidify ing the urine, or using disinfecting washes hav e not been shown to prev ent urinary tract infections. 7 3 7 . Vancom y cin plus cefepim e is the m ost appropriate em piric

antim icrobial therapy for a patient with an epidural abscess and a history of injection drug use. 7 3 8. The dev elopm ent of focal ly m phadenitis in a patient with HIV infection is m ost com m only caused by m y cobacteria, Streptococcus species, or Staphy lococcus species. 7 3 9 . Cry ptococcal infection in transplant recipients is associated with high m orbidity and m ortality . 7 4 0. Flucy tosine plus a lipid form ulation of am photericin B is usually effectiv e for treating cry ptococcal infections in transplant recipients. 7 4 1 . Em piric antibiotic therapy while awaiting culture results is required for patients with an infected clenched-fist injury . 7 4 2 . Oral v alacy clov ir is the m ost appropriate antiv iral agent for a patient with genital herpes sim plex v irus infection without sy stem ic com plications. 7 4 3 . The four D's that characterize botulism are diplopia, dy sphonia, dy sarthria, and dy sphagia. 7 4 4 . Fatal fam ilial insom nia is the rarest of the prion diseases. 7 4 5. Fatal fam ilial insom nia is characterized by sev ere insom nia, confusion, other signs of dem entia, and autonom ic nerv ous sy stem instability 7 4 6 . Anaplasm osis (form erly hum an granulocy tic ehrlichiosis) is characterized by fev er, flu-like sy m ptom s, leukopenia, throm bocy topenia, liv er chem istry abnorm alities, and a peripheral blood sm ear showing m orulae. 7 4 7 . Doxy cy cline is the treatm ent of choice for anaplasm osis. 7 4 8. A patient with suspected herpes sim plex v irus encephalitis requires poly m erase chain reaction of the cerebrospinal fluid and MRI of the brain to confirm the diagnosis. 7 4 9 . Acy clov ir is the preferred initial therapy for a patient with herpes sim plex v irus encephalitis. 7 50. Keeping m echanically v entilated patients sem i-recum bent (at a 4 5-degree angle) helps prev ent dev elopm ent of v entilatorassociated pneum onia. 7 51 . Throm bocy topenia m ay occur in patients who take linezolid for 2 or m ore weeks. 7 52 . The decision about whether adm ission to an intensiv e care unit is needed for patients with com m unity -acquired pneum onia is based on the presence of specific m ajor and m inor criteria. 7 53 . Because Legionella pneum onia is of particular concern in a

patient with sev ere com m unity -acquired pneum onia, testing for urinary Legionella antigen is indicated. 7 54 . Whenev er possible, outpatient parenteral therapy should use drugs that can be giv en once daily for conv enience and patient com fort. 7 55. In patients with HIV infection and Kaposi's sarcom a, the sarcom a frequently regresses and som etim es resolv es com pletely after successful treatm ent with highly activ e antiretrov iral therapy . 7 56 . Oral lev ofloxacin rather than intrav enous lev ofloxacin is indicated for em piric treatm ent of a highly com pliant patient with acute py elonephritis who can eat and drink. 7 57 . The m ost appropriate treatm ent for a cat bite in a patient with a penicillin allergy is trim ethoprim sulfam ethoxazole plus clindam y cin. 7 58. Patients with progressiv e m assiv e fibrosis are at increased risk for dev eloping tuberculosis. 7 59 . The m ost appropriate diagnostic studies for suspected tuberculosis are tuberculin skin testing and sputum for acid-fast stain and culture. 7 6 0. Staphy lococcus aureus and Pseudom onas aeruginosa are the m ost likely causes of septic arthritis in an injection drug user. 7 6 1 . Enterotoxigenic Escherichia coli is the m ost com m on cause of diarrhea in trav elers to dev eloping countries. 7 6 2 . Diarrhea due to enterotoxigenic E. coli is usually a m ild and self-lim ited illness. 7 6 3 . West Nile v irus encephalitis is m ost likely to occur in patients 6 5 y ears of age and older. 7 6 4 . Findings in patients with West Nile v irus encephalitis include fev er, sev ere headache, m arked m uscle weakness inv olv ing the lower m otor neurons, m ental status changes, and possibly seizures. 7 6 5. The need for isolation precautions is based on the route of transm ission of the suspected pathogen or the clinical sy m ptom s of the patient. 7 6 6 . Because Francisella tularensis is not transm itted from person to person, only standard precautions, rather than isolation procedures, are required for patients with tularem ia. 7 6 7 . Esophagitis in an im m unosuppressed patient is m ost often caused by Candida. 7 6 8. Echinocandins and triazoles are both effectiv e for treating

Candida esophagitis. 7 6 9 . Shiga toxinproducing Escherichia coli is associated with dev elopm ent of the hem oly tic urem ic sy ndrom e. 7 7 0. Adm inistration of foscarnet is indicated for a patient with acy clov ir-resistant herpes sim plex v irus infection. 7 7 1 . Adm inistration of foscarnet m ay be associated with significant electroly te abnorm alities. 7 7 2 . Prophy laxis is not required for household contacts of patients with an inv asiv e streptococcal infection. 7 7 3 . If two or m ore cases of inv asiv e streptococcal disease occur in postpartum or postsurgical patients hospitalized within 6 m onths in the sam e institution, an epidem iologic inv estigation is required to determ ine if a hospital worker is a carrier. 7 7 4 . Im m unosuppressed patients are at increased risk for dev eloping nosocom ial pneum onia ev en when m echanical v entilation is not required. 7 7 5. A halo sign (a nodular lesion with a surrounding ground-glass appearance) on chest radiographs is characteristic of Aspergillus pneum onia. 7 7 6 . Bactericidal agents such as daptom y cin are m andatory for treatm ent of endocarditis. 7 7 7 . Em ergence of resistance to daptom y cin is rare, and daptom y cin is not correlated with cross-resistance to any other drug class. 7 7 8. Current recom m endations 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. 7 7 9 . Pneum ococcal strains are becom ing increasingly resistant to penicillins and m acrolides. 7 80. Most experts and guidelines support the use of a thirdgeneration cephalosporin plus a m acrolide for treatm ent of com m unity -acquired pneum onia. 7 81 . West Nile v irus can be transm itted by blood transfusions. 7 82 . West Nile v irus can be transm itted to transplant recipients from organ donors. 7 83 . he prim ary pathogens associated with bloodborne exposures in health care workers are HIV, hepatitis B, and hepatitis C. 7 84 . Two or three antiretrov iral agents are recom m ended when a health care worker sustains a deep, penetrating injury from a source patient who is HIV seropositiv e.

7 85. Oral v alganciclov ir is as effectiv e as intrav enous ganciclov ir for treating patients with cy tom egalov irus retinitis. 7 86 . A m aculopapular rash, especially on the palm s and soles, is characteristic of dissem inated (secondary ) sy philis. 7 87 . A patient with possible neurosy philis should receiv e intrav enous aqueous cry stal penicillin G for 1 4 day s. 7 88. Patients with osteom y elitis and an epidural abscess who do not hav e focal neurologic deficits can usually be treated with antim icrobial therapy alone, but m ust be m onitored carefully . 7 89 . Aspiration and culture of joint fluid is the m ost appropriate test for determ ining whether a prosthetic joint is infected. 7 9 0. Patients with pneum onic plague ty pically present with high fev er, headache, m y algias, dy spnea, hem opty sis, and watery sputum . 7 9 1 . Patients with pneum onic plague hav e a m ortality rate approaching 1 00% if not treated with streptom y cin within 2 4 hours of dev elopm ent of sy m ptom s. 7 9 2 . Angiostrongy lus cantonensis (the rat lungworm ) is the m ost com m on cause of eosinophilic m eningitis worldwide. 7 9 3 . Prev ention of nosocom ial m y cobacterial infections requires airborne isolation of the patient and personal respirators for health care workers. 7 9 4 . The m ost com m on distribution of herpes zoster (shingles) is a unilateral rash in the thoracic region. 7 9 5. Fam ciclov ir and v alacy clov ir hav e replaced acy clov ir as the treatm ent of choice for patients with herpes zoster. 7 9 6 . Cutaneous My cobacterium m arinum infection is m ost often associated with exposure to fish tanks. 7 9 7 . The m ost appropriate diagnostic study is biopsy of a nodule for histopathologic exam ination, acid-fast stain, and culture. 7 9 8. Trim ethoprim sulfam ethoxazole is the preferred antim icrobial therapy for a patient with a brain abscess caused by Nocardia species. 7 9 9 . Patients with a presum ptiv e diagnosis of Rocky Mountain spotted fev er should receiv e treatm ent with doxy cy cline ev en before the diagnosis is confirm ed. 800. Cam py lobacter jejuni is the m ost com m on cause of bacterial diarrheal disease in the United States. 801 . C. jejuni often causes disease by cross-contam ination of cooking utensils or surfaces such as countertops.

802 . A com plete history of antiretrov iral drug use is essential for a patient with HIV infection who has been on m any drugs and is not benefiting from the current treatm ent regim en. 803 . Aspergillosis is the m ost com m on pulm onary m old infection in im m unosuppressed patients in the United States. 804 . Aspergillus infection cannot be distinguished from infection caused by Pseudallescheria before culture results are av ailable 805. Nosocom ial outbreaks of Clostridium difficile and norov irus hav e been well docum ented in recent y ears. 806 . Nosocom ial outbreaks of C. difficile and norov irus require contact isolation and increased cleaning of all patients' room s. 807 . Options for treatm ent of com m unity -acquired pneum onia in an outpatient without additional risk factors include an adv ancedgeneration m acrolide or a ketolide or doxy cy cline. 808. Treatm ent of an outpatient with com m unity -acquired pneum onia should be started without waiting for results of Gram stain and culture. 809 . Patients with central nerv ous sy stem Ly m e disease who are allergic to -lactam antibiotics should be giv en doxy cy cline. 81 0. Corticosteroids hav e been shown to significantly allev iate acute pain in patients with herpes zoster (shingles). 81 1 . Corticosteroids are contraindicated in patients with poorly controlled plasm a glucose lev els, osteoporosis, or hy pertension. 81 2 . Hos
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triplehelix - 01-12-09 23:54 81 2 . Hospitalized patients with com m unity -acquired pneum onia can usually be changed from an intrav enous to an oral antibiotic regim en when fev er, cough, and dy spnea hav e resolv ed; oral intake

is satisfactory ; and the leukocy te count is returning towards norm al. 81 3 . Asy m m etric m igratory joint pain and pustular lesions are characteristic of dissem inated gonococcal infection. 81 4 . Cultures of the phary nx, cerv ix, and anus should be obtained for a wom an with suspected dissem inated gonococcal infection. 81 5. Approxim ately 50% of patients with AIDS and progressiv e m ultifocal leukoencephalopathy will surv iv e the latter disease if highly activ e antiretrov iral therapy is adm inistered. 81 6 . Poly m erase chain reaction of cerebrospinal fluid is the preferred test for diagnosing herpes sim plex v irus encephalitis. 81 7 . Acute cellulitis in an im m unosuppressed patient m ay be due to unusual pathogens, such as Cry ptococcus neoform ans. 81 8. Adm inistration of zidov udine to a pregnant patient with HIV infection is believ ed to reduce the risk of m aternal-to-child transm ission of HIV. 81 9 . Efav irenz is contraindicated in a pregnant patient with HIV infection. 82 0. Cy closporiasis is associated with positiv e acid-faststained stool specim ens and copious diarrhea without fev er. 82 1 . The treatm ent of choice for cy closporiasis is trim ethoprim sulfam ethoxazole. 82 2 . The incidence of fluoroquinolone-resistant N. gonorrhoeae has been increasing, especially on the West Coast of the United States and in Hawaii. 82 3 . The m ost appropriate treatm ent for concurrent gonorrhea and a chlam y dial infection is a single dose of intram uscular ceftriaxone plus oral azithrom y cin. 82 4 . Patient-adm inistered antibiotic therapy is usually appropriate for wom en with recurrent episodes of uncom plicated urinary tract infections. 82 5. Risk factors for aspiration pneum onia include difficulty swallowing, episodes of depressed consciousness, and m echanical factors such as esophageal obstruction. 82 6 . Clindam y cin prov ides effectiv e treatm ent for anaerobic aspiration pneum onia. 82 7 . Necrotizing fasciitis in an injection drug user m ay be due to m any different organism s. 82 8. The m ost effectiv e initial em piric antibiotic regim en for necrotizing fasciitis in an injection drug user is v ancom y cin plus

piperacillintazobactam plus clindam y cin. 82 9 . The m ost successful therapy for treating infected prosthetic joints inv olv es rem ov al of the prosthesis and a 6-week course of antim icrobial therapy followed by reim plantation of a new prosthesis. 83 0. Aztreonam can be used safely in patients who are allergic to penicillin. 83 1 . The U.S. Centers for Disease Control and Prev ention include aerosolized v iruses that cause Ebola, Marburg, and Lassa fev ers; Argentine hem orrhagic fev er; and Boliv ian hem orrhagic fev er as m ost likely to be used as biochem ical weapons. 83 2 . Influenza v irus resistance dev elops rapidly following exposure to rim antadine. 83 3 . If one fam ily m em ber dev elops resistance after taking rim antadine for treatm ent of influenza, the resistant v irus can be transm itted to other fam ily m em bers. 83 4 . Hy ponozoites of Plasm odium v iv ax m alaria m ay rem ain in the liv er for long periods and becom e reactiv ated at a later date.

here is the Gastroenterology and hepatology notes: Gastroenterology and hepatology 83 9 . Crohn's disease is m ore com m on in current sm okers, whereas ulcerativ e colitis occurs m ore often in form er sm okers and nonsm okers. 84 0. Colonoscopic findings in Crohn's disease include deep ulcerations separated by areas of norm al m ucosa (skip lesions) and rectal sparing. 84 1 . Colonoscopic findings in ulcerativ e colitis include continuous inflam m ation, ty pically including the rectum , but without deep ulcerations or skip lesions. 84 2 . Approxim ately 7 0% of patients with gastric or duodenal ulcer disease also hav e Helicobacter py lori infection. 84 3 . Patients with dy spepsia without alarm features (v om iting, weight loss, anem ia) can usually be treated em pirically for H. py lori infection. 84 4 . Patients with acute gallstone pancreatitis present with elev ated serum am inotransferase v alues and pancreatic enzy m e v alues that rapidly return toward norm al.

84 5. Patients with hepatitis C and cirrhosis are at increased risk for dev elopm ent of hepatocellular carcinom a. 84 6 . The finding of a new m ass with v ascular enhancem ent in a patient with hepatitis C and cirrhosis alm ost certainly indicates hepatocellular carcinom a. 84 7 . The m ost com m on cause of ody nophagia (pain on swallowing) is pill-induced esophagitis. 84 8. Gastroparesis is a well-recognized com plication of diabetes m ellitus. 84 9 . Patients with gastroparesis should be started on sm all, frequent feedings of a diet low in fiber, fat, and refined sugar. 850. Patients with choledocholithiasis ty pically hav e m oderate to sev ere epigastric or right upper quadrant abdom inal pain that is usually interm ittent, inconsistently associated with nausea or v om iting, and occasionally nocturnal. 851 . Sy m ptom atic patients with choledocholithiasis alm ost alway s hav e elev ated serum am inotransferase v alues. 852 . Upper endoscopy with sm all bowel biopsies is the definitiv e test to confirm or exclude a diagnosis of celiac sprue. 853 . Antim itochondrial antibody titers of m ore or equal to 1 :4 0 occur in approxim ately 9 0% of patients with prim ary biliary cirrhosis. 854 . Marked v olum e depletion is a poor prognostic sign in a patient with acute pancreatitis. 855. Vigorous hy dration is critical in a patient with acute pancreatitis and m arked v olum e depletion in order to m axim ize pancreatic perfusion and reduce subsequent com plications. 856 . Patients who hav e had pancolitis for 1 0 or m ore y ears should undergo colonoscopy with biopsies ev ery 1 to 2 y ears for colorectal cancer surv eillance. 857 . Elev ated serum am inotransferase v alues and a positiv e assay for antibody to hepatitis C v irus (anti-HCV) in a patient with risk factors for HCV are highly suggestiv e of the presence of hepatitis C. 858. Patients with a positiv e assay for antibody to hepatitis C v irus (anti-HCV) should be tested for HCV RNA to determ ine if v irem ia is present. 859 . A Dieulafoy lesion is an abnorm ally large artery located just below the gastric m ucosa that is prone to rupture and cause largev olum e bleeding. 86 0. Proton pum p inhibitors are m ost effectiv e for treating an

activ e nonsteroidal anti-inflam m atory drug (NSAID)induced ulcer when the NSAID cannot be discontinued. 86 1 . Patients with orophary ngeal dy sphagia ty pically hav e difficulty swallowing both solid foods and liquids, coughing and choking during m eals, and changes in v oice quality . 86 2 . A v ideofluoroscopy study is the m ost appropriate initial test in patients with suspected orophary ngeal dy sphagia. 86 3 . Gastrointestinal bleeding, fev er, abdom inal pain, and leukocy tosis in a patient with an abdom inal prosthetic v ascular graft should raise suspicion for an aortoenteric fistula. 86 4 . Upper endoscopy is the initial diagnostic study for ev aluation of a possible aortoenteric fistula. 86 5. If upper endoscopy is norm al despite a strong clinical suspicion for an aortoenteric fistula, a contrast-enhanced CT scan of the abdom en should be done next. 86 6 . Patients with sev ere cholangitis generally present with fev er, jaundice, and altered m ental status; abdom inal pain is usually , but not inv ariably , present. 86 7 . Patients with cholangitis require endoscopic retrograde cholangiopancreatography to determ ine the presence of com m on bile duct stones and prov ide endoscopic therapy , if indicated. 86 8. Endoscopic ultrasonography is the m ost sensitiv e test for diagnosing an insulinom a of the pancreas. 86 9 . In patients with chronic ulcerativ e colitis, the finding of low-grade dy splasia on surv eillance colonoscopy is associated with an increased risk of progression to high-grade dy splasia or cancer. 87 0. Patients with chronic ulcerativ e colitis and dy splasia of any grade detected on surv eillance colonoscopy should be referred for colectom y . 87 1 . Liv er biopsy should be considered for selected patients with suspected nonalcoholic fatty liv er disease. 87 2 . Rosiglitazone or pioglitazone m ay be indicated for patients with nonalcoholic steatohepatitis and features of the m etabolic sy ndrom e in order to prev ent progression of the liv er disease. 87 3 . Intraoperativ e endoscopy m ay be needed for a patient with unexplained sev ere recurrent gastrointestinal bleeding that cannot be diagnosed by less inv asiv e studies. 87 4 . Patients with short bowel sy ndrom e associated with less than 1 1 5 cm of sm all intestine in the absence of a colon will m ost likely require continuous total parenteral nutrition.

87 5. A proton pum p inhibitor or an H2 -receptor antagonist m ay help reduce excessiv e gastric secretions and stom al fluid losses in patients with short bowel sy ndrom e. 87 6 . Bariatric surgery is effectiv e for reducing m orbidity associated with obesity -related disorders, such as ty pe 2 diabetes m ellitus, hy pertension, obstructiv e sleep apnea, and hy perlipidem ia. 87 7 . Dev elopm ent of gallstones is a com m on com plication following bariatric surgery 87 8. The incidental finding of indirect (unconjugated) hy perbilirubinem ia in an asy m ptom atic patient with a norm al hem oglobin lev el and otherwise norm al liv er tests is indicativ e of Gilbert's sy ndrom e. 87 9 . Tenesm us (a sensation of incom plete ev acuation of the bowels) indicates the presence of proctitis. 880. Neisseria gonorrhoeae infection should be considered as a cause of proctitis in sexually activ e patients. 881 . A patient with acute pancreatitis should be ev aluated for the presence of hy pertrigly ceridem ia. 882 . Patients with diabetes m ellitus and associated neuropathy are at increased risk for dev elopm ent of sm all bowel bacterial ov ergrowth. 883 . Patients with sm all bowel bacterial ov ergrowth often hav e secondary lactose intolerance 884 . Patients with acute gastrointestinal bleeding associated with decreased consciousness, an absent gag reflex, and continued hem atem esis require airway protection as the initial step in m anagem ent. 885. Preoperativ e endoscopic retrograde cholangiopancreatography is indicated prior to laparoscopic cholecy stectom y only for patients with gallstones and possible concom itant com m on bile duct stones. 886 . Patients with a high-risk poly poid lesion detected and rem ov ed during screening colonoscopy should undergo surv eillance colonoscopy in 3 y ears. 887 . Sy m ptom s of noncardiac chest pain frequently m im ic those of cardiac chest pain. 888. The diagnosis of noncardiac chest pain can only be m ade after a thorough ev aluation has ruled out cardiac causes for the pain. 889 . Low-dose antidepressants m ay be helpful in treating patients with noncardiac chest pain. 89 0. Antinuclear antibody and antism ooth m uscle antibody

titers m ore or equal to 1 :80 support a diagnosis of autoim m une hepatitis. 89 1 . Antim itochondrial antibody is the serologic m arker for prim ary biliary cirrhosis. 89 2 . Gastrinom a (Zollinger-Ellison sy ndrom e) and gastric distention related to gastric outlet obstruction are causes of hy pergastrinem ia. 89 3 . A helical CT scan of the abdom en is a reasonable initial test when ev aluating a patient for a possible gastrinom a. 89 4 . Patients who hav e had two or m ore episodes of div erticulitis are m ore likely to dev elop com plications such as abscesses, strictures, and perforation. 89 5. Patients who hav e had two or m ore episodes of div erticulitis should undergo surgical resection of the affected intestine. 89 6 . An asy m ptom atic patient with a single positiv e fecal occult blood test on routine screening requires follow-up with colonoscopy . 89 7 . Candidiasis is the m ost com m on esophageal disorder in patients with HIV infection. 89 8. Patients with HIV infection associated with dy sphagia and ody nophagia should receiv e an em piric trial of fluconazole. 89 9 . Nonulcer dy spepsia is the m ost com m on cause of epigastric pain in a y oung, otherwise healthy patient. 9 00. A trial of a proton pum p inhibitor is warranted in a y oung patient with a first episode of nonulcer dy spepsia and a negativ e serologic test for Helicobacter py lori. 9 01 . Chronic intestinal pseudo-obstruction m ay be associated with a paraneoplastic sy ndrom e. 9 02 . The hallm ark of m esenteric ischem ia is the presence of pain that is out of proportion to the phy sical exam ination findings. 9 03 . The m ost com m on cause of m esenteric ischem ia is a prothrom botic state due to an inherited or acquired coagulation disorder or m alignancy . 9 04 . CT angiography is usually done to establish the diagnosis of m esenteric ischem ia. 9 05. Patients with sev ere, acute pancreatitis require enteral, rather than parenteral, nutrition. 9 06 . Fulm inant hepatic failure is the clinical sy ndrom e of sev ere acute liv er failure and encephalopathy in a patient without pre-existing liv er disease. 9 07 . Patients with fulm inant hepatic failure require im m ediate

