BOARD STUDY APRIL 2022 Flashcards

Question

``` Which one of the following electrolyte disturbances would be consistent with tumor lysis syndrome? A) Hypocalcemia B) Hypokalemia C) Hyponatremia D) Hypophosphatemia E) Hypouricemia ```

Answer 1

A Hyperphosphatemia, hyperkalemia, and hyperuricemia are indicative of tumor lysis syndrome. Calcium levels are decreased due to binding with free phosphorus and a depletion of calcium in the bloodstream. Sodium electrolyte levels are not as likely to be affected.

Answer 2

A Hyperphosphatemia, hyperkalemia, and hyperuricemia are indicative of tumor lysis syndrome. Calcium levels are decreased due to binding with free phosphorus and a depletion of calcium in the bloodstream. Sodium electrolyte levels are not as likely to be affected.

Answer 3

E Initial general neurovascular assessment of an upper extremity injury includes evaluating for radial pulse and digit movement and sensation. Weakness of the thumb and index finger pincer mechanism is indicative of an ulnar nerve injury. Weakness in the shoulder or upper arm would indicate a potential brachial plexus injury. Symptoms related to the median nerve generally include paresthesia of the thumb, index finger, and long finger. Weakness of supination of the forearm would indicate a potential musculocutaneous nerve injury. Weakness of active wrist extension would indicate a potential radial nerve injury.

Answer 4

There are multiple criteria for conduct disorder - including aggression toward people and animals, theft, starting fires, and truancy. It may be associated with other disorders. Antisocial personality disorder, which is usually diagnosed after age 18, involves a disregard for the rights of others. ODD - is getting in trouble, but no actually harming others etc...

Answer 5

Antibiotic prophylaxis is not indicated unless the | patient has undergone aortic valve replacement or has a history of endocarditis.

Answer 6

D According to a Cochrane review of 10 trials without a meta-analysis, antitussives and expectorants are no more effective than placebo for cough. Intranasal ipratropium is the only medication that improves persistent cough related to upper respiratory infection in adults. Intranasal antibiotics, antihistamines, corticosteroids, and saline would not improve this patient’s cough.

Answer 7

Studies of other medication classes with proven benefit for heart failure with reduced ejection fraction, including ACE inhibitors, -blockers, spironolactone, and the angiotensin receptor–neprilysin inhibitor sacubitril/valsartan, have not shown the same effects in the setting of heart failure with preserved ejection fraction. For patients with heart failure with preserved ejection fraction, the use of these other medication classes should be limited to the treatment of other comorbid conditions, such as hypertension, coronary artery disease, atrial fibrillation, or chronic kidney disease.

Answer 8

false - this happens in bariatric surgery that causes malabsorption - roux en y, duodenal switch.

Answer 9

>180/110–120 mm

Answer 10

Patients without symptoms in the setting of severe hypertension rarely have end-organ damage. Patients who are asymptomatic with persistently elevated blood pressures can be safely treated with oral antihypertensives with close follow-up (SOR C). There is no standard workup for patients with hypertensive urgencies, but common practice includes obtaining a basic metabolic panel, CBC, urinalysis, EKG, and troponin to rule out end-organ damage. Oral medications to lower blood pressure in a patient with a hypertensive urgency are not indicated unless the patient is symptomatic. Symptoms such as headache or epistaxis warrant acute lowering of blood pressure. Preferred medications include clonidine, labetalol, and captopril, among others. Oral nifedipine is not recommended due to unpredictable blood pressure responses. Patients with physical or laboratory evidence of end-organ damage should be admitted to the intensive-care unit for intravenous treatment of blood pressure. Without symptoms of end-organ damage there is no need to transport patients to the emergency department, as hypertensive urgencies can be managed with outpatient care.

Answer 11

Patients without symptoms in the setting of severe hypertension rarely have end-organ damage. Patients who are asymptomatic with persistently elevated blood pressures can be safely treated with oral antihypertensives with close follow-up (SOR C). There is no standard workup for patients with hypertensive urgencies, but common practice includes obtaining a basic metabolic panel, CBC, urinalysis, EKG, and troponin to rule out end-organ damage. Oral medications to lower blood pressure in a patient with a hypertensive urgency are not indicated unless the patient is symptomatic. Symptoms such as headache or epistaxis warrant acute lowering of blood pressure. Preferred medications include clonidine, labetalol, and captopril, among others. Oral nifedipine is not recommended due to unpredictable blood pressure responses. Patients with physical or laboratory evidence of end-organ damage should be admitted to the intensive-care unit for intravenous treatment of blood pressure. Without symptoms of end-organ damage there is no need to transport patients to the emergency department, as hypertensive urgencies can be managed with outpatient care.

Answer 12

18 months | 50%–90% can speak six words.

Answer 13

YES - lots of it. Think of GI.

Answer 14

false - Albuterol is ineffective for the wheezing associated with RSV since the mechanism of wheezing is not due to bronchospasm

Answer 15

false - Albuterol is ineffective for the wheezing associated with RSV since the mechanism of wheezing is not due to bronchospasm

Answer 16

differin - | you shouldn't use monotherapy topical abx due to resistance.

Answer 17

screen for depression

Answer 18

Common variable immunodeficiency (CVID) is the only immunodeficiency condition listed that can present later in life, while severe combined immunodeficiency, DiGeorge syndrome, and Wiskott-Aldrich syndrome typically present prior to 6 months of age. CVID is a condition of impaired humoral immunity and thus should be considered in a patient this age in the setting of recurrent bacterial infections such as sinusitis or pneumonia. The blunted response to a vaccination challenge implies impaired IgG antibody response, which differentiates CVID from a selective IgA deficiency.

Answer 19

A think about the USPSTF for the exam.

Answer 20

Paroxetine should generally be avoided in older patients due to a higher likelihood of adverse effects that include sedation and orthostatic hypotension.

Answer 21

labral tear labral tears usually present with anterior hip pain and may have catching, popping, or clicking sounds associated with activities such as gymnastics, soccer, dancing, basketball, or hockey

Answer 22

``` 60-90 = grade 2 45-60 = 3a 30-45 = 3b = Ben is in his 30's, Ben has 3 letters 15-30 = 4 0-15= 5 ```

Answer 23

A The USPSTF went on to conclude that the current evidence is insufficient to assess the balance of benefits and harms of screening for elevated blood lead levels in asymptomatic children 5 years of age and younger. Although children living in older housing with lead-based paint are at higher risk of elevated blood lead levels than those living in housing built after 1978, the USPSTF does not recommend routine screening in asymptomatic children based on this risk factor.

Answer 24

B don't for IPF as a diagnosis for my patients. it is in the family of ILD Spirometry usually shows a restrictive pattern, although it may be normal in early disease or with comorbid emphysema.

Answer 25

E Losartan is the DOC in someone who has gout. Both hydrochlorothiazide and losartan are known to have effects on the serum urate concentrations, with hydrochlorothiazide causing an increase and losartan causing a decrease. The American College of Rheumatology guideline does not recommend for or against the use of atenolol, hydralazine, and lisinopril as antihypertensive treatment in patients with gout.

Answer 26

E Losartan is the DOC in someone who has gout. Both hydrochlorothiazide and losartan are known to have effects on the serum urate concentrations, with hydrochlorothiazide causing an increase and losartan causing a decrease. The American College of Rheumatology guideline does not recommend for or against the use of atenolol, hydralazine, and lisinopril as antihypertensive treatment in patients with gout.

Answer 27

E However, these immunoassays do not reliably detect synthetic or semisynthetic opioids such as oxycodone, oxymorphone, methadone, buprenorphine, and fentanyl, as well as many benzodiazepines. Confirmatory testing is needed in situations with an unexpected negative result in order to distinguish a false negative from a true negative.

Answer 28

C regular NS w/ dextrose

Answer 29

Treatments with evidence of effectiveness for knee osteoarthritis include exercise, physical therapy, knee taping, and tai chi. Medical treatments should begin with full-strength acetaminophen and topical therapy, then NSAIDs and, selectively, tramadol or other opioids. Lateral wedge insoles, vitamin D supplements, glucosamine and chondroitin supplements, and hyaluronic acid injections are all ineffective.

Answer 30

A Parkinson’s disease is a clinical diagnosis and seldom requires testing. Imaging such as CT, MRI, or EEG can be useful in ruling out other diagnoses but will not reveal findings suggestive of Parkinson’s disease.

Answer 31

not great. Excisions are better

Answer 32

10 U nightly

Answer 33

E Opiates are the most effective agents for treating dyspnea and the resultant anxiety in patients with terminal cancer. Not D Dexamethasone, hyoscyamine, and lorazepam have a frequent role in patients such as this one, but morphine sulfate or a similar fast-acting opiate is the drug of choice (SOR B).

Answer 34

1-, 2-, 4-, | and 6-month well child visits.

Answer 35

just beware of the AAP vs the USPSTF.... I doubt there will be questions on this as a result.... but I would probably go with the USPSTF

Answer 36

only limited data = so nope GnRH agonists are effective for providing symptom relief and reducing fibroid size, but their use results in a hypoestrogenized state and should not be continued long term for a sustained effect in premenopausal women. embolization, surgery

Answer 37

triad: hearing loss, tinnitus, vertigo. vestibular migraines usually dont have tinnitus - but can have eveything else. Patients with vestibular schwannoma typically present with gradual asymmetric hearing loss, but they can have tinnitus and vertigo as well.

Answer 38

triad: hearing loss, tinnitus, vertigo. vestibular migraines usually dont have tinnitus - but can have eveything else. Patients with vestibular schwannoma typically present with gradual asymmetric hearing loss, but they can have tinnitus and vertigo as well.

Answer 39

So almost 5 ft

Answer 40

A No periurethral antiseptics reduce rates of CAUTI. Catheters and drainage bags should only be changed when clinically indicated, such as when there is an infection or obstruction.

Answer 41

confusion, uremia, RR, BP >65 0-1 outpatient 2 - inpatient >3 = icu

Answer 42

Macrolides such as azithromycin are the treatment of choice for previously healthy outpatients with no history of antibiotic use within the past 3 months.

Answer 43

Macrolides such as azithromycin are the treatment of choice for previously healthy outpatients with no history of antibiotic use within the past 3 months.

Answer 44

the E to A sound when listening

Answer 45

the hands on the back... you feel more dull vibrations or lack of movement on the infected side.

Answer 46

Treatment consists of short arm immobilization, which is most easily performed with a removable splint or wrist brace. The Choosing Wisely campaign states that these fractures do not require repeat imaging if there is no longer any tenderness or pain with palpation after 4 weeks of splinting, and the patient can return to full activity as tolerated.

Answer 47

fibrate if they have an ASCVD - treat that with statins, but fibrate is first.

Answer 48

counselling The USPSTF could not find evidence that exercise, amitriptyline, or sertraline were beneficial.

Answer 49

B Not sure on this one because of ... "Oral PrEP is the use of antiretroviral (ARV) drugs before HIV exposure by people who are not infected with HIV in order to block the acquisition of HIV." I think A is wrong, because you do need an HIV test before starting PrEP

Answer 50

PEP is the use of antiretroviral drugs after a single high-risk event to stop HIV seroconversion. PEP must be started as soon as possible to be effective—and always within 72 hours of a possible exposure.

Answer 51

n/v, weight loss, abd px, yellow vision changes (but they probs won't give this info as it is too easy)

Answer 52

A In 2020 the American College of Physicians and the American Academy of Family Physicians published a guideline regarding the treatment of acute pain from musculoskeletal injuries (non–low back related). This systematic review found good evidence to support the recommendation that topical NSAIDs be used as first-line therapy to reduce pain and improve physical function. Topical NSAIDs were the only intervention that improved multiple outcomes and were not associated with a statistically significant increase in the risk for adverse events. Oral NSAIDs and acetaminophen were recommended as second-line therapies, as they were found to be effective for pain relief but were associated with an increased risk for adverse events. Topical menthol gel was not found to be effective as monotherapy but may be considered when combined with a topical NSAID. Nonpharmacologic approaches with evidence of benefit include specific acupressure and use of a transcutaneous electrical nerve stimulation (TENS) unit.

Answer 53

C Using the Jones criteria for diagnosis, this patient has acute rheumatic fever, with two major criteria (carditis and polyarthritis) and two minor criteria (fever and positive erythrocyte sedimentation rate). NSAIDs such as naproxen can provide significant relief and should be administered as soon as acute rheumatic fever is diagnosed (SOR B). Hydroxychloroquine is not FDA approved for the treatment of acute rheumatic fever and would not be appropriate. Treatment with corticosteroids, intravenous immunoglobulins, and plasmapheresis is not considered appropriate for acute rheumatic fever but may be indicated for management of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS).

Answer 54

C Using the Jones criteria for diagnosis, this patient has acute rheumatic fever, with two major criteria (carditis and polyarthritis) and two minor criteria (fever and positive erythrocyte sedimentation rate). NSAIDs such as naproxen can provide significant relief and should be administered as soon as acute rheumatic fever is diagnosed (SOR B). Hydroxychloroquine is not FDA approved for the treatment of acute rheumatic fever and would not be appropriate. Treatment with corticosteroids, intravenous immunoglobulins, and plasmapheresis is not considered appropriate for acute rheumatic fever but may be indicated for management of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS).

Answer 55

A Cognitive changes are normal with menopause in like ~60% of women. But you only need HRT if you are going to help hot flashes and GU symptoms

Answer 56

A The American Thyroid Association recommends observation for asymptomatic patients with mildly low TSH (0.1–0.4 U/mL), so further evaluation is not indicated in this patient. Further evaluation including thyroid antibody studies and a thyroid uptake scan with radioactive iodine should be considered in older patients (>65 years), those with very low TSH (<0.1 U/mL), and those with comorbidities.

Answer 57

A Anti-citrullinated protein antibody is >95% specific for RA when significantly elevated. Rheumatoid factor is also nonspecific for RA and may be positive due to cancer, infection, and other autoimmune conditions.

Answer 58

C In patients on monotherapy with a long-acting bronchodilator such as a long-acting muscarinic agonist (LAMA) or long-acting -agonist (LABA) who have continued dyspnea, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines recommend escalating therapy to two bronchodilators. This patient has persistent dyspnea and is being treated with a single agent, a LAMA, so his regimen needs to be escalated to include a LABA such as salmeterol. Once the symptoms are stabilized, treatment can be de-escalated to a single agent. For patients with frequent COPD exacerbations or with a diagnosis of asthma and COPD, the guidelines recommend adding an inhaled corticosteroid (ICS) such as fluticasone to a LABA, LAMA, or both. Triple therapy with a LABA, a LAMA, and an ICS is not indicated at this time as the patient has not yet been treated with a combination of a LAMA and LABA and has not had any recent exacerbations. The addition of azithromycin may be considered in patients who are already on triple therapy with a LABA, a LAMA, and an ICS and still having exacerbations. Monotherapy with an ICS is not indicated in COPD and has been shown to increase the risk of developing pneumonia.

