IM Boards Flashcards

Question

VT vs other conditions

Answer 1

Several important clinical and ECG features can distinguish VT from other conditions. The presence of irregular jugular venous pulsations of greater amplitude than normal venous waves (cannon waves) signal the presence of atrioventricular dissociation and support the diagnosis of VT. **Wide-complex tachycardias **that are **positive in lead aVR**, have a **QRS morphology that is concordant (all predominantly positive or negative) in the precordial leads**, have **QRS morphology other than typical right or left bundle branch block**, and exhibit **extreme axis deviation (“northwest” axis)** are usually VT. **Fusion beats** (supraventricular and ventricular impulses coinciding to produce a hybrid complex) and **capture beats** (a sinus conducted beat producing a normal QRS) are all highly suggestive of VT. Of importance, the fact that the patient is awake, alert, and interactive and/or has a measurable blood pressure does not exclude VT.

Answer 2

Beta blocker or calcium channel blocker First-line treatment for symptomatic premature ventricular contraction suppression is **β-blocker or calcium channel blocker therapy**; β-blockers are preferred in patients with ventricular dysfunction. Ambulatory ECG monitoring can help clarify the burden of premature ventricular contractions (PVCs); patients with PVCs that account for more than 10% to 15% of beats may be at risk for PVC-induced cardiomyopathy.

Answer 3

*Brugada pattern *is distinguished by a structurally normal heart (normal echocardiogram) and **right precordial ECG abnormalities, including ST-segment coving (concave or linear downsloping ST segment) in leads V1 through V3 with or without right bundle branch block**. *Brugada syndrome* is the association of **Brugada pattern with ventricular fibrillation, arrhythmogenic syncope, or cardiac arrest.** Brugada syndrome has an increased prevalence in **men** and persons of **Asian** descent. Arrhythmic events, including sudden cardiac death, in patients with Brugada syndrome are more common at night, during sleep. Abnormalities on ECG may be intermittent and may be elicited by fever or pharmacologic challenge with sodium channel blockade, such as procainamide infusion.

Answer 4

Idiopathic ventricular tachycardia occurs in the absence of structural heart disease, typically manifesting as palpitations in the third to fifth decades of life, often triggered by stress, emotion, or sleeplessness. ICD placement is generally unnecessary in idiopathic VT, owing to the benign prognosis and high efficacy of other therapies.

Answer 5

Among patients with atrial fibrillation who have undergone percutaneous coronary intervention for acute coronary syndrome, **double therapy** with clopidogrel or ticagrelor plus a direct oral anticoagulant is recommended over triple therapy with an oral anticoagulant, aspirin, and P2Y12 inhibitor to reduce the risk for bleeding.

Answer 6

Flecainide and other class IC antiarrhythmic agents (propafenone) are contraindicated in patients with ischemic heart disease. Others: -ischemic or structural heart disease -sinus node dysfunction -second- or third-degree AV block or bundle branch disease without a pacemaker

Answer 7

Aggressive efforts to achieve **rhythm control **in patients with atrial fibrillation and concomitant heart failure decrease morbidity and mortality.

Answer 8

Patients with bronchospastic lung disease should not receive adenosine.

Answer 9

Severe aortic stenosis is typically defined by: -**small valve area (≤1.0 cm2)** , -**high peak velocity (>4 m/s)**, and/or -**high mean gradient (>40 mm Hg)** There are two patient subsets in which severe aortic stenosis may be present with a small valve area and either low velocity or low gradient: (1) patients with severe LV dysfunction and low cardiac output (low-flow, low-gradient aortic stenosis) and (2) patients with preserved LV function and paradoxical low-flow, low-gradient aortic stenosis.

Answer 10

-presence of **symptoms** (e.g., dyspnea, angina, presyncope, syncope, or heart failure) -**LV systolic dysfunction** (ejection fraction <50%) in an asymptomatic patient or a --concomitant **cardiac surgical procedure** for other indications (e.g., coronary artery bypass grafting or ascending aorta surgery). Aortic valve replacement is reasonable in asymptomatic patients with very severe aortic stenosis and low surgical risk and asymptomatic patients with abnormal results on supervised exercise testing, such as poor exercise tolerance, abnormal ECG changes, or hypotension during testing.