ev aluation for liv er transplantation. 9 08. Patients with inflam m atory bowel disease hav e an increased risk for dev eloping prim ary sclerosing cholangitis and superim posed cholangiocarcinom a. 9 09 . A decreasing hem oglobin lev el in a stable patient with a recent episode of upper gastrointestinal bleeding m ay be due to redistribution of fluid into the v ascular space rather than to continuing bleeding. 9 1 0. Ultrasonographic findings of gallstones, a thickened gallbladder wall, pericholecy stic fluid, and a positiv e sonographic Murphy 's sign are highly specific for a diagnosis of acute cholecy stitis. 9 1 1 . Initial m anagem ent of a patient with acute cholecy stitis includes pain m edication, broad-spectrum antibiotics, and surgical consultation for electiv e cholecy stectom y . 9 1 2 . Artificial sweeteners that contain poorly absorbed carbohy drates (e.g., sorbitol, m annitol) m ay cause flatulence and diarrhea. 9 1 3 . Anal fissures generally cause rectal outlet bleeding and pain with defecation. 9 1 4 . Anal fissures m ay occur after a period of constipation. 9 1 5. Nutcracker esophagus is a spastic condition characterized by high-am plitude peristaltic wav es on esophageal m anom etry . 9 1 6 . Patients with nutcracker esophagus should be ev aluated for the presence of gastroesophageal reflux disease. 9 1 7 . A person who has a first-degree relativ e with colorectal cancer should initially undergo colorectal cancer screening 1 0 y ears before the age of diagnosis of the affected relativ e or at age 4 0 y ears, whichev er com es first. 9 1 8. Patients with chronic pancreatitis often require narcotics for pain control. 9 1 9 . Patients with acute hepatitis generally hav e m ore sy m ptom s, are m ore likely to be jaundiced, and hav e higher serum am inotransferase v alues than those with chronic hepatitis. 9 2 0. Adults with hepatitis A are generally jaundiced, whereas m any infants and children with this infection do not hav e jaundice. 9 2 1 . A Mallory -Weiss tear is a laceration near the gastroesophageal junction that often results from forceful retching. 9 2 2 . Bleeding from a Mallory -Weiss tear stops spontaneously in m ore than 9 0% of patients. 9 2 3 . Mesalam ine enem as are the m ost effectiv e initial treatm ent for

patients with ulcerativ e proctosigm oiditis. 9 2 4 . The m ost com m on finding in patients with peptic ulcer disease is gnawing epigastric pain. 9 2 5. Pulm onary infiltrates, hepatom egaly , and a high alkaline phosphatase v alue are indicativ e of hepatic sarcoidosis. 9 2 6 . Recurrent attacks of pancreatitis in a postcholecy stectom y patient are m ost often caused by sphincter of Oddi dy sfunction or pancreas div isum . 9 2 7 . Fev er, alcoholism , findings consistent with chronic liv er disease, and a serum aspartate am inotransferase to serum alanine am inotransferase ratio (AST:ALT) m ore than 2 are associated with alcoholic hepatitis. 9 2 8. Self-lim ited hem atochezia is a com m on cause of ischem ic colitis in elderly patients. 9 2 9 . Diagnostic studies, other than colonoscopy or flexible sigm oidoscopy , are usually not needed after an episode of ischem ic colitis. 9 3 0. Patients with docum ented gallbladder stones and unexplained, nonspecific gastrointestinal sy m ptom s should undergo diagnostic studies to identify other potential causes before cholecy stectom y is perform ed. 9 3 1 . Elderly patients with chronic hepatitis C v irus infection who hav e other com orbid illnesses m ay not be candidates for treatm ent of hepatitis. 9 3 2 . The age of a patient with obscure gastrointestinal bleeding helps guide the choice of diagnostic studies to be perform ed. 9 3 3 . A y oung patient with obscure gastrointestinal bleeding should undergo diagnostic studies for Meckel's div erticulum . 9 3 4 . An older patient with obscure gastrointestinal bleeding should undergo studies for angiectasias. 9 3 5. An intra-abdom inal infection should be excluded before beginning im m unosuppressiv e agents in a patient with a sev ere flare of Crohn's disease. 9 3 6 . Hepatic adenom as are the m ost likely benign liv er tum or to cause bleeding. 9 3 7 . Hepatic adenom as should be resected whenev er possible because of their potential for becom ing m alignant and their risk for bleeding. 9 3 8. Cam eron's erosions are m ost often found in patients with large hiatal hernias and iron deficiency anem ia.

9 3 9 . Barrett's esophagus is a risk factor for the dev elopm ent of esophageal adenocarcinom a. 9 4 0. Patients with Barrett's esophagus without dy splasia should undergo surv eillance upper endoscopy with esophageal biopsies ev ery 3 y ears after the original diagnosis. 9 4 1 . Patients with secretory diarrhea of unknown cause should be ev aluated for the presence of m icroscopic colitis. 9 4 2 . Biopsies of the colonic m ucosa at the tim e of flexible sigm oidoscopy or colonoscopy are the definitiv e study for diagnosing m icroscopic colitis. 9 4 3 . Cav ernous hem angiom as are benign lesions that are found in 2 % of the general population. 9 4 4 . Cav ernous hem angiom as are usually found incidentally when patients hav e im aging studies for other indications. 9 4 5. Patients who hav e diarrhea associated with fev er, abdom inal pain, and leukocy tosis should be ev aluated for the presence of an inv asiv e or inflam m atory bowel disease. 9 4 6 . Visualization and biopsies of the colonic m ucosa at the tim e of flexible sigm oidoscopy or colonoscopy are the definitiv e studies for diagnosing the cause of inv asiv e or inflam m atory diarrhea. 9 4 7 . Upper endoscopy is the m ost appropriate initial diagnostic study for a patient with suspected peptic ulcer disease and one or m ore alarm features (v om iting, weight loss, anem ia) suggestiv e of a possible ulcer-related com plication. 9 4 8. Marked elev ations in serum aspartate am inotransferase and alanine am inotransferase v alues m ay occur in patients with a skeletal m uscle injury . 9 4 9 . The least inv asiv e palliativ e procedure for a patient with m etastatic pancreatic adenocarcinom a and m alignant obstructiv e jaundice is placem ent of an expandable m etal stent during endoscopic retrograde cholangiopancreatography . 9 50. Cholangitis is the m ost com m on cause of liv er abscesses. 9 51 . Percutaneous aspiration is helpful for both diagnosis and treatm ent of py ogenic liv er abscesses. 9 52 . Patients with am y loidosis frequently hav e diarrhea and bleeding in addition to other signs and sy m ptom s. 9 53 . Patients with prim ary sclerosing cholangitis hav e a 1 0% to 3 0% lifetim e risk of dev eloping cholangiocarcinom a. 9 54 . Eosinophilic esophagitis is occurring m ore often in adults, especially those with other atopic disorders.

9 55. Treatm ent of eosinophilic esophagitis includes an elem ental diet and either oral or topical corticosteroids. 9 56 . A patient with suspected AIDS cholangiopathy should undergo endoscopic retrograde cholangiopancreatography (ERCP) to confirm the diagnosis. 9 57 . A patient with AIDS cholangiopathy associated with extrahepatic bile duct obstruction should undergo ERCP with sphincterotom y . 9 58. Hepatic ischem ia is characterized by m arked elev ations in serum am inotransferase v alues that rapidly im prov e within sev eral day s. 9 59 . Patients with nonulcer dy spepsia in whom H2 -receptor antagonists hav e been ineffectiv e should be treated with a proton pum p inhibitor. 9 6 0. Com m on v ariable im m unodeficiency should be suspected in a patient with recurrent gastrointestinal infections (especially giardiasis) and respiratory infections. 9 6 1 . Pneum atic dilation is the initial treatm ent for patients with achalasia. 9 6 2 . Patients with achalasia who do not respond to pneum atic dilation m ay require m y otom y . 9 6 3 . Patients with cirrhosis should undergo upper endoscopy to determ ine the presence of esophageal v arices. 9 6 4 . Patients with large esophageal v arices should receiv e a nonselectiv e -blocker for prophy laxis against v ariceal bleeding. 9 6 5. Certain m edications, including antidepressant agents and calcium channel blockers, increase colonic transit tim e and m ay cause constipation. 9 6 6 . Triple therapy (a proton pum p inhibitor and two antibiotics) is the m ost effectiv e regim en for eradication of Helicobacter py lori. 9 6 7 . Triple therapy for eradication of H. py lori should be giv en for 1 0 to 1 4 day s. 9 6 8. Patients with hereditary hem ochrom atosis usually present with abnorm al liv er tests, arthropathy , fatigue, and im potence. 9 6 9 . The m ost appropriate initial diagnostic study for a patient with suspected hereditary hem ochrom atosis is determ ination of transferrin saturation 9 7 0. A low-dose antidepressant m ay be effectiv e for treating patients with nonulcer dy spepsia. 9 7 1 . CT enterography is the m ost appropriate study for a patient

with possible Crohn's disease but with a norm al colonoscopic exam ination. 9 7 2 . Persons with one or m ore adenom atous colorectal poly ps hav e an increased risk for dev eloping colorectal cancer. 9 7 3 . Persons with one or m ore adenom atous colorectal poly ps should undergo periodic colonoscopic surv eillance to detect colorectal cancer. 9 7 4 . In patients with chronic hepatitis B and cirrhosis, one of the oral agents is preferred to pegy lated interferon because interferon m ay be associated with m ore serious com plications, such as hepatic decom pensation and infection. 9 7 5. Patients with cirrhosis and gastrointestinal bleeding should receiv e a 7 -day course of norfloxacin as prophy laxis against spontaneous bacterial peritonitis. 9 7 6 . Patients with ischem ic colitis m ay hav e a hy potensiv e episode followed by abdom inal pain and subsequently by hem atochezia. 9 7 7 . Fundic gland poly ps are the m ost com m on ty pe of non-neoplastic poly p found in the stom ach. 9 7 8. Fundic gland poly ps are asy m ptom atic and do not present a risk for m alignant transform ation. 9 7 9 . The treatm ent of choice for a patient with the HELLP sy ndrom e (hem oly sis, elev ated liv er enzy m es, low platelets) is prom pt deliv ery of the infant. 9 80. Adm inistration of oral pancreatic enzy m e supplem ents m ust be spaced out during a m eal (one third at the start of the m eal, one third during the m eal, and one third directly after the m eal) in order to be effectiv e. 9 81 . Either azathioprine or 6 -m ercaptopurine prov ides effectiv e m aintenance therapy following a corticosteroid-induced rem ission in patients with ulcerativ e colitis. 9 82 . Early detection and surgical resection prov ide the only chance for cure in a patient with gastric cancer. 9 83 . New-onset obstructiv e jaundice in an elderly patient is m ost often due to pancreatic or biliary tract cancer. 9 84 . Pseudoachalasia m ay be associated with the presence of a m alignant disorder. 9 85. Elderly patients with achalasia should undergo upper endoscopy to rule out pseudoachalasia. 9 86 . The sy m ptom s of pseudoachalasia m ay m im ic those of idiopathic (benign) achalasia.

9 87 . The m ost com m on causes of serum am inotransferase v alues m ore than 5000 U/L are acetam inophen hepatotoxicity , hepatic ischem ia, and hepatitis due to unusual v iruses. 9 88. Persons with alcoholism can dev elop acetam inophen hepatotoxicity when taking lower doses of acetam inophen than those necessary to cause liv er dam age in persons without alcoholism . 9 89 . Endoscopic treatm ent of pancreatic duct strictures m ay reduce abdom inal pain. 9 9 0. Radiation colitis ty pically occurs 9 m onths to 4 y ears after radiation therapy for prostate, gy necologic, or other pelv ic m alignancies. 9 9 1 . Sy m ptom s of radiation colitis include tenesm us, diarrhea, and hem atochezia. 9 9 2 . Acute colonic pseudo-obstruction is a frequent postoperativ e com plication that is aggrav ated by electroly te im balances and adm inistration of narcotics. 9 9 3 . The m ajor com plications of acute colonic pseudo-obstruction are cecal ischem ia and possible perforation of the cecum . 9 9 4 . Patients ov er 4 0 y ears of age who hav e had chronic sy m ptom s of gastroesophageal reflux disease for m ore than 5 y ears should undergo screening for Barrett's esophagus. 9 9 5. Upper endoscopy is the test of choice for patients with gastroesophageal reflux disease who are undergoing screening for Barrett's esophagus. 9 9 6 . Budesonide is the drug of choice for treating a Crohn's disease flare that is lim ited to the ileum . 9 9 7 . Colorectal cancer screening for av erage-risk persons should begin at 50 y ears of age. 9 9 8. Recom m ended colorectal cancer screening studies for av erage-risk persons include fecal occult blood testing, flexible sigm oidoscopy , barium enem a exam ination, and colonoscopy . 9 9 9 . Most patients with prim ary sclerosing cholangitis also hav e ulcerativ e colitis. 1 000. The diagnosis of prim ary sclerosing cholangitis is established by im aging studies that show a string of beads pattern in the biliary tree. 1 001 . Pancreaticoduodenectom y (Whipple procedure) offers the best chance of cure for a patient with cancer of the head of the pancreas. 1 002 . For im m unosuppressed transplant recipients who dev elop ody nophagia, upper endoscopy to establish the cause should be

considered rather than em piric therapy . 1 003 . Bism uth subsalicy late is effectiv e for inducing prolonged rem issions in patients with collagenous colitis. 1 004 . The 1 4 C-urea breath test is the m ost sensitiv e and specific noninv asiv e study for docum enting activ e Helicobacter py lori infection. 1 005. A positiv e serologic test for H. py lori indicates only past exposure to the organism ; this test does not determ ine activ e infection. 1 006 . Findings of v asculitis and positiv e antibody to hepatitis C v irus (anti-HCV) are consistent with cry oglobulinem ia associated with hepatitis C. 1 007 . Angiectasias (v ascular m alform ations) are m ost often diagnosed in elderly patients with chronic occult gastrointestinal bleeding. 1 008. Angiectasias m ay occur any where in the gastrointestinal tract and m ay be bey ond the reach of standard upper endoscopes and colonoscopes. 1 009 . A helical CT scan of the abdom en is the m ost sensitiv e and specific initial im aging study for a patient with possible pancreatic adenocarcinom a. 1 01 0. The first step in ev aluating a patient with recurrent nausea is to rule out com m on sy stem ic disorders such as thy roid disease, diabetes m ellitus, and electroly te abnorm alities. 1 01 1 . Spontaneous bacterial peritonitis is an ascitic fluid infection that is a com m on com plication in patients with cirrhosis. 1 01 2 . Spontaneous bacterial peritonitis should be suspected in any patient with cirrhosis and new or worsening decom pensation. 1 01 3 . 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 com orbid conditions. 1 01 4 . Drugdrug interactions are com m on in patients taking tacrolim us or cy closporine plus other m edications. 1 01 5. Calcium channel blockers m ay interfere with the m etabolism of tacrolim us. 1 01 6 . Dy ssenergic defecation (pelv ic floor dy sfunction) refers to im paired defecation caused by inappropriate contraction or im paired relaxation of the puborectalis and external anal sphincter m uscles. 1 01 7 . Anorectal m anom etry is the m ost appropriate study for

diagnosing dy ssenergic defecation. 1 01 8. The m ost com m on sy m ptom s of paraesophageal hernia are postprandial fullness, pain, and v om iting. 1 01 9 . A paraesophageal hernia m ay be associated with gastric ischem ia as a result of torsion of the stom ach. 1 02 0. The recom m ended treatm ent for a sy m ptom atic paraesophageal hernia is urgent repair of the hernia. 1 02 1 . Eradication of Helicobacter py lori is associated with a significant decrease in the risk of dev eloping a recurrent ulcer. 1 02 2 . Eradication of H. py lori does not reduce the risk of dev eloping gastric cancer. 1 02 3 . Because patients with celiac sprue are at increased risk for osteoporosis and osteom alacia, m onitoring of serum v itam in D and calcium lev els is required. 1 02 4 . The m ost appropriate treatm ent for prim ary biliary cirrhosis is ursodeoxy cholic acid. 1 02 5. Approxim ately 3 % to 5% of patients found to hav e one colorectal cancer will hav e one or m ore sy nchronous cancers in other areas of the colon. 1 02 6 . A patient diagnosed with colorectal cancer requires ev aluation of the entire colon either preoperativ ely or postoperativ ely to detect possible sy nchronous lesions. 1 02 7 . Patients with longstanding ulcerativ e colitis hav e an increased risk of dev eloping colorectal cancer. 1 02 8. Proctocolectom y should be considered for patients with ulcerativ e colitis associated with colonic dy splasia 1 02 9 . The ov erall risk of m aternalfetal transm ission of hepatitis C is approxim ately 5%. 1 03 0. Mothers infected with both hepatitis C and HIV hav e an increased risk of transm itting hepatitis C to their newborns. 1 03 1 . To determ ine the occurrence of m aternalfetal transm ission of hepatitis C, the newborn should be checked for HCV RNA at 2 to 6 m onths of age. 1 03 2 . Patients with postcholecy stectom y bile leak usually present with diffuse abdom inal pain, nausea, fev er, and m ild hy perbilirubinem ia. 1 03 3 . Postcholecy stectom y bile leaks can be identified by endoscopic retrograde cholangiopancreatography 1 03 4 . The presence of a hy perv ascular hepatic m ass in a patient with cirrhosis and a high serum -fetoprotein lev el is diagnostic of

hepatocellular carcinom a. 1 03 5. Patients with adv anced liv er disease and hepatocellular carcinom a should usually be ev aluated for liv er transplantation. 1 03 6 . Patients with fam ilial pancreatitis are at increased risk for dev eloping pancreatic adenocarcinom a. 1 03 7 . The initial test in a patient with possible gastric outlet obstruction is upper endoscopy . 1 03 8. A serum ascites album in gradient (SAAG) m ore than or equal to 1 .1 g/dL is consistent with portal hy pertension. 1 03 9 . Portal hy pertension is m ost often due to cirrhosis. 1 04 0. Fundoplication should be considered for a patient with sev ere iron deficiency anem ia associated with Cam eron's erosions who cannot tolerate oral iron therapy . 1 04 1 . The great m ajority of recurrent colorectal cancers dev elop within 2 y ears postoperativ ely . 1 04 2 . A patient who has undergone resection for colorectal cancer requires surv eillance colonoscopy 3 y ears postoperativ ely to detect the possible presence of m etachronous lesions. 1 04 4 . Pill-induced esophagitis is characterized by the acute onset of painful swallowing (ody nophagia) shortly after a patient begins taking a drug. 1 04 5. Treatm ent of pill-induced esophagitis inv olv es discontinuing the causativ e drug. 1 04 6 . Wilson's disease should be considered in a y oung patient with abnorm al liv er chem istry studies, cognitiv e changes, and hem oly sis. 1 04 7 . A low serum ceruloplasm in v alue ( less than 2 0 m g/dL) is indicativ e of Wilson's disease. 1 04 8. Patients with acute div erticulitis who are able to take liquids and are not dehy drated can usually be m anaged on an outpatient basis. 1 04 9 . The initial steps in m anaging outpatients with acute div erticulitis are adm inistration of oral antibiotics and re-ev aluation in sev eral day s. 1 050. The preferred treatm ent of gastroparesis in the United States is adm inistration of m etoclopram ide. 1 051 . Ery throm y cin should be considered for patients with gastroparesis who cannot tolerate m etoclopram ide. 1 052 . Obesity , hy perlipidem ia, and hy pergly cem ia are risk factors for nonalcoholic fatty liv er disease.

1 053 . Nearly 4 0% of patients with nonalcoholic fatty liv er disease do not hav e obv ious risk factors for this condition. 1 054 . A m ucinous cy stic neoplasm of the pancreas is often asy m ptom atic and is detected as an incidental finding during abdom inal im aging studies for other causes. 1 055. Because of its m alignant potential, a m ucinous cy stic neoplasm of the pancreas should be surgically resected. 1 056 . Patients who hav e undergone gastrectom y m ay dev elop dum ping sy ndrom e, which is characterized by nausea, abdom inal pain and distention, lightheadedness, and diaphoresis. 1 057 . Patients with dum ping sy ndrom e should initially be treated conserv ativ ely with a diet consisting of six sm all m eals daily . 1 058. A Dieulafoy lesion is an unusually large aberrant subm ucosal artery that can cause significant gastrointestinal bleeding. 1 059 . A Dieulafoy lesion m ay be m issed on upper endoscopy unless activ e bleeding is occurring at the tim e of the endoscopic exam ination. 1 06 0. A proton pum p inhibitor is the agent of choice for healing a nonsteroidal anti-inflam m atory drug (NSAID)induced gastric ulcer after the NSAID has been discontinued. 1 06 1 . Prostaglandin analogues m ay prev ent NSAID-induced lesions but do not treat an activ e ulcer. 1 06 2 . Patients with either chronic m esenteric ischem ia or a m alignancy m ay present with sim ilar findings of postprandial pain, weight loss, and anorexia. 1 06 3 . The diagnosis of chronic m esenteric ischem ia is established by the clinical history and findings of com prom ised m esenteric v essels on im aging studies. 1 06 4 . The treatm ent of chronic m esenteric ischem ia is either a surgical or an interv entional radiologic rev ascularization procedure. 1 06 5. Patients with chronic hem oly sis m ay dev elop secondary iron ov erload.

RHEUMATOLOGY 1 06 6 . Manifestations of sy stem ic lupus ery them atosus include arthralgias, photosensitiv e rash, m alar rash, oral ulcers, pancy topenia, and serositis.

1 06 7 . The m ost com m on joints inv olv ed in osteoarthritis are the knee, hip, distal and proxim al interphalangeal, and first carpom etacarpal. 1 06 8. Osteoarthritis is characterized by pain that worsens with activ ity and m orning joint stiffness that lasts less than 3 0 m inutes. 1 06 9 . Postm enopausal wom en who use diuretics hav e an increased risk for tophaceous gout of the distal interphalangeal joints. 1 07 0. Patients with diffuse cutaneous sy stem ic sclerosis are at increased risk for dev eloping interstitial lung disease. 1 07 1 . AntiScl-7 0 antibodies are m ost frequently associated with diffuse cutaneous sy stem ic sclerosis and an increased risk for interstitial lung disease. 1 07 2 . Chest radiography frequently does not detect early interstitial fibrosis. 1 07 3 . The chronic inflam m atory state of rheum atoid arthritis is associated with an increased risk for death from a coronary ev ent. 1 07 4 . The ery throcy te sedim entation rate is useful for m onitoring chronic inflam m atory changes but m ay be elev ated in the setting of adv anced age, anem ia, and other disease states. 1 07 5. Takay asu's arteritis is a chronic, idiopathic, granulom atous inflam m atory disease prim arily of the aorta and its m ain branches that affects reproductiv e-age wom en. 1 07 6 . Constitutional sy m ptom s and ischem ic signs or sy m ptom s in the territory of one or m ore large arteries in a wom an 1 8 m onths of m inocy cline exposure. 1 09 5. Liv er inv olv em ent in m inocy cline-induced lupus often m im ics autoim m une hepatitis. 1 09 6 . The clinical presentation of adult contacts of children with parv ov irus B1 9 infection m ay m im ic rheum atoid arthritis. 1 09 7 . Parv ov irus B1 9 related arthritis is self-lim ited, m ay not hav e an associated rash, resolv es within 1 to 2 m onths, and usually responds to nonsteroidal anti-inflam m atory drugs. 1 09 8. Poly m y algia rheum atica is characterized by pain or m orning stiffness in the neck or torso, shoulders and upper arm s, or hips and thighs in patients > 50 y ears of age with an ery throcy te sedim entation rate > 4 0 m m /h. 1 09 9 . Prednisone therapy rapidly allev iates sy m ptom s of poly m y algia rheum atica. 1 1 00. Olecranon bursitis m ay be infectious, cry stalline, or traum atic.