Answer 59

C In patients on monotherapy with a long-acting bronchodilator such as a long-acting muscarinic agonist (LAMA) or long-acting -agonist (LABA) who have continued dyspnea, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines recommend escalating therapy to two bronchodilators. This patient has persistent dyspnea and is being treated with a single agent, a LAMA, so his regimen needs to be escalated to include a LABA such as salmeterol. Once the symptoms are stabilized, treatment can be de-escalated to a single agent. For patients with frequent COPD exacerbations or with a diagnosis of asthma and COPD, the guidelines recommend adding an inhaled corticosteroid (ICS) such as fluticasone to a LABA, LAMA, or both. Triple therapy with a LABA, a LAMA, and an ICS is not indicated at this time as the patient has not yet been treated with a combination of a LAMA and LABA and has not had any recent exacerbations. The addition of azithromycin may be considered in patients who are already on triple therapy with a LABA, a LAMA, and an ICS and still having exacerbations. Monotherapy with an ICS is not indicated in COPD and has been shown to increase the risk of developing pneumonia.

Answer 60

naltrexone Evidence does not support the use of disulfiram for AUD but it may be offered in selected circumstances, particularly when patients do not tolerate other options and their goal is abstinence.

Answer 61

EGD can often miss a narrowing or esohpageal webs etc... this is when the barium esophagram is great.

Answer 62

Increasing fluid intake to 2.5–3 L/day diet rich in fiber and vegetables with normal calcium content (1–1.2 g/day), limited sodium intake (4–5 g/day), and limited animal protein intake (0.8–1 g/kg/day) is strongly encouraged. - limit protein, limit sodium . -reduction in BMI is also helpful.

Answer 63

Thiazide diuretics in higher dosages, such as 50 mg daily of hydrochlorothiazide, have also been shown to be effective in preventing calcium stone formation. Furosemide increases urinary calcium excretion and would increase the likelihood of calcium stone formation.

Answer 64

B Primary care physicians should ensure that their patients who have undergone treatment for breast cancer follow the recommendations of their oncologist, as well as receive a history evaluation and health maintenance examination every 3–6 months for 3 years, every 6–12 months for 2 more years, and then on an annual basis. For ongoing surveillance only annual mammography is recommended (SOR A), which is bilateral in breast-conserving therapy and unilateral following a mastectomy.

Answer 65

No estrogen only.

Answer 66

ANSWER: B Hallux rigidus affects as many as 50% of women and 40% of men by the age of 70. It is usually due to osteoarthritis of the metatarsophalangeal (MTP) joint and presents as decreased range of motion, swelling, and pain. With progression of the condition, flare-ups become more frequent and more severe, and it can be mistaken for gout. Initial treatment is restriction of motion across the MTP joint. A stiffening shoe insert does relieve pain and most patients see improvement without surgery. Custom orthotics, rigid inserts, or hard-soled shoes are options that are more effective than NSAIDs. Corticosteroid injections, preferably administered with ultrasound guidance, and surgery are reserved for those who fail to respond to more conservative measures. Stretching and strengthening exercises are recommended for plantar fasciitis more so than for hallux rigidus.

Answer 67

I disagree with this question. The answer should be A C Current guidelines recommend initiating a statin, in addition to education regarding a healthy diet and physical activity, for pediatric patients in this high-risk category with an LDL-cholesterol level >100 mg/dL. Statins such as atorvastatin are recommended for first-line treatment according to multiple studies that demonstrate their efficacy and benefits in reduction of cardiovascular morbidity and mortality, along with long-term studies demonstrating their safety. --------- UTD We agree with the following ADA guidelines for screening for hyperlipidemia in children with T1DM [11,104]: ●Obtain a lipid profile at diagnosis, after glycemic control is well established and ideally in the fasting state. Perform the initial screen at age ≥2 years. ●If the profile is within the accepted risk levels (LDL <100 mg/dL), initiate serial testing at 9 to 11 years of age and repeat every three years. Borderline or abnormal values should be repeated for confirmation in the fasting state. If lipids are abnormal, annual monitoring is recommended. If the initial screen is normal but the child's diabetes is in poor control (eg, A1C >9 percent), we suggest screening annually. Pharmacologic treatment with lipid-lowering agents is recommended for children with diabetes over 10 years of age if LDL exceeds the following levels despite dietary and other lifestyle changes [11,104]: * LDL ≥160 mg/dL (4.1 mmol/L) * LDL between 130 and 159 (3.4 to 4.1 mmol/L) if one or more other cardiovascular risk factors are present (including obesity, tobacco use, or a family history of early cardiovascular disease)

Answer 68

D malignancy heart accident suicide Accidents are the third most common cause of mortality in people 45–64 years of age, but they are the leading cause of mortality among people 15–44 years of age Heart disease is the second most common cause of mortality in people 45–64 years of age, but it is the leading cause of mortality in people 65 years of age and older. Suicide is the fourth most common cause of mortality in adults 45–54 years of age, and the eighth most common cause in adults 55–64 years of age.

Answer 69

A The application of duct tape has not been shown to be more effective than placebo. Manual paring and extraction of plantar warts carries a greater risk for complications and is not necessary for these flat, minimally bothersome warts. *** the key to this question was minimally symptomatic.

Answer 70

B - Checking LH and FSH levels is recommended to evaluate for primary hypogonadism. need to find a cause of the hypogonadism Before initiating testosterone therapy, checking the patient’s PSA level and performing a digital rectal examination are recommended, but in this case the initial workup is not yet complete.

Answer 71

Complex regional pain syndrome (CRPS) is defined as a disorder of the extremities characterized by regional pain that is disproportionate in time or degree to the usual course of any known trauma or other lesion. The pain is not restricted to a specific nerve territory or dermatome and usually has a distal predominance of abnormal sensory, motor, sudomotor, vasomotor, and/or trophic findings. The main clinical symptoms of CRPS are pain, sensory changes, motor impairments, autonomic symptoms, and trophic changes in the affected limb. Of these, pain is typically the most prominent and debilitating symptom

Answer 72

obstructive

Answer 73

restrictive

Answer 74

B Adjustable orthotic shoes in infants who are not yet walking can be effective for the treatment of metatarsus adductus (SOR B). These orthotics can be adjusted to apply an abduction force on the forefoot while maintaining the heel in a neutral position. UTD disagrees- they recommend stretching. ***the key to this question is that it is RIGID!

Answer 75

220/120 for the first 24 hours

Answer 76

u/s tsh if tsh is low - then you need a scan (to see if it is a hot nodule) - radioactive iodine ablation. if normal TSH/low TSH - the nodule needs biopsy depending on the u/s findings (it may say just monitor).

Answer 77

C meh - I think this is a bad question. CBT is also appropriate for "her condition".

Answer 78

- age >55 - isolated tenderness to the patella - ttp fib head - inability to flex to90 degrees - inability to bear wear for 4 steps ***pain over the joint line does NOT count.

Answer 79

anterior medial aspect of the tibia

Answer 80

B oral rehydration is obviously best. A randomized, controlled trial has shown that initial rehydration with diluted apple juice followed by preferred fluids resulted in fewer treatment failures than use of a formal electrolyte solution. This is likely due to the increased likelihood that children will drink preferred fluids due to better taste, tolerability, and ease of administration. Therefore, in high-income countries, this should be the recommended initial treatment for mild dehydration due to gastroenteritis.

Answer 81

if you don't know the cuase (after virus etc...) and iti s refractory to NSAIDs/Colchicine

Answer 82

Irregular menses can occur during the perimenopausal period but this patient’s increased frequency and volume of vaginal bleeding combined with her age warrant further evaluation. Transvaginal ultrasonography is recommended if a bimanual examination is abnormal or if symptoms persist despite treatment..... (I disagree)

Answer 83

no pain no fever no sign of systemic illness = not cellulitis. DM, BMI, neuropathy = think charcot E - xrays could show you fractures of the midfoot. It is usually PAINLESS.

Answer 84

Valvular = Warfarin If a patient has moderate to severe mitral stenosis or a mechanical valve, then vitamin K antagonists are the preferred agent. Non-valvular- DOAC

Answer 85

D ***the key is 90 days! When the contact occurred more than 90 days before confirmation of a negative serologic test result, no treatment is necessary. For patients with a penicillin allergy, oral treatment with doxycycline, 100 mg twice daily; tetracycline, 500 mg four times daily; or azithromycin, 2 g as a single dose, has been effective as an alternate treatment option but should only be used when penicillin is contraindicated and should be followed by close monitoring of serologic tests.

Answer 86

heels, hips, sacrum

Answer 87

While treatment of the initial episode with broad-spectrum antibiotics, early CT imaging to detect complications, and colonoscopy 4–6 weeks after the resolution

Answer 88

C If iron deficiency anemia is the cause of koilonychia, the nail will return to a normal appearance when the anemia is corrected. Chronic pulmonary disease is associated with clubbing of the nails. Hyperthyroidism can result in onycholysis (nail separation) and brown discoloration of the nail plate. Psoriasis typically causes pitted nails, although patients can also have some hyperkeratosis and onycholysis.

Answer 89

Pharmacologic treatment should be initiated in patients with gestational diabetes mellitus (GDM) when nutrition and exercise therapy are not adequate to meet goals. Accepted goals are fasting blood glucose levels <95 mg/dL, 1-hour postprandial glucose levels <140 mg/dL, and 2-hour glucose levels <120 mg/dL.

Answer 90

B remember DM is a RF. Splinting, which is a first-line treatment, has been shown to be effective. Single-joint orthoses at either the metacarpophalangeal or the proximal interphalangeal joint can be effective (SOR B). The duration of splinting can range from 6 weeks to 3 months. A retrospective case series analysis of trigger finger managed by observation only found that trigger finger resolved spontaneously in 52% of patients, with the majority resolving within 1 year.

Answer 91

coreg estrogens streoids cholestyramine thiazides

Answer 92

Heliox is a helium and oxygen mixture that theoretically decreases airflow resistance but there is no clear evidence to support its use at this time. Humidified air inhalation has not been shown to have a clinical benefit in terms of croup scores or hospital admissions. * **Nebulized epinephrine should be reserved for patients with moderate to severe croup. **Oxygen should be administered if there are signs of hypoxemia or severe respiratory distress

Answer 93

E SSRI is after if therapy is not available or effective. prozac, paxil, zoloft Benzodiazepines and escitalopram are not recommended in the treatment of PTSD. Dialectical behavioral therapy is used in the treatment of borderline personality disorder.

Answer 94

SLE DNA - Dana had Sam Earl

Answer 95

B Antiviral medications are recommended for the treatment of influenza only within 48 hours of symptom onset (SOR A). However, in high-risk patient populations and in severe cases of disease, antivirals should be provided regardless of the duration of symptoms (SOR B). According to the CDC, oseltamivir remains the drug of choice for the treatment of influenza during pregnancy because it has good safety data.

Answer 96

false Verapamil has previously been considered effective, but on reevaluation of previous studies, the supporting data for verapamil is insufficient to prove efficacy. Divalproex, topiramate, metoprolol, propranolol, and timolol have been shown to be effective for migraine

Answer 97

false Verapamil has previously been considered effective, but on reevaluation of previous studies, the supporting data for verapamil is insufficient to prove efficacy. Divalproex, topiramate, metoprolol, propranolol, and timolol have been shown to be effective for migraine

Answer 98

D Left heart disease, including both preserved and reduced systolic function, is the most common cause of pulmonary hypertension, while chronic thromboembolism, COPD, and sleep-disordered breathing are other possible but less common causes. Idiopathic pulmonary arterial hypertension is a rare cause.

Answer 99

``` Many systemic drugs have been reported to trigger dry eye, including diuretic agents, beta-blockers, other antihypertensive agents such as candesartan, antihistamines, decongestants, medications for Parkinson’s disease, antidepressant agents such as amitriptyline, anxiolytic agents, antispasmodic agents, anticonvulsant agents, gastric protection agents, oral contraceptives, and some herbal supplements. ```

Answer 100

10,000 - think of barbara richins a line - 20 procedure 50 neuroaxial surg 100

Answer 101

E Megestrol is a synthetic progestin with antiestrogenic properties which disrupt the estrogen receptor cycle. Most progestins I feel like end in -enone (drospirenone) (norethindrone) norgestimate ... progester RONE YES - progesterone by itslef increases the risk of clots. This is a chemo treatment... so think hair loss, decreased libido, thrombocytopenia... and oddly hyperglycemia (maybe like a steroid response)

Answer 102

under the patella.

Answer 103

B \The only vaccine indicated for this patient would be the HPV vaccine, which the CDC recommends as a routine vaccination for all patients starting at 11 or 12 years of age through 26 years of age but can also be considered in adults 27–45 years of age who have not previously received the vaccine and are most likely to benefit. Routine vaccination for hepatitis A is recommended only for patients who are at high risk of hepatitis A infection, but that is not the case with this patient. meningococcal is not given after the age of 24.

Answer 104

There is only 1 vaccine now - they no longer do the zostavax. The RZV requires two doses administered intramuscularly for protection. The second dose should be administered two to six months after the first This schedule should be used for all patients, including those with a history of prior herpes zoster and those who previously received zoster vaccine live (ZVL). Although data are limited, the United States Centers for Disease Control and Prevention (CDC) advises that recombinant vaccines, such as RZV, can be administered at the same time as other adult vaccines but at different anatomic sites if recent infection - wait 1 year

Answer 105

a First-line therapy for hirsutism in women who do not desire pregnancy and for whom cosmetic treatments are not effective is combined oral contraceptives (SOR B), which decrease androgen production in the ovaries by decreasing LH levels. Metformin is not effective for the treatment of hirsutism (SOR B). While this patient likely has PCOS, the anti-insulin medications will not affect excess hair growth. Antiandrogen treatments such as spironolactone and finasteride are second-line therapies that can be added to the combined oral contraceptives if there is no improvement after the first 6 months (SOR A).

Answer 106

a First-line therapy for hirsutism in women who do not desire pregnancy and for whom cosmetic treatments are not effective is combined oral contraceptives (SOR B), which decrease androgen production in the ovaries by decreasing LH levels. Metformin is not effective for the treatment of hirsutism (SOR B). While this patient likely has PCOS, the anti-insulin medications will not affect excess hair growth. Antiandrogen treatments such as spironolactone and finasteride are second-line therapies that can be added to the combined oral contraceptives if there is no improvement after the first 6 months (SOR A).

Answer 107

Finasteride Pharmacologic options for benign prostatic hyperplasia and lower urinary tract symptoms include an α-adrenergic blocker, a 5-α-reductase inhibitor (if there is evidence of prostatic enlargement or a PSA level >1.5 ng/mL), a phosphodiesterase-5 inhibitor, or antimuscarinic therapy. So ED and BPH - could try tadalafil

Answer 108

miralax baby Evidence does not support the use of fiber supplements in the treatment of functional constipation.

Answer 109

nope, as long as you are not worried about a fracture

Answer 110

E They should be started at the onset of menses and continued for the first 1–2 days of the menstrual cycle. Combined oral contraceptives may be effective for primary dysmenorrhea, but there is a lack of high-quality randomized, controlled trials demonstrating pain improvement (SOR B).

Answer 111

Patients who have essential tremor have symmetric, fine tremors that may involve the hands, wrists, head, voice, or lower extremities. This may improve with ingestion of small amounts of alcohol. There is no specific diagnostic test but the tremor is treated with propranolol or primidone. Enhanced physiologic tremor is a postural tremor of low amplitude exacerbated by medication. There is usually a history of caffeine use or anxiety. - caused by something (caffeine, anxiety, medication) Cerebellar tremor is an intention tremor with ipsilateral involvement on the side of the lesion.

Answer 112

D Based on CDC guidelines an induration 5 mm at 48–72 hours following an intradermal injection of tuberculin is a positive test in individuals who have been in recent contact with a person with infectious TB, those with radiographic evidence of prior TB, HIV-infected persons, and immunosuppressed patients. For other individuals at increased risk for TB, the threshold for a positive test is an induration 10 mm at 48–72 hours. For those with no known risks for TB infection, the induration must exceed 15 mm in size to be considered positive. Once positive, there is no indication for additional skin tests. A positive screening test along with a review of systems, a physical examination, and a chest radiograph that do not show evidence of active infection confirms the diagnosis of latent TB.

Answer 113

B There is no correlation between shellfish allergies and allergic reactions to contrast. Patients with moderately severe to severe reactions to IV contrast in the past would need pretreatment with corticosteroids.

Answer 114

B urine osmolality must be high in conjunction with both low serum sodium and low osmolality. The BUN should be normal or low and the fractional excretion of sodium >1%.

Answer 115