Answer 11

-jet width that occupies 65% or more of the LV outflow tract -vena contracta (the width of the regurgitant jet at its most narrow portion) greater than 0.6 cm -holodiastolic flow in the descending aorta -regurgitation volume of 60 mL or more -effective regurgitant orifice area of 0.3 cm2 or greater

Answer 12

-**mitral valve area of 1.5 cm2 or less,** which usually corresponds to a mean mitral gradient of more than 5 to 10 mm Hg at a normal heart rate

Answer 13

Percutaneous balloon mitral commissurotomy (PBMC) is the procedure of choice for patients with significant rheumatic mitral stenosis when the valve is pliable and not severely calcified. PBMC is indicated for symptomatic patients with severe rheumatic mitral stenosis and favorable valve morphology and is reasonable in asymptomatic patients with severe rheumatic mitral stenosis and a pulmonary artery systolic pressure greater than 50 mm Hg. PBMC should not be performed in patients with LA thrombus or moderate or severe mitral regurgitation, both of which are optimally evaluated with TEE. In appropriately selected patients, the success rate with PBMC is 95%, and complications occur in fewer than 5% of patients. Mitral valve surgery is indicated in patients with severe mitral stenosis, New York Heart Association functional class III or IV symptoms, and a nonpliable valve and in asymptomatic patients with severe mitral stenosis undergoing concomitant cardiac surgery for another indication.

Answer 14

Severe primary mitral regurgitation is defined by several parameters, the most common of which are an effective regurgitant orifice area of 0.4 cm2 or larger, regurgitant volume of 60 mL or more, and vena contracta of 0.7 cm or larger.

Answer 15

2.5 or 3 if higher risk for thrombosis

Answer 16

3 (mechanical mitral: 2.5-3.5)

Answer 17

Warfarin for 3-6 months INR 2.5

Answer 18

Adding aspirin (75-100 mg/d) to warfarin in patients with a mechanical prosthesis decreases the risk for stroke and death and may be considered in patients who have an indication for antiplatelet therapy when the bleeding risk is low. Low-dose aspirin is reasonable for all patients with a bioprosthesis.

Answer 19

Modified Duke criteria The diagnostic criteria for definite IE include either two major criteria, one major criterion plus three minor criteria, or five minor criteria. Possible IE requires one major criterion and one minor criterion, or three minor criteria. IE is excluded when there is a firm alternative diagnosis, resolution of IE syndrome with antibiotic therapy for 4 days or less, or no pathologic evidence of IE at surgery or at autopsy with antibiotic therapy for 4 days or less. (2 + 0; 1+3; or 0 + 5) Major Criteria 1. **Blood culture positive for infective endocarditis** Typical microorganisms consistent with infective endocarditis from two separate blood cultures: Viridans streptococci, Streptococcus bovis, HACEK group (Haemophilus spp., Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella spp., and Kingella kingae), Staphylococcus aureus; or community-acquired enterococci, in the absence of a primary focus; or Microorganisms consistent with infective endocarditis from persistently positive blood cultures, defined as follows: At least two positive cultures of blood samples drawn 12 h apart; or All of three or a majority of at least four separate cultures of blood (with first and last samples drawn at least 1 h apart) Single blood culture positive for Coxiella burnetii or antiphase I IgG antibody titer >1:800 2. **Evidence of endocardial involvement** Echocardiogram positive for infective endocarditis (TEE recommended in patients with prosthetic valves, rated at least “possible infective endocarditis” by clinical criteria, or complicated infective endocarditis [paravalvular abscess]; TTE as first test in other patients), defined as follows: Oscillating intracardiac mass on valve or supporting structures, in the path of regurgitant jets, or on implanted material in the absence of an alternative anatomic explanation; or Abscess; or New partial dehiscence of prosthetic valve New valvular regurgitation (worsening or changing of pre-existing murmur not sufficient) Minor Criteria 1. Predisposition, predisposing heart condition, or injection drug use 2. Fever (temperature >38°C [100.4°F]) 3. Vascular phenomena: major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and Janeway lesions 4. Immunologic phenomena: glomerulonephritis, Osler nodes, Roth spots, and rheumatoid factor 5. Microbiologic evidence: positive blood culture but does not meet a major criterion as noted abovea or serologic evidence of active infection with organism consistent with infective endocarditis

Answer 20

-History of endocarditis -Cardiac transplantation with valve regurgitation due to a structurally abnormal valve -Prosthetic valve -Prosthetic material used for cardiac valve repair, including annuloplasty rings and clips -Left ventricular assist device -Unrepaired congenital heart disease -Repaired congenital heart disease with residual defects at the site or adjacent to the site of a prosthetic patch or device -A defect that has been repaired with prosthetic material (surgical or catheter-based) within the previous 6 months -Surgical or transcatheter pulmonary artery valve or conduit placement, such as Melody valve and Contegra conduit

Answer 21

TAVI is recommended in preference to SAVR for symptomatic patients with severe aortic stenosis who are older than 80 years or for younger patients with a life expectancy less than 10 years. TAVI is also recommended for symptomatic patients of any age with severe aortic stenosis and a high or prohibitive surgical risk if predicted postprocedure survival is more than 12 months with an acceptable quality of life. For symptomatic patients aged 65 to 80 years, either SAVR or TAVI is appropriate following shared decision making.