1 1 01 . Bursa aspiration is indicated for patients with acute olecranon bursitis to guide therapy . 1 1 02 . Patients with fibrom y algia hav e widespread m usculoskeletal pain and stiffness, paresthesias, nonrestorativ e sleep, fatigue, and m ultiple sy m m etrical painful tender points. 1 1 03 . Results of laboratory studies in patients with fibrom y algia are norm al. 1 1 04 . Patients with a long history of Ray naud's phenom enon and diffuse or lim ited cutaneous scleroderm a are at risk for pulm onary v ascular disease. 1 1 05. High-dose corticosteroid therapy in the setting of scleroderm a m ay be associated with norm otensiv e renal crisis. 1 1 06 . Inv asiv e diagnostic studies or em pirical treatm ent is not indicated in asy m ptom atic patients with an isolated elev ated creatine kinase lev el. 1 1 07 . Anticy clic citrullinated peptide antibody positiv ity is strongly associated with rheum atoid arthritis and m ay hav e the best predictiv e v alue when com bined with rheum atoid factor m easurem ent. 1 1 08. Patients taking prednisone, equal or m ore than 5 m g/d, for m ore than 3 m onths m ay benefit from calcium and v itam in D supplem ents and a bisphosphonate. 1 1 09 . Allopurinol is equally effectiv e in the setting of inefficient excretion and ov erproduction of urate. 1 1 1 0. Allopurinol at a dose of m ore than 3 00 m g/d is necessary for approxim ately 50% of patients with hy peruricem ia in order to achiev e urate lev els less than 6 m g/dL. 1 1 1 1 . Antibiotics, such as am picillinsulbactam and others with broad-spectrum cov erage, are indicated for anim al bites. 1 1 1 2 . There is no treatm ent for scleroderm a that is disease m odify ing. 1 1 1 3 . Therapy for scleroderm a inv olv es sy stem atic m anagem ent of end-organ inv olv em ent. 1 1 1 4 . In patients with scleroderm a, high-dose corticosteroid therapy m ay be associated with norm otensiv e renal crisis. 1 1 1 5. Estrogen therapy is contraindicated in wom en with antiphospholipid antibodies. 1 1 1 6 . An unexplained prolonged activ ated partial throm boplastin tim e raises suspicion for the antiphospholipid antibody sy ndrom e. 1 1 1 7 . Rheum atoid arthritis predisposes patients to secondary

osteoarthritis. 1 1 1 8. Im m ediate prednisone therapy is indicated for patients with clinical suspicion for giant cell arteritis before tem poral artery biopsy to decrease the risk for v isual loss. 1 1 1 9 . Low-dose aspirin m ay decrease v isual loss and cerebrov ascular incidents in the setting of giant cell arteritis. 1 1 2 0. Left shoulder pain m ay be referred from the neck; chest; or subdiaphragm atic area, including the spleen. 1 1 2 1 . Intra-articular corticosteroid injections effectiv ely reliev e sy m ptom s of knee osteoarthritis. 1 1 2 2 . Sm all-bowel bacterial ov ergrowth is a com m on cause of diarrhea in patients with scleroderm a and is treated with interm ittent broad-spectrum antibiotics. 1 1 2 3 . Opioid antidiarrheal therapy is not indicated for patients with scleroderm a because it m ay worsen intestinal m otility disorders. 1 1 2 4 . Psoriatic arthritis is associated with dacty litis and asy m m etrical distal interphalangeal joint inflam m ation. 1 1 2 5. The risk for m alignant disease is increased in derm atom y ositis and poly m y ositis and in inclusion body m y ositis. 1 1 2 6 . Ev aluation for an underly ing m alignancy is indicated in patients with refractory m y ositis 1 1 2 7 . Com bination therapy with m ethotrexate and antitum or necrosis factor agents is the m ost likely regim en to im prov e function, lim it further dam age, and control disease in sev ere rheum atoid arthritis. 1 1 2 8. Im m unosuppressed patients hav e increased risk for dev eloping prim ary or reactiv ation tuberculosis. 1 1 2 9 . Prophy lactic isoniazid therapy is beneficial in patients who use prednisone, equal or m ore than 1 5 m g/d, or any other im m unosuppressiv e agent and who hav e equal or m ore than 5 m m of induration on tuberculin skin testing. 1 1 3 0. Urate lev els in patients with tophaceous gout should be reduced to 6 .0 m g/dL (0.3 6 m m ol/L) to dissolv e tophi and other urate depositions in the tissue. 1 1 3 1 . Because decreasing the urate lev el in a patient with tophaceous gout m ay induce a gouty attack, continuation of prophy lactic doses of colchicine is indicated until the tophi resolv e and the urate lev el stabilizes. 1 1 3 2 . Acetam inophen is an effectiv e, safe, and inexpensiv e treatm ent for osteoarthritis.

1 1 3 3 . Patients with osteoarthritis who hav e high risk for nonsteroidal anti-inflam m atory drug com plications m ay use alternate therapy with acetam inophen, often without com prom ising pain control. 1 1 3 4 . Patients with joint abnorm alities hav e an increased risk for joint infection. 1 1 3 5. Intra-articular corticosteroid therapy is contraindicated until infection is excluded. 1 1 3 6 . Alv eolar hem orrhage m ay dev elop in sy stem ic lupus ery them atosus ev en without hem opty sis. 1 1 3 7 . Am y loidosis is an uncom m on but potentially sev ere side effect of chronic inflam m atory diseases, such as rheum atoid arthritis. 1 1 3 8. Rheum atoid arthritisassociated am y loidosis prim arily inv olv es the kidney s and m ay lead to the nephrotic sy ndrom e and renal failure. 1 1 3 9 . Patients treated with cy clophospham ide hav e increased risk for transitional cell carcinom a of the bladder. 1 1 4 0. Lifelong screening for bladder cancer is indicated for patients treated with cy clophospham ide. 1 1 4 1 . Adequate drainage and intrav enous antibiotics are standard treatm ent for a closed-space joint infection. 1 1 4 2 . The m alar rash of sy stem ic lupus ery them atosus is often photosensitiv e and spares the nasolabial folds and areas below the nares and lower lip. 1 1 4 3 . Rosacea is an inflam m atory derm atitis characterized by ery them a, telangiectasias, papules, pustules, and sebaceous hy perplasia that affects the central face, including the nasolabial folds. 1 1 4 4 . Antitum or necrosis factor- therapy is contraindicated in patients with infection. 1 1 4 5. Corticosteroid-induced m y opathy is characterized by continued or worsening proxim al m uscle weakness, particularly in the lower extrem ities, after a decrease in or norm alization of m uscle enzy m e lev els. 1 1 4 6 . Tram adol is as effectiv e as ibuprofen in allev iating pain in osteoarthritis of the hip and knee in patients in whom nonsteroidal anti-inflam m atory drugs are contraindicated or do not prov ide adequate pain relief. 1 1 4 7 . Upper- and lower-extrem ity weakness and gait abnorm alities associated with rheum atoid arthritis strongly suggest cerv ical spine

im pingem ent. 1 1 4 8. Im m ediate MRI scanning is indicated in patients with rheum atoid arthritis with suspected cerv ical spine im pingem ent. 1 1 4 9 . Postexposure prophy laxis m ay benefit im m unocom prom ised patients exposed to influenza v irus. 1 1 50. Adm inistration of antiv iral therapy does not affect the im m une response to inactiv ated influenza v accine. 1 1 51 . Intranasal triv alent liv e-attenuated influenza v accination is contraindicated in im m unosuppressed patients. 1 1 52 . Colchicine toxicity m ay cause acute v acuolar m y opathy and axonal neuropathy . 1 1 53 . Use of colchicine with inhibitors of CYP3 A4 and P-gly coprotein, which m etabolize and transport this agent, respectiv ely , m ay increase the likelihood of drug toxicity . 1 1 54 . Calcification of the cartilage, particularly the fibrocartilage of the knee m eniscus, sy m phy sis pubis, and glenoid and acetabular labrum and the triangular cartilage of the wrist, is pathognom ic for calcium py rophosphate deposition disease. 1 1 55. An aty pical distribution of osteoarthritis without a history of traum a suggests calcium py rophosphate deposition disease. 1 1 56 . Prednisone and hy droxy chloroquine are the preferred anti-inflam m atory drugs during pregnancy . 1 1 57 . Upward titration of prednisone m ay be indicated if other im m unosuppressant agents are discontinued during pregnancy . 1 1 58. Hem orrhagic cy stitis and bladder cancer are uncom m on side effects of cy clophospham ide therapy . 1 1 59 . Follow-up cy stoscopy is indicated for patients with hem aturia and a history of treatm ent with cy clophospham ide. 1 1 6 0. Methotrexate rem ains a v ital drug in the treatm ent of rheum atoid arthritis. 1 1 6 1 . Com bination therapy with m ethotrexate and antitum or necrosis factor- agents prov ides the best suppression of joint dam age and leads to m axim al clinical im prov em ent in rheum atoid arthritis. 1 1 6 2 . Wegener's granulom atosis is a necrotizing granulom atous inflam m ation of sm all- to m edium -sized v essels with a predilection for the upper and lower respiratory tracts and kidney s. 1 1 6 3 . Lfgren's sy ndrom e, a v ariant of sarcoidosis, is characterized by the concom itant presence of acute ery them a nodosum , hilar adenopathy , arthritis or periarthritis, and fev er.

1 1 6 4 . Com pared with phy sical exam ination, radiography of the hands is less sensitiv e and specific for sy m ptom atic hand osteoarthritis. 1 1 6 5. The m ost characteristic radiographic finding of osteoarthritis is osteophy tes with joint-space narrowing. 1 1 6 6 . The m ost characteristic radiographic finding of psoriatic arthritis is the coexistence of erosiv e changes and new bone form ation in the distal joints. 1 1 6 7 . Methotrexate is m etabolized by the liv er and excreted by the kidney s and should be reduced or discontinued in the setting of renal insufficiency . 1 1 6 8. Inclusion body m y ositis is characterized by proxim al and distal m uscle inv olv em ent, asy m m etrical m uscle weakness and atrophy , falls, and m ixed neuropathic and m y opathic findings on electrom y ography . 1 1 6 9 . Muscle biopsy is the diagnostic study of choice for m y ositis. 1 1 7 0. Characteristic radiographic changes of the hands associated with rheum atoid arthritis include juxta-articular osteoporosis and m arginal erosions in the m etacarpophalangeal joints. 1 1 7 1 . Propy lthiouracil use is strongly associated with the dev elopm ent of antineutrophil cy toplasm ic antibodies directed against m y eloperoxidase and associated v asculitis. 1 1 7 2 . Antineutrophil cy toplasm ic antibody positiv e drug-induced v asculitis m ay continue to progress after discontinuation of the inciting m edication. 1 1 7 3 . Whipple's disease is a chronic infection with m ultiorgan m anifestations, including uv eitis, diplopia, asy m m etrical inflam m atory arthritis, and weight loss. 1 1 7 4 . Corticosteroid therapy often resolv es poly m y algia rheum atica sy m ptom s within 2 4 hours. 1 1 7 5. The m ean duration of therapy for poly m y algia rheum atica is 2 .4 y ears at an av erage prednisone dose of 9 .6 m g/d. 1 1 7 6 . Hy droxy chloroquine therapy is associated with retinal toxicity . 1 1 7 7 . Antinuclear antibody positiv ity m ay occur in 1 0% to 1 5% of healthy y oung wom en, in pregnancy , and with increasing age. 1 1 7 8. An antinuclear antibody assay is indicated only if there is a high pretest probability of sy stem ic lupus ery them atosus or another connectiv e tissue disease. 1 1 7 9 . Inflam m atory changes in anky losing spondy litis begin in the

T1 2 to L1 region of the spine and ev entually lead to ossification of the outer fibers of the annulus fibrosis and the dev elopm ent of sy ndesm ophy tes. 1 1 80. Cry oglobulinem ic v asculitis is characterized by palpable purpura, arthritis, weakness, neuropathy , and a m em branoproliferativ e glom erulonephritis. 1 1 81 . Laboratory findings in cry oglobulinem ic v asculitis include circulating cry oglobulins, rheum atoid factor positiv ity , hy pocom plem entem ia, and an elev ated ery throcy te sedim entation rate. 1 1 82 . Hepatitis C is a com m on cause of cry oglobulinem ic v asculitis. 1 1 83 . Arthritis associated with hepatitis C infection m ay occur early or late in the disease course of this infection and m ay m im ic rheum atoid arthritis. 1 1 84 . Ev en in the absence of arthritis, patients with hepatitis C infection often are rheum atoid factor positiv e. 1 1 85. Prim ary Ray naud's phenom enon is not ty pically associated with dam aging digital ischem ia. 1 1 86 . The preferred initial treatm ent for prim ary Ray naud's phenom enon is nonpharm acologic. 1 1 87 . Concom itant use of sulfam ethoxazole and m ethotrexate is contraindicated. 1 1 88. Manifestations of inflam m atory m y ositis m ay include elev ated antinuclear antibody titers and creatine kinase lev els, abnorm al electrom y ography findings, proxim al m uscle weakness, interstitial lung disease, arthritis, and skin rashes. 1 1 89 . Reactiv e arthritis is a sy stem ic inflam m atory disorder triggered by a m ucosal infection in the urethra or the bowel and is m anifested by a nonseptic oligoarticular arthritis; enthesitis; and, occasionally , ey e, skin, or m ucosal inflam m ation. 1 1 9 0. Sjgren's sy ndrom e is characterized by oral and ocular dry ness and anti-Ro/SSA and/or anti-La/SSB antibody positiv ity in wom en between 4 0 and 6 0 y ears of age. 1 1 9 1 . Sjgren's sy ndrom e is associated with an increased risk for non-Hodgkin's ly m phom a and other ly m phoproliferativ e conditions. 1 1 9 2 . A com plete response to appropriate antibiotic therapy for dissem inated gonorrhea m ay take up to 7 2 hours. 1 1 9 3 . Patients with nongonococcal septic arthritis m ay hav e positiv e blood cultures and extra-articular sites of infection. 1 1 9 4 . Hem orrhagic cy stitis is a possible com plication of

cy clophospham ide therapy . 1 1 9 5. Mononeuritis m ultiplex is a com m on presenting feature of poly arteritis nodosa. 1 1 9 6 . Extra-articular m anifestations of anky losing spondy litis include aortitis with aortic insufficiency , upper-lobe pulm onary fibrocy stic disease, am y loidosis, cardiac conduction disease, and recurrent uv eitis. 1 1 9 7 . Relapsing poly chondritis is characterized by inflam m ation and destruction of cartilaginous structures. 1 1 9 8. The m ost com m on presenting feature associated with relapsing poly chondritis is auricular pain and swelling. 1 1 9 9 . Reactiv e arthritis is characterized by large-joint oligoarthritis; enthesitis inv olv ing tendon insertion sites; and extraarticular m anifestations, including uv eitis. 1 2 00. Reactiv e arthritis is triggered by infections in the intestines; urogenital tract; and, less com m only , throat or respiratory tract. 1 2 01 . Needle aspiration is the least inv asiv e m ethod for draining an easily accessible joint, such as the knee. 1 2 02 . In the setting of septic arthritis, a decrease of fluid v olum e and leukocy te and neutrophil counts in serial sam ples suggests adequate needle drainage, whereas persistence of inflam m atory fluid after 7 day s of therapy suggests treatm ent failure. 1 2 03 . Antitum or necrosis factor- therapy increases the risk for reactiv ation tuberculosis. 1 2 04 . Ev aluation for possible septic arthritis is indicated for all patients with acute m onoarticular arthritis. 1 2 05. Patients with prev iously dam aged joints and im m unosuppression are at particularly high risk for septic arthritis. 1 2 06 . Peripheral joint disease in psoriatic arthritis responds to m ethotrexate and sulfasalazine, whereas related spinal inflam m ation does not. 1 2 07 . Psoriatic spinal inflam m ation responds to antitum or necrosis factor therapy . 1 2 08. Behet's disease is characterized by recurrent aphthous oral ulcers and at least two or m ore of the following features: recurrent genital ulceration, ey e or cutaneous lesions, or positiv e findings on pathergy testing. 1 2 09 . Sy nov ial fluid in osteoarthritis usually is clear, v iscous, and noninflam m atory with a leukocy te count less than 2 000/L (2 1 09 /L).

1 2 1 0. Gout and pseudogout are associated with inflam m atory sy nov ial fluid with a leukocy te count between 2 000/L (2 1 09 /L) and 50,000/L (50 1 09 /L) but m ay be higher. 1 2 1 1 . Sy nov ial fluid in septic arthritis is generally highly inflam m atory with a leukocy te count between 1 0,000/ L (1 0 1 09 /L) and 50,000/L (50 1 09 /L) and is often higher. 1 2 1 2 . Patients with the clinical triad of asthm a, nasal poly ps, and aspirin allergy also m ay hav e cross-reactiv ity to nonsteroidal anti-inflam m atory drugs. 1 2 1 3 . Nonacety lated salicy late agents m ay be safely used in patients with aspirin sensitiv ity and asthm a. 1 2 1 4 . Anteroposterior plain radiography of the pelv is is the initial im aging test of choice for suspected sacroiliitis. 1 2 1 5. If findings on plain radiography are unequiv ocal or norm al, MRI m ay detect subchondral osteitis and bone m arrow edem a associated with early sacroiliitis and enthesitis. Here is the Hem atology Oncology notes: 1 2 1 1 . Patients with acute v enous throm boem bolism and m etastatic cancer are at higher risk for recurrent v enous throm bosis than those without m alignancy . 1 2 1 2 . Chronic low-m olecular-weight heparin at therapeutic doses reduces the risk for throm botic recurrence com pared with standardintensity warfarin in patients with v enous throm boem bolism and cancer. 1 2 1 3 . Hem atologic findings in iron-deficiency anem ia consist of m icrocy tic, hy pochrom ic red blood cells; abnorm alities in ery throcy te size and shape; and occasional bizarre-shaped red blood cells. 1 2 1 4 . Iron-deficiency anem ia is treated with iron therapy . 1 2 1 5. Transfusion-related acute lung injury is an inflam m atory infusion reaction in the pulm onary v asculature m anifested prim arily by hy poxem ia. 1 2 1 6 . Major diagnostic criteria of poly cy them ia v era include an elev ated red blood cell m ass, a norm al blood oxy gen saturation, and the presence of splenom egaly . 1 2 1 7 . Low-dose aspirin reduces the risk of throm botic com plications in poly cy them ia v era. 1 2 1 8. The electrophoretic gel in patients with hem oglobin SC disease is characterized by two bands of equal intensity that are

slow-m igrating. 1 2 1 9 . Monoclonal gam m opathy of unknown significance (MGUS) is characterized by the presence of serum m onoclonal gam m aglobulin without the clinical features of m ultiple m y elom a, a paraprotein lev el less than 3 .5 g/dL (3 5 g/L), and less than 1 0% plasm acy tosis in the bone m arrow. 1 2 2 0. Managem ent of MGUS requires routine follow-up to identify signs of progression to m ultiple m y elom a and periodic m easurem ent of serum m onoclonal protein concentration. 1 2 2 1 . Intraoperativ e acute norm ov olem ic hem odilution ensures deliv ery of autologous blood with a hem atocrit higher than the blood lost during surgery and has none of the clerical risks associated with blood banking. 1 2 2 2 . Peripheral neuropathy is a com m on side effect of bortezom ib therapy , occurring in approxim ately 3 0% of patients who take this agent. 1 2 2 3 . A rapidly falling platelet count occurring within day s of heparin adm inistration is indicativ e of heparin-induced throm bocy topenia (HIT). 1 2 2 4 . In patients with HIT, heparin therapy m ust stopped and alternativ e anticoagulation with a direct throm bin inhibitor instituted im m ediately . 1 2 2 5. Estrogen-containing oral contraceptiv es confer a fourfold increased relativ e risk for v enous throm boem bolism in wom en of childbearing age without heritable throm bophilia and a 3 5-fold increased risk in wom en who are heterozy gous for the factor V Leiden m utation. 1 2 2 6 . Oral progestin-only containing contraceptiv es appear to confer little, if any , increased risk for v enous throm bosis. 1 2 2 7 . No other interv ention is required in handling a delay ed hem oly tic transfusion reaction except for av oidance of the incom patible antigen. 1 2 2 8. Signs suggestiv e of disease transform ation from m y elody splastic sy ndrom e to acute m y eloid leukem ia (AML) include sev ere pancy topenia and circulating m y eloid blasts on peripheral blood sm ear. 1 2 2 9 . Patients with transform ed v ersus de nov o AML hav e poorer response rates and disease-free surv iv al, despite receiv ing the sam e chem otherapeutic regim en. 1 2 3 0. Patients with the -thalassem ia trait hav e a two-gene defect