``` A For African-Americans, thiazide diuretics and calcium channel blockers, both as monotherapy and as a component in multidrug regimens, have been shown to be more effective in lowering blood pressure than ACE inhibitors, angiotensin II receptor blockers, or β-blockers, and should be considered as first-line options over the other classes of antihypertensive drugs unless a comorbid condition is present that would be better addressed with a different class of drugs ``` AA and Hispanics think thiazides or CCB AA is not the same as ArB or ACei

Answer 116

Think of A as hospice and hospital B as clinic D as meds

Answer 117

C Liraglutide, exenatide, and dulaglutide are all GLP-1 receptor agonists. Of these, only liraglutide has been shown to lower the risk of recurrent cardiovascular events and has received FDA approval for this indication. Empagliflozin, an SGLT2 inhibitor, has also been associated with secondary prevention of cardiovascular disease. Em and Liz are the best at protecting my heart!

Answer 118

5th times the charm E Individuals with sickle cell disease are at increased risk for vascular disease, especially stroke. All sickle cell patients 2–16 years of age should be screened with transcranial Doppler ultrasonography (SOR A). A chest radiograph, abdominal ultrasonography, a DXA scan, and renal Doppler ultrasonography are not recommended for screening patients with sickle cell disease. UTD: In children ≤16 years of age with hemoglobin SS or hemoglobin S-beta thalassemia that produces no hemoglobin A, referred to as S beta thalassemia zero, cerebral blood flow should be evaluated by transcranial Doppler (TCD) annually, because children at risk for strokes can be identified with this technique and the incidence of stroke can be reduced by the use of regular blood transfusion therapy aimed at maintaining the maximum hemoglobin S level at less than 30 percent

Answer 119

also 5th times the charm A In addition to clinodactyly, fetal alcohol syndrome is associated with camptodactyly (flexion deformity of the fingers), other flexion contractures, radioulnar synostosis, scoliosis, and spinal malformations. It is also associated with many neurologic, behavioral, and cardiovascular abnormalities, as well as other types of abnormalities.

Answer 120

hypothyroidism

Answer 121

hypothyroidism

Answer 122

C Stone cutting, sand blasting, mining, and quarrying expose patients to silica, which is an inorganic dust that causes pulmonary fibrosis (silicosis). Occupational exposure to beryllium, which is also an inorganic dust, occurs in the high-tech electronics manufacturing industry and results in chronic beryllium lung disease. Exposure to organic agricultural dusts (fungal spores, vegetable products, insect fragments, animal dander, animal feces, microorganisms, and pollens) can result in “farmer’s lung,” a hypersensitivity pneumonitis. Other organic dust exposures, such as exposures to grain dust in bakers, can lead to asthma, chronic bronchitis, and COPD. Firefighters are at risk of smoke inhalation and are exposed to toxic chemicals that can cause many acute and chronic respiratory symptoms.

Answer 123

B The World Health Organization recommends oral rehydration with low osmolarity drinks (oral rehydration solution) and early refeeding. Half-strength apple juice has been shown to be effective, and it approximates an oral rehydration solution. Its use prevents patient measurement errors and the purchase of beverages with an inappropriate osmolarity. Low osmolarity solutions contain glucose and water, which decrease stool frequency, emesis, and the need for intravenous fluids compared to higher osmolarity solutions like soda and most sports drinks Early refeeding has been shown to decrease the duration of illness.

Answer 124

you are increasing afterload, HCOM

Answer 125

abilify if geri- think abilify Aripiprazole produces small reductions in behavioral and psychological symptoms of dementia, and it has the least adverse effects of the atypical antipsychotics. Typical antipsychotics such as haloperidol have significant side effects and would not be a good choice

Answer 126

nope - they will not have suppressed ovulation and the bleeding will be irratic

Answer 127

D Patients <75 years of age with established coronary artery disease should be on high-intensity statin regimens if tolerated. These regimens include atorvastatin, 40–80 mg/day, and rosuvastatin, 20–40 mg/day. Moderate-intensity regimens include simvastatin, 40 mg/day. hhigh intensity = think Rich Allen = Rosuva and Aotrva 20-40/40-80

Answer 128

B Common causes of subclinical hyperthyroidism include Graves disease, autonomous functioning thyroid adenoma, and multinodular toxic goiter. Subclinical hyperthyroidism may progress to overt hyperthyroidism; this is more likely in patients with TSH levels <0.1 μU/mL. Even in the absence of overt hyperthyroidism these patients are at higher risk for several health conditions, including atrial fibrillation, heart failure, and osteoporosis. For this reason it is important to assess for these conditions and consider treating the underlying thyroid condition, as well as the complication. The American Thyroid Association recommends treating patients with complications who are either over age 65 or have a TSH level <0.1 μU/mL.

Answer 129

A The Dix-Hallpike maneuver, which involves moving the patient from an upright to a supine position with the head turned 45° to one side and the neck extended 20° with the affected ear down, will elicit a specific series of responses in these patients. Following a latency period that typically lasts 5–20 seconds but sometimes as long as 60 seconds, the patient will experience the onset of rotational vertigo. The objective finding of a torsional, upbeating nystagmus will be associated with the vertigo. The vertigo and nystagmus typically increase in intensity and then resolve within 1 minute from onset. YOU HAVE TO WAIT....

Answer 130

Paroxetine should generally be avoided in older patients due to a higher likelihood of adverse effects

Answer 131

true - Benzodiazepines such as lorazepam can treat symptoms of hyperarousal but have been associated with adverse effects and should be avoided in the treatment of PTSD (SOR B).

Answer 132

st johns wort

Answer 133

avoid benzos

Answer 134

8-15 On examination the most indicative sign is limited internal rotation of the involved hip. Bilateral radiographs of the hips, including frog-leg lateral views, should be obtained in any adolescent who presents with a new limp and pain in the groin, hip, thigh, or knee (SOR C).

Answer 135

E A healthy patient would be classified as ASA I, while a patient with mild systemic disease would be classified as ASA II. All patients who are having major surgery should be offered preoperative laboratory testing, including a CBC and renal function testing. For patients who are ASA III or IV and have chronic liver disease or take anticoagulants, coagulation testing should be considered. There is no compelling evidence to support either a chest radiograph or an EKG as part of a routine preoperative evaluation.

Answer 136

C think of bradley - no weight bearing, then a walking boot quickly Callus formation on a radiograph and a lack of point tenderness signify adequate healing, and immobilization can be discontinued. Other recommended conservative therapy includes modified rest for 6–8 weeks with continuation of activities of daily living and limited walking. Normal activity can be resumed after 2–3 weeks with no pain.

Answer 137

B Confirming the presence of proteinuria is the next step in this case because functional (exercise/stress-induced) and orthostatic proteinuria are common types of proteinuria and are transient. The pediatric nephrology panel of the National Kidney Foundation reported that a spot protein/creatinine ratio is a reliable test for ruling out proteinuria. A specialist referral, blood analysis, and ultrasonography are unnecessary unless persistent proteinuria is identified.

Answer 138

this of this with the elderly that are on it for alzheimers delirium

Answer 139

8-10 weeks, so about 2 months.

Answer 140

think of Kara - vestibulodynia patient.

Answer 141

B For those who are intolerant of high-intensity statins, a trial of a moderate-intensity statin is appropriate. There is evidence to support ezetimibe plus a statin in patients with acute coronary syndrome or chronic kidney disease. Omega-3 fatty acids, fibrates, and niacin should not be prescribed for primary or secondary prevention of atherosclerotic cardiovascular disease because they do not affect patient-oriented outcomes. PCSK9 inhibitors such as evolocumab are injectable monoclonal antibodies that lower LDL-cholesterol levels significantly and have produced some promising results, but more studies are needed to determine when this would be cost effective.

Answer 142

E This patient has Dupuytren’s disease with a contracture of the affected finger. Surgical release is indicated when the metacarpophalangeal joint contracture reaches 30° or with any degree of contracture of the proximal interphalangeal joint. Intralesional injection may reduce the need for later surgery in a patient with grade 1 disease, but not if there is a contracture. There is no evidence to support the use of physical therapy or cryosurgery.

Answer 143

a Azithromycin is preferred to treat severe traveler’s diarrhea. Rifaximin or fluoroquinolones may be used to treat severe nondysenteric traveler’s diarrhea. PEPTO CAN HELP PREVENT For patients at high risk, bismuth subsalicylate reduces the risk but does not need to be initiated prior to travel. There is insufficient evidence for the use of probiotics to prevent traveler’s diarrhea.

Answer 144

The risk of mortality increases with a respiratory rate 30/min, hypotension, confusion or disorientation, a BUN level 20 mg/dL, age >65 years, male sex, or the presence of heart failure or COPD.

Answer 145

an appetite stimulant

Answer 146

an appetite stimulant

Answer 147

E This is generally a benign disease except in pregnancy. The epidemiology and clinical course suggest an infectious etiology. Pregnant women are more susceptible to pityriasis rosea because of decreased immunity. Pityriasis rosea is associated with an increased rate of spontaneous abortion in the first 15 weeks of gestation.

Answer 148

E Then if no ovulation check B Treatment can be initiated if findings reveal the cause of the problem, but if they are unremarkable it is reasonable to try clomiphene to induce ovulation. If this is unsuccessful, referral would be the next step.

Answer 149

5th times the charm B Diarrhea that develops in patients with ileal Crohn’s disease or following ileal resection is usually due to increased amounts of bile acid remaining in the stool. This affects colonic secretion and motility and various protein factors in the gut, resulting in the development of bile acid diarrhea (BAD). Although various tests can be performed to evaluate the stool, gut flora, and bowel function, a therapeutic trial with a bile acid sequestrant such as cholestyramine is most often used for both the diagnosis and treatment of BAD. Reducing fat intake may also be beneficial. Loperamide can lessen the diarrhea in some patients but should not be the primary treatment because chronic use can result in constipation. Fiber supplementation may help to produce a more formed stool and could be used as an adjunct treatment when appropriate.

Answer 150

A donepezil use should be avoided in patients with syncope, due to an increased risk of bradycardia (Moderate Evidence Level; Strong Strength of Recommendation). Due to their cholinergic effect, these medications have a vagotonic effect on the sinoatrial and atrioventricular nodes.

Answer 151

A donepezil use should be avoided in patients with syncope, due to an increased risk of bradycardia (Moderate Evidence Level; Strong Strength of Recommendation). Due to their cholinergic effect, these medications have a vagotonic effect on the sinoatrial and atrioventricular nodes.

Answer 152

D Currently known risks include increased fractures of the hip, wrist, and spine (SOR B), community-acquired pneumonia (SOR B), Clostridium difficile and other enteric infections (SOR C), hypomagnesemia (SOR B), and cardiac events when coadministered with clopidogrel (SOR B). PPIs may also affect the absorption of vitamins and minerals, including iron, vitamin B12, and folate (SOR C). There is no known association of PPIs with nephrolithiasis or urinary tract infections.

Answer 153

D assume this is a concussion I guess - maybe the mild dizziness.

Answer 154

A preoperative EKG may be considered for asymptomatic patients without known coronary artery disease who are undergoing intermediate and high-risk surgeries (SOR B). A preoperative EKG is reasonable for patients who have known heart disease, peripheral artery disease, or cerebrovascular disease who are undergoing intermediate and high-risk surgeries (SOR B).

Answer 155

a The American Academy of Pediatrics (AAP) recommends that children found to be infested with lice remain in class but be discouraged from close contact with others until treated appropriately with a pediculicide. The AAP position also recommends abandonment of “no nits” school policies, which prohibit attendance until no visible nits are identified. Nits can be found long after their deposition at the scalp level and generally have already hatched by the time they are easily noted at some distance from the scalp.

Answer 156

B The first step in the evaluation of nonmassive hemoptysis is to obtain a chest radiograph. If this is normal and there is a high risk of malignancy (patient age 40 years or older with at least a 30-pack year smoking history), chest CT should be ordered. Bronchoscopy should also be considered in the workup of high-risk patients. If a chest radiograph shows an infiltrate, treatment with antibiotics is warranted. If the chest radiograph is normal the patient is at low risk for malignancy, and if the history does not suggest lower respiratory infection and hemoptysis does not recur, observation can be considered.

Answer 157

C D/e is if conservative management fails

Answer 158

Black cohosh is considered a safe alternative for treating menopausal vasomotor symptoms, but not for treating sexual arousal dysfunction in women who are premenopausal.

Answer 159

The initial treatment of blepharitis consists of lid hygiene using warm compresses to remove dried secretions and debris. Mild shampoo can help in this process and aid in keeping the bacterial colonization load down. In severe or recalcitrant cases a topical antibiotic ointment may be applied to the lids. Oral antibiotics can be considered for more severe cases.

Answer 160

The initial treatment of blepharitis consists of lid hygiene using warm compresses to remove dried secretions and debris. Mild shampoo can help in this process and aid in keeping the bacterial colonization load down. In severe or recalcitrant cases a topical antibiotic ointment may be applied to the lids. Oral antibiotics can be considered for more severe cases.