Answer 22

In patients with a bicuspid valve undergoing surgery for severe aortic stenosis or regurgitation, surgical repair of the ascending aorta is advised when the aortic diameter is greater than 4.5 cm. In the absence of surgical indications for a stenotic or regurgitant aortic valve, surgical repair of the ascending aorta or aortic sinuses is advised when the aortic diameter is greater than 5.5 cm or when the diameter is greater than 5.0 cm in a patient with additional risk factors for dissection (family history, rate of progression ≥0.5 cm/year).

Answer 23

In patients with rheumatic mitral stenosis and a discrepancy between resting echocardiographic findings and clinical symptoms, exercise echocardiography or exercise testing during cardiac catheterization is recommended to further assess the valve.

Answer 24

Guidelines recommend cardiac catheterization to evaluate patients with suspected significant aortic stenosis when there is a discrepancy between the clinical evaluation and the echocardiogram.

Answer 25

For patients in whom there is a discrepancy between physical examination findings and transthoracic echocardiographic assessment of mitral regurgitation severity, cardiac magnetic resonance imaging or transesophageal echocardiography should be used to quantitatively assess mitral regurgitation and resolve the discrepancy.

Answer 26

In symptomatic patients with severe aortic regurgitation, aortic valve surgery is indicated regardless of left ventricular systolic function. In asymptomatic patients with chronic severe aortic regurgitation and left ventricular systolic dysfunction (ejection fraction ≤55%), aortic valve surgery is indicated.

Answer 27

Any one of: -ratio of pleural fluid protein to serum protein >0.5 -ratio of pleural-fluid lactate dehydrogenase [LDH] to serum LDH > 0.6 -pleural-fluid LDH > two thirds of the upper limit of normal for serum LDH = EXUDATIVE (most likely malignancy or infection)

Answer 28

Debulking plus adjuvant platinum-taxane chemotherapy, followed by maintenance PARP inhibitor (if platinum sensitive) Women with advanced ovarian cancer and BRCA mutations who achieve some response to platinum-based chemotherapy should receive subsequent maintenance therapy with a poly (ADP-ribose) polymerase inhibitor. PARP inhibitor is also recommended in those without BRCA1/2 mutations, but the benefit is less

Answer 29

Elevated ESR, normal CK

Answer 30

Atorvastatin (hepatically cleared and may have beneficial effect on proteinuria)

Answer 31

Pulmonary artery pressure > 20

Answer 32

Patients with long-standing, poorly controlled ankylosing spondylitis can develop **renal (AA) amyloidosis,** the major cause of kidney disease in these patients. AA amyloidosis most commonly affects the kidneys, manifesting as **proteinuria** and, eventually, renal insufficiency.

Answer 33

Analgesic nephropathy may develop after years of NSAID use and typically presents with abnormalities on routine urinalysis, including **pyuria, proteinuria, and hematuria**. Chronic kidney disease and end-stage kidney disease can develop in some patients.

Answer 34

Interstitial nephritis can be caused by a variety of medications, including NSAIDs, antibiotics, and proton pump inhibitors. Symptoms may include **fever, rash, and eosinophilia/eosinophiluria**. All patients will have a **rise in serum creatinine levels as well as pyuria, hematuria, and proteinuria**. **Leukocyte casts** are typically seen on urinalysis.

Answer 35

Clues to an SLE flare include markers of lupus activity, such as rising anti–double-stranded DNA antibody titers and falling serum complement levels. The serum urate level is often elevated in preeclampsia but not in SLE flares. Treat SLE flare with glucocorticoids

Answer 36

OCPs ok if no aura, but contraindicated if aura

Answer 37

Vitamin B12 deficiency and subacute combined degeneration of the spinal cord. Myelopathy, myeloneuropathy, and subacute combined degeneration have been reported in abusers of nitrous oxide, as have mood disorders and psychosis.

Answer 38

Current guidelines based on high-quality evidence strongly recommend that **antibiotics be avoided in select patients with uncomplicated diverticulitis.** Immunocompromised patients with acute diverticulitis and those with systemic infection or associated comorbidities should be treated with antibiotics.