([ ,--]/[ ,--]) in the -globin gene chain of chrom osom e 1 6 . 1 2 3 1 . Patients who hav e -thalassem ia trait hav e m ild m icrocy tic anem ia with prom inent target cells on peripheral blood sm ear. 1 2 3 2 . Routine blood transfusion during pregnancy in patients with sickle cell disease is not necessary unless m andated by other high-risk conditions. 1 2 3 3 . The risk for recurrent v enous throm bosis in patients with the factor V Leiden m utation is not greater than that in those without an underly ing throm bophilic abnorm ality . 1 2 3 4 . Patients at high risk for recurrent throm bosis should receiv e long-term anticoagulation therapy with warfarin. 1 2 3 5. Patients with delay ed-onset heparin-induced throm bocy topenia (HIT) can present with ty pical m anifestations of HIT as late as 3 to 4 weeks after heparin exposure. 1 2 3 6 . Patients with delay ed-onset HIT require anticoagulation therapy with a direct throm bin inhibitor and no further exposure to heparin. 1 2 3 7 . Acute chest sy ndrom e (ACS) is characterized by fev er, chest pain, shortness of breath, hy poxia, and a chest infiltrate in a patient with a sickling disorder. 1 2 3 8. Patients with ACS require ery throcy te transfusion to achiev e a target hem oglobin of 1 0 g/dL (1 00 g/L). 1 2 3 9 . Ery thropoietin therapy has been shown to im prov e anem ia and reduce transfusion requirem ents in som e patients with transfusion-dependent m y elody splastic sy ndrom e. 1 2 4 0. Patients with a drug-induced antibody reaction do not hav e indications of hem oly sis or ev idence of com plem ent activ ation on direct antibody testing. 1 2 4 1 . Factor V Leiden and prothrom bin G2 02 1 0A m utations are the m ost com m on m utations predisposing to v enous throm bosis in white populations, but are rare in Asian and black populations. 1 2 4 2 . Lev els of protein S are reduced during pregnancy , m aking testing for deficiency of this protein unreliable. 1 2 4 3 . Bone m arrow aspirate and biopsy should be perform ed in patients with suspected idiopathic throm bocy topenic purpura who do not respond to prednisone therapy . 1 2 4 4 . Im m unosuppressiv e therapy with antithy m ocy te globulin and cy closporine is effectiv e in reducing transfusion requirem ents in m ore than 7 0% of patients with aplastic anem ia. 1 2 4 5. Inflam m atory anem ia is characterized by a low or norm al

serum iron concentration, reduced serum total iron-binding capacity , and serum ferritin that is not decreased. 1 2 4 6 . Hy percalcem ia, bone pain, anem ia, and clusters of large plasm a cells on bone m arrow aspirate sm ear are diagnostic of m ultiple m y elom a. 1 2 4 7 . The risk for throm bosis in asy m ptom atic pregnant wom en who are heterozy gous for the factor V Leiden m utation is low. 1 2 4 8. Com plete hem atologic rem ission rates for patients with CML who receiv ed im atinib m esy late com pared with interferon and low-dose cy tarabine were 95% and 56 %, respectiv ely . 1 2 4 9 . Throm botic throm bocy topenia purpura (TTP) is characterized by fev er, neurologic abnorm alities, throm bocy topenia, m icroangiopathic hem oly tic anem ia, and renal insufficiency . 1 2 50. The treatm ent of choice for TTP is em ergent plasm a exchange, followed by plasm a infusion when the form er is not im m ediately av ailable. 1 2 51 . Patients with heart failure and hem oly sis require im m ediate transfusion, ev en when only incom patible blood is av ailable, to av oid cardiov ascular collapse. 1 2 52 . The initial treatm ent in patients with warm antibody autoim m une hem oly tic anem ia is corticosteroid therapy . 1 2 53 . Patients whose first throm botic ev ents are associated with transient risk factors are at relativ ely low risk for a spontaneous recurrent v enous throm botic episode. 1 2 54 . Incidental throm bocy topenia of pregnancy requires careful follow-up m onitoring of the platelet count. 1 2 55. Patients with incidental throm bocy topenia of pregnancy require further diagnostic ev aluation when platelet v alues decrease to lower than 7 0,000/L (7 0 1 09/L). 1 2 56 . Drug-induced agranulocy tosis is the m ost likely diagnosis in patients with sepsis, sev ere neutropenia, and relativ ely well-preserv ed hem atocrit and platelet counts after ingestion of trim ethoprim sulfam ethoxazole 1 2 57 . A history of m ucosal bleeding and a m ildly prolonged activ ated partial throm boplastin tim e is consistent with a diagnosis of v on Willebrand's disease. 1 2 58. Factor V Leiden m utation is associated with v enous, not arterial, throm boses. 1 2 59 . Ery thropoietin failure in patients receiv ing dialy sis can be

caused by iron deficiency , folate deficiency , ongoing blood loss, or iron ov erload. 1 2 6 0. Supplem ental v itam in C can im prov e the response to ery thropoietin in patients receiv ing dialy sis. 1 2 6 1 . Patients with iron-deficiency anem ia require iron-replacem ent therapy , not blood transfusion. 1 2 6 2 . Prim ary (AL) am y loidosis should be suspected in patients with nephrotic-range proteinuria in the presence of m onoclonal gam m aglobulin in serum or urine. 1 2 6 3 . A diagnosis of prim ary (AL) am y loidosis can be established by kidney biopsy . 1 2 6 4 . Bleeding sy m ptom s and hem atologic abnorm alities in patients with autoim m une disorders, m alignancy , or in the postpartum setting m ay be suggestiv e of an acquired factor VIII inhibitor. 1 2 6 5. Fondaparinux adm inistered for 2 8 day s results in a low frequency of v enous throm boem bolism after hip-fracture repair and is FDA approv ed for extended throm boprophy laxis following this procedure. 1 2 6 6 . Patients with hereditary spherocy tosis hav e predom inantly spherocy tic red cells on the peripheral blood sm ear; a m ild, Coom b'snegativ e, hem oly tic anem ia; and an elev ated m ean cellular hem oglobin concentration. 1 2 6 7 . A new alloantibody is not alway s detectable in patients with sickle cell disease who hav e adv erse transfusion reactions. 1 2 6 8. Patients with sickle cell disease m ay experience infusionrelated reactions that are m anifested by lower, rather than higher, reticulocy te counts. 1 2 6 9 . Fatigue, weight loss, m assiv e splenom egaly , and teardropshaped ery throcy tes on peripheral blood are consistent with m y elofibrosis. 1 2 7 0. Chronic transfusion therapy is an appropriate m anagem ent option for som e patients with m y elofibrosis. 1 2 7 1 . Isolated throm bocy topenia in an otherwise-healthy y oung patient is m ost com m only due to idiopathic throm bocy topenic purpura (ITP). 1 2 7 2 . Patients with ITP and low risk for bleeding as dem onstrated by a platelet count > 4 0,000 require only periodic m onitoring of the platelet count. 1 2 7 3 . Patients with v enous throm boem bolism associated with oral

contraceptiv es are generally at low risk for recurrent v enous throm boem bolism . 1 2 7 4 . Long-term oral anticoagulation is recom m ended in patients with unprov oked v enous throm botic ev ents in association with antiphospholipid antibody sy ndrom e. 1 2 7 5. Patients with asy m ptom atic inflam m atory anem ia do not require additional diagnostic testing. 1 2 7 6 . Nonhem oly tic transfusion reactions result in inflam m atory -ty pe sy m ptom s without ev idence of hem oly sis. 1 2 7 7 . Stopping the blood transfusion is the only interv ention required in the m anagem ent of nonhem oly tic transfusion reactions and should result in quick sy m ptom atic resolution. 1 2 7 8. A disease-free and ov erall surv iv al benefit is observ ed in patients receiv ing high-dose chem otherapy and autologous stem cell transplantation during first rem ission from m ultiple m y elom a. 1 2 7 9 . The HELLP sy ndrom e (hem oly sis, elev ated liv er enzy m es, and low platelets) usually resolv es within sev eral day s after deliv ery of the fetus. 1 2 80. An inherited throm bocy topenic disorder should be suspected in otherwise-healthy patients with a low platelet count, giant platelets on peripheral blood sm ear, a fam ily history of throm bocy topenia, and who are refractory to corticosteroids 1 2 81 . Patients with v itam in B1 2 deficiency hav e elev ated serum lactate dehy drogenase and unconjugated bilirubin and m ay hav e increased forgetfulness. 1 2 82 . Supplem ental v itam in B1 2 does not alway s rev erse the neurologic findings of B1 2 deficiency but m ay prev ent further deterioration of m ental status. 1 2 83 . Patients with pulm onary hem orrhage and those undergoing m ost ty pes of m ajor surgery need sustained platelet counts of 4 0,000 (4 0 1 09 /L) to 50,000/L (50 1 09 /L). 1 2 84 . The sy m ptom s of serotonin sy ndrom e m ay include tachy cardia, hy pertension, hy pertherm ia, m y driasis, hy peractiv e bowel sounds, diaphoresis, hy perreflexia, clonus, and changes in m ental status. 1 2 85. Warfarin with a target INR of 2 to 3 is adequate for prev enting recurrent v enous throm bosis in patients with antiphospholipid antibody sy ndrom e. 1 2 86 . Patients with thalassem ia m ay experience secondary iron ov erload due to increased iron absorption from the gut.

1 2 87 . Deferoxam ine is a parenteral iron chelator that is used to decrease the tissue iron in patients with thalassem ia. 1 2 88. Leukoreduced blood should be used in pregnant patients in whom the cy tom egalov irus infection status is not known. 1 2 89 . Im atinib m esy late can cause a m ild, m aculopapular rash that is m ost prom inent ov er the extrem ities and trunk, and ty pically resolv es within a week of interruption of therapy . 1 2 9 0. For m ost patients who experience an im atinib-induced rash, the drug can be re-instituted after the rash resolv es, without recurrence. 1 2 9 1 . Consum ptiv e coagulopathy is often accom panied by throm bocy topenia and a prolonged prothrom bin tim e. 1 2 9 2 . All stages of Hodgkin's ly m phom a now are treated with sy stem ic chem otherapy and no longer require inv asiv e testing to identify the extent of disease. 1 2 9 3 . Mortality in patients with stage III colon cancer treated with surgical resection and adjuv ant chem otherapy is decreased by as m uch as 3 3 %. 1 2 9 4 . Patients with BRCA1 /2 m utations hav e a higher risk for breast and ov arian cancer com pared with the general population. 1 2 9 5. Patients with a fam ily history suggestiv e of germ linesusceptibility cancer should be referred for genetic counseling. 1 2 9 6 . Gonadotropin-releasing horm one agonists such as leuprolide m ay result in bone loss in the lum bar spine in patients with prostate cancer. 1 2 9 7 . -Carotene is associated with an increased risk for lung cancer in patie #2

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triplehelix - 01-12-09 23:55 1 2 9 7 . -Carotene is associated with an increased risk for lung cancer in patients who already hav e an elev ated risk for this disease because of sm oking history . 1 2 9 8. Serum -fetoprotein has a half-life of 1 week and requires re-m easurem ent at 1 4 to 2 1 day s after surgery . 1 2 9 9 . Surgery alone is curativ e for patients with early -stage ov arian cancer in 9 0% of cases. 1 3 00. Ly m phadenopathy in the supraclav icular region alm ost

alway s indicates an infectious or neoplastic cause and requires an im m ediate diagnostic procedure. 1 3 01 . A com plete ly m ph node excision is alway s preferred ov er a percutaneous needle biopsy in patients with suspected Hodgkin's or non-Hodgkin's ly m phom a. 1 3 02 . Patients with colon cancer and unresectable liv er m etastases require sy stem ic treatm ent with chem otherapy . 1 3 03 . Additional diagnostic testing for extrahepatic m etastases is necessary only when surgical resection of hepatic m etastases is a consideration. 1 3 04 . A diet high in fruits and v egetables is associated with a lower risk for cardiov ascular disease but not for cancer. 1 3 05. Hy perv iscosity sy ndrom e m ust be considered in patients who hav e ly m phoplasm acy tic ly m phom a (Waldenstrm 's m acroglobulinem ia) with an elev ated serum IgM concentration and sy m ptom s suggestiv e of congestiv e heart failure. 1 3 06 . Em ergent plasm apheresis and im m ediate sy stem ic chem otherapy is required in patients with ly m phoplasm acy tic ly m phom a and a serum v iscosity concentration m ore than 3 .0 with suspicious sy m ptom s, or a v alue of m ore than 4 .0 without suspicious sy m ptom s. 1 3 07 . Patients with prostate cancer are generally asy m ptom atic at diagnosis. 1 3 08. Patients with recently diagnosed prostate cancer and a prostate-specific antigen concentration less than 1 0 ng/m L (1 0 g/L) hav e a low incidence of bony m etastasis. 1 3 09 . Only wom en who are at high risk for ov arian cancer should consider prophy lactic bilateral oophorectom y . 1 3 1 0. Lung cancer screening does not decrease m ortality and is not supported by ev idence. 1 3 1 1 . In patients with adenocarcinom a of unknown prim ary site, the workup should be guided by the patient's history and phy sical and laboratory findings. 1 3 1 2 . Gem citabine is Food and Drug Adm inistration approv ed for the treatm ent of m etastatic pancreatic cancer and results in im prov ed clinical benefit and ov erall surv iv al com pared with 5-fluorouracil. 1 3 1 3 . Hodgkin's ly m phom a surv iv ors who receiv e extended-field radiation hav e a 1 % risk/y ear for dev eloping solid tum ors. 1 3 1 4 . Tum or ly sis sy ndrom e is a consideration in patients who hav e

bulky Burkitt's ly m phom a and sy m ptom s of v om iting and dehy dration. 1 3 1 5. Patients with sy m ptom atic bulky ly m phom a require hy dration, urinary alkalinization, and adm inistration of a xanthine oxidase inhibitor before chem otherapy to prev ent tum or ly sis sy ndrom e. 1 3 1 6 . Breast-conserv ing surgery results in sim ilar and som etim es superior surv iv al in patients with early -stage breast cancer regardless of patient age com pared with m astectom y . 1 3 1 7 . Re-excision is indicated in patients with positiv e tum or m argins detected after breast-conserv ing surgery . 1 3 1 8. Av oiding direct sunlight during peak hours and other sun-av oidance strategies are associated with a decreased risk for squam ous cell carcinom a and m alignant m elanom a. 1 3 1 9 . Sunscreen m ay decrease the risk for dev eloping squam ous cell carcinom a but not m alignant m elanom a. 1 3 2 0. Selenium has been associated with an increased risk for nonm elanom atous skin cancer com pared with placebo. 1 3 2 1 . Treatm ent of patients with testicular cancer m etastatic to the brain consists of whole-brain radiation therapy and com bination chem otherapy . 1 3 2 2 . Preoperativ e radiation therapy plus chem otherapy can reduce tum or size and facilitates sphincter-preserv ing surgery in patients with distal rectal tum ors. 1 3 2 3 . Gastric m ucosa-associated ly m phoid tissue (MALT) ly m phom a is alm ost alway s associated with Helicobacter py lori infection. 1 3 2 4 . Disease in m ost patients with MALT ly m phom a regresses after treatm ent with antibiotics alone within sev eral m onths. 1 3 2 5. Most patients with sm all-cell lung cancer respond dram atically to com bination chem otherapy and whole-brain radiation therapy . 1 3 2 6 . Bisphosphonates such as pam idronate or zolendronate help reduce skeletal-related ev ents in patients with m etastatic lung cancer. 1 3 2 7 . Patients with abnorm al breast findings on phy sical exam ination and norm al m am m ogram should undergo further ev aluation with breast ultrasonography and biopsy . 1 3 2 8. Sensitiv ity of m am m ography ranges from 7 5% to 9 0%, with false-negativ e results m ost likely in wom en with dense breasts.

1 3 2 9 . Patients with stage T1 c prostate cancer and a PSA less than 1 0 ng/m L (1 0 g/L) rarely hav e m etastatic disease and don't need extensiv e staging 1 3 3 0. Ov arian cancer screening does not result in decreased m ortality in general or high-risk populations. 1 3 3 1 . The infrequency of ov arian cancer occurrence and inv asiv eness of the associated diagnostic procedures m ake routine ov arian cancer screening inappropriate. 1 3 3 2 . The risks of chem otherapy in bedbound patients with colorectal cancer who hav e a poor perform ance status outweigh its benefits because of poor likelihood for response and therapy -induced toxicity . 1 3 3 3 . Patients with histologically confirm ed adenocarcinom a of the axillary ly m ph nodes but no clinically or radiologically detected breast abnorm alities should be treated for stage II breast cancer. 1 3 3 4 . Watchful waiting is appropriate for patients with adv anced-stage follicular ly m phom a unless the disease progresses rapidly or poses an im m inent threat to well-being. 1 3 3 5. Although there is no current cure for patients with adv anced-stage follicular ly m phom a, the m edian surv iv al ranges from 1 0 to 1 4 y ears. 1 3 3 6 . Tam oxifen decreases breast cancer risk by approxim ately 50% in pre- and postm enopausal wom en who hav e an elev ated risk for this disease. 1 3 3 7 . Tam oxifen is the only Food and Drug Adm inistrationapprov ed m edication for use in decreasing breast cancer risk. 1 3 3 8. Infection with hepatitis B or C is associated with an increased risk for hepatocellular carcinom a. 1 3 3 9 . Hepatitis B and C are endem ic to m any parts of the dev eloping world, especially Southeast Asia. 1 3 4 0. In the Gleason histologic scoring sy stem , grade 1 represents the m ost well-differentiated tum ors, and grade 5 represents the m ost poorly differentiated tum ors. 1 3 4 1 . Gleason scores consist of two scores deriv ed from the m ost prev alent and second m ost prev alent differentiated tum ors, which results in a com bined score. 1 3 4 2 . The first of the two reported Gleason scores in the com bined score m ay be m ost predictiv e of outcom e. 1 3 4 3 . Mixed sem inom atous and nonsem inom atous germ cell tum ors

should be m anaged as though they were nonsem inom atous tum ors. 1 3 4 4 . Chem otherapy is indicated in the treatm ent of m ixed sem inom atous and nonsem inom atous germ cell tum ors. 1 3 4 5. Flow cy tom etry of the peripheral blood is the best and least inv asiv e way to establish a diagnosis in patients with suspicious ly m phocy tosis. 1 3 4 6 . Sm all-cell lung cancer is presum ed to be a sy stem ic disease with m icrom etastases, ev en when it appears to be isolated and resectable. 1 3 4 7 . Sy stem ic chem otherapy is a required com ponent of therapy in patients with sm all-cell lung cancer, ev en in those with lim ited-stage disease. 1 3 4 8. The concom itant use of chem otherapy and radiation therapy confers a sm all surv iv al benefit ov er sequential use of these m odalities or chem otherapy alone. 1 3 4 9 . Finasteride reduces prostate cancer prev alence by 2 5%. 1 3 50. Finasteride is associated with higher-grade tum ors and m ore sexual side effects but fewer sy m ptom s of urinary obstruction com pared with placebo. 1 3 51 . Patients with squam ous cell carcinom a (SCC) of unknown prim ary site and upper or m idcerv ical ly m ph node inv olv em ent should be treated for locally adv anced SCC of the head and neck. 1 3 52 . Arom atase inhibitors are m ore effectiv e v ersus tam oxifen in prev enting breast cancer recurrence in postm enopausal wom en. 1 3 53 . Marginal-zone B-cell ly m phom a has been associated with hepatitis C v irus in som e patients; treatm ent of the underly ing infection m ay result in rem ission of the ly m phom a. 1 3 54 . Young, m ale patients with poorly differentiated m idline carcinom a containing germ cell cancer m arkers and isochrom osom e 1 2 p are likely to hav e extragonadal germ cell cancer and m ay respond to cisplatin-based chem otherapy . 1 3 55. Docetaxel plus prednisone im prov es surv iv al in m en with m etastatic prostate cancer refractory to horm onal ablation therapy when com pared with m itoxantrone plus prednisone. 1 3 56 . Most patients becom e azoosperm ic shortly after chem otherapy for testicular germ cell cancer, but they m ay regain norm alized sperm counts within 2 y ears; howev er, m any rem ain infertile or subfertile. 1 3 57 . Sperm storage is offered to m en with testicular cancer before they undergo chem otherapy .

1 3 58. In patients with m etastatic HER2 -positiv e breast cancer, trastuzum ab and chem otherapy result in prolonged surv iv al com pared with chem otherapy alone. 1 3 59 . In patients with early -stage resectable nonsm all-cell lung cancer, the use of adjuv ant chem otherapy is a new standard of care replacing the form er approach of prov iding no further therapy . 1 3 6 0. Diffuse large B-cell ly m phom a requires sy stem ic therapy ev en when results of CT scans and positron em ission tom ography (PET) are negativ e. 1 3 6 1 . Rituxim ab and CHOP (cy clophospham ide, doxorubicin, v incristine, and prednisone), with or without radiation therapy , is curativ e for m ost patients with diffuse large B-cell ly m phom a. 1 3 6 2 . Follow-up ev aluation of postm enopausal wom en with breast cancer who undergo successful treatm ent consists of annual m am m ography . 1 3 6 3 . Sm oking cessation is the m ost effectiv e cancer prev ention strategy for patients who are at high risk for lung cancer. 1 3 6 4 . Bronchioloalv eolar cell carcinom a has a distinct pattern of presentation and responds uniquely to therapy with the new epiderm al growth factor receptor inhibitors. 1 3 6 5. Som e patients with prim ary or recurrent bronchioloalv eolar cell carcinom a who receiv e daily oral erlotinib or gefitinib hav e periods of disease reduction lasting from 1 to 2 y ears. 1 3 6 6 . Com bination horm one replacem ent therapy has been shown to increase the risk for breast cancer. 1 3 6 7 . Follow-up exam inations for patients with successfully treated testicular cancer should include studies focused only on new sy m ptom s rather than an arbitrary schedule of im aging or workups. 1 3 6 8. Patients with a poor perform ance status and widely m etastatic nonsm all-cell lung cancer of squam ous cell histology alm ost nev er respond to any ty pe of therapy and require hospice care. 1 3 6 9 . Wom en with a history of ov arian cancer hav e a higher risk for breast cancer than that of the av erage population. 1 3 7 0. Ov arian cancer m etastasizes com m only to the pleura and peritoneum , rarely to bone or liv er, and alm ost nev er to breast. 1 3 7 1 . Breast cancer m etastasizes com m only to the pleura, peritoneum , liv er and bone.