Answer 161

D Malignant epidural spinal cord compression is an oncologic emergency that requires urgent MRI to confirm the diagnosis. It is caused by a tumor compressing the dural sac and should be suspected with new-onset progressive back pain that is worse when the patient is lying down.

Answer 162

24 or less

Answer 163

might be able to if they have capacity. It is patient specific. the MMSE just makes it look like the patient might have some impairment.

Answer 164

1 liter | 2 months

Answer 165

1 liter | 2 months

Answer 166

20 think of intiail presentation potential or growth.

Answer 167

Scoliosis typically does not cause pain and it is more likely that this patient’s weight is contributing to her back pain.

Answer 168

Varicella-zoster immune globulin would be indicated if she had no immunity to varicella and had been exposed to varicella or if she had a rash that was suspected to be chickenpox.

Answer 169

an increased risk of overdose death

Answer 170

Radiography is an appropriate initial imaging modality but the results are often interpreted as normal early in the disease process. MRI is the modality of choice for a definitive diagnosis and may demonstrate periarticular bone marrow edema, adjacent soft-tissue edema, joint effusion, and microtrabecular or stress fractures. The treatment of acute Charcot neuroarthropathy is immobilization with total contact casting, which increases the total surface area of contact to the entire lower extremity, distributing pressure away from the foot. Immobilization is typically required for at least 3–4 months but in some cases may be needed for up to 12 months.

Answer 171

C the patient’s FEV1/FVC ratio is normal, which neither confirms nor rules out asthma. A methacholine challenge is recommended in this scenario to assess for the airway hyperresponsiveness that is the hallmark of asthma. If the FEV1/FVC ratio is reduced on initial spirometry, a bronchodilator response should be tested.

Answer 172

A Management of asymptomatic peripheral artery disease (PAD) should initially be conservative and should include a walking program (SOR A), smoking cessation, and a healthy diet. Statins should be started for all patients with PAD regardless of their LDL-cholesterol levels (SOR A). A single antiplatelet agent is recommended for patients with PAD. Both aspirin and clopidogrel are effective in the reduction of stroke, but the combination of the two is recommended only after revascularization surgery.

Answer 173

B Elevated blood pressure is defined as a systolic pressure of 120–129 mm Hg and a diastolic pressure <80 mm Hg. A blood pressure of 130–139/80–89 mm Hg is classified as stage 1 hypertension and a systolic pressure 140 mm Hg or a diastolic pressure 90 mm Hg is classified as stage 2 hypertension. Don't pick the 5's.

Answer 174

B Elevated blood pressure is defined as a systolic pressure of 120–129 mm Hg and a diastolic pressure <80 mm Hg. A blood pressure of 130–139/80–89 mm Hg is classified as stage 1 hypertension and a systolic pressure 140 mm Hg or a diastolic pressure 90 mm Hg is classified as stage 2 hypertension. Don't pick the 5's.

Answer 175

B The goal fasting blood glucose level in patients with gestational diabetes is <95 mg/dL. A fasting glucose level <80 mg/dL is associated with increased maternal and fetal complications. The goal 2-hour postprandial glucose level is <120 mg/dL and the goal 1-hour postprandial glucose level is <140 mg/dL.

Answer 176

C The ability to point to body parts or pictures after they are named is expected at 2 years of age. At 18 months a child would be expected to scribble spontaneously but not to copy a vertical line

Answer 177

D Allergy testing can be helpful in patients with persistent sinus infections, allergic rhinitis, and poorly controlled asthma.

Answer 178

a Patients are at risk of developing glucocorticoid-induced osteoporosis if they are on long-term glucocorticoid therapy, defined as >2.5 mg of prednisone for a duration of 3 months or longer. The American College of Rheumatology recommends pharmacologic treatment for these patients, a

Answer 179

Early remission | is defined as the absence of symptoms for at least 3 months but less than 12 months.

Answer 180

E Exercise, probiotics, antibiotics, antispasmodics, antidepressants, psychological treatments, and peppermint oil all have evidence that they may improve IBS symptoms (SOR B). amitripytline would have been right too because thtat is an antidepressant

Answer 181

it is when ADH doesn't work - whether central, not having enough vasopressin, or nephro - where the vasopressin is given, it just doesn't work. So no ADH, no retention of fluid - and you get polyuria nad hyponatremia.

Answer 182

acetazolamide dexamethasone

Answer 183

E Dual antiplatelet therapy should extend beyond 1 year for patients with acute coronary syndrome who are not considered at high risk of bleeding, especially those with risk factors associated with high ischemic risk such as diabetes mellitus, peripheral artery disease, left main stenting, or a history of a cardiovascular event. For dual antiplatelet therapy that continues beyond a year, either ticagrelor, 60 mg twice daily, or clopidogrel, 75 mg daily, is recommended in addition to aspirin. The patient’s bleeding and ischemic risk should be reevaluated at least annually. Dual antiplatelet therapy should continue for at least 1 year in patients who are considered at high risk of bleeding. For patients who are at very high risk of bleeding or who experience significant bleeding while on dual antiplatelet therapy, a duration of less than 1 year is recommended. UDT For stable patients treated with intracoronary stents who are not at high bleeding risk and who do not have planned noncardiac surgery within one year, we recommend aspirin and a platelet P2Y12 receptor blocker for at least 6 to 12 months after stent placement rather than a shorter treatment duration (Grade 1B). For stable patients who have not had a significant complication with DAPT during the first 6 to 12 months, especially those with higher ischemic risk, we suggest continuing such therapy, rather than aspirin monotherapy, for an additional 18 months (Grade 2B). It is reasonable for patients to stop DAPT after 6 to 12 months if they are particularly concerned about the increased risk of bleeding, if the bleeding risk exceeds ischemic benefit (eg, DAPT score <2), or if there is a hardship associated with continuing DAPT.

Answer 184

E Dual antiplatelet therapy should extend beyond 1 year for patients with acute coronary syndrome who are not considered at high risk of bleeding, especially those with risk factors associated with high ischemic risk such as diabetes mellitus, peripheral artery disease, left main stenting, or a history of a cardiovascular event. For dual antiplatelet therapy that continues beyond a year, either ticagrelor, 60 mg twice daily, or clopidogrel, 75 mg daily, is recommended in addition to aspirin. The patient’s bleeding and ischemic risk should be reevaluated at least annually. Dual antiplatelet therapy should continue for at least 1 year in patients who are considered at high risk of bleeding. For patients who are at very high risk of bleeding or who experience significant bleeding while on dual antiplatelet therapy, a duration of less than 1 year is recommended. UDT For stable patients treated with intracoronary stents who are not at high bleeding risk and who do not have planned noncardiac surgery within one year, we recommend aspirin and a platelet P2Y12 receptor blocker for at least 6 to 12 months after stent placement rather than a shorter treatment duration (Grade 1B). For stable patients who have not had a significant complication with DAPT during the first 6 to 12 months, especially those with higher ischemic risk, we suggest continuing such therapy, rather than aspirin monotherapy, for an additional 18 months (Grade 2B). It is reasonable for patients to stop DAPT after 6 to 12 months if they are particularly concerned about the increased risk of bleeding, if the bleeding risk exceeds ischemic benefit (eg, DAPT score <2), or if there is a hardship associated with continuing DAPT.

Answer 185

D fluoroquinolones can increase the occurrence of aortic dissections or ruptures. Drugs in this group should be avoided in patients with an existing aortic aneurysm or in patients at increased risk for developing an aortic aneurysm unless there are no other treatment options available.

Answer 186

Radioactive iodine ablation and thyroidectomy with subsequent thyroid hormone replacement are both appropriate treatments for toxic multinodular goiter, but thyroidectomy is indicated for this patient because she has compressive symptoms from the goiter itself.

Answer 187

Neuromas present with a burning, tingling, or numb sensation and a painful lump. The etiology of Morton neuroma is not fully understood but is thought to be similar to metatarsalgia, involving collapse of the transverse arch that places traction and increased pressure on the interdigital nerve, ultimately leading to injury. Overpronation and tight shoes are often associated with the condition. Morton neuroma is a common problem in athletic and non-athletic populations. Females are approximately five times more likely than males to develop Morton neuroma [33]. The patient with a neuroma most commonly complains of a burning pain in the third intermetatarsal space (between the third and fourth distal metatarsals) that may radiate towards the toes

Answer 188

Conservative treatment should precede expensive diagnostic procedures. This approach involves decreasing pressure on the metatarsal heads by using a metatarsal support or bar or padded shoe insert. If conservative measures fail to relieve symptoms, a single injection of a glucocorticoid and local anesthetic into the site of tenderness can be performed using a dorsal, not plantar, approach

Answer 189

A Hematocrit, BUN, and creatinine levels are the most useful predictors of the severity of pancreatitis, reflecting the degree of intravascular volume depletion. Ranson's criteria

Answer 190

A Fructosamine correlates well with hemoglobin A1c levels and is recommended instead of hemoglobin A1c for monitoring glucose control in patients with diabetes and hemoglobinopathies. the answer is basically never to refer

Answer 191

C In patients with atrial fibrillation and stable coronary artery disease, novel oral anticoagulants are preferred (SOR A). They reduce the risk of reinfarction, stroke, and overall mortality in patients with a past history of myocardial infarction, and also help prevent PE/DVT.

Answer 192

a smooth philtrum, shortened palpebral fissures, and a thin vermilion border of the upper lip. Two out of these three characteristics are required for the diagnosis of fetal alcohol syndrome.

Answer 193

A Premature adrenarche without development of secondary sex characteristics is usually idiopathic and does not lead to an abnormal pattern of development.

Answer 194

C Renal parenchymal diseases such as glomerulonephritis, congenital abnormalities, and reflux nephropathy are the most common cause of hypertension in preadolescent children. Preadolescent children with hypertension should be evaluated for possible secondary causes and renal ultrasonography should be the first choice of imaging in this age group.

Answer 195

E Topiramate increases the risk of kidney stones. It is a carbonic anhydrase inhibitor, which induces a metabolic acidosis that leads to hypercalciuria and the formation of calcium phosphate stones.

Answer 196

B Nondisplaced tuberosity fractures can generally be treated with compressive dressings such as an Aircast or Ace bandage, with weight bearing and range-of-motion exercises as tolerated. ``` Minimally displaced (<3 mm) avulsion fractures of the fifth metatarsal tuberosity can be treated with a short leg walking boot. ``` If the displacement is >3 mm, an orthopedic referral is warranted.

Answer 197

Children who receive the first dose of the vaccine before the age of 15 and receive two doses are considered adequately vaccinated. If the first dose is given after age 15, a three-dose series is recommended.

Answer 198

D Atrial ventricular nodal ablation is recommended for patients whose atrial fibrillation is refractory to medical therapy, and requires that patients be anticoagulated for at least 1 month prior to the procedure and for several months afterward (SOR C) Atrial ventricular nodal ablation is not necessary for patients successfully converted to sinus rhythm or for those who are successfully treated with medical interventions for rate control and anticoagulation.

Answer 199

If the patient is allergic to penicillin, clindamycin plus | levofloxacin or moxifloxacin, which has anaerobic coverage, can be used.

Answer 200

D This patient has symptoms consistent with hyperthyroidism, which could be caused by any of the options listed. TSH is suppressed and free T4 and free T3 are elevated in all of these conditions. Only Graves disease, however, will cause high radioactive iodine uptake on a thyroid scan. Uptake will be low in the other conditions.

Answer 201

FALSE - It may be useful for hypoactive sexual desire in postmenopausal women.

Answer 202

e Node-blocking medications such as diltiazem and metoprolol should not be used for the long-term treatment of WPW, due to the increased risk of ventricular fibrillation.

Answer 203

B ***key to this question, is that it is his first time getting the vaccine - so he needs 2 doses in the first year at least 1 month apart. quad + tri, doesn't matter.

Answer 204

E Log roll is normal. A positive flexion, abduction, external rotation (FABER) test that produces pain at the sacroiliac joint, lumbar spine, and posterior hip is associated with sacroiliac joint dysfunction. While femoroacetabular impingement may be associated with a positive FABER test, it would produce pain in the groin.

Answer 205

A Oral anticholinergics such as oxybutynin can be considered if other first-line treatments fail.

Answer 206

dry eyes some glare issues but pt's still love it

Answer 207

B Although regular physical activity has clear health benefits, the methods are so varied in studies of physical activity that there is currently no strong evidence to show it reduces hospitalizations in COPD patients

Answer 208

B Although regular physical activity has clear health benefits, the methods are so varied in studies of physical activity that there is currently no strong evidence to show it reduces hospitalizations in COPD patients

Answer 209

A The TSH reference range is lower during pregnancy because of the cross-reactivity of the -subunit of hCG. Levels of hCG peak during weeks 7–13 of pregnancy, and hCG has mild TSH-like activity, leading to slightly high free T4 levels in early pregnancy. This leads to a feedback decrease in TSH.

Answer 210

A Mammograms of both breasts or the remaining breast are recommended no more often than yearly (SOR A). Breast MRI is not recommended on a regular basis unless the patient has a high risk of recurrence, a significant family history of breast or ovarian cancer, or a personal history of Hodgkin’s disease (SOR C).

Answer 211

D Sensitive = D-Dimer D-dimer is NOT specific.

Answer 212

A not D - this would be graves B - hashimotos C - isn't that useful ever. Postpartum thyroiditis is defined as a transient or persistent thyroid dysfunction that occurs within 1 year of childbirth, miscarriage, or medical abortion. Release of preformed thyroid hormone in the bloodstream initially results in hyperthyroidism. During the hyperthyroid phase, radioactive iodine uptake will be low,

Answer 213

acute pyelo

Answer 214

false- just RF

Answer 215

E Most outpatient clinics do not have the ability to administer intravenous metoclopramide, which is the preferred treatment. However, most clinics do have the ability to administer intramuscular prochlorperazine or promethazine. Oral butalbital/acetaminophen/caffeine and oral ergotamine/caffeine have less evidence of success in the treatment of acute migraine.

Answer 216

E - MRI This patient has a calcaneal stress fracture as suggested by the history of increased running on a hard surface, improvement with rest, and a positive calcaneal squeeze on examination. A delay in diagnosis increases the risk of delayed union. MRI is the preferred imaging modality because radiographs often do not detect a calcaneal stress fracture. a nerve conduction veloctiy test = EMG

Answer 217

C Any plaque is disease... and should be on statin therapy. Asymptomatic carotid artery disease is considered a coronary artery disease risk equivalent; therefore, statin therapy is indicated. Repeating ultrasonography annually to monitor for progression of the disease and to guide intervention is also considered reasonable. According to the 2014 guidelines for the primary prevention of stroke issued by the American Heart Association/American Stroke Association, prophylactic carotid artery stenting might be considered in highly selected asymptomatic patients with >70% carotid stenosis, but the effectiveness of this intervention compared with statin therapy alone is not well established. The guidelines also state that it is reasonable to consider carotid endarterectomy for asymptomatic patients with >70% stenosis if the risks of perioperative complications are low.