Endocrinology and m etabolism 1 3 7 2 . The insulin sensitizing drugs m etform in and the thiazolidinediones are contraindicated in patients with adv anced heart failure. 1 3 7 3 . Thy roid horm one increases the m etabolism of warfarin but increases the turnov er of clotting proteins ev en m ore, resulting in a decreased dose requirem ent of warfarin. 1 3 7 4 . In an asy m ptom atic patient with m ild hy percalcem ia and an inappropriately norm al parathy roid horm one lev el, the m ain differential includes prim ary hy perparathy roidism v ersus benign fam ilial hy pocalciuric hy percalcem ia. 1 3 7 5. Fam ilial hy pocalciuric hy percalcem ia is diagnosed by a urinary calcium /creatinine clearance ratio less than 0.01 m easured in a fasting m orning urine spot collection. 1 3 7 6 . Sev ere hy pogonadism in a y oung m ale with an elev ated serum prolactin lev el strongly suggests pituitary m acroadenom a and warrants ev aluation of the entire pituitary . 1 3 7 7 . Patients with Cushing's sy ndrom e produce three to four tim es the am ount of urine free cortisol that unaffected persons produce. 1 3 7 8. The three screening tests for Cushing's sy ndrom e are m easurem ent of urine free cortisol, the ov ernight dexam ethasone suppression test, and the late-ev ening saliv ary cortisol test. 1 3 7 9 . Risk factors for hy popituitarism include prev ious m acroadenom a, pituitary surgery , and brain radiation. 1 3 80. Multiple endocrine neoplasia ty pe 2 A is characterized by pheochrom ocy tom a, m edullary thy roid carcinom a, and hy perparathy roidism due to parathy roid hy perplasia. 1 3 81 . The goal of preoperativ e blood pressure control in patients with pheochrom ocy tom a is less than 1 4 0/90 m m Hg. 1 3 82 . -Adrenergic blockade is used to reduce preoperativ e blood pressure in patients with pheochrom ocy tom a. 1 3 83 . No pharm acologic therapy is m ore effectiv e than diet and exercise in prev enting the progression to ty pe 2 diabetes in patients with prediabetes. 1 3 84 . The indications for parathy roidectom y in a patient with m ild, asy m ptom atic hy percalcem ia secondary to prim ary hy perparathy roidism are age less than 50 y ears, serum calcium lev el m ore than 1 .0 m g/dL (0.2 5 m m ol/L) abov e the upper lim it of

norm al, 2 4 -hour urine calcium excretion m ore than 4 00 m g (1 0 m m ol), creatinine clearance reduced by m ore than 3 0%, and a bone m ineral density T score less than 2 .5 at any site. 1 3 85. The cause of prim ary hy perparathy roidism in m ost cases is a single parathy roid adenom a. 1 3 86 . Substernal goiter results in a narrowed thoracic inlet, which is further com prom ised by extension of the arm s ov er the head, resulting in com pression of the great v eins of the neck and the m arked facial plethora known as Pem berton's sign. 1 3 87 . Pituitary apoplexy is the sudden onset of headache, v isual disturbances, opthalm oplegia, and m ental status changes caused by the acute hem orrhage or infarction of the pituitary gland. 1 3 88. Urgent neurosurgical ev acuation of the hem orrhage is generally indicated for patients with pituitary apoplexy and rapidly progressing v isual disturbances and/or m ental status changes. 1 3 89 . A noncontrast CT scan can distinguish between pituitary apoplexy and subarachnoid hem orrhage as patients with pituitary apoplexy will dem onstrate acute hem orrhage in the region of the sella turcica. 1 3 9 0. In a patient with androgen-dependent hirsutism who does not wish to becom e pregnant, antiandrogen and ov arian suppression therapy is usually effectiv e. 1 3 9 1 . The 2 5-hy droxy v itam in D lev el is a m arker of body stores of v itam in D and is m easured as the initial step in the ev aluation of suspected nutritional v itam in D deficiency . 1 3 9 2 . Coronary artery disease m ay be silent in patients with long-standing diabetes m ellitus or present aty pically . 1 3 9 3 . Dy spnea in a patient with an extensiv e history of com plicated diabetes should be considered an anginal equiv alent. 1 3 9 4 . Subclinical hy pothy roidism is an elev ated serum TSH lev el with a free T4 that is still within the population reference range. 1 3 9 5. Patients with subclinical hy pothy roidism who hav e a serum TSH v alue abov e 1 0 U/m L (1 0 m U/L) hav e been shown to hav e reductions in their LDL cholesterol concentrations when treated with lev othy roxine. 1 3 9 6 . Hy pom agnesem ia in the patient with alcoholism can m im ic hy poparathy roidism , including sev ere hy pocalcem ia and hy perphosphatem ia. 1 3 9 7 . New-onset hirsutism with v irilization, particularly in an older wom an, and accom panied by a serum total testosterone lev el

m ore than 2 00 ng/dL (6 .9 nm ol/L) is alm ost alway s due to a tum or. 1 3 9 8. Excision of a cortisol-producing adrenal adenom a results in rapid clearance of cortisol within the first 2 4 hours after surgery and subsequent acute adrenal insufficiency ; corticosteroid replacem ent is the appropriate therapy 1 3 9 9 . Growth horm one stim ulation testing is m ore sensitiv e and specific for determ ining growth horm one deficiency than m easuring basal horm one lev els. 1 4 00. Because of the potential nephrotoxicity of intrav enous radiocontrast agents, m etform in, which accum ulates in renal insufficiency , should not be adm inistered when any radiographic procedure using an intrav enous contrast agent is perform ed. 1 4 01 . Inhibition of the renin-angiotensin axis reduces proteinuria and preserv es renal function in patients with diabetes m ellitus. 1 4 02 . A dom inant thy roid nodule shown to be benign by fine-needle aspiration biopsy should be followed by serial m onitoring with ultrasound to assess size stability . 1 4 03 . Pseudo-Cushing's sy ndrom e consists of hy percortisolism in patients with such disorders as depression and alcohol use that alter hy pothalam ic - pituitary - adrenal function enough to perturb screening tests for Cushing's sy ndrom e. 1 4 04 . If standard screening tests are equiv ocal in a patient with a strong pretest probability for Cushing's sy ndrom e, the com bined dexam ethasone - CRH stim ulation test m ay distinguish Cushing's sy ndrom e from pseudo-Cushing's sy ndrom e. 1 4 05. The therapy of choice for uncom plicated Paget's disease is an oral bisphosphonate. 1 4 06 . In m en, excessiv e production of glucocorticoids causes hy pogonadotropic hy pogonadism with dim inished libido and loss of secondary sexual characteristics, in conjunction with com m only recognized m anifestations of Cushing's sy ndrom e. 1 4 07 . On CT scan of the adrenal glands, adenom as usually hav e sm ooth borders, are less than 4 cm in diam eter, unilateral, hom ogenous in consistency , and less than 1 0 Hounsfield units in density . 1 4 08. The serum TSH cannot be used to m onitor thy roid horm one replacem ent therapy in patients with central hy pothy roidism 1 4 09 . On patients with central hy pothy roidism , the goal of thy roid horm one replacem ent is to titrate the dose to norm alize the free T4 (or total T4 and free thy roxine index) not to norm alize the TSH.

1 4 1 0. Patients with ty pe 2 diabetes taking m onotherapy often require m ultidrug therapy as the duration of disease increases and beta-cell destruction progresses. 1 4 1 1 . The addition of one class of drug to another is the current fav ored approach in the patient with ty pe 2 diabetes and progressiv e hy pergly cem ia despite m onotherapy . 1 4 1 2 . Measurem ent of TSH-receptor autoantibodies, which are present in m ore than 9 0% of patients with Grav es' disease but are not present in postpartum thy roiditis, can distinguish between the two disorders in a patient with postpregnancy thy rotoxicosis. 1 4 1 3 . Patients with gestational diabetes m ellitus hav e a 50% risk of dev eloping ty pe 2 diabetes m ellitus in the 5 to 1 0 y ears after the diagnosis of gestational diabetes. 1 4 1 4 . Nonparathy roid horm onem ediated hy percalcem ia is characterized by suppressed parathy roid horm one lev els. 1 4 1 5. In m ost cases of m alignancy -associated hy percalcem ia, the tum or produces parathy roid horm onerelated peptide, which shares significant hom ology with m any of the m etabolic actions of parathy roid horm one. 1 4 1 6 . A gradual decline in strength, cognitiv e and sexual function, and anhedonia in an elderly m ale suggests testosterone deficiency , and replacem ent therapy m ay be offered. 1 4 1 7 . Electroly te abnorm alities are generally not observ ed in patients with central adrenal insufficiency due to the fact that the aldosterone sy stem is still functional. 1 4 1 8. Multiple endocrine neoplasia (MEN) ty pe 2 A is an autosom al dom inant sy ndrom e in which adult carriers of the RET m utation are predisposed to m edullary thy roid carcinom a, unilateral or bilateral pheochrom ocy tom as, and hy perparathy roidism . 1 4 1 9 . Pendred's sy ndrom e is an autosom al-recessiv e disorder of iodine organification characterized by congenital sensorineural hearing loss com bined with goiter. 1 4 2 0. Osteom alacia is a m etabolic bone disease with failure of the organic m atrix (osteoid) of bone to m ineralize norm ally in adults. 1 4 2 1 . Looser's zones or Milkm ans' fractures (pseudofractures) on radiography are pathognom onic of osteom alacia. 1 4 2 2 . In patients with ty pe 1 diabetes and suboptim al glucose control, m ore com plex regim ens with m ore frequent injections of both short/rapid and long/interm ediate acting insulins usually prov ide m ore effectiv e control.

1 4 2 3 . The ADA recom m ended goals for m anagem ent of adults with diabetes are hem oglobin A1 C less than 7 .0%, preprandial plasm a glucose 9 0-1 3 0 m g/dL (5-7 .2 2 m m ol/L), peak (2 hour) postprandial plasm a glucose less than 1 80 m g/dL (9.9 9 m m ol/L), blood pressure less than 1 3 0/80 m m Hg, trigly cerides less than 1 50 m g/dL (1 .6 9 m m ol/L), HDL cholesterol m ore than 4 0 m g/dL (1 .03 m m ol/L), and LDL cholesterol less than 1 00 m g/dL (2 .59 m m ol/L). 1 4 2 4 . Benign adrenal adenom as generally hav e sm ooth borders, attenuation v alues less than 1 0 Hounsfield units, and are hom ogenous in consistency . 1 4 2 5. The size of an adrenal lesion is predictiv e of m alignant potential; 2 5% of lesions m ore than 6 cm are carcinom as. 1 4 2 6 . In patients with m alignancy -associated hy percalcem ia, therapy with zoledronate, a long-acting intrav enous nitrogencontaining bisphosphonate, induces rapid and long-lasting hy pocalcem ic response. 1 4 2 7 . Multiple endocrine neoplasia (MEN) 2 a sy ndrom e consists of m edullary thy roid cancer, pheochrom ocy tom a, and hy perparathy roidism due to four-gland hy perplasia. 1 4 2 8. In patients with hy pergly cem ic hy perosm olar sy ndrom e, the preserv ation of v ascular v olum e is critical, and norm al saline is the initial fluid of choice, ev en before intrav enous insulin. 1 4 2 9 . The differential diagnosis in patients with apparently inappropriate TSH secretion includes a TSH-producing pituitary adenom a and congenital thy roid horm one resistance. 1 4 3 0. he Am erican Diabetes Association criteria for the diagnosis of diabetes m ellitus are a fasting plasm a glucose m ore or equal 1 2 6 m g/dL (6 .9 9 m m ol/L), a 2 -hour plasm a glucose m ore or equal 2 00 m g/dL (1 1 .1 m m ol/L) after a 7 5-g oral glucose load, or a random glucose m ore or equal 2 00 m g/dL (1 1 .1 m m ol/L) plus sy m ptom s of diabetes. 1 4 3 1 . Thiazide diuretics stim ulate renal tubular calcium reabsorption and in som e patients lead to a m ild hy percalcem ia, which usually resolv es when the diuretic therapy is discontinued. 1 4 3 2 . Prim ary hy pothy roidism is a com m on secondary cause of hy perprolactinem ia, likely caused by increased stim ulation of the pituitary gland by thy rotropin-releasing horm one. 1 4 3 3 . Serum TSH should be m easured with prolactin in the ev aluation of a patient with galactorrhea and irregular m enses. 1 4 3 4 . Causes of ACTH-dependent Cushing's sy ndrom e can be

distinguished by the dexam ethasone 8-m g (high-dose) ov ernight suppression test and the corticotropin-releasing horm one (CRH) stim ulation test. 1 4 3 5. The av erage patient with ty pe 1 diabetes m ellitus who does not hav e coexisting insulin resistance requires a total daily dose of about 0.4 to 0.5 units of insulin per kg of body weight. 1 4 3 6 . In the water depriv ation test, im paired ability to concentrate urine is consistent with either nephrogenic or central diabetes insipidus. 1 4 3 7 . In the water depriv ation test, a large increase in urine osm olarity after the adm inistration of desm opressin is indicativ e of central diabetes insipidus; no such increase occurs in nephrogenic diabetes insipidus. 1 4 3 8. Hy pocalcem ia frequently occurs after rem ov al of a hy perfunctioning parathy roid adenom a because of deficient secretion of parathy roid horm one by the rem aining prev iously suppressed parathy roid tissue. 1 4 3 9 . Perm anent hy poparathy roidism after an initial neck exploration for prim ary hy perparathy roidism is rare, but the incidence is greatly increased with repeated neck surgery for recurrent or persistent hy perparathy roidism and after subtotal parathy roidectom y for parathy roid hy perplasia 1 4 4 0. In a patient with unstable coronary artery disease and hy pothy roidism , therapy with thy roid horm one could increase m y ocardial m etabolic dem and and precipitate a m y ocardial infarction. 1 4 4 1 . Hy perprolactinem ia can cause hy pogonadism because prolactin directly suppresses gonadotropin-releasing horm one secretion and thus luteinizing horm one and testosterone production. 1 4 4 2 . The initial treatm ent for prolactin-producing m acroadenom as is a dopam ine agonist, such as brom ocriptine or cabergoline, which decreases prolactin lev el, shrinks the tum or, and im prov es v isual fields and pituitary function in m ost patients. 1 4 4 3 . Inferior petrosal sinus sam pling is a confirm atory test for Cushing's sy ndrom e in patients with am biguous results in screening tests; the technique is v ery sensitiv e and specific, but extrem ely costly , technically difficult, and som ewhat hazardous. 1 4 4 4 . Metform in should not be used in m en with creatinine lev els greater than 1 .5 m g/dL (1 3 2 .6 3 m ol/L) or in wom en with creatinine lev els greater than 1 .4 m g/dL (1 2 3 .7 9 m ol/L).

1 4 4 5. A thiazolidinedione should not be used in patients with class III congestiv e heart failure and will often cause worsening edem a ev en in patients with less sev ere congestiv e heart failure. 1 4 4 6 . In euthy roid patients, am iodarone therapy results in high free and total T4 , low-norm al T3 , and high-norm al TSH. 1 4 4 7 . Osteoporosis is diagnosed by the presence of fragility fractures or by a bone m ineral density v alue less than 2 .5 in patients who hav e not experienced a fragility fracture. 1 4 4 8. The classic characteristics of prolactinom a are am enorrhea and galactorrhea. 1 4 4 9 . Serum prolactin lev els greater than 2 00 ng/m L (2 00 m g/L) in a nonpregnant wom an usually suggest a tum or instead of another cause of hy perprolactinem ia. 1 4 50. Secondary diabetes m ellitus m ay be the direct result of such underly ing disease states as other endocrinopathies, islet cell neoplasm s, and disorders of the exocrine pancreas such as pancreatitis, pancreatic m alignancies, and cy stic fibrosis. 1 4 51 . Localizing the ectopic source of ACTH in a patient with ev idence of ACTH-dependent Cushing's sy ndrom e m ay require com bination CT/MRI/octreotide im aging of chest/abdom en/pelv is. 1 4 52 . In patients with sev ere prim ary hy pothy roidism , decreased negativ e feedback of thy roid horm one at the lev el of the hy pothalam us leads to release of thy rotropin-releasing horm one, which stim ulates expansion of TSH-producing pituitary cells, causing pituitary hy perplasia. 1 4 53 . Exenatide, an incretin m im etic that increases insulin secretion, is an alternativ e to insulin therapy in patients who hav e not achiev ed optim al gly cem ic control with m ulti-agent oral therapy . 1 4 54 . Tertiary hy perparathy roidism is a rare disorder that usually occurs after m any y ears of chronic renal insufficiency and secondary hy perparathy roidism . 1 4 55. Cinacalcet hy drochloride is a calcim im etic agent that has been shown to significantly parathy roid horm one lev els in patients with chronic kidney disease and uncontrolled secondary hy perparathy roidism . 1 4 56 . The classic presentation of hereditary hem ochrom atosis includes hy pogonadism , diabetes m ellitus, liv er dy sfunction, and skin hy perpigm entation. 1 4 57 . The m ost com m only affected organs in hereditary

hem ochrom atosis are the pituitary gland, pancreas, liv er, and heart. 1 4 58. Postprandial glucose excursions in patients with diabetes should ideally be 3 0 to 50 m g/dL (1 .6 7 to 2 .7 8 m m ol/L) abov e prem eal glucose v alues. 1 4 59 . Significant postprandial hy pergly cem ia can be m anaged by using a bolus of short-acting insulin (lispro or aspart) just before or with each m eal. 1 4 6 0. The absence of m enses for sev eral m onths after dilation and curretage raises the possibility of endom etrial dam age or form ation of scar tissue causing an outflow tract obstruction (Asherm an's sy ndrom e). 1 4 6 1 . Pheochrom ocy tom as usually occur within the adrenal m edulla, are rarely bilateral, occur m ore com m only in the right adrenal, are rarely m etastatic to the local ly m phatic v essels and /or liv er, and are usually m ore or equal to 2 cm in diam eter and heterogeneous in consistency . 1 4 6 2 . Com puted tom ography of the abdom en with thin sections through the adrenals is the preferred initial localizing study for pheochrom ocy tom a. 1 4 6 3 . Patients with Hashim oto's thy roiditis are at risk for other autoim m une endocrine disorders, including adrenal insufficiency , pernicious anem ia, ty pe 1 diabetes m ellitus, v itiligo, and prem ature ov arian failure. 1 4 6 4 . The classic sy m ptom s of renal osteody strophy are v ague bone pain localized to the lower back, hips, or legs; m uscle weakness often occurs with norm al m uscle enzy m es and nonspecific electrom y ography changes. 1 4 6 5. The m ain radiographic feature of renal osteody strophy is increased bone resorption, m ost com m only in the subperiosteal surfaces of the hands, neck of fem ur, and clav icle. 1 4 6 6 . The presence of three or m ore pituitary horm one deficiencies has a positiv e predictiv e v alue for growth horm one deficiency of 9 5%. 1 4 6 7 . Replacem ent of growth horm one in horm one-deficient adults has been shown to im prov e body com position, lipid param eters, and bone m ineral density . 1 4 6 8. Therapy with an angiotensin II receptor blocker delay s the progression of nephropathy in diabetic patients with hy pertension, m acroalbum inuria, and renal insufficiency .

1 4 6 9 . -Blocker therapy to reduce thy rotoxic sy m ptom s is the m ost appropriate therapy during the hy perthy roid phase of postpartum thy roiditis. 1 4 7 0. Approxim ately 7 5% of patients with postpartum thy roiditis recov er, whereas 2 5% dev elop perm anent hy pothy roidism . 1 4 7 1 . Hem ochrom atosis can result in v arious endocrinopathies, including hy pogonadism , adrenal insufficiency , and diabetes m ellitus. 1 4 7 2 . Growth horm one replacem ent is started at a low dose and titrated up based on the patient's insulin-like growth factor 1 lev el, sy m ptom control, and side effects of therapy . 1 4 7 3 . The goal of growth horm one replacem ent is to norm alize the insulin-like growth factor 1 lev el and allev iate sy m ptom s without causing adv erse side effects. 1 4 7 4 . Adv erse effects of growth horm one replacem ent therapy include parasthesias, m y algias, edem a, and joint pain. 1 4 7 5. In patients with bilateral adrenal hy perplasia, spironolactone therapy reduces blood pressure and elim inates the requirem ent for potassium supplem entation. 1 4 7 6 . In m en with bilateral adrenal hy perplasia in whom spironolactone therapy causes painful gy necom astia, epleronone m ay be substituted for spironolactone. 1 4 7 7 . Paget's disease is a focal disorder of bone rem odeling that leads to greatly accelerated rates of bone turnov er, disruption of the norm al architecture of bone, and som etim es to gross deform ities of bone (enlargem ent of the skull, bowing of the fem ur or tibia). 1 4 7 8. Osteom alacia usually presents with an elev ation of alkaline phosphatase in association with hy pocalcem ia and hy pophosphatem ia. 1 4 7 9 . In patients with the em pty sella sy ndrom e, the pituitary gland is not usually dam aged and pituitary function is usually norm al. 1 4 80. Fasting blood glucose lev els, which are due prim arily to excessiv e hepatic glucose production, are controlled m ainly by the basal insulin dose. 1 4 81 . Patients on basal bolus insulin therapy often take 4 0% to 50% of their total daily dose as basal insulin (glargine) and 50% to 6 0% as m eal boluses (lispro or aspart). 1 4 82 . Postm enopausal wom en with subclinical hy perthy roidism and an undetectable TSH hav e an increased risk of dev eloping

osteoporosis. 1 4 83 . Hy pogly cem ia unawareness, a dangerous sequela of long-standing insulin-treated diabetes m ellitus, is an adaptiv e central nerv ous sy stem response and is exacerbated by recurrent episodes of hy pogly cem ia. 1 4 84 . In patients with ty pe 1 diabetes m ellitus and hy pogly cem ic unawareness, insulin dose should be reduced and treatm ent goals relaxed. 1 4 85. The classic triad of sy m ptom s for pheochrom ocy tom a consists of headaches, palpitation and diaphoresis. 1 4 86 . The sensitiv ity of fractionated plasm a m etanephrines for catecholam ine-producing tum ors is nearly 97 %; howev er, the specificity is 85%. 1 4 87 . The first step in the ev aluation of a thy roid nodule is m easurem ent of serum TSH; if TSH is norm al, the nodule is m ost likely nonfunctioning or cold; if TSH is low, the nodule is m ore likely to be hy perfunctioning or hot. 1 4 88. Measurem ent of serum thy roglobulin is useful for following thy roid cancers in response to treatm ent, but a serum thy roglobulin lev el is not useful in distinguishing benign from m alignant nodules. 1 4 89 . Very high lev els of hum an chorionic gonadotropin (hCG) are sufficient to stim ulate the thy roid gland to release excess thy roid horm one. 1 4 9 0. Risk factors for osteoporosis in m en include a BMI less than 1 8, a history of sm oking or excessiv e alcohol consum ption, fam ily history of osteoporotic fractures, hy pogonadism , history of corticosteroid use, v itam in D deficiency , and m edications causing osteom alacia or hy pogonadism . 1 4 9 1 . Hy pogonadism increases the skeletal sensitiv ity to parathy roid horm one and decreases intestinal calcium absorption, predisposing to osteoporosis. 1 4 9 2 . The objectiv es in ev aluating pituitary incidentalom as are to determ ine whether they are secreting pituitary horm ones, causing deficiencies of pituitary horm ones, and growing. 1 4 9 3 . Close observ ation of the tum or to detect growth and pituitary horm one deficiency is the treatm ent choice for clinically silent sm all adenom as. 1 4 9 4 . DEXA scanning has the best correlation of procedures for m easuring bone loss with fracture risk, requires a short scanning tim e, and m easures the bone m ineral density of all areas of the

skeleton with high accuracy and reproducibility and low exposure to radiation. 1 4 9 5. Features of the euthy roid sick sy ndrom e include a precipitous drop in serum total and free T3 lev els, and a concom itant increase in rev erse T3 . 1 4 9 6 . The changes in thy roid horm one lev els during an acute illness are likely adaptiv e, as a m eans of protecting the body from catabolic illness; thy roid horm one therapy in patients with euthy roid sick sy ndrom e has not been shown to be beneficial. 1 4 9 7 . Hy pergly cem ia after cardiac surgery and during critical illness is a strong predictor of adv erse outcom es, including infectious com plications and death. 1 4 9 8. Intrav enous insulin infusion in hy pergly cem ic patients in the intensiv e care unit reduces m ortality . 1 4 9 9 . Potential com plications of Paget's disease of the bone include osteogenic sarcom a in affected bone, hy percalcem ia, high-output congestiv e heart failure, deafness, and excessiv e bleeding during surgery as a result of hy perv ascular bone. 1 500. Non-tum or causes of elev ated prolactin lev els are ty pically associated with lev els less than 1 00 ng/dL (1 00 m g/L). 1 501 . Psy chotropic m edications m ay raise serum prolactin lev els m odestly ; patients with hy perprolactinem ia and sev ere psy chiatric illnesses requiring continued therapy with psy chotropic agents can be treated with estrogen- and progesterone-containing oral contraceptiv es to restore norm al m enses and prev ent bone loss 1 502 . Prim ary hy pogonadism in a y oung m ale m ay be due to Klinefelter's sy ndrom e; therefore, any y oung m ale with a high serum FSH lev el should hav e a kary oty pe study . 1 503 . The m ost sensitiv e screening test for prim ary aldosteronism is the plasm a aldosterone-plasm a renin activ ity ratio. 1 504 . Secondary causes of hy pertension include prim ary aldosteronism , acrom egaly , pheochrom ocy tom a, and Cushing's sy ndrom e. 1 505. During a norm al pregnancy , thy roid horm one production m ust be increased to prov ide thy roid horm one to the dev eloping fetus; m ost wom en who are taking thy roid horm one replacem ent require a 3 0% to 50% increase in their thy roid horm one dose during their pregnancy . 1 506 . Risk factors for gestational diabetes m ellitus include obesity , a fam ily history of ty pe 2 diabetes, and a history of gestational

diabetes in prev ious pregnancies. 1 507 . The diagnosis of gestational diabetes m ellitus requires any two of the following four v alues in a 3 -h, 1 00-g oral glucose tolerance test: fasting equal or m ore than 95 m g/dL (5.2 7 m m ol/L); 1 -h equal or m ore than 1 80 m g/dL (9.9 9 m m ol/L); 2 -h equal or m ore than 55 m g/dL (3 .05 m m ol/L); 3 -h equal or m ore than 1 4 0 m g/dL (7 .7 7 m m ol/L). 1 508. Therapy for gestational diabetes m ellitus consists of restricted diet, with insulin if gly cem ic target v alues are not achiev ed. 1 509 . In hy percalcem ia secondary to production of parathy roid horm one-related peptide by a carcinoid, the serum parathy roid horm one lev el is suppressed. 1 51 0. In patients with Grav es' ophthalm opathy and blurry v ision, the presence of an afferent pupillary defect (Marcus Gunn pupil) and greatly dim inished unilateral v isual acuity suggest optic nerv e im pingem ent by enlarged extraocular m uscles. 1 51 1 . Parathy roidectom y causes rapid im prov em ent in the bone m ineral density in patients with osteoporosis associated with prim ary hy perparathy roidism . 1 51 2 . The use of antiresorptiv e agents is not recom m ended in osteoporosis secondary to prim ary hy perparathy roidism . 1 51 3 . Obese, insulin-resistant m en generally hav e a reduced serum total testosterone concentration, prim arily as a result of a low sex-horm one binding globulin concentration. 1 51 4 . Orthostatic hy potension is a com m on m anifestation of diabetic autonom ic neuropathy , reflecting loss of norm al v asoconstrictor tone, with deranged com pensation to upright posture. 1 51 5. Fludrocortisone therapy expands the plasm a v olum e, thereby raising blood pressure and im prov ing sy m ptom s in diabetic autonom ic neuropathy . 1 51 6 . After biochem ical confirm ation of prim ary aldosteronism , localization procedures differentiate aldosterone-producing adenom as from bilateral adrenal hy perplasia; aldosteronism producing adenom as are am enable to laparoscopic resection, whereas bilateral adrenal hy perplasia is m edically treated. 1 51 7 . Radiographic im aging rarely differentiates aldosteroneproducing adenom as from bilateral adrenal hy perplasia in patients with prim ary aldosteronism . 1 51 8. Intestinal calcium absorption is reduced and osteoclastic activ ity is increased in hy perthy roidism , and the high lev els of free

T4 and free T3 likely produce hy percalcem ia through excessiv e osteoclastic activ ity . 1 51 9 . Hy percalcem ia associated with thy rotoxicosis usually resolv es when the patient becom es euthy roid. 1 52 0. Exogenous testosterone suppresses sperm production, resulting in infertility . 1 52 1 . Treatm ent with exogenous testosterone at norm al doses does not norm ally cause perm anent infertility , but restoration of sperm production requires gonadotropins. 1 52 2 . Silent thy roiditis is an autoim m une disorder characterized by high lev els of antithy roid peroxidase antibodies, painless enlargem ent of the thy roid gland, and a triphasic course with early thy rotoxicosis followed by hy pothy roidism and then a return to euthy roidism in m ost patients. 1 52 3 . Most patients with interferon alfaassociated thy roid dy sfunction recov er after the drug is discontinued. 1 52 4 . Hy popituitarism is a frequent outcom e of patients treated with irradiation of the thy roid gland. 1 52 5. In a patient with hy popituitarism , docum entation and therapy of adrenal insufficiency takes priority ov er other anterior pituitary horm onal deficiencies. 1 52 6 . Infection is a com m on precipitant of m y xedem a com a, and pan-culture and em piric antibiotic therapy with broad-spectrum antibiotics is recom m ended for all affected patients. 1 52 7 . Signs of androgen excess (increased m uscle m ass, irritability , and pustular acne) with sm all testes and low serum testosterone and gonadotropins in a y oung m ale suggest androgenic anabolic steroid abuse. 1 52 8. In patients with m acroprolactinom a and norm al v isual fields, dopam ine agonist therapy effectiv ely reduces prolactin secretion and tum or size. 1 52 9 . ACE inhibitors reduce album inuria and retard the progression of renal disease in diabetic patients with and without hy pertension. 1 53 0. Angiotensin II receptor blockers prev ent progression of nephropathy in patients with ty pe 2 diabetes and m acroalbum inuria and hy pertension. 1 53 1 . Breast enlargem ent in a y oung m an occurs m ost com m only with drugs or substances or alterations in the androgen/estrogen ratioeither androgen deficiency or estrogen excess

1 53 2 . High concentrations of hCG in a m an suggest the diagnosis of choriocarcinom a, an aggressiv e germ cell tum or. 1 53 3 . The m easurem ent of insulin-like growth factor 1 is m ore sensitiv e than serum growth horm one m easurem ents for acrom egaly in patients with a high pretest probability for acrom egaly . 1 53 4 . Corticosteroid therapy results in a decrease in intestinal calcium absorption and an increase in urinary calcium excretion; secondary hy perparathy roidism occurs. 1 53 5. The prev ention and treatm ent of corticosteroid-induced osteoporosis includes calcium and v itam in D supplem entation, a DEXA scan at the initiation of therapy , and bisphosphonates in patients taking prednisone equal or m ore than 5 m g/d (or its equiv alent) for m ore than 3 m onths. 1 53 6 . As m any as 3 % of patients with poorly controlled diabetes m ellitus (hem oglobin A1 c m ore than 8.0%) hav e Cushing's sy ndrom e. 1 53 7 . The treatm ent of choice for a nonfunctioning pituitary adenom a is transsphenoidal tum or resection. 1 53 8. Benign adrenal adenom as are hom ogenous and hav e sm ooth borders and attenuation v alues of less than 1 0 Hounsfield units on unenhanced CT. 1 53 9 . The classic presentation of thy roid ly m phom a is an elderly wom an with autoim m une thy roiditis and a rapidly expanding thy roid m ass. 1 54 0. Latent autoim m une diabetes of adulthood (LADA) occurs in lean patients with initially apparent ty pe 2 diabetes who becom e insulin-dependent later in life and exhibit the labile gly cem ic tendencies and m any of the autoim m une m arkers of patients with ty pe 1 diabetes. 1 54 1 . Latent autoim m une diabetes of adulthood (LADA) is characterized by slowly progressiv e loss of beta-cell function, leading to sev ere insulin deficiency and labile gly cem ic control. 1 54 2 . Patients with latent autoim m une diabetes of adulthood (LADA) becom e refractory to oral agents and as insulin-dependent and ketosis-prone as patients with ty pe 1 diabetes. 1 54 3 . Pericardial effusion is a consequence of m oderate to sev ere hy pothy roidism and is indicated by dim inished heart sounds, low v oltage on electrocardiography , and an enlarged cardiac silhouette. 1 54 4 . The hy pothy roid heart refers to decreased

contractility and pulse rateboth contributing to a decreased cardiac output at a tim e when peripheral v ascular resistance is increased. 1 54 5. In a patient with acrom egaly based on elev ated serum insulin-like growth factor 1 and growth horm one lev els, MRI of the head is indicated to identify and characterize the causativ e pituitary tum or. 1 54 6 . Multiple endocrine neoplasia ty pe 1 is characterized by pituitary tum ors, pancreatic islet tum ors, and hy perparathy roidism due to parathy roid hy perplasia. 1 54 7 . Fam ilial hy perparathy roidism , which is alm ost alway s due to parathy roid hy perplasia, is treated with subtotal parathy roidectom y in which 3 parathy roid glands are rem ov ed. 1 54 8. Chem otherapy with alky lating agents often induces irrev ersible dam age to sperm production in y oung m en. 1 54 9 . Subacute thy roiditis is characterized by a prodrom e of arthralgias, m alaise, and anorexia followed by pain in the thy roid bed and thy rotoxicosis. 1 550. Teriparatide (recom binant hum an parathy roid horm one [1 -3 4 ]) stim ulates osteoblastic bone form ation; it significantly increases bone m ass in patients with osteoporosis and can decrease the incidence of both v ertebral and nonv ertebral fractures. 1 551 . Kallm an's sy ndrom e is X-linked hy pothalam ic hy pogonadism accom panied by anosm ia. 1 552 . In patients with diabetes and sev erely im paired beta-cell secretory capacity , basal insulin is effectiv e on fasting glucose but cannot adequately control post-prandial glucose. 1 553 . The ov erall goal of therapy for acrom egaly is norm alization of the serum growth horm one and insulin-like growth factor 1 lev els. 1 554 . An increased dose requirem ent for lev othy roxine m ay occur as due to m alabsorption (for exam ple, celiac disease), accelerated m etabolism , or an increased occupancy of binding proteins 1 555. Most adrenal nodules are horm onally silent and hav e no m alignant potential. 1 556 . Patients with an incidentally detected adrenal m ass should be screened for pheochrom ocy tom a, Cushing's sy ndrom e, and prim ary aldosteronism . 1 557 . In a patient with norm al ov ulation but autoim m une disease and repeated fetal loss, ev aluation for a hy percoagulable state is indicated.

1 558. In patients with concom itant autoim m une adrenal and thy roid failure (Schm idt's sy ndrom e), adrenal failure is often unrecognized initially ; as thy roxine deficiency is corrected, the patient dev elops clinical adrenal insufficiency , requiring glucocorticoid supplem entation. 1 559 . Testosterone therapy does not cause prostate cancer but can stim ulate the growth of occult tum ors. 1 56 0. In patients beginning testosterone therapy , a rectal exam ination of the prostate gland before the first dose and the serum prostate-specific antigen should be m easured at 3 , 6, and 1 2 m onths after the start of therapy . 1 56 1 . Vitam in D deficiency m ust be corrected before starting other activ e osteoporosis therapy because the response to the therapy will be im paired by the defectiv e m ineralization associated with v itam in D deficiency and osteom alacia. 1 56 2 . Prediabetes gly cem ic states consist of im paired glucose tolerance, defined as a 2 -hour glucose lev el of 1 4 0-1 9 9 m g/dL (7 .7 7 -1 1 .04 m m ol/L) during an oral glucose tolerance test, and im paired fasting glucose, defined as a fasting glucose lev el of 1 00-1 2 5 m g/dL (5.55-6 .9 4 m m ol/L). 1 56 3 . Narcotics suppress gonadotropins and testosterone production. 1 56 4 . The m ajor storage form of v itam in D in the body is 2 5-dihy droxy v itam in D, and therefore this is the best test to assess for v itam in D deficiency . 1 56 5. In a short y oung wom an with prim ary am enorrhea, ev en in the absence of associated stigm ata and com orbidities, Turner's sy ndrom e (or m osaic) is the m ost likely diagnosis. 1 56 6 . High-risk patients with obesity and m etabolic sy ndrom e can m ost effectiv ely reduce their risk of dev eloping ty pe 2 diabetes with a conscientious lifesty le m odification program consisting of diet, exercise, and weight loss. 1 56 7 . The two causes of central hy perthy roidism are a TSH-producing adenom a and the resistance to thy roid horm one sy ndrom e. 1 56 8. The two causes of central hy perthy roidism , TSH-producing adenom a and the resistance to thy roid horm one sy ndrom e, can be distinguished by m easuring TSH subunit. 1 56 9 . Testosterone stim ulates production of ery thropoietin, and the hem atocrit and ery throcy te indices rise significantly during testosterone replacem ent therapy .

1 57 0. The som atostatin analogue, octreotide, reduces growth horm one production and shrinks tum or in patients with acrom egaly and is first-line therapy for patients not cured by surgery alone or surgery com bined with radiation 1 57 1 . The hum oral m ediator of hy percalcem ia of m alignancy in m ost cases, especially in lung cancer, is parathy roid horm onerelated peptide (PTHrp), which is secreted by the tum or. 1 57 2 . In gonadotropinom a, the gonadotropins are often detected on im m unostaining of the surgical specim en but are rarely secreted into the bloodstream in m eaningful am ounts.

Pulm onology and critical care 1 57 3 . In a patient taking high-dose inhaled corticosteroids as part of therapy for persistent asthm a whose disease is stable, reducing the dose of corticosteroids should be considered to prev ent therapy related side effects. 1 57 4 . High-resolution com puted tom ographic scanning (HRCT) is m ore sensitiv e than plain chest radiography for detecting interstitial lung disease and m ore specific for the potential diagnoses. 1 57 5. In hepatic hy drothorax, underly ing cirrhosis results in usually right-sided pleural effusion that is transudativ e as a result of hy poalbum inem ia and reduced serum oncotic pressure. 1 57 6 . In patients with sev ere sepsis from nosocom ial pneum onia, the v entilator should be adjusted by using a protectiv e lung strategy with 6 m L/kg of ideal body weight and a plateau pressure less than 3 0 cm H2 O. 1 57 7 . Low-dose dopam ine has been shown to be of no benefit in critically ill patients with early renal dy sfunction. 1 57 8. Interm ittent pneum atic com pression is effectiv e prophy laxis in patients at m oderate to high risk for v enous throm bosis in whom heparin and low-m olecular-weight heparin are contraindicated. 1 57 9 . Inadequate am ount of sleep is the m ost com m on cause of day tim e som nolence in y oung adults; im prov ed sleep hy giene and increased am ount of sleep are the initial m anagem ent. 1 580. Noninv asiv e positiv e pressure v entilation in selected patients with m oderate respiratory distress has been shown to im prov e heart

and respiration rates, gas exchange; and to reduce m orbidity and m ortality rates, the need for intubation, and the length of hospital stay . 1 581 . Contraindications to noninv asiv e positiv e pressure v entilation in patients with m oderate respiratory distress include excessiv e secretions, uncooperativ eness, and acute ischem ic changes on electrocardiography . 1 582 . The diagnosis of rhabdom y oly sis is based on clinical findings and a history of a predisposing factor(s) and confirm ed by the presence of m y oglobinuria, an increased serum creatine kinase, and hy perkalem ia. 1 583 . Early aggressiv e fluid therapy is essential in rhabdom y oly sis to counteract fluid loss from sequestration into dam aged m uscle and to increase renal perfusion. 1 584 . The diagnostic y ield of current im aging and biopsy m ethods in v ery sm all incidentally detected pulm onary lesions is v ery sm all. 1 585. Incidentally detected v ery sm all pulm onary lesions should be m onitored periodically to detect signs of growth com patible with lung cancer. 1 586 . The clinical presentation of hy persensitiv ity pneum onitis is ty pically recurrent acute episodes of fev er, cough, and dy spnea that begin 4 to 6 hours after antigen exposure and resolv e spontaneously 2 4 to 4 8 hours after antigen av oidance. 1 587 . Rev ersible airflow obstruction is a nonspecific finding that can occur with asthm a, postinfectious bronchial hy perreactiv ity , endotoxin inhalation, or hy persensitiv ity pneum onitis 1 588. In patients with persistent asthm a not adequately controlled with daily low- or m oderate-dose inhaled corticosteroids, adding a long-acting -agonist im prov es asthm a control and quality of life. 1 589 . In idiopathic pulm onary fibrosis, a characteristic HRCT pattern is seen in approxim ately 50% of patients and the extent of disease on HRCT is a predictor of surv iv al. 1 59 0. Patients with sev ere sepsis and refractory shock despite adequate fluid resuscitation should be treated with replacem ent-dose corticosteroids. 1 59 1 . High-dose corticosteroid therapy is ineffectiv e and m ay be harm ful in patients with sev ere septic shock and relativ e adrenal insufficiency . 1 59 2 . Pleural effusion in tuberculosis is usually associated with a ly m phocy tic pleocy tosis.

1 59 3 . Tuberculous pleural effusion m ost often dev elops from a cell-m ediated im m une response to tuberculosis antigens. 1 59 4 . In patients with potentially operable non-sm all-cell lung cancer, pulm onary function tests are indicated to assess pulm onary reserv e. 1 59 5. Brain scan and bone scan are needed in patients with potentially operable non-sm all-cell lung cancer. 1 59 6 . Unfractionated and low-m olecular-weight heparins reduce the risk of clinically im portant v enous throm boem bolism in critically ill patients by up to 60%. 1 59 7 . Aspirin has not been shown to reduce the incidence of throm boem bolism in m ost populations at risk. 1 59 8. In patients with cardiogenic pulm onary edem a, continuous positiv e airway pressure (CPAP) and noninv asiv e positiv e pressure v entilation (NPPV) m ore rapidly im prov e dy spnea, v ital signs and gas exchange, and av oid intubation m ore effectiv ely than oxy gen supplem entation plus standard therapy . 1 59 9 . The standard of practice to determ ine the optim al continuous positiv e airway pressure lev el to m anage obstructiv e sleep apnea is an attended laboratory poly som nography with CPAP pressure titration. 1 6 00. The goal of therapy for hy pertensiv e crisis is not to decrease the blood pressure to norm al lev els but to prev ent further end-organ dam age; precipitous reduction of blood pressure increases the risk for cerebral, cardiac, and renal ischem ia. 1 6 01 . In prospectiv ely ev aluation by HRCT, up to 6 0% of patients with rheum atoid arthritis hav e radiographic abnorm alities consistent with interstitial lung disease. 1 6 02 . In drug-induced interstitial lung disease, there are not specific pathologic patterns that would prov ide a definitiv e diagnosis. 1 6 03 . In patients with v ocal cord dy sfunction, oxy gen saturation is norm al during an acute exacerbation; lary ngoscopy during an exacerbation shows adduction of the v ocal cords during inspiration. 1 6 04 . Treatm ent of hepatic hy drothorax is directed to m anagem ent of cirrhosis and ascites with salt restriction and diuretic therapy . 1 6 05. Sy m ptom s of anaphy laxis include flushing, urticaria, conjunctiv al pruritus, bronchospasm , nausea, and v om iting which dev elop within 3 0 m inutes to 1 hour after the offending antigen is injected or up to 2 hours after the antigen is ingested. 1 6 06 . Patients with m oderate to sev ere anaphy laxis should be

m onitored for at least 1 2 hours for a possible late recurrence (biphasic anaphy laxis) 1 6 07 . Risk factors for noninv asiv e v entilatory failure include the acute respiratory distress sy ndrom e (ARDS) or sev ere com m unity acquired pneum onia, PaO2 /FiO2 ratio less than 1 4 6 , and age greater than 4 0 y ears. 1 6 08. The CAM-ICU, a clinical instrum ent for use in ev aluating a patient in the intensiv e care unit for delirium , takes less than a m inute and is recom m ended for all m echanically v entilated patients. 1 6 09 . Pregnant wom en with deep v enous throm boem bolism or pulm onary em bolism are treated with either unfractionated heparin or a low-m olecular-weight heparin during the pregnancy and for 6 weeks post partum . 1 6 1 0. Silicosis with sm all nodules in the lungs on radiographs is not associated with sy m ptom s or phy siologic abnorm alities, but continued exposure and dev elopm ent of progressiv e m assiv e fibrosis causes disabling sy m ptom s. 1 6 1 1 . Screening for lung cancer with chest radiography or sputum cy tology does not lower lung cancer m ortality in the screened population and is not indicated. 1 6 1 2 . The anti-Xa test is a sensitiv e m arker for anticoagulant activ ity of low-m olecular-weight heparins and fondaparinux. 1 6 1 3 . More than 9 0% of patients with sarcoidosis hav e pulm onary inv olv em ent that is m anifest radiographically as hilar and m ediastinal ly m phadenopathy , with or without parenchy m al disease. 1 6 1 4 . Treatm ent of sarcoidosis is generally reserv ed for those with disabling sy m ptom s, ev idence for progressiv e lung disease, extrapulm onary disease, or com plications such as hy percalcem ia. 1 6 1 5. Patients with radiographic stage 1 sarcoidosis (hilar and/or m ediastinal ly m phadenopathy without infiltrates) and no sy stem ic sy m ptom s hav e spontaneous rem ission rates of 50% to 9 0%. 1 6 1 6 . Exposure to nerv e agents causes a cholinergic crisis by inhibiting cholinesterase and causing m uscarinic, nicotinic, and central nerv ous sy stem effects. 1 6 1 7 . Pralidoxim e (2 -PAM) reactiv ates acety lcholinesterase, and can rev erse the m uscle weakness, paraly sis, and respiratory depression caused by exposure to nerv e agents. 1 6 1 8. Predictors of failure of noninv asiv e v entilation in patients

with an exacerbation of COPD include a respiration rate m ore than 3 5/m in, APACHE score m ore than 2 9 , pH less than 7 .2 5, and Glasgow com a score less than 1 1 . 1 6 1 9 . Patients with predom inant supine-dependent sleep apnea can be m anaged initially with a trial of restricting sleep to lateral recum bency . 1 6 2 0. The adv anced cardiac life support guidelines state that a single dose of v asopressin can be adm inistered as a one-tim e alternativ e to epinephrine in patients with v entricular fibrillation or pulseless v entricular tachy cardia. 1 6 2 1 . In patients with v entricular fibrillation or pulseless v entricular tachy cardia, the guidelines for adv anced cardiac life support recom m end the following sequence of interv entions: defibrillation, COTE [cardiopulm onary resuscitation, oxy gen, tubes (endotracheal and intrav enous), epinephrine (or v asopressin)], and m ore defibrillation. 1 6 2 2 . D-dim er reflects the presence of throm bosis (or inflam m ation), but does not reflect the activ ity of throm bosis. 1 6 2 3 . Hy pocapnia is the cause of central sleep apnea in patients with Chey ne-Stokes respiration. 1 6 2 4 . A short course of oral corticosteroids m ay help restore asthm a control in prev iously well-controlled patients who hav e dev eloped unstable disease as a result of a respiratory tract infection 1 6 2 5. Daily hem odialy sis has been shown to significantly reduce in-hospital deaths in patients with acute renal failure in surgical and m edical intensiv e care units. 1 6 2 6 . Inhaled corticosteroids with as-needed albuterol is the cornerstone of therapy for persistent asthm a. 1 6 2 7 . In a patient with sev ere COPD and respiratory failure with sev ere carbon dioxide retention, inappropriately high rate and tidal v olum e of m echanical v entilation can cause 1 ) excessiv ely rapid reduction in PaCO2 potentially causing sev ere alkalem ia and 2 ) the induction of dy nam ic hy perinflation leading to a sev ere elev ation of intrinsic positiv e end-expiratory pressure (auto-PEEP). 1 6 2 8. Helical CT scanning without contrast enhancem ent is not sensitiv e for diagnosing pulm onary em bolism . 1 6 2 9 . In a patient presenting with likely adv anced m etastatic lung cancer, a biopsy of an accessible site should be done to confirm the diagnosis of m etastatic disease with a m inim um of discom fort, risk, and expense.