Answer 218

D . Smokers have a seven times greater risk of developing an AAA compared with nonsmokers. This single factor outweighs all of the other risk factors except age.

Answer 219

C Although behavioral interventions are the mainstay of treatment for insomnia, they often need to be supplemented by pharmacologic therapy. When both doxepin and extended-release melatonin fail to provide benefit, a member of the Z-drug class should be tried next. Among the Z-drugs only eszopiclone provides an early peak onset and a long half-life, with a 1-hour approximate time to peak and a 6-hour half-life.

Answer 220

These headaches typically present with severe unilateral pain that lasts from 15 minutes to 3 hours. The headaches occur anywhere from every other day up to 8 times a day, often in cycles for 4–12 weeks. Cluster headaches respond to most of the same medications as migraine headaches (DHE, ergotamines, triptans). They also respond well to 100% oxygen therapy. Paroxysmal hemicranias are very unusual and present with a similar type of pain, but the attacks are usually short and they are more common in women.

Answer 221

These headaches typically present with severe unilateral pain that lasts from 15 minutes to 3 hours. The headaches occur anywhere from every other day up to 8 times a day, often in cycles for 4–12 weeks. Cluster headaches respond to most of the same medications as migraine headaches (DHE, ergotamines, triptans). They also respond well to 100% oxygen therapy. Paroxysmal hemicranias are very unusual and present with a similar type of pain, but the attacks are usually short and they are more common in women.

Answer 222

C The most common form of advance directive is a patient’s conversations with relatives and friends, and these carry the same ethical and legal weight as written directives. Since the patient has previously expressed his wishes, it is unnecessary to have the court appoint a surrogate decision maker.

Answer 223

C anti-TNF agents such as infliximab should be considered in patients with moderate to severe Crohn’s disease who do not respond to initial corticosteroid or immunosuppressive therapy, but these are not recommended for initial treatment.

Answer 224

A 7 no tonsillar exudate no cough Virus...

Answer 225

B the loss of pleasure or interest in all activities. Episodic feelings of guilt, anxiety, and helplessness, and even thoughts of wanting to die can and do occur with grief reactions, but these feelings are not constant and over time the symptoms gradually wane. T

Answer 226

C Although patients with chronic mild liver disease may take NSAIDs, they should be avoided in all patients with cirrhosis, due to the risk of precipitating hepatorenal syndrome. Pregabalin and gabapentin are not metabolized by the liver and can be quite helpful. Acetaminophen, while toxic in high doses, can be used safely in dosages of 2–3 g/day. Tramadol is also safe in patients with cirrhosis.

Answer 227

erythromycin

Answer 228

D An ABI >1.4 indicates noncompressible arteries (calcified vessels). In patients with arterial calcification, such as diabetic patients, more reliable information is often obtained by using toe pressures to calculate a toe-brachial index and from pulse volume recordings. ***diabetic - should have known.

Answer 229

include individuals who worked in construction trades or as boilermakers, shipyard workers, or railroad workers, as well as U.S. Navy veterans. Berylliosis is an occupational disease related to mining and manufacturing. Silicosis is seen in sandblasters, miners, persons who have worked with abrasives, and several other occupations. Uranium exposure occurs after nuclear reactor leaks or blasts. Uranium compounds are also used in photography and as dyes or fixatures

Answer 230

false - it will altitude sickness is common at 8200

Answer 231

B Joint pain in the presence of fever with no apparent source indicates a possible infection, malignancy, or rheumatologic condition and requires further workup. Laboratory evaluation, including a CBC, a C-reactive protein level, and an erythrocyte sedimentation rate can help assess for these conditions, even though none of the tests is sufficiently sensitive to rule out these diseases, and they are not specific to a single disease entity. Knee joint aspiration would be indicated to rule out septic arthritis in the presence of a joint effusion. If the hip were painful or had decreased range of motion, then ultrasonography could help identify a hip joint effusion, which would need to be aspirated. MRI may be needed in this patient, but it would likely require sedation and thus is more invasive. Starting with laboratory work is a good first step toward identifying the source of his pain and fever.

Answer 232

B Joint pain in the presence of fever with no apparent source indicates a possible infection, malignancy, or rheumatologic condition and requires further workup. Laboratory evaluation, including a CBC, a C-reactive protein level, and an erythrocyte sedimentation rate can help assess for these conditions, even though none of the tests is sufficiently sensitive to rule out these diseases, and they are not specific to a single disease entity. Knee joint aspiration would be indicated to rule out septic arthritis in the presence of a joint effusion. If the hip were painful or had decreased range of motion, then ultrasonography could help identify a hip joint effusion, which would need to be aspirated. MRI may be needed in this patient, but it would likely require sedation and thus is more invasive. Starting with laboratory work is a good first step toward identifying the source of his pain and fever.

Answer 233

E Topical testosterone, in either patch or gel form, has shown consistent improvements in arousal, desire, fantasy, orgasm, and overall satisfaction in cases of HSDD.

Answer 234

C The appropriate management of a thrombosed hemorrhoid presenting within 72 hours of the onset of symptoms is elliptical excision of the hemorrhoid and overlying skin under local anesthesia, such as 0.5% bupivacaine hydrochloride in 1:200,000 epinephrine, infiltrated slowly with a 27-gauge needle. Rubber band ligation is an excellent technique for management of internal hemorrhoids, Banding an external hemorrhoid would cause exquisite pain.

Answer 235

C A Cochrane review of 15 studies involving 922 patients showed that antidepressants had a beneficial effect on the symptoms of irritable bowel syndrome (IBS). Both SSRIs and tricyclic antidepressants have shown benefit. Another Cochrane review of 12 randomized, controlled trials did not show any benefit from the use of fiber in any type of IBS.

Answer 236

E Testing for diabetes mellitus should be considered in all asymptomatic adults who have: a BMI ≥25 kg/m2 AND have one or more additional risk factors such as physical inactivity, a first degree relative with diabetes, a high-risk ethnicity, hypertension, hyperlipidemia, or polycystic ovary syndrome. In asymptomatic patients with no risk factors, screening should begin at age 45.

Answer 237

D Myelodysplastic syndrome is a hematologic malignancy with a predisposition to leukemic transformation. It can present with findings of anemia, thrombocytopenia, neutropenia, or any combination of these. Anemia occurs in 80%–85% of patients and is typically macrocytic.

Answer 238

B Intermittent: Symptoms less than or equal to twice weekly, nighttime awakenings ≤2 times/month, short-acting β-agonist usage ≤2 days/week, no interference with daily activities, and normal FEV1 and FEV1/FVC ratio at baseline Mild Persistent: Symptoms >2 days/week but not daily, nighttime awakenings 3–4 times/month, short-acting β-agonist usage >2 days/week but not more than once daily, minor limitation to daily activities, FEV1 ≥80% predicted, and normal FEV1/FVC ratio Moderate Persistent: Daily symptoms, nighttime awakenings greater than once weekly but not nightly, daily use of a short-acting β-agonist, some limitation to daily activity, FEV1 >60% but <80% of predicted, and FEV1/FVC ratio reduced by 5% Severe Persistent: Symptoms throughout the day, nighttime awakenings nightly, short-acting β-agonist usage several times daily, extremely limited daily activities, FEV1 <60% of predicted, and FEV1/FVC ratio reduced by >5%

Answer 239

a previous history of severe hypoglycemia that required external assistance. It is thought that hypoglycemia reduces the body’s protective responses (glucagon and epinephrine) to subsequent episodes of hypoglycemia (SOR C).

Answer 240

when in doubt... do not refer, haha.

Answer 241

Generally, people with a tear of the labrum will have increased pain with overhead activity, popping or grinding, loss of strength, and trouble locating a specific point of pain. A tear of the labrum can occur with acute trauma or from repetitive shoulder motion.

Answer 242

false = thye have little benefit

Answer 243

b Marfan syndrome is an autosomal dominant disease manifested by skeletal, ophthalmologic, and cardiovascular abnormalities. Men taller than 72 inches and women taller than 70 inches who have two or more manifestations of Marfan syndrome should be screened by echocardiography for associated cardiac abnormalities. These signs and symptoms include cardiac murmurs or clicks, kyphoscoliosis, anterior thoracic deformity, arm span greater than height, upper to lower body ratio more than 1 standard deviation below the mean, myopia, and an ectopic lens. you are not looking for HCOM with marfans, you are looking for aortic valve stuff. . Patients with Marfan syndrome who have echocardiographic evidence of aortic abnormalities should be placed on β-blockers and monitored with echocardiography every 6 months.

Answer 244

A heat exhaustion is less bad heat stroke is WORSE Evidence of central nervous system dysfunction is evidence of heatstroke rather than heat exhaustion, even if other symptoms are not severe and point to heat exhaustion. Heatstroke is a medical emergency.

Answer 245

***low yield A Aggressive neurosurgical intervention is not indicated to evacuate clots in patients with intracerebral hemorrhage except in those with a cerebellar hemorrhage, which is always an indication for neurosurgical consultation. Guidelines have been developed by the American Heart Association for lowering blood pressure in patients with a systolic blood pressure >180 mm Hg, or a mean arterial pressure >130 mm Hg. The use of various forms of osmotherapy, including mannitol, to prevent the development of cerebral edema has not been shown to improve outcomes. The data regarding hypothermia induction is unclear. Patients with an INR >1.5 should receive therapy to replace vitamin K–dependent factors and have their warfarin withheld.

Answer 246

***low yield A Aggressive neurosurgical intervention is not indicated to evacuate clots in patients with intracerebral hemorrhage except in those with a cerebellar hemorrhage, which is always an indication for neurosurgical consultation. Guidelines have been developed by the American Heart Association for lowering blood pressure in patients with a systolic blood pressure >180 mm Hg, or a mean arterial pressure >130 mm Hg. The use of various forms of osmotherapy, including mannitol, to prevent the development of cerebral edema has not been shown to improve outcomes. The data regarding hypothermia induction is unclear. Patients with an INR >1.5 should receive therapy to replace vitamin K–dependent factors and have their warfarin withheld.

Answer 247

E B A - surgery is a LAST resort per AAFP estrogen would worsen the problem. TXA would just mask the problem progestational - are not like prenatals, these are prostestins, like IUDS!

Answer 248

E Maternal varicella infection is particularly problematic during weeks 13–20 of pregnancy (resulting in a 2% risk of congenital varicella in the newborn) and when the onset of maternal symptoms occurs from 5 days before until 2 days after delivery. Administration of varicella immune globulin to the expectant mother has not been shown to benefit the fetus or infant, but because pregnancy can increase the risk of serious complications in the mother the Advisory Committee on Immunization Practices (ACIP) recommends that administration to pregnant women be considered following known exposure. The ACIP also recommends that term infants born within the 7-day window described above, as well as all preterm infants, receive varicella immune globulin, and that those who develop any signs of varicella infection also be given intravenous acyclovir. Term infants delivered more than 5 days after the onset of maternal varicella are thought to have adequate passive immunity for protection and the expected benign course generally requires only observation.

Answer 249

E Maternal varicella infection is particularly problematic during weeks 13–20 of pregnancy (resulting in a 2% risk of congenital varicella in the newborn) and when the onset of maternal symptoms occurs from 5 days before until 2 days after delivery. Administration of varicella immune globulin to the expectant mother has not been shown to benefit the fetus or infant, but because pregnancy can increase the risk of serious complications in the mother the Advisory Committee on Immunization Practices (ACIP) recommends that administration to pregnant women be considered following known exposure. The ACIP also recommends that term infants born within the 7-day window described above, as well as all preterm infants, receive varicella immune globulin, and that those who develop any signs of varicella infection also be given intravenous acyclovir. Term infants delivered more than 5 days after the onset of maternal varicella are thought to have adequate passive immunity for protection and the expected benign course generally requires only observation.

Answer 250

D - don't take a CIP or you might get the trots! Fluoroquinolones such as ciprofloxacin have been shown to significantly reduce the duration and severity of traveler’s diarrhea when given for 1–3 days. Think ETEC Not Erythro... but Azithro. Cipro and Azithro - .... Carribean and Africa

Answer 251

D . Constipation is easier to prevent than to treat, so it is important to start an appropriate bowel regimen with the initiation of opioid therapy. Fiber supplements and detergents (such as docusate) are inadequate for the prevention of opioid-induced constipation

Answer 252

A ***pain is the indication for surgeyr

Answer 253

D . Constipation is easier to prevent than to treat, so it is important to start an appropriate bowel regimen with the initiation of opioid therapy. Fiber supplements and detergents (such as docusate) are inadequate for the prevention of opioid-induced constipation

Answer 254

UTD First-line pharmacotherapy options for painful diabetic neuropathy include several antidepressants (eg, duloxetine, venlafaxine, amitriptyline and other tricyclic drugs) and the gabapentinoid antiseizure medications (pregabalin, gabapentin)

Answer 255

C Wheezing associated with feeding is most commonly due to gastroesophageal reflux disease (level of evidence 3). Tracheoesophageal fistula and laryngeal cleft also cause wheezing associated with feeding, but are rare. The wheezing present with tracheomalacia is position related.

Answer 256

E Basic activities of daily living, such as dressing, eating, toileting, and grooming, are generally intact in early dementia. In contrast, instrumental activities of daily living, such as managing money and medications, shopping, cooking, housekeeping, and transportation, which often require calculation or planning, are frequently impaired in early dementia. Think of which one involves more thought... grooming you can do without much thought, but cooking takes more thought because of the time.

Answer 257

haldol There is a consensus based on observational evidence and experience that antipsychotic agents such as haloperidol are effective for the management of delirium, and they are widely used. However, there have been few randomized, controlled trials to assess their effectiveness. While benzodiazepines are used extensively in persons with delirium who are terminally ill, there is no evidence from well-conducted trials that they are beneficial.

Answer 258

aldosterone holds the water, sodium comes up too... but you spill potassium = hypokalemia

Answer 259

D There is strong evidence that static stretching significantly slows performance in sprints up to 100 meters. Based on current understanding of sports performance, static stretching is of most benefit when performed during the cool-down period following exercise, which has been found to increase flexibility, and is best avoided immediately before athletic endeavors. A preparatory aerobic warm-up combined with dynamic range-of-motion exercises may be of some benefit for runners.

Answer 260

e anti-epileptics

Answer 261

e anti-epileptics

Answer 262

D preschool Guidelines from the American Academy of Pediatrics state that stimulant medication can be prescribed for preschool children, but only after a thorough trial of behavior modification. Foods and additives have never been shown to cause or aggravate ADHD. Children with ADHD often have other behavioral problems such as depression or oppositional-defiant disorder.

Answer 263

downhill downhill lengthens the stride.... and you have more weight when you land. Patellofemoral pain syndrome can be treated with exercises to strengthen the quadriceps and hips, and by using a knee sleeve with a doughnut-type cushion that the patella fits into.

Answer 264

A The current management of methanol intoxication, depending on its severity, includes ethanol administration to inhibit the metabolism of methanol, hemodialysis to remove alcohol and its toxins, and vigorous management of metabolic acidosis with bicarbonate therapy

Answer 265

C Ultrasonography will not show an undescended testis in many cases and is therefore not recommended. Treatment for a unilateral undescended testis should be started at 6–12 months of age to avoid testicular damage.

Answer 266

D Head trauma is a known cause of the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). This patient’s course has been very acute, with hyponatremia developing within 48 hours. Such a precipitous drop in serum sodium may lead to cerebral and pulmonary edema. If left untreated the patient can have seizures, become obtunded, and die from brain herniation. These dangers require immediate treatment with hypertonic saline to correct the falling levels of sodium. This must be done cautiously so as to not overcorrect the sodium level too quickly, which could lead to osmotic demyelination syndrome. An increase in serum sodium levels of about 6 mEq/L should be enough to reduce symptoms and prevent progressive cerebral edema.

Answer 267

slap cheek URI sx It is also associated with nonspecific fever, arthropathy, chronic anemia, and transient aplastic crisis.

Answer 268

B dumb question ... data isn't even great. While there were some significant ethnic differences, placental abnormalities and obstetric complications were the largest category of causes in white women, and this was even more true after 32 weeks gestation. Other important causes included infection and fetal defects. More than one cause was found in one-third of cases.

Answer 269

B dumb question ... data isn't even great. While there were some significant ethnic differences, placental abnormalities and obstetric complications were the largest category of causes in white women, and this was even more true after 32 weeks gestation. Other important causes included infection and fetal defects. More than one cause was found in one-third of cases.

Answer 270

D . Treatment should include both antiviral and antibacterial agents that include coverage against methicillin-resistant Staphylococcus aureus (MRSA), the most common bacterial pathogen isolated from critically ill patients with coinfection.

Answer 271

There is often a family history of Meniere’s disease, and there is frequently an association with allergies. The condition can also get worse with caffeine use. treu

Answer 272

not appe, not intussusception, not testicular torsion.... bilious vomit = volvulus. D In young children with bilious emesis, anorexia, and lack of fever, the most likely diagnosis is intestinal malrotation with volvulus. Abdominal ultrasonography is less sensitive and specific for malrotation than an upper gastrointestinal series, so an upper GI series should be ordered initially if volvulus is suspected. If appendicitis were suspected, ultrasonography would be preferred. CT is not a good choice because of the amount of radiation it delivers, especially given efforts to decrease the use of CT in children unless absolutely necessary. This patient’s presentation is not typical for testicular torsion, therefore scrotal ultrasonography should not be the initial test of choice.

Answer 273

Metronidazole, vancomycin, and fidaxomicin are the three medications recommended for treatment of Clostridium difficile colitis infections. Only metronidazole is effective intravenously, because its biliary excretion and possibly exudation through the colonic mucosa allows it to reach the colon via the bloodstream. Treatment for this condition with vancomycin and fidaxomicin is oral. C

Answer 274

Calcaneal apophysitis, also called Sever’s disease, is a common cause of heel pain in young athletes, E is the wrong answer.

Answer 275

Calcaneal apophysitis, also called Sever’s disease, is a common cause of heel pain in young athletes, E is the wrong answer.

Answer 276

The recommended workup includes blood and urine testing, as well as renal ultrasonography. An evaluation for end-organ damage is also recommended, including retinal evaluation and echocardiography. ***find the cause, don't just treat

Answer 277

E Splinting, physical therapy, and corticosteroid injections have all been shown to result in short-term improvement. Patients with persistent symptoms achieve the best long-term relief with surgery.

Answer 278

C Inflammatory mediators are released in response to the pulmonary infection or injury. The syndrome has an acute onset and is manifested by rapidly developing profound hypoxia with bilateral pulmonary infiltrates. The mortality rate in patients with ARDS may be as high as 55%. Early recognition and prompt treatment with intubation and mechanical ventilation is necessary to improve chances for survival. Patients with ARDS should be started at lower tidal volumes (6 mL/kg) instead of the traditional volumes (10–15 mL/kg) (SOR A). These patients also often require higher positive end-expiratory pressure settings (SOR B).

Answer 279

B ***I feel like CT is never the asnwer in kids

Answer 280

B ***I feel like CT is never the asnwer in kids Ultrasonography is highly sensitive for the effusion seen in septic arthritis, which can be aspirated to confirm the diagnosis (SOR A) If ultrasonography is negative, a bone scan should be done.

Answer 281

A Asymptomatic gallstones are not usually an indication for prophylactic cholecystectomy, as most patients remain asymptomatic throughout their lives, and only 1%–4% develop symptoms or complications from gallstones each year. Only 10% of patients found to have asymptomatic gallstones develop symptoms within the first 5 years after diagnosis, and only 20% within 20 years.

Answer 282

A The criteria for chronic fatigue syndrome include fatigue for 6 months and a minimum of four of the following physical symptoms: impaired memory, postexertional malaise, muscle pain, polyarthralgia, tender lymph nodes, sore throat, new headaches, and unrefreshing sleep. Both cognitive-behavioral therapy and graded exercise therapy have been shown to improve fatigue levels, anxiety, work/social adjustment, and postexertional malaise (SOR A).

Answer 283

B drug induced lupus There are many drugs that can induce a syndrome resembling systemic lupus erythematosus, but the most common offenders are antiarrhythmics such as procainamide. Hydralazine is also a common cause. While all patients with this condition have positive antinuclear antibody titers and most have antibodies to histones, antibodies to double-stranded DNA and decreased complement levels are rare, which distinguishes drug-induced lupus from idiopathic lupus. The best initial management for drug-induced lupus is to withdraw the drug, and most patients will improve in a few weeks. For those with severe symptoms, a short course of corticosteroids is indicated. Once the offending drug is discontinued, symptoms seldom last beyond 6 months.

Answer 284

E If a metal foreign body is present on the cornea for more than 24 hours a rust ring will often be present in the superficial layer of the cornea. This material is toxic to the cornea and should be removed as soon as possible, but it is not an emergency. The proper removal of a rust ring requires the use of a slit lamp and specialized ophthalmic equipment. Referral to an eye specialist within 24–48 hours is the best management in this case.

Answer 285

B Children younger than 1 year of age should receive immunoglobulin. Family members should receive prophylaxis only during an outbreak and if their child is still in diapers. Workers and children at child care centers should receive postexposure prophylaxis if one or more cases of hepatitis A is found in a child or worker. Hepatitis A vaccine is preferred over immunoglobulin because of its long-lasting effect, ease of administration, and efficacy.

Answer 286

true, so no xray

Answer 287

A meta-analysis of 11 randomized, controlled trials of combination T3/T4 therapy versus T4 monotherapy showed no improvements in pain, depression, or quality of life (SOR A).

Answer 288

nope Desiccated thyroid hormone preparations are not recommended by the American Association of Clinical Endocrinologists for the treatment of hypothyroidism.

Answer 289

A High-risk locations include the “mask” areas of the face, which include the central face, eyelids, eyebrows, periorbital area, nose, lips (cutaneous and vermilion), chin, mandible, preauricular and postauricular skin/sulci, temple, and ear. Other high-risk sites include the genitalia, hands, and feet or are >20mm

Answer 290

false - Elevated (-glutamyl transpeptidase (GGTP) is also associated with alcohol abuse, especially in a patient with an AST/ALT ratio >2.

Answer 291

B Terbinafine has equal effectiveness and requires a significantly shorter duration of therapy, but it is only available in tablet form. Since tinea capitis most commonly occurs in children, tablets would have to be cut and/or crushed prior to administration. Oral itraconazole, fluconazole, and ketoconazole have significant side effects. Topical antifungals such as ketoconazole and miconazole are ineffective against tinea capitis.

Answer 292

B Terbinafine has equal effectiveness and requires a significantly shorter duration of therapy, but it is only available in tablet form. Since tinea capitis most commonly occurs in children, tablets would have to be cut and/or crushed prior to administration. Oral itraconazole, fluconazole, and ketoconazole have significant side effects. Topical antifungals such as ketoconazole and miconazole are ineffective against tinea capitis.

Answer 293

A . Withdrawal can be divided into four levels of severity: minor, major, seizures, and delirium tremens. Minor alcohol withdrawal is characterized by tremor, anxiety, nausea, vomiting, and/or insomnia 6–24 hours after the patient’s last drink. Major withdrawal occurs 10–72 hours after the last drink and can include the signs and symptoms of minor withdrawal, as well as visual and auditory hallucinations, diaphoresis, tachycardia, and elevated blood pressure. Alcoholic seizure generally occurs within 2 days of the last drink and may be the only sign of withdrawal, although approximately one-third of these patients will progress to delirium tremens. The onset of delirium tremens can occur anytime within 3–10 days following the last drink. The defining clinical finding is delirium, but the findings seen in milder forms of alcohol withdrawal can also be present, and may be more severe. ***Fever is most often seen with delirium tremens and is less common with less severe forms of alcohol withdrawal.

Answer 294

A . Withdrawal can be divided into four levels of severity: minor, major, seizures, and delirium tremens. Minor alcohol withdrawal is characterized by tremor, anxiety, nausea, vomiting, and/or insomnia 6–24 hours after the patient’s last drink. Major withdrawal occurs 10–72 hours after the last drink and can include the signs and symptoms of minor withdrawal, as well as visual and auditory hallucinations, diaphoresis, tachycardia, and elevated blood pressure. Alcoholic seizure generally occurs within 2 days of the last drink and may be the only sign of withdrawal, although approximately one-third of these patients will progress to delirium tremens. The onset of delirium tremens can occur anytime within 3–10 days following the last drink. The defining clinical finding is delirium, but the findings seen in milder forms of alcohol withdrawal can also be present, and may be more severe. ***Fever is most often seen with delirium tremens and is less common with less severe forms of alcohol withdrawal.

Answer 295

b ***3 hospitalizations - assume he is already on BB, ACEI, AA. The combination of the vasodilators hydralazine and isosorbide dinitrate has been shown to be effective in the treatment of heart failure when standard treatment with diuretics, β-blockers, and an ACE inhibitor (or ARB) is insufficient to control symptoms or cannot be tolerated. This combination is particularly effective in African-Americans with NYHA class III or IV heart failure, with advantages including reduced mortality rates and improvement in quality-of-life measures. Digoxin, a long-time standard for the treatment of heart failure, is useful in reducing the symptoms of heart failure but has not been shown to improve survival.

Answer 296

D In addition to hypoventilation, a multifactorial acute lung injury occurs within 2–4 hours of the overdose and is associated with hypoxemia and a hypersensitivity reaction, resulting in noncardiogenic pulmonary edema. Findings include hypoxia, crackles on lung auscultation, and pink, frothy sputum. Treatment must include respiratory support with intubation, mechanical ventilation, and oxygen, as well as opiate reversal with naloxone, which may require repeat doses or intravenous infusion.

Answer 297

It has little effect with | complete heart block and Mobitz type II atrioventricular block

Answer 298

E Morphine is the best first choice for chronic potent opioid therapy (SOR B). It is reliable and inexpensive, and equivalent doses can be easily calculated if the patient must later be switched to another medication. Transdermal fentanyl and hydromorphone are reasonable second-line choices; however, they are not recommended as first-line therapy because they are expensive and can produce tolerance relatively quickly (SOR B). Methadone is another second-line option and tolerance is usually less of a problem. It is inexpensive and long-acting but also has unique pharmacokinetics. It has a very long elimination half-life, and its morphine-equivalent equianalgesic conversion ratio increases as dosages increase. Methadone can prolong the QT interval, especially in patients who are taking other QT-prolonging medications (SOR B). Buprenorphine is a partial opioid agonist that is usually used for treatment of patients with opioid addictions. Although it can be effective for treatment of pain, it is expensive and requires special prescriber training, so it is currently not recommended as a first-line agent for treatment of chronic pain (SOR C).

Answer 299

you can try, but there is very limited data

Answer 300

B This is a normal EF - which definitely is not systolic. Diastolic dysfunction is now recognized as an important cause of heart failure. It is due to left ventricular hypertrophy as a response to chronic systolic hypertension. The ventricle becomes stiff and unable to relax or fill adequately, thus limiting its forward output. The typical patient is an elderly person who has systolic hypertension, left ventricular hypertrophy, and a normal ejection fraction (50%–55%).

Answer 301

nope, not unless they have high cholesterol and you are treating that.

Answer 302

A if a sterile procedure only need petroleum. Topical antibiotics have not been shown to reduce the rate of infection in clean surgical wounds compared to the use of nonantibiotic ointment or no ointment.

Answer 303

A reduction of the pain caused by abdominal palpation when the abdominal muscles are tightened is known as Carnett’s sign. If the cause of the pain is visceral, the taut abdominal muscles may protect the locus of pain. In contrast, intensification of pain with this maneuver points to a source of pain within the abdominal wall itself. No carnetts - think abdominal wall.

Answer 304

E Mild cognitive impairment is an intermediate stage between normal cognitive function and dementia. Motor function remains normal. Patients have essentially normal functional activities but there is objective evidence of memory impairment, and the patient may express concerns about cognitive decline.

Answer 305

Patients with four positive criteria should be treated with antibiotics, those with three positive criteria should be tested and treated if positive, and those with 0–1 positive criteria should be treated with analgesics and supportive care only.

Answer 306

D For patients with advanced irreversible disease, defibrillator shocks rarely prevent death, may be painful, and are distressing to caregivers and family members. Advance care planning discussions should include the option of deactivating the implanted cardioverter-defibrillator when it no longer supports the patient’s goals.

Answer 307

C | can lead to torsades

Answer 308

D The initial management of hypercalcemic crisis involves volume repletion and hydration. The combination of inadequate fluid intake and the inability of hypercalcemic patients to conserve free water can lead to calcium levels >14–15 mg/dL. Because patients often have a fluid deficiency of 4–5 liters, delivering 1000 mL of normal saline during the first hour, followed by 250–300 mL/hour, may decrease the hypercalcemia to less than critical levels (<13 mg/dL). If the clinical status is not satisfactory after hydration alone, then renal excretion of calcium can be enhanced by saline diuresis using furosemide. Intravenous pamidronate, a bisphosphonate, reduces the hypercalcemia of malignancy and is best used in the semi-acute setting, since calcium levels do not start to fall for 24 hours. Glucocorticoids are useful in the treatment of hypercalcemia associated with certain malignancies (multiple myeloma, leukemia, several lymphomas, and breast cancer) or with vitamin D intoxication. The onset of action, however, takes several days, with the effect lasting days to weeks.