1 6 3 0. Lung disease is the m ost com m on cause of m orbidity and m ortality in sy stem ic sclerosis. 1 6 3 1 . In scleroderm a, both interstitial lung disease and pulm onary hy pertension can dev elop (both independently or together) and hav e an adv erse effect on outcom e. 1 6 3 2 . Pulm onary disease can be the initial clinical m anifestation of scleroderm a. 1 6 3 3 . In a patient with potential sm oke inhalation injury , the presence of facial burns, soot in the m outh, carbonaceous sputum , or singed nasal hairs m ay correlate with upper airway injury and a high risk of delay ed airway com prom ise from edem a. 1 6 3 4 . Approxim ately one fifth of adult patients with cy stic fibrosis dev elop pneum othorax at som e tim e in their liv es. 1 6 3 5. Tube thoracostom y is the preferred treatm ent for secondary pneum othorax. 1 6 3 6 . Patients with cy stic fibrosis hav e a high rate of recurrent pneum othorax; therefore, parietal pleurectom y , pleural abrasion, and thoracoscopy with talc pleurodesis are reasonable interv entions after initial m anagem ent of the pneum othorax with tube thoracostom y . 1 6 3 7 . Placem ent of a pulm onary artery catheter in critically ill ICU patients has not been shown to hav e a benefit on m ortality or other outcom es. 1 6 3 8. The diagnosis of the acute respiratory distress sy ndrom e (ARDS) requires a PaO2 /FiO2 less than 2 00 in com bination with bilateral infiltrates and the absence of other ev idence for congestiv e heart failure. 1 6 3 9 . The lung protectiv e strategy for intubation in patients with ARDS consists of the tidal v olum e at 6 m L/kg ideal body weight and plateau pressure kept less than 3 0 cm H2 O. 1 6 4 0. Nocturnal pulse oxim etry can docum ent nocturnal hy poxem ia causing pulm onary hy pertension in patients with obstructiv e lung disease. 1 6 4 1 . Intrav enous heparin has im m ediate onset of action and has a half-life of under an hour after discontinuation. 1 6 4 2 . Low-m olecular-weight heparins and fondaparinux hav e onset of action within about a half hour of subcutaneous adm inistration, and the effect lasts throughout m uch of the subsequent day . 1 6 4 3 . The characteristic features of allergic bronchopulm onary aspergillosis include m oderate to sev ere persistent asthm a,

bronchiectasis and chest radiographic abnorm alities, elev ated serum IgE, eosinophilia, and a positiv e skin test to Aspergillus fum igatus. 1 6 4 4 . The pathologic pattern nonspecific interstitial pneum onitis (NSIP) can occur in v arious clinical disorders, including infections, drug reactions, hy persensitiv ity pneum onitis, and connectiv e tissue diseases. 1 6 4 5. Patients in the intensiv e care unit generally require 2 5 to 3 0 nonprotein kcal/kg/d and 1 .0 to 1 .5 protein kcal/kg/d to m eet the energy expenditures associated with critical illness 1 6 4 6 . In patients with adv anced neurom uscular disease, inspiratory capacity is too sm all for an adequate cough, and cough assistance m ay be required in such patients with upper respiratory tract infection. 1 6 4 7 . Clinical findings of cocaine toxicity include tachy cardia, hy pertension, hy pertherm ia, m y driasis, agitation, and psy chosis. 1 6 4 8. Hy pertension in cocaine toxicity usually responds to control of agitation. 1 6 4 9 . The Churg-Strauss sy ndrom e is a sm all-v essel v asculitis ty pically associated with significant eosinophilia, pulm onary infiltrates in the setting of asthm a, the use of a leukotriene receptor antagonist, and withdrawing oral corticosteroids. 1 6 50. Extubation to noninv asiv e v entilation has been shown to im prov e outcom es in carefully selected intubated COPD patients who fail spontaneous breathing trials. 1 6 51 . Exercise-induced asthm a is confirm ed by exercise challenge (to m ore than 85% of m axim al predicted heart rate) with post-exercise spirom etry showing a 2 0% fall in FEV1 . 1 6 52 . Treatm ent with short-acting inhaled -agonists 5 to 1 0 m inutes before exercise prev ents exercise-induced asthm a in > 80% of patients. 1 6 53 . Metabolic signs of salicy late toxicity include respiratory alkalosis, anion gap m etabolic acidosis, and hy pertherm ia; other signs and sy m ptom s include depressed lev el of consciousness, noncardiogenic pulm onary edem a, prolonged prothrom bin tim e, hepatic toxicity , and hy pogly cem ia. 1 6 54 . Managem ent of salicy late toxicity includes alkalinization of urine to enhance excretion of salicy lates and hem odialy sis for sev ere toxicity . 1 6 55. Enoxaparin is cleared by the kidney , and if used in patients

with chronic kidney disease, therapeutic drug m onitoring is required for possible dosage adjustm ent. 1 6 56 . Malignant pleural effusions are ty pically ly m phocy tic and are usually exudativ e. 1 6 57 . Pleural fluid ery throcy te counts m ore than 1 00,000/L (1 00 1 09/L), when not associated with traum a or pulm onary infarction, are suggestiv e of pleural m alignancy . 1 6 58. In patients with neurom uscular disease and chronic hy pov entilation, noninv asiv e m echanical v entilation is required to m aintain v entilation during sleep. 1 6 59 . Metastasectom y is indicated in patients with m ultiple lung m etastases who hav e a resectable prim ary tum or, a low likelihood of other m etastases, and norm al pulm onary function. 1 6 6 0. No m edical therapy has been shown to clearly alter the natural history of idiopathic pulm onary fibrosis. 1 6 6 1 . Lung transplantation has been shown to im prov e surv iv al, quality of life, and functional status in patients with end-stage fibrotic lung disease. 1 6 6 2 . Adm inistration of ty pe A equine antitoxin within 1 2 hours of diagnosis of wound botulism m ay significant shorten the duration of m echanical v entilation. 1 6 6 3 . In a patient with acute sev ere asthm a, prom pt adm inistration of aerosolized bronchodilators is indicated after sy stem ic corticosteroid therapy is started. 1 6 6 4 . Approxim ately 80% of effusions associated with pulm onary em boli are exudativ e, usually sm all and unilateral, and tend not to be progressiv e or to persist bey ond 7 day s after form ation. 1 6 6 5. In m ost patients treated with heparin for pulm onary em bolism , a substantial portion of their perfusion defects resolv e within the first week. 1 6 6 6 . CT scanning to follow the resolution of pulm onary em bolism is not well standardized. 1 6 6 7 . No specific therapy is indicated for asy m ptom atic bronchial hy perresponsiv eness. 1 6 6 8. The co-presence of focal areas of fat and calcium are v irtually pathognom onic of ham artom a. 1 6 6 9 . Malignant lung lesions tend to hav e a doubling tim e of between 3 0 and 4 00 day s; benign lesions double in less than 3 0 day s or ov er v ery long periods of slow growth. 1 6 7 0. Patients with anaerobic bacterial infection inv olv ing the

pleural space usually hav e subacute presentations with weight loss and a history of alcoholism , unresponsiv eness, possible aspiration, and poor oral hy giene. 1 6 7 1 . Fibrinoly tic therapy m ay be considered in patients with em py em a who are poor surgical candidates. 1 6 7 2 . Organizing pneum onia is a pathologic pattern of lung injury that can occur in v arious settings, including infections, connectiv e tissue diseases, and as a com plication of treatm ents, such as am iodarone or radiation therapy . 1 6 7 3 . Urinary Legionella pneum ophila antigen test should be done in patients with suspected Legionella pneum onia. 1 6 7 4 . Early therapy with azithrom y cin plus ceftriaxone is considered adequate initial cov erage for a sev ere com m unity acquired pneum onia. 1 6 7 5. A history of orthopnea, abdom inal paradox, and a decrease in forced v ital capacity m ore than 2 5% when the patient goes from the upright to supine position are diagnostic of diaphragm paraly sis. 1 6 7 6 . Patients with hy pov entilation secondary to diaphragm paraly sis should be treated with nocturnal noninv asiv e positiv e airway pressure to augm ent their v entilation during sleep. 1 6 7 7 . Clinical findings in hy drogen cy anide toxic #3

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triplehelix - 01-12-09 23:56 1 6 7 7 . Clinical findings in hy drogen cy anide toxicity include com a, hy potension, cardiac irritability , and profound anion gap m etabolic acidosis in the setting of adequate v olum e resuscitation and oxy gen adm inistration. 1 6 7 8. The treatm ent for cy anide poisoning is intrav enous sodium thiosulfate. 1 6 7 9 . In patients with sev ere sepsis, early goal-directed therapy within the first 6 hours to m aintain a central v enous oxy gen saturation of m ore than 7 0% and to resolv e lactic acidosis im prov es surv iv al ov er m ore delay ed resuscitation attem pts. 1 6 80. Acute m ountain sickness is characterized by poor sleep, anorexia, fatigue, nausea, and v om iting. 1 6 81 . Acetazolam ide taken for 2 day s before ascent to high altitude is effectiv e prophy laxis for acute m ountain sickness.

1 6 82 . Diffuse alv eolar hem orrhage is characterized by dy spnea and diffuse alv eolar infiltrates; it can be the initial m anifestation of prim ary or secondary pulm onary v asculitis, drug reactions, coagulation disorders, and infection. 1 6 83 . The diagnosis of diffuse alv eolar hem orrhage is m ade with bronchoalv eolar lav age, with serial sam plings showing a persistently bloody fluid. 1 6 84 . Malignant hy pertherm ia is a life-threatening inherited skeletal m uscle disorder characterized by a hy perm etabolic state precipitated by exposure to v olatile inhalational anesthetics and depolarizing m uscle relaxants. 1 6 85. Heparin, low-m olecular-weight heparins, and fondaparinux all cataly ze antithrom bin to neutralize clotting enzy m es, and these drugs can be assay ed by incubation of the patient's plasm a with activ ated factor Xa. 1 6 86 . The reactiv e airway dy sfunction sy ndrom e follows a single, accidental inhalation of high lev els of a nonspecific respiratory irritant in patients who ty pically do not hav e a history of asthm a. 1 6 87 . The diagnosis of the reactiv e airway s dy sfunction sy ndrom e is based on history and confirm ed by positiv e m ethacholine challenge. 1 6 88. The m ost com m on causes of chy lothorax are cancer and traum a; other causes are pulm onary tuberculosis, chronic m ediastinal infections, sarcoidosis, ly m phangioleiom y om atosis, and radiation fibrosis. 1 6 89 . In a com petent, sev erely ill patient in the ICU with a treatable condition but a clearly expressed preference for com fort m easures rather than m ore aggressiv e interv ention, com fort m easures to prov ide good end-of-life care should be prov ided 1 6 9 0. Although a fixed therapeutic dose of subcutaneous heparin m ay be appropriate for treatm ent of deep v enous throm bosis and pulm onary em bolism , aPTT m onitoring and dose adjustm ent are required for patients at high risk of bleeding. 1 6 9 1 . Renal ultrasound with renal artery Doppler exam ination prov ides anatom ic and functional assessm ent of the renal arteries, and has a sensitiv ity of 7 2 % to 92 % for renov ascular hy pertension. 1 6 9 2 . Idiopathic pulm onary fibrosis (IPF) is the m ost com m on of the idiopathic interstitial pneum onias, and by far m ore com m on than other m em bers of the group. 1 6 9 3 . Sarcoidosis, the m ost com m on interstitial lung disease, is a sy stem ic disorder and its radiographic presentation is generally

dom inated by m ediastinal and hilar adenopathy with or without parenchy m al changes. 1 6 9 4 . For v entilator-associated pneum onia m anifesting clinical resolution of sy m ptom s and signs of infection, radiologic im prov em ent, and requirem ent for less v entilatory support with im prov ing oxy genation, courses of no m ore than 8 day s of antibiotic therapy are associated with as good outcom es as longer courses. 1 6 9 5. Activ ated protein C has anticoagulant properties, and ev idence of activ e bleeding is a contraindication to its use in patients with sepsis. 1 6 9 6 . Patients with COPD m ay experience a fall in PaO2 of as m uch as 2 5 to 3 0 m m Hg during air trav el, and pre-flight assessm ent is useful to determ ine the need for in-flight oxy gen supplem entation with the goal of m aintaining PaO2 either at equal or m ore than 50 m m Hg or, in high risk patients, at the PaO2 with which the patient is clinically stable at sea lev el. 1 6 9 7 . The neuroleptic m alignant sy ndrom e is a rare, but potentially fatal, com plication of the adm inistration of neuroleptic (antipsy chotic) drugs such as haloperidol. 1 6 9 8. Acute hy poxem ia and sy stem ic hy potension in com bination with an increase in peak airway pressure and asy m m etric chest wall expansion are cardinal features of an acute tension pneum othorax 1 6 9 9 . In patients taking theophy lline as part of asthm a therapy , concom itant ciprofloxacin therapy can decrease theophy lline clearance in the liv er, increasing theophy lline blood lev els and leading to potential theophy lline toxicity . 1 7 00. Theophy lline clearance is decreased by v arious drugs as well as in the elderly and patients with congestiv e heart failure. 1 7 01 . Insertion of an inferior v ena cav a filter reduces the short-term incidence of pulm onary em bolism in patients being anticoagulated for deep v enous throm bosis. 1 7 02 . Lung transplant-related bronchiolitis obliterans, which is probably a form of chronic rejection, occurs in up to 50% of long-term surv iv ors of transplantation. 1 7 03 . The ty pical findings of lung transplant-related bronchiolitis obliterans include cough, dy spnea, early inspiratory crackles, and sev ere airflow obstruction. 1 7 04 . Obstructiv e sleep apnea can exacerbate nocturnal asthm a; CPAP therapy for sleep apnea can im prov e asthm a control.

1 7 05. Prom pt intubation is indicated in patients with sev ere pneum onia whose condition is deteriorating on conv entional therapy . 1 7 06 . Intubation rates are high in non-COPD patients with sev ere com m unity -acquired pneum onia treated with noninv asiv e v entilation. 1 7 07 . Hy pergly cem ia should be treated in critically ill patients with aggressiv e insulin therapy to m aintain tight gly cem ic control. 1 7 08. Interm ittent bolus dosing of sedativ es titrated v ia a v alidated sedation scale is consistent with the guidelines for the use of sedation in critically ill patients. 1 7 09 . Antipsy chotic agents m ay cause torsades de pointes in patients with prolonged QTc interv als. 1 7 1 0. Patients with ev idence of a phy siologically sev ere and progressiv e fibrosing lung disease should be referred early for ev aluation for lung transplantation. 1 7 1 1 . In patients with acute lung injury /ARDS on m echanical v entilation with a lung protectiv e strategy , PEEP should be increased in 2 - to 3 -cm H2 O increm ents to lower FiO2 to 6 0%, if possible, and to m aintain an arterial oxy gen saturation of 88% and 9 5% 1 7 1 2 . Vocal cord dy sfunction m im ics asthm a, but unlike asthm a, it begins and ends abruptly , does not respond to -agonists, and airflow lim itation is m ainly during inspiration. 1 7 1 3 . The ultrasound m ay be abnorm al for sev eral m onths after a deep v enous throm bosis, and the v enous wall does not return to norm al com pressibility at all in som e patients. 1 7 1 4 . The m ost com m on form of delirium in the ICU is hy poactiv e or quiet delirium . 1 7 1 5. Delirium is a form of acute brain dy sfunction that occurs in 50% to 80% of v entilated patients in the intensiv e care unit; it is associated with higher m ortality rates, longer hospital and ICU stay , higher costs, and chronic cognitiv e deficits. 1 7 1 6 . The cardinal features of delirium are 1 ) acute onset or fluctuations in m ental status ov er a 2 4 hour period, 2 ) inattention, 3 ) disorganization of thinking, and 4 ) an altered lev el of consciousness at the tim e of the ev aluation. 1 7 1 7 . Patients with potential healthcare-acquired pneum onia (HCAP) require initial cov erage for resistant organism s including m ethicillin-resistant Staphy lococcus aureus and Pseudom onas.

1 7 1 8. Segm ental perfusion defects in patients with right heart failure and right v entricular hy pertrophy strongly suggests the diagnosis of chronic throm boem bolic pulm onary hy pertension (CTEPH). 1 7 1 9 . Surgical pulm onary throm boendarterectom y can im prov e cardiac output, reduce m ortality , and enhance quality of life in patients with throm boem bolic pulm onary hy pertension (CTEPH) 1 7 2 0. Cry togenic organizing pneum onia is an idiopathic interstitial pneum onia that clinically resem bles a flulike sy ndrom e, and is characterized by crackles and patchy persistent infiltrates on chest radiograph, and restrictiv e lung defect with decrease in carbon m onoxide diffusing capacity . 1 7 2 1 . Inability to protect the airway because of im paired swallowing or cough function is a contraindication to the use noninv asiv e positiv e pressure v entilation. 1 7 2 2 . In a neurom uscular disease patient who cannot m anage airway secretions, sev ere restriction with a v ital capacity of less than 1 5-2 0 m L/kg is an indicator of the need for intubation. 1 7 2 3 . No drug is FDA-approv ed for the treatm ent of delirium , but clinical practice guidelines recom m end antipsy chotic agents, such as haloperidol. 1 7 2 4 . All antipsy chotics, and especially ty pical agents, pose a risk of torsades de pointes and extrapy ram idal side-effects as well as the m ore rare neuroleptic m alignant sy ndrom e. 1 7 2 5. Patient education and encouragem ent in the use of CPAP and m anagem ent of associated adv erse effects im prov es com pliance with CPAP in sev ere sleep apnea. 1 7 2 6 . A highly elev ated peak pulm onary artery pressure is consistent with pulm onary hy pertension, but not necessary to confirm the diagnosis and m ay be inaccurate for ev aluating sev erity . 1 7 2 7 . In patients in status asthm aticus, pulse oxim etry is a good m onitoring tool but is not a substitute for determ ining actual oxy genation by m easuring arterial blood gases. 1 7 2 8. The characteristic clinical features of interstitial lung disease are progressiv e dy spnea, diffuse radiographic pulm onary infiltrates, restrictiv e pulm onary phy siology , and oxy gen desaturation with exertion. 1 7 2 9 . In the correct clinical setting, bronchoscopy with bronchoalv eolar lav age can prov ide a specific diagnosis in

interstitial lung disease. 1 7 3 0. Epoprostenol is first-line therapy for patients with sev ere pulm onary hy pertension, and m ay be life-sav ing for patients in cor pulm onale. 1 7 3 1 . Bosentan causes pulm onary artery v asodilation and is associated with a reduction in m ortality in patients with pulm onary artery hy pertension 1 7 3 2 . Intubated patients should receiv e a tracheostom y as soon as it is deem ed unlikely that they will wean from m echanical v entilation within 2 1 day s. 1 7 3 3 . In patients with asthm a who hav e increased nocturnal sy m ptom s despite adequate day tim e control, a trial of gastric acid suppression therapy is warranted. 1 7 3 4 . In selected im m unosuppressed patients with respiratory failure, noninv asiv e positiv e pressure v entilation is associated with a lower m ortality rate than conv entional oxy gen therapy and intubation. 1 7 3 5. Hereditary hem orrhagic telangiectasia (HHT) is diagnosed clinically by the presence of three of the following four criteria: (1 ) recurrent epistaxis; (2 ) telangiectasias in the lips, oral cav ity , fingers, or nose; (3 ) v isceral lesions such as gastrointestinal telangiectasias, or arteriov enous m alform ations in the lung, liv er, or brain; and (4 ) first-degree relativ es with the sy ndrom e. 1 7 3 6 . The propofol infusion sy ndrom e in adults occurs prim arily in patients with acute neurologic or acute inflam m atory diseases com plicated by sev ere infection or sepsis, and receiv ing catecholam ines and/or corticosteroids in addition to propofol. 1 7 3 7 . The m ain features of the propofol infusion sy ndrom e are cardiac failure, rhabdom y oly sis, sev ere m etabolic acidosis, and renal failure associated with hy perkalem ia. 1 7 3 8. Noninv asiv e positiv e pressure v entilation can rev erse hy pov entilation and allev iate cor pulm onale in patients with obesity hy pov entilation sy ndrom e. 1 7 3 9 . Methacholine challenge testing is m ost useful in ev aluating patients with suspected asthm a but who has episodic sy m ptom s and norm al baseline spirom etry . 1 7 4 0. The diagnosis of cough-v ariant asthm a is suggested by the presence of airway hy perresponsiv eness and confirm ed when cough resolv es with asthm a therapy . 1 7 4 1 . A trial of inhaled albuterol can help control sy m ptom s and

confirm the diagnosis of cough-v ariant asthm a. 1 7 4 2 . Poor technique in the use of a m etered-dose inhaler (MDI) or other inhalation dev ices is a m ajor reason patients do not respond well to m edications. 1 7 4 3 . All patients with COPD who hav e interm ittent sy m ptom s should receiv e a short-acting bronchodilator. 1 7 4 4 . For patients with stage 3 COPD, especially those with frequent exacerbations, inhaled corticosteroids should be part of their regular therapy . 1 7 4 5. In the staging of patients with dy spnea for therapy , the post-bronchodilator FEV1 is m ost relev ant finding. 1 7 4 6 . A postbronchodilator FEV1 /FVC ratio greater than 7 0% indicates stage 0 (at risk) chronic obstructiv e pulm onary disease. 1 7 4 7 . Chronic obstructiv e pulm onary disease is corticosteroidinsensitiv e, and inhaled corticosteroids do not change the rate of FEV1 decline in affected patients. 1 7 4 8. In patients with COPD, cor pulm onale usually occurs in GOLD stage 3 or 4 in patients with an FEV1 equal or less than 1 L. 1 7 4 9 . In patients with end-stage chronic obstructiv e pulm onary disease, pulm onary rehabilitation im prov es sy m ptom s, exercise endurance, and quality of life. 1 7 50. Patients with GOLD stage 4 chronic obstructiv e pulm onary disease who hav e an acute exacerbation should be treated like patients with com m unity -acquired pneum onia.