Answer 309

C They are talking about revisiting abx usage. After 48 hours, many things are r/o and you can d/c the abx

Answer 310

C Oral therapy has been shown to be as effective as the intravenous route in patients who can tolerate oral intake (SOR B). A randomized, controlled trial has demonstrated that 5-day courses of systemic corticosteroid therapy are at least as effective as 14-day courses (SOR A).

Answer 311

D Morphine should be avoided in patients with renal insufficiency because the toxic metabolites morphine-3-glucuronide and morphine-6-glucuronide are not eliminated by the kidneys. Accumulation of these metabolites causes neuroexcitatory effects, including confusion, sedation, respiratory depression, and myoclonus.

Answer 312

E Statin drugs are effective for preventing stroke, which should be the key goal in this high-risk patient. They may stabilize the intimal wall. Rapid lowering of blood pressure could cause brain injury by reducing blood flow in patients with carotid stenosis. Combination therapy with aspirin and clopidogrel is associated with an increased risk of bleeding and is not recommended for stroke prevention. Patients over age 70 have worse outcomes with carotid stenting than with endarterectomy.

Answer 313

D Common features of acute adrenal insufficiency include fatigue and lack of energy, weight loss, hypotension, loss of appetite, nausea, and vomiting. Other features such as dry skin, hyperpigmentation, and abdominal pain are seen to varying degrees. Common laboratory findings include electrolyte disturbances, hyponatremia, hyperkalemia, hypercalcemia, azotemia, anemia, and eosinophilia. Patients can also have unexplained hypoglycemia. Patients with advanced-stage cancer (especially of the lung or breast) may develop acute adrenal insufficiency from metastatic infiltration of the adrenal glands. Intravenous hydrocortisone is the treatment of choice in the management of adrenal crisis. For managing hypotension, dopamine is recommended for patients with sepsis, dobutamine for those in cardiogenic shock, and packed RBCs for those with hemorrhagic shock. Broad-spectrum antibiotics are part of the therapy for sepsis, but are not first-line agents for hypotension (SOR B). ``` dobutamine = cardiogenic shock dopamine = hypotension. ```

Answer 314

D The sensitivity of triple-phase technetium bone scans is up to 90% but they have low specificity for osteomyelitis. The 90% sensitivity and 80% specificity of MRI is superior to all other imaging modalities.

Answer 315

A . According to the CDC guidelines, this patient does not need to use backup contraception if her IUD is inserted today because it was inserted within 7 days after menstrual bleeding started. If the levonorgestrel IUD is inserted more than 7 days after menstrual bleeding starts, the patient needs to abstain from sexual intercourse or use additional contraceptive protection for the next 7 days.

Answer 316

A According to the American Academy of Pediatrics, preschool-age children with ADHD should receive behavioral therapy alone, administered by a parent and/or teacher. Initially prescribing behavioral therapy alone is supported by strong overall evidence and also by a study finding that many preschool-age children with moderate to severe dysfunction had improved symptoms with behavioral therapy alone. If significant improvement is not observed, then methylphenidate can be added. Medications combined with behavioral therapy should be prescribed in elementary school–age children.

Answer 317

C This patient has lichen simplex chronicus, consisting of lichenified plaques and excoriations that result from excessive scratching. Treatment focuses on stopping the itch-scratch cycle. Topical corticosteroids under an occlusive dressing or intralesional corticosteroids can be helpful.

Answer 318

A Amlodipine is metabolized by the cytochrome P450 3A4 enzyme. Clarithromycin is a strong 3A4 inhibitor that can slow the metabolism of calcium channel blockers metabolized by this enzyme, thus increasing their levels

Answer 319

A It is a self-limited condition and usually resolves within 12–18 months without treatment. It is not an inflammatory condition and anti-inflammatory agents have not been found to be beneficial. Corticosteroid injections have been found to be associated with poor long-term outcomes, as well as high recurrence rates. Neither physical therapy, bracing, nor splinting is proven to provide long-term pain relief. Approximately 90%–95% of all patients with lateral epicondylitis show improvement at 1 year despite the type of therapy utilized (SOR A).

Answer 320

d Data obtained from numerous studies provides considerable evidence of moderate quality that individuals with no significant findings other than rectal or sigmoid hyperplastic polyps of this size should be included in the same low-risk cohort as those who have an unremarkable colonoscopy. For patients at low risk the recommended interval between screening colonoscopies is 10 years. Reductions in this interval are recommended for patients with one or two small tubular adenomas (5–10 years) or those with three or more tubular adenomas (3 years);

Answer 321

E If the classic “Five Ps” (pain, paresthesia, pallor, pulselessness, and paralysis) are all present, the outcome will most certainly be bad, even limb-threatening. Early identification with a high index of suspicion and urgent referral for fasciotomy is necessary to prevent tragic results. Before the classic findings develop, patients will have tenderness out of proportion to the physical appearance of the injury and, most importantly, severe pain in the involved compartment with passive stretching of the involved muscles.

Answer 322

E If the classic “Five Ps” (pain, paresthesia, pallor, pulselessness, and paralysis) are all present, the outcome will most certainly be bad, even limb-threatening. Early identification with a high index of suspicion and urgent referral for fasciotomy is necessary to prevent tragic results. Before the classic findings develop, patients will have tenderness out of proportion to the physical appearance of the injury and, most importantly, severe pain in the involved compartment with passive stretching of the involved muscles.

Answer 323

whooping cough or pertussis Whooping cough has reemerged over the past few years. The initial catarrhal stage is manifested by nonspecific symptoms similar to those of a viral upper respiratory illness. This stage is usually 1–2 weeks in duration, and the patient is highly contagious. The paroxysmal stage is manifested by severe coughing spells that occur in paroxysms and may be followed by the inspiratory whoop (much more likely in children). Post-tussive emesis is another classic sign. There are no characteristic findings on examination other than signs induced by extreme coughing. The CDC recommends both a nasopharyngeal culture and polymerase chain reaction testing to confirm the diagnosis. Azithromycin should be used as initial therapy, but this is to decrease transmission of the illness and does not improve symptoms.

Answer 324

benefits = bones and decreased risk for endometrial cancer. risks = that hormone therapy actually increases the risk for coronary heart disease, stroke, breast cancer, gallbladder disease, dementia, and venous thrombosis, particularly in older women.

Answer 325

anti-thyroidperoxidase or anti-thyroglobulin antibodies.

Answer 326

B The majority of symptoms associated with sports-related concussions resolve within 72 hours of injury. Loss of consciousness and amnesia have not been found to be related to recovery time. Convulsions associated with the injury are benign and do not affect prognosis.

Answer 327

c Bisphosphonates should not be used in patients with a creatinine clearance <35 mL/min/1.73 m2, but denosumab is not cleared by the kidneys and is safe in patients with chronic kidney disease.

Answer 328

e Typical symptoms include decreased libido, erectile dysfunction, amenorrhea, or fatigue.

Answer 329

A Trace mitral, tricuspid, and pulmonic regurgitation can be detected in 70%–90% of normal individuals and has no adverse clinical implications.

Answer 330

B In patients with esotropia the reflex will be over the lateral portion of the iris in the affected eye. In exotropia the light reflex is over the medial iris, in hypertropia it is over the inferior iris, and in hypotropia it is over the superior iris. The finding observed in this child, hypertropia, will occur with a congenital palsy involving the superior oblique muscle, which is innervated by the fourth cranial nerve.

Answer 331

B no need to lower BP with meds - Elevated blood pressures can be managed with hydralazine and labetalol. Normalizing blood pressure is not recommended, but these drugs should be used when blood pressure is over 160/105 mm Hg. no need for steroids after 34 weeks no need for C section

Answer 332

yes DRE = dex, then racemic epi Racemic epinephrine, which has been shown to reduce symptoms at 30 minutes but not at 2 hours or 6 hours, is recommended for the treatment of moderate to severe croup when patients are being observed in a medical setting such as the emergency department or hospital (SOR A).

Answer 333

yes DRE = dex, then racemic epi Racemic epinephrine, which has been shown to reduce symptoms at 30 minutes but not at 2 hours or 6 hours, is recommended for the treatment of moderate to severe croup when patients are being observed in a medical setting such as the emergency department or hospital (SOR A).

Answer 334

D Although high-dose amoxicillin (90 mg/kg/day) is recommended as the antibiotic of choice for acute otitis media (AOM) in the nonallergic patient, amoxicillin/clavulanate is recommended if a child has received antibiotic therapy in the previous 30 days.

Answer 335

3 infectiosn in the last 6 months | 4 in the last year with at least one episode in the past 6 months.

Answer 336

D Pretibial myxedema, exophthalmos, and a thyroid thrill or bruit can all be found in Graves disease, but are not associated with subacute granulomatous thyroiditis.

Answer 337

E In fact, there is good evidence that those with uncomplicated diverticulitis (no signs of abscess, fistula, phlegmon, obstruction, bleeding, or perforation) can be treated without the use of antibiotics, using only bowel rest and close follow-up. Among patients who require hospitalization, it is estimated that <10% of cases will require surgical intervention. Thus, the majority of patients hospitalized with this condition, even those with complicated diverticulitis, will respond well to bowel rest and intravenous antibiotics. Indications for surgery include generalized peritonitis, unconfined perforation, uncontrolled sepsis, an undrainable abscess, and failure of conservative management. CT-guided percutaneous drainage of an accessible abscess is a well-proven treatment to avoid the use of open surgery. Prevention of future episodes of diverticulitis increasingly revolves around the use of daily oral medications. Some experts recommend considering surgery to remove a section of bowel after a patient’s third admission for diverticulitis.

Answer 338

A Oral antihistamines are not effective for the pruritus associated with atopic dermatitis.

Answer 339

B There is a significant association between lichen planus and hepatitis C virus infection.

Answer 340

C LRs correspond to the clinical impression of how well a test rules in or rules out a given disease. A test with an LR of 1.0 indicates that it does not change the probability of disease. The higher above 1 the LR is, the more likely it is that the disease is present (an LR >10 is considered good). Conversely, the lower the LR is below 1, the more likely it is that the disease is not present (an LR <0.1 is considered good).

Answer 341

B ***read all of the answer choices before making a decision Protein C deficiency is associated with recurrent deep vein thrombophlebitis, but does not cause elevation of aPTT. Hemophilia A is associated with an elevated aPTT which corrects with the addition of normal plasma. In chronic liver disease one would expect an elevation of the prothrombin time also. Von Willebrand disease is not associated with thrombophlebitis or recurrent abortion.

Answer 342

D In fact, bisphosphonates are used as a treatment for hypercalcemia. They do not affect phosphorus or vitamin D levels.

Answer 343

A Experts are divided as to whether hip subluxation can be merely observed during the newborn period, but if there is any question of a hip problem on examination by 2 weeks of age, the recommendation is to refer to a specialist for further testing and treatment. Studies show that these problems disappear by 1 week of age in 60% of cases, and by 2 months of age in 90% of cases. Because the condition can be difficult to diagnose, and can result in significant problems, the current recommendation is to treat all children with developmental dysplasia of the hip. Closed reduction and immobilization in a Pavlik harness, with ultrasonography of the hip to ensure proper positioning, is the treatment of choice until 6 months of age. The American Academy of Pediatrics recommends ultrasound screening at 6 weeks for breech females, breech males (optional), and females with a positive family history of developmental dysplasia of the hip.

Answer 344

The sensation of reduction or dislocation is distinct and best described as a "jerk" or "clunk." This sensation is different from that of the high pitch benign joint popping, clicking, or snapping caused by the snapping of tendons or ligaments in and around the hip and knee. The term "hip click" is misleading and is best avoided; isolated hip clicks are not suggestive of DDH

Answer 345

Fentanyl is metabolized in the liver and has no active metabolites. All of the other listed opioid medications have active metabolites that can accumulate in patients with renal failure, leading to serious side effects. These agents should be avoided in patients on dialysis. B

Answer 346

Health care workers rarely become colonized with C. difficile, and screening them has not been shown to affect nosocomial transmission rates. Handwashing with soap and water removes C. difficile from the hands of health care workers and remains the cornerstone of prevention efforts. Itis better than alcohol as spores can still live Additional contact precautions such as the use of gloves and gowns may also be helpful.

Answer 347

paroxetine is not the first choice in the elderly because of its long half-life. In addition, its concentrations are increased 70%–80% in the elderly compared to younger adults, its clearance is decreased, and it has multiple side effects and drug interactions.

Answer 348

A he diffusion capacity provides a general assessment of the air-blood interface. Reduced values are seen with severe interstitial fibrosis, or when the capillary surface has been compromised by vascular obstruction (pulmonary embolism) or is destroyed by emphysema. Chronic pulmonary embolism causes a low diffusing capacity of the lung for carbon monoxide (DLCO) with normal pulmonary function tests. Emphysema causes a low DLCO and an obstructive pattern on pulmonary function testing (PFT). Interstitial lung disease and hypersensitivity pneumonitis both cause a low DLCO with a restrictive pattern of PFTs. the only one with normal PFTs is A. Hypersensitivity pneumonitis is restrictive.

Answer 349

C The inability to contract a muscle is scored as 0. Contraction without movement constitutes grade 1 strength. Movement with the effect of gravity neutralized is grade 2 strength, while movement against gravity only is grade 3 strength. Movement against gravity plus some additional resistance indicates grade 4 strength.

Answer 350

50-80 20 year pack hx recent quit within 15 years

Answer 351

anti-psychotics benzodiazepines and barbiturates should be avoided because they can make delirium worse.

Answer 352

B Medical conditions that decrease responsiveness to warfarin and reduce the INR include - hypothyroidism, visceral carcinoma, increased vitamin K intake, diabetes mellitus, and hyperlipidemia malnturtion, cirrrhosis, AKI, heart failure... you need less. think of hepatorenal or heart failure leading to liver dysfunction.

Answer 353

B Each of the options listed raises the possibility of heart failure but the only one that has a specificity >90% is the third heart sound, which is 99% specific for the diagnosis of heart failure. Other findings with >90% sensitivity include a displaced point of maximal impulse, interstitial edema or venous congestion on a chest radiograph, jugular vein distention, and hepatojugular reflux. The other options listed here have specificities for heart failure that fall within the range of 65%–80%.

Answer 354

C Starting with a low-fat solid diet has been shown to be safe compared with clear liquids, providing more calories and shortening hospital stays.