Last part of the notes, now it is COMPLETE !! Nephrology : 1 7 51 . Sleep apnea is associated with resistant hy pertension and is particularly prev alent in obese patients. 1 7 52 . Hy pertension associated with sleep apnea m ay be related to insulin resistance, increased activ ity of the sy m pathetic nerv ous sy stem , and increased sodium retention. 1 7 53 . Referral to a nephrologist for education and ev aluation for consideration of preem ptiv e kidney transplantation is indicated for patients with chronic kidney disease when the glom erular filtration rate reaches the 3 0 m L/m in range 1 7 54 . Minim al change disease is the m ost com m on cause of the

nephrotic sy ndrom e in children and y oung adults. 1 7 55. The presence of num erous ov al fat bodies on urinaly sis is a hallm ark of a proteinuric state. 1 7 56 . Decreased thresholds for arginine v asopressin in norm al pregnancy cause relativ ely lower sodium lev els. 1 7 57 . Increased v asodilation in pregnancy is associated with a decreased blood pressure m easurem ent and an increased heart rate. 1 7 58. In norm al pregnancy , increases in the glom erular filtration rate and renal blood flow result in decreased creatinine and blood urea nitrogen lev els. 1 7 59 . The sudden dev elopm ent of hy perkalem ia in a patient on dialy sis m ay be a sign of tissue necrosis. 1 7 6 0. Abdom inal pain, hem atochezia, and lactic acidosis are suggestiv e of bowel infarction. 1 7 6 1 . HenochSchnlein purpura is a renalderm al v asculitis sy ndrom e that m ay present with interm ittent episodes of m ild abdom inal pain. 1 7 6 2 . Patients with chronic kidney disease hav e increased risk for acute renal failure because of their use of osm otic agents such as dextran 4 0, m annitol, and sucrose-containing preparations of intrav enous im m une globulin. 1 7 6 3 . Reduction in blood pressure has been shown to influence the progression of renal disease and the dev elopm ent of cardiov ascular disease in patients with diabetes. 1 7 6 4 . Dialy sis should be considered early in the course of tum or ly sis sy ndrom e in patients with oliguric acute renal failure. 1 7 6 5. Measurem ent of urine m icroalbum in is the screening test of choice for diabetic nephropathy . 1 7 6 6 . A 2 4 -hour urine collection is no longer recom m ended to assess kidney function or quantify proteinuria. 1 7 6 7 . Com bination therapy with angiotensin-conv erting enzy m e inhibitors and angiotensin receptor blockers m ay be m ore renoprotectiv e than single-agent therapy with either drug in patients with diabetic nephropathy . 1 7 6 8. An antiglom erular basem ent m em brane antibody assay is indicated to diagnose Goodpasture's sy ndrom e. 1 7 6 9 . In selected patients, am bulatory blood pressure m onitoring should be used to diagnose white coat hy pertension. 1 7 7 0. The sy ndrom e of inappropriate antidiuretic horm one secretion (SIADH) is defined as hy potonic hy ponatrem ia with a

urine osm olality m ore than 1 00 m osm /kg H2 O in the absence of v olum e depletion, adrenal insufficiency , congestiv e heart failure, hy pothy roidism , cirrhosis, and/or renal im pairm ent. 1 7 7 1 . The classical triad of acute interstitial nephritis (fev er, skin rash, and arthralgias) in the setting of acute or subacute renal failure is present in only a m inority of affected patients. 1 7 7 2 . The presence of a slowly progressiv e nephrotic sy ndrom e suggests the possibility of solid tum orassociated m em branous nephropathy 1 7 7 3 . Nonsteroidal anti-inflam m atory drugs can cause acute interstitial nephritis as well as prerenal acute renal failure through changes in local glom erular hem ody nam ics. 1 7 7 4 . Abdom inal CT or ultrasonography are the recom m ended im aging m odalities for uric acid stones. 1 7 7 5. Patients with progressiv e chronic kidney disease should be referred for creation of a perm anent v ascular dialy sis access when the glom erular filtration rate decreases below 3 0 m L/m in. 1 7 7 6 . Blood pressure m easurem ents in elderly patients who tolerate m edication poorly m ay be higher in the office than at hom e. 1 7 7 7 . In selected patients, am bulatory blood pressure m onitoring can exclude white coat hy pertension. 1 7 7 8. Am bulatory blood pressure m onitoring can detect sy m ptom s that m ay be related to excessiv e reduction of blood pressure. 1 7 7 9 . Elev ated blood pressure in early pregnancy is m ost likely caused by a chronic condition. 1 7 80. Glom erulonephritis, not preeclam psia, is the m ost likely diagnosis in patients with elev ated creatinine lev els and proteinuria early in pregnancy . 1 7 81 . Patients with m em branous nephropathy are at increased risk for renal v ein throm bosis. 1 7 82 . CT, MRI, or v enography is indicated to definitiv ely diagnose renal v ein throm bosis. 1 7 83 . Hy pertonic saline is not indicated for asy m ptom atic hy ponatrem ia. 1 7 84 . Focal segm ental glom erulosclerosis is the m ost com m on cause of the nephrotic sy ndrom e in black patients, particularly those of y ounger age. 1 7 85. Antiretrov iral therapy and plasm apheresis are indicated for patients with HIV infection and throm botic throm bocy topenic purpura.

1 7 86 . Listeria is a com m on cause of m eningitis in renal transplant recipients. 1 7 87 . Increasing dietary calcium intake to 1 g/d to 4 g/d decreases the risk for recurrent calcium oxalate stones. 1 7 88. High-protein and -sodium diets can worsen kidney stone disease by causing hy percalciuria and hy peruricosuria. 1 7 89 . A decrease in the bicarbonate lev el accom panied by an elev ated anion gap is consistent with a prim ary m etabolic acidosis. 1 7 9 0. In a patient with a prim ary m etabolic acidosis, a PCO2 that is m uch higher than would be expected based on the degree of acidem ia indicates a condition that is secondary to inadequate v entilation. 1 7 9 1 . Com pared with hem odialy sis therapy , renal transplantation offers a surv iv al adv antage in patients with diabetic nephropathy and end-stage renal disease. 1 7 9 2 . Renal transplantation is m ost beneficial in y oung people and in patients with diabetes m ellitus. 1 7 9 3 . Hy peraldosteronism should be considered in patients with difficult-to-control hy pertension and hy pokalem ia in the absence of diuretic use. 1 7 9 4 . Hy peraldosteronism should be considered in patients with difficult-to-control hy pertension ev en in the absence of hy pokalem ia. 1 7 9 5. The aldosteronerenin ratio is a reasonable screening study for prim ary hy peraldosteronism . 1 7 9 6 . Rhabdom y oly sis-associated acute renal failure presents with dipstick-positiv e hem aturia but no intact ery throcy tes on m icroscopic analy sis of the urine sedim ent. 1 7 9 7 . Heparin therapy inhibits aldosterone sy nthesis and therefore m ay cause hy perkalem ia. 1 7 9 8. The dev elopm ent of the nephrotic sy ndrom e in the setting of urinary reflux is m ost likely caused by focal segm ental glom erulosclerosis. 1 7 9 9 . The fractional excretion of sodium m ay be m ore than 4 % in patients with prerenal acute renal failure who use diuretics. 1 800. Patients with the nephrotic sy ndrom e are predisposed to dev elop deep v enous and renal v ein throm bosis. 1 801 . Staghorn calculi form as a result of chronic infections with urease-splitting organism s such as Proteus or Klebsiella. 1 802 . Stone rem ov al in struv ite stone disease often is indicated to

prev ent recurrence of infection and stone growth. 1 803 . Angiotensin-conv erting enzy m e inhibitor therapy has been shown to prev ent the dev elopm ent of m icroalbum inuria in patients who hav e diabetes and norm oalbum inuria. 1 804 . Microalbum inuria is the first clinical sign of diabetic nephropathy and a m ajor risk factor for the dev elopm ent of clinical proteinuria, chronic kidney disease progression, and cardiov ascular death. 1 805. The m ost com m on causes of prim ary hy peraldosteronism are aldosterone-producing adenom a (Conn's sy ndrom e) and bilateral adrenal hy perplasia. 1 806 . Hy potonic fluids should not be used postoperativ ely . 1 807 . Norm al saline (0.9 %) is the m ost appropriate intrav enous fluid when fluid therapy is indicated in the postoperativ e setting. 1 808. Sjgren's sy ndrom e is a com m on cause of interstitial nephritis. 1 809 . A collapsing form of focal segm ental glom erulosclerosis is the m ost likely diagnosis in black patients with HIV infection who hav e the nephrotic sy ndrom e. 1 81 0. Postinfectious glom erulonephritis associated with hepatitis C ty pically presents with hem aturia, proteinuria, and low C3 and C4 lev els. 1 81 1 . Album in infusions decrease the risk for acute renal failure in patients undergoing paracentesis with m ore than 5 L of v olum e rem ov ed and in patients with spontaneous bacterial peritonitis. 1 81 2 . Octogenarians with poor functional status are unlikely to experience im prov em ent or benefit from dialy sis. 1 81 3 . Increasing calcium intake decreases the risk for calcium oxalate stones because calcium binds to gastrointestinal sources of oxalate and therefore prev ents absorption. 1 81 4 . Dietary m odifications such as decreasing anim al protein intake, decreasing sodium intake, and increasing citrate can reduce the risk for recurrent kidney stones without additional m edical therapy . 1 81 5. Clinical m anifestations of autosom al dom inant poly cy stic kidney disease include renal, hepatic, and pancreatic cy sts; intracranial, thoracic, and abdom inal aortic aneury sm s; and colonic div erticulae. 1 81 6 . Certain m anifestations of autosom al dom inant poly cy stic kidney disease, such as intracranial aneury sm s, tend to cluster in

fam ilies. 1 81 7 . Patients with pheochrom ocy tom a should receiv e an -blocker 2 weeks before surgery . 1 81 8. -Blockade in the absence of -blockade is contraindicated in patients with pheochrom ocy tom a and m ay lead to hy pertensiv e crisis. 1 81 9 . The com bination of upper and/or lower respiratory tract disease and proteinase-3 antinuclear cy toplasm ic antibody positiv ity at the tim e of diagnosis is associated with the highest likelihood of relapsing disease in antinuclear cy toplasm ic antibody associated sm all-v essel v asculitis. 1 82 0. Hy drochlorothiazide can cause sev ere hy ponatrem ia. 1 82 1 . Cry oglobulinem ia is characterized by Ray naud's phenom enon, a purpuric rash, abnorm al findings on liv er function studies, and the presence of glom erulonephritis. 1 82 2 . Cry oglobulinem ia ty pically decreases the C4 lev el, which indicates activ ation of the classical pathway of com plem ent activ ation, m ore than the C3 lev el. 1 82 3 . Renal biopsy is indicated for patients with acute glom erulonephritis of unknown cause. 1 82 4 . Pulm onary hem orrhage associated with acute glom erulonephritis is associated with substantial m orbidity and m ortality . 1 82 5. Atheroem bolic disease can m im ic v asculitis. 1 82 6 . The presence of liv edo reticularis, Hollenhorst plaque, cy anotic toe, low C3 lev els, and peripheral eosinophilia suggests a diagnosis of atheroem bolic disease. 1 82 7 . Atheroem bolic disease should be suspected in patients with erosiv e atherosclerosis presenting with acute renal failure. 1 82 8. Asy m ptom atic hy percalcem ia in a patient with a history of calcium stones warrants ev aluation for prim ary hy perparathy roidism . 1 82 9 . Parathy roidectom y should be considered for patients with calcium -containing stones secondary to prim ary hy perparathy roidism . 1 83 0. Alport's sy ndrom e causes persistent m icroscopic hem aturia, progressiv e nephritis with proteinuria, and progressiv e decline in renal function to end-stage renal disease. 1 83 1 . Alport's sy ndrom e is an inherited condition that m ay present with high-frequency sensorineural hearing loss and/or ocular

abnorm alities. 1 83 2 . Isotonic saline is preferred ov er bicarbonate-containing solutions for resuscitation of patients with rhabdom y oly sis. 1 83 3 . In the absence of renal failure or flash pulm onary edem a, m edical rather than inv asiv e therapy is preferred for blood pressure control, ev en when renov ascular hy pertension is suspected. 1 83 4 . Solute diuresis secondary to a high urea load is a com m on cause of hy pernatrem ia in the critical care setting. 1 83 5. Sim ple cy sts discov ered on renal im aging studies require no therapy . 1 83 6 . Com plex renal cy sts on ultrasonography require follow-up im aging with CT or MRI. 1 83 7 . Kidney biopsy is contraindicated in patients with com plex renal m asses suspicious for m alignancy . 1 83 8. A paraprotein associated with sy stem ic am y loidosis or m ultiple m y elom a is a likely cause of the nephrotic sy ndrom e in older patients. 1 83 9 . Angiotensin-conv erting enzy m e inhibitor therapy is warranted in patients with stage III and stage IV chronic kidney disease unless the creatinine lev el rises > 3 0% after initiation of therapy . 1 84 0. Once-daily dosing of angiotensin-conv erting enzy m e inhibitors can decrease the risk for hy perkalem ia. 1 84 1 . Sarcoidosis m ay cause nephrolithiasis, nephrocalcinosis, and interstitial nephritis. 1 84 2 . Angiotensin-conv erting enzy m e inhibitors or angiotensin receptor blockers are the agents of choice for the treatm ent of hy pertension in chronic kidney disease. 1 84 3 . An anion gap m etabolic acidosis m ay be present in a patient with sev ere hy poalbum inem ia and a norm al anion gap. 1 84 4 . Renal ultrasonography can be norm al early in the course of acute urinary tract obstruction. 1 84 5. Urinary tract obstruction should be suspected in elderly m en with acute renal failure. 1 84 6 . IgA glom erulonephritis is m anifested by the nephritic sy ndrom e and is associated with dy sm orphic ery throcy tes and ery throcy te casts. 1 84 7 . Diabetic ketoacidosis can lead to an anion gap m etabolic acidosis and m etabolic alkalosis sim ultaneously . 1 84 8. Iatrogenic respiratory alkalosis m ay dev elop after initiation of

m echanical v entilation. 1 84 9 . Antihy pertensiv e agents such as diuretics and -blockers hav e been associated with an increased risk for ty pe 2 diabetes m ellitus, whereas angiotensin-conv erting enzy m e inhibitors and angiotensin receptor blockers m ay im prov e insulin sensitiv ity . 1 850. Risk factors for contrast nephropathy include diabetic nephropathy , dehy dration, heart failure, age m ore than 7 0 y ears, im paired kidney function, and concurrent use of nephrotoxic drugs and high-osm olar or high doses of radiocontrast m edium . 1 851 . Prev ention of contrast nephropathy in patients at increased risk for this condition inv olv es discontinuing nephrotoxic drugs, using the lowest possible dose of low-osm olality contrast m edium for the study , and adm inistering intrav enous therapy with 0.9 % saline at 1 m L/kg/h for 2 4 hours beginning 1 2 hours before adm inistration of contrast m edium . 1 852 . My elom a-related kidney disorders should be suspected in patients with anem ia, a low serum anion gap, and renal failure. 1 853 . A low serum anion gap warrants ev aluation for m y elom a due to an increase in unm easured cations such as calcium and im m unoglobulins. 1 854 . My elom a kidney is associated with a discrepancy in proteinuria detection between the dipstick urinaly sis and a spot urine collection. 1 855. Mathem atical equations such as CockcroftGault or Modification of Diet in Renal Disease are recom m ended for the assessm ent of glom erular filtration rate rather than 2 4 -hour urine collections or radioim aging studies. 1 856 . Indiv iduals with uncontrolled hy pertension and recurrent episodes of flash pulm onary edem a should be screened for renov ascular disease. 1 857 . In patients with suspected renov ascular disease and a glom erular filtration rate m ore than 6 0 m L/m in, m agnetic resonance angiography is the im aging study of choice to av oid the risk for contrast-induced acute renal failure. 1 858. A low glom erular filtration rate is the m ain cause of phosphate retention and hy perphosphatem ia in patients with chronic kidney disease. 1 859 . Diuretics are effectiv e antihy pertensiv e agents in elderly patients but m ay cause electroly te abnorm alities. 1 86 0. The presentation of anion gap m etabolic acidosis and

respiratory alkalosis suggests salicy late toxicity . 1 86 1 . Im m obilization in the exaggerated lithotom y position can result in rhabdom y oly sis. 1 86 2 . An extrem ely elev ated creatine kinase lev el and elev ated urine m y oglobin lev el suggest a diagnosis of pigm ent nephropathy . 1 86 3 . Com bination therapy with an angiotensin-conv erting enzy m e inhibitor and an angiotensin receptor blocker is associated with decreasing proteinuria in patients with nondiabetic renal disease. 1 86 4 . Thin basem ent m em brane disease (benign fam ilial hem aturia) is characterized by glom erular hem aturia with dy sm orphic ery throcy tes on m icroscopic analy sis of the urine and no ev idence of proteinuria. 1 86 5. Patients with ethy lene gly col poisoning presenting with both an increased anion and osm olar gap m etabolic acidosis require dialy sis in addition to either fom epizole or ethanol. 1 86 6 . Am y loidosis is a com m on cause of the nephrotic sy ndrom e in nondiabetic patients > 50 y ears of age. 1 86 7 . Phosphate binders m ay help to treat hy perphosphatem ia in patients with chronic kidney disease. 1 86 8. Black patients with kidney disease and hy pertension hav e better renal outcom es after treatm ent with angiotensin-conv erting enzy m e inhibitor therapy com pared with am lodipine or -blockers. 1 86 9 . In pregnancy , labetalol is preferable to pure -blockers, which m ay be associated with low birthweight. 1 87 0. Angiotensin-conv erting enzy m e inhibitors and angiotensin receptor blockers are contraindicated in pregnancy . 1 87 1 . A highly negativ e urine anion gap suggests that the kidney is appropriately excreting acid during m etabolic acidosis. 1 87 2 . Alport's sy ndrom e is associated with a glom erulonephritis with dy sm orphic ery throcy tes, m ild proteinuria, and a high-frequency hearing loss. 1 87 3 . Wegener's granulom atosis is characterized by upper and lower airway disease, glom erulonephritis, and positiv e findings on a proteinase-3 antineutrophil cy toplasm ic antibody assay . 1 87 4 . A disparity between the dipstick protein lev el and quantified urinary protein excretion, a low anion gap, and an increase in the globulin fraction of the total protein lev el suggests m ultiple m y elom a. 1 87 5. Microscopic poly angiitis is a nongranulom atous or sm all-

v essel v asculitis occasionally accom panied by m edium -sized v essel inv olv em ent that causes a pulm onary renal sy ndrom e. 1 87 6 . Renal transplant recipients who are EpsteinBarr v irusnegativ e are at increased risk for post-transplant ly m phoproliferativ e disorder, especially after receiv ing an organ from an EpsteinBarr v iruspositiv e donor. 1 87 7 . One of the m ost im portant initial steps in the ev aluation of m icroscopic hem aturia is urine m icroscopy to assess ery throcy te m orphology . 1 87 8. Glom erular hem aturia is associated with dy sm orphic ery throcy tes and ery throcy te casts on urinaly sis. 1 87 9 . Obesity m ay lead to proteinuria and chronic kidney disease. 1 880. Lowering blood pressure to appropriate targets is particularly im portant in patients with diabetes who hav e increased risk for cardiov ascular and renal com plications. 1 881 . Diuretics potentiate the blood pressurelowering effects of angiotensin-conv erting enzy m e inhibitors and -blockers. 1 882 . Postinfectious glom erulonephritis m ay present 3 weeks after onset of the inciting infection and is associated with low C3 lev els and norm al C4 lev els. 1 883 . Respiratory alkalosis com m only dev elops in end-stage liv er disease. 1 884 . The refeeding sy ndrom e is a potential com plication in m alnourished patients who suddenly receiv e a large calorie load. 1 885. Rhabdom y oly sis is a potentially sev ere com plication of the refeeding sy ndrom e. 1 886 . The antiphospholipid antibody sy ndrom e is characterized by throm bosis in association with a lupus anticoagulant or persistently elev ated lev els of anticardiolipin antibodies. 1 887 . A peritoneal fluid cell count m ore than 1 00 total nucleated cells/L is abnorm al and consistent with the diagnosis of peritonitis. 1 888. Antibiotic therapy cov ering both gram -negativ e and gram -positiv e pathogens should be started im m ediately in a patient with suspected peritoneal dialy sisrelated peritonitis. 1 889 . Acute tubular necrosis is the m ost com m on cause of acute renal failure after acetam inophen poisoning. 1 89 0. Patients with chronic kidney disease should be educated to av oid v enipuncture and intrav enous catheters in v eins abov e the lev el of the wrist in both arm s to preserv e v eins for future creation of

arteriov enous fistulas. 1 89 1 . Subclav ian v ein lines should be strictly av oided in patients with chronic kidney disease. 1 89 2 . Creation of an arteriov enous fistula is indicated m onths before initiation of dialy sis. 1 89 3 . Patients m ore than 50 y ears of age with persistent hem aturia should be ev aluated for genitourinary tract m alignancy . 1 89 4 . Nonsteroidal anti-inflam m atory drug use is a com m on cause of resistance to antihy pertensiv e therapy . 1 89 5. Acetazolam ide m ay cause nonanion gap m etabolic acidosis. 1 89 6 . In addition to corticosteroids, the m ost appropriate treatm ent for lupus nephritis is intrav enous cy clophospham ide followed by m aintenance m y cophenolate m ofetil once rem ission is achiev ed. 1 89 7 . Infusion of norm al saline before and after exposure to radiocontrast is the m ost effectiv e m ethod to decrease the risk for radiocontrast nephropathy . 1 89 8. Calcific urem ic arteriolopathy ty pically presents with painful v iolaceous nodules on the trunk, proxim al extrem ities, and buttocks in patients with chronic kidney disease. 1 89 9 . Quantification of urinary protein in upright and recum bent positions to ev aluate for orthostatic proteinuria is indicated for y oung adults with proteinuria and no other ev idence of kidney disease. 1 9 00. Acute glom erulonephritis is uncom m on without hem aturia and a bland urine sedim ent. 1 9 01 . Hospitalization and deliv ery are indicated for wom en with preeclam psia at term . 1 9 02 . The m anifestations of the HELLP sy ndrom e (hem oly sis, elev ated liv er enzy m es, and low platelets) are features of sev ere preeclam psia. Posted by dokidok at 2 :1 0 PM Labels: step 3

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