Answer 355

B Unstable angina patients at high risk include those with at least one of the following: * Angina at rest with dynamic ST-segment changes 1 mm * Angina with hypotension * Angina with a new or worsening mitral regurgitation murmur * Angina with an S3 or new or worsening crackles * Prolonged (>20 min) anginal pain at rest * Pulmonary edema most likely related to ischemia

Answer 356

gastrointestinal

Answer 357

C includes decompression sickness and wounds caused by crush injuries. Hyperbaric oxygen treatment has been shown to improve diabetic foot ulcers in the short term but studies have so far failed to prove long-term benefit. Decompression sickness, also called generalized barotrauma or the bends, refers to injuries caused by a rapid decrease in the pressure that surrounds you, of either air or water. It occurs most commonly in scuba or deep-sea divers, although it also can occur during high-altitude or unpressurized air travel.

Answer 358

D In this case, however, the patient is already taking an antibiotic for streptococcal disease so the emergence of new symptoms over a week after starting therapy is highly unlikely. A viral exanthem could also cause a skin rash similar to the one described here. Unfortunately, differentiating between a drug-induced rash and a viral exanthem is not clinically possible. If this differentiation is necessary, the patient should undergo a skin biopsy and allergy testing to determine the offending agent. However, since this approach is impractical in the ambulatory setting, it is most straightforward to discontinue the agent she is on and list it as a potential allergy. An alternative antibiotic such as erythromycin could be used to complete the course of treatment at the discretion of the physician.

Answer 359

D In this case, however, the patient is already taking an antibiotic for streptococcal disease so the emergence of new symptoms over a week after starting therapy is highly unlikely. A viral exanthem could also cause a skin rash similar to the one described here. Unfortunately, differentiating between a drug-induced rash and a viral exanthem is not clinically possible. If this differentiation is necessary, the patient should undergo a skin biopsy and allergy testing to determine the offending agent. However, since this approach is impractical in the ambulatory setting, it is most straightforward to discontinue the agent she is on and list it as a potential allergy. An alternative antibiotic such as erythromycin could be used to complete the course of treatment at the discretion of the physician.

Answer 360

A ***pain and obesity... duloxetine doesn't cause weight gain.

Answer 361

B Patients with microscopic hematuria should initially be assessed for benign causes such as urinary tract infection, vigorous exercise, menstruation, and recent urologic procedures. If none of these is found, the next step would be assessing for renal disease using urine microscopy to look for casts or dysmorphic blood cells, and checking renal function. If the results are negative, CT urography and cystoscopy should be performed. CT evaluates the upper urinary tract for nephrolithiasis and renal cancer, while cystoscopy evaluates the bladder for bladder cancer, urethral strictures, and prostatic problems. urine cytology is cystoscopy

Answer 362

It is ideally administered between 27 and 36 weeks gestation to maximize the maternal antibody response and passive antibody transfer to the infant.

Answer 363

C The presence of eosinophiluria in a patient with acute kidney injury (AKI) suggests acute interstitial nephritis, which is typically an allergic reaction to medications such as penicillins, sulfa-containing antibiotics and diuretics, NSAIDs, proton pump inhibitors, etc. Patients with acute interstitial nephritis may also present with a rash, fever, eosinophilia, and other constitutional symptoms. An elevated uric acid level along with a history of rapidly proliferating tumors or recent chemotherapy suggests tumor lysis syndrome and malignancy. Poisoning with ethylene glycol or methanol should be suspected in a patient with AKI and altered mental status with an increased anion gap and osmolar gap.

Answer 364

A The most common bacterial organisms in this age group are group B Streptococcus and Escherichia coli. However, many other pathogens have been known to cause sepsis; therefore, broad empiric coverage with ampicillin and cefotaxime is recommended (SOR B). Gentamicin is commonly used, but should be used in combination with ampicillin. Vancomycin is not recommended as first-line treatment unless the child has evidence of a soft-tissue infection suspected to be methicillin resistant (SOR C). Ciprofloxacin and clindamycin are not indicated treatments in this case. so Amp and Gent would not have been wrong.

Answer 365

Immunoglobulin A vasculitis (IgAV), formerly called Henoch-Schönlein purpura (HSP), is the most common systemic vasculitis of childhood. IgAV occurs primarily between the ages of 3 and 15 years. The underlying cause of IgAV is unknown. It is thought that IgAV represents an immune-mediated vasculitis that may be triggered by a variety of antigens, which may include various infections or other environmental exposures. (See 'Pathogenesis' above.) ●Clinical manifestations – IgAV is a self-limited disease and is characterized by a tetrad of clinical manifestations that vary in their occurrence and order of presentation (see 'Clinical manifestations in children' above): * Palpable purpura without thrombocytopenia and coagulopathy (picture 2A-E) - PALPABLE * Arthralgia and/or arthritis * Abdominal pain * Kidney disease ●Diagnosis – The diagnosis of IgAV is usually based upon clinical manifestations of the disease. There are no diagnostic laboratory tests for IgAV.

Answer 366

Immunoglobulin A vasculitis (IgAV), formerly called Henoch-Schönlein purpura (HSP), is the most common systemic vasculitis of childhood. IgAV occurs primarily between the ages of 3 and 15 years. The underlying cause of IgAV is unknown. It is thought that IgAV represents an immune-mediated vasculitis that may be triggered by a variety of antigens, which may include various infections or other environmental exposures. (See 'Pathogenesis' above.) ●Clinical manifestations – IgAV is a self-limited disease and is characterized by a tetrad of clinical manifestations that vary in their occurrence and order of presentation (see 'Clinical manifestations in children' above): * Palpable purpura without thrombocytopenia and coagulopathy (picture 2A-E) - PALPABLE * Arthralgia and/or arthritis * Abdominal pain * Kidney disease ●Diagnosis – The diagnosis of IgAV is usually based upon clinical manifestations of the disease. There are no diagnostic laboratory tests for IgAV.

Answer 367

C Uveitis is inflammation of the uveal tract and can affect any or all of its components, including the iris. It is the most common extra-articular manifestation of ankylosing spondylitis (AS), seen in up to 60% of patients with AS. Iritis presents with a painful red eye with conjunctival injection, photophobia, and a sluggishly reacting pupil. A hazy-appearing anterior chamber results from the iris producing an inflammatory exudate. Treatment includes topical corticosteroids, but oral or parenteral corticosteroids and NSAIDs are also effective. Reduced anterior spine flexion (a positive modified Schober test) results from the skeletal manifestations of AS. A “bamboo spine” is classically seen on lumbar radiographs.

Answer 368

C Cerebrospinal fluid (CSF) rhinorrhea is not that rare, and has both surgical and nonsurgical causes. It results from a direct communication between the subarachnoid space and the paranasal sinuses. Accidental trauma causes 70%–80% of CSF rhinorrhea cases, with 2%–4% of acute head injuries resulting in CSF rhinorrhea. Nontraumatic CSF rhinorrhea includes high-pressure and normopressure leaks from causes including tumors, processes including boney erosion, empty sella syndrome, and congenital defects including meningoceles. The rhinorrhea is clear and often has a sweet or salty taste. The drainage can be continuous or intermittent, and is often associated with a gush when changing from a recumbent to an upright position. CSF rhinorrhea can lead to meningitis or other infections by serving as a pathway for bacteria.

Answer 369

a non-allergic rhinitis characterized by intermittent symptoms of congestion (stuffiness) and/or watery nasal discharge, and an exaggerated reaction to nonspecific irritants, such as air pollution or temperature changes, especially exposure to cold, dry air

Answer 370

***READ ALL OF THE ANSWER CHOICES e In recalcitrant plantar fasciitis plain films may be helpful for detecting bony lesions of the foot. Discomfort in the proximal plantar fascia can be elicited by passive ankle/first toe dorsiflexion.

Answer 371

B Deep suction ... is still upper airway. Tracheal is not included in this.

Answer 372

***READ ALL OF THE ANSWER CHOICES BEFORE PICKING!!! C Doxy would have been a good choice if he was older. Pneumococcus and Haemophilus influenzae are often resistant to trimethoprim/sulfamethoxazole and azithromycin, and these agents are therefore not recommended for the treatment of acute bacterial sinusitis in the penicillin-allergic patient. Doxycycline should not be used in children younger than 8 years of age except for anthrax and some tickborne infections.

Answer 373

B they have non-specific symptoms

Answer 374

B Left bundle branch block makes the EKG uninterpretable during an exercise stress test, and can also interfere with nuclear imaging performed during the test.

Answer 375

E poison oak Short bursts of low-potency oral corticosteroids such as a methylprednisolone dose pack have a high rate of relapse as the taper finishes, so the expert consensus is to use a higher dosage tapered over a longer period, generally 10–14 days, in order to prevent a relapse. Most experts recommend oral corticosteroids over intramuscular corticosteroid suspensions, which may not provide high enough concentrations in the skin (SOR C). However, 40–80 mg of intramuscular triamcinolone (or an equivalent) is an alternative to oral treatment, especially if adherence is an issue. Pruritus can be treated

Answer 376

E While all of the options listed may have some value in evaluating the preoperative status of a patient with long-standing rheumatoid arthritis, imaging of the patient’s cervical spine to detect atlantoaxial subluxation would be most important for preventing a catastrophic spinal cord injury during intubation.

Answer 377

A Current guidelines recommend that patients with an ST-elevation myocardial infarction (STEMI) who also have atrial fibrillation take dual antiplatelet therapy such as aspirin plus clopidogrel and a vitamin K antagonist, with a goal INR of 2.0–3.0. If a patient was already taking a direct-acting oral anticoagulant (DOAC) instead of warfarin for atrial fibrillation, the patient should continue with the DOAC in addition to dual antiplatelet therapy. The duration of triple therapy should be as short as possible, and aspirin can often be discontinued after 1–3 months. However, this patient’s STEMI occurred less than 2 weeks ago and he should continue triple therapy.

Answer 378

A Current guidelines recommend that patients with an ST-elevation myocardial infarction (STEMI) who also have atrial fibrillation take dual antiplatelet therapy such as aspirin plus clopidogrel and a vitamin K antagonist, with a goal INR of 2.0–3.0. If a patient was already taking a direct-acting oral anticoagulant (DOAC) instead of warfarin for atrial fibrillation, the patient should continue with the DOAC in addition to dual antiplatelet therapy. The duration of triple therapy should be as short as possible, and aspirin can often be discontinued after 1–3 months. However, this patient’s STEMI occurred less than 2 weeks ago and he should continue triple therapy.

Answer 379

Legg-Calve-Perthes

Answer 380

A Individuals on the National Weight Control Registry typically eat a low-fat diet rich in complex carbohydrates, eat breakfast daily, weigh themselves at least once a week, and are physically active for 60–90 minutes a day.

Answer 381

For previously healthy individuals who have not taken antibiotics in the previous 3 months the most appropriate treatment for CAP is empiric treatment with an oral macrolide such as azithromycin, clarithromycin, or erythromycin (level I evidence) or doxycycline (level III evidence). In the presence of comorbidities such as diabetes, alcoholism, or chronic heart, lung, liver, or renal diseases, the treatment of CAP should provide broader coverage with dual antibiotic treatment regimens including combinations of fluoroquinolones, p-lactam drugs, and macrolide options, and hospitalization is often indicated. A

Answer 382

For previously healthy individuals who have not taken antibiotics in the previous 3 months the most appropriate treatment for CAP is empiric treatment with an oral macrolide such as azithromycin, clarithromycin, or erythromycin (level I evidence) or doxycycline (level III evidence). In the presence of comorbidities such as diabetes, alcoholism, or chronic heart, lung, liver, or renal diseases, the treatment of CAP should provide broader coverage with dual antibiotic treatment regimens including combinations of fluoroquinolones, p-lactam drugs, and macrolide options, and hospitalization is often indicated. A

Answer 383

polymyositis

Answer 384

Current guidelines recommend beginning screening colonoscopy 10 years after the initial diagnosis and continuing every 2–5 years, with the interval based on the findings.

Answer 385

no, you need an eval

Answer 386

no, you need an eval

Answer 387

. Although clonidine has been used for smoking cessation it is considered a second-line agent and is not FDA approved for smoking cessation.

Answer 388

depo-provera

Answer 389

B Pessaries are considered first-line treatment for pelvic organ prolapse (SOR C). Ring pessaries provide support and are the initial choice in most circumstances. Sexual intercourse can still occur with a ring pessary, which can be inserted and removed by the patient. Space-occupying pessaries are associated with more vaginal discharge and irritation and do not allow for sexual intercourse.

Answer 390

E All oral NSAIDs increase the risk of myocardial infarction (relative risk versus placebo from 1.5 for ibuprofen to 1.7 for celecoxib), with the exception of naproxen Aleve or Naproxen (andrew or anna Neff) are the safest for the heatt

Answer 391

C ***even with negative chlamydia - treat! The emergence of fluoroquinolone-resistant gonorrhea has led the Centers for Disease Control and Prevention to no longer recommend the use of fluoroquinolones for treatment of gonorrhea. Cephalosporins are currently the only recommended antibiotic, with ceftriaxone being the preferred agent. Patients with gonorrhea often have a Chlamydia infection as well. It is recommended that they be treated for both, even with a negative test for Chlamydia. The recommended regimen for treatment of gonorrhea is ceftriaxone, 250 mg intramuscularly, and azithromycin, 1 g orally, or doxycycline, 100 mg twice daily for 7 days. All sexual partners in the previous 60 days should be treated as well.

Answer 392

Dextromethorphan, diphenhydramine, ibuprofen, and even fluoroquinolones are among the many agents that can cause a false-positive urine drug screen for opioids.

Answer 393

A Fiber is ineffective in the treatment of adult irritable bowel syndrome (IBS) (SOR A). Symptoms do improve, however, with several different medications and alternative therapies. Exercise, probiotics, antibiotics, antispasmodics, antidepressants, psychological treatments, and peppermint oil all have evidence that they may improve IBS symptoms (SOR B).

Answer 394

true - because waiting can be detrimental to their fertility

Answer 395

A This presentation is typical of either transient synovitis or septic arthritis of the hip. Because the conditions have very different treatment regimens and outcomes, it is important to differentiate the two. It is recommended that after plain films, the first studies to be performed should be a CBC and an erythrocyte sedimentation rate (ESR). Studies have shown that septic arthritis should be considered highly likely in a child who has a fever >38.7°C (101.7°F), refuses to bear weight on the affected leg, has a WBC count >12,000 cells/mm3, and has an ESR >40 mm/hr. If several or all of these conditions exist, aspiration of the hip guided by ultrasonography or fluoroscopy should be performed by an experienced practitioner. MRI may be helpful when the diagnosis is unclear based on the initial evaluation, or if other etiologies need to be excluded.

Answer 396

no, not unless they are not improving after 48 hours or if you are worried about a complication

Answer 397

no, not unless they are not improving after 48 hours or if you are worried about a complication you should get an u/s of the RUQ though

Answer 398

E Calcium carbonate is the least expensive and most commonly used supplement, but it is constipating and stomach acid improves its absorption. Calcium citrate is less dependent on stomach acidity for absorption and it may be used with long-term gastric acid suppression agents. It may be taken without regard to food or meals.

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