Answer 39

If colorectal cancer is diagnosed in a first-degree relative aged less than 60 years or two or more first-degree relatives at any age, colonoscopy should begin **at age 40 years or 10 years earlier than the age of the youngest first-degree relative at diagnosis, whichever comes first.**

Answer 40

Relapsing polychondritis is a chronic inflammatory disease involving the cartilage (but not noncartilaginous structures) of the ears, nasal bridge (saddle nose deformity), joints, and trachea, as well as involvement of the connective tissue of the eye. Treatment -NSAIDs and dapsone for mild symptoms and high-dose glucocorticoids for initial management of acute and/or severe involvement -oral immunosuppressants (e.g., methotrexate) may be added. The tumor necrosis factor inhibitors infliximab and adalimumab and the anti–interleukin-6 agent tocilizumab may also be effective.

Answer 41

Initial pharmacologic therapy for exercise-induced bronchoconstriction can include administration of either an **inhaled short-acting β2-agonist (SABA), such as albuterol**, or **low-dose budesonide-formoterol,** *15 minutes before exercise.* (A decrease in FEV1 of greater than 10% within 30 minutes of exercise is diagnostic of EIB)

Answer 42

Nonpharmacologic therapies are the first-line treatment of Sjögren syndrome–related oral dryness, including local moistening with water, sugar-free acidic candies, lozenges, and/or mechanical stimulants (such as sugar-free chewing gum). Pharmacologic stimulation of salvia with **cevimeline** (cholinergic muscarinic agonist) or **pilocarpine** (muscarinic agonist) is indicated for oral dryness not relieved with nonpharmacologic therapies.

Answer 43

Manifestation of ** IgG4 disease** Symptoms: painless jaundice CT: diffusely enlarged pancreas with indistinct borders and delayed contrast enhancement. Diagnosis: **>10 IgG4-positive cells/hpf** (significantly elevated serum IgG4 is also suggestive) Other organ involvement: can be any organ, but commonly lymph nodes, salivary glands, and the biliary system. Retroperitoneal fibrosis may also be related to IgG4 disease. Treatment: high-dose prednisone taper (failure should prompt consideratio of other diagnoses); for relapse, can repeat steroids or use immunomodulators (6-mercaptopurine, azathioprine, mycophenolate, or rituximab) Diagnostic criteria for AIP are known by the acronym **HISORt** (diagnostic Histology, suggestive Imaging, Serology with elevated serum IgG4, Other organ involvement, or Response to therapy with glucocorticoids)

Answer 44

AKA **idiopathic duct-centric pancreatitis** does not demonstrate IgG4-positive cells but is instead characterized by **granulocytic lesions**. Type 2 AIP may be associated with inflammatory bowel disease.

Answer 45

HBIG is indicated if the source patient is positive for HBV and the healthcare worker is a vaccine nonresponder (anti-HBs <10 mU/mL), is unvaccinated, or is incompletely vaccinated. When HBIG is indicated, it should be administered as soon as possible after exposure and ideally within 7 days.

Answer 46

In healthy persons, the ankle pressure should be the same as or slightly higher than the brachial pressure; therefore, **a normal resting ABI is between 1.00 and 1.40.** In the presence of atherosclerotic narrowing of the limb arteries, the downstream blood pressure and concomitant ABI value is lower. **A resting ABI of 0.90 or less is diagnostic for PAD** and correlates with abnormalities seen on imaging of the arterial tree. **A resting ABI greater than 1.40 indicates the presence of noncompressible, calcified arteries in the lower extremities and is considered uninterpretable**. This is most commonly found in patients with diabetes mellitus and/or advanced chronic kidney disease. In patients with an ABI greater than 1.40, a **toe-brachial index** is used for diagnosis. A toe-brachial index less than 0.70 is diagnostic for PAD. Exercise ankle-brachial index testing can be useful if there is a high clinical suspicion for peripheral artery disease but normal resting ankle-brachial index measurements.

Answer 47

Urticarial vasculitis is characterized by urticarial lesions that last longer than 24 hours and that burn and sting rather than itch; wheals that resolve with hyperpigmentation; and associated systemic symptoms, such as fever and joint pain. Skin biopsy is diagnostic. When urticarial vasculitis is accompanied by decreased serum complement (C3 or C4), it is classified as hypocomplementemic urticarial vasculitis; these cases are strongly associated with systemic lupus erythematosus and glomerulonephritis.

Answer 48

Patients with persistent fasting severe hypertriglyceridemia (**triglycerides ≥500 **mg/dL) are at risk for acute pancreatitis. Diet: low fat Supplement: omega-3 fatty acid Therapy: **fibrate** (fenofibrate)

Answer 49

Surgery and penicillin + clindamycin

Answer 50

Surgery and ceftazidime + doxycycline Infection usually occurs in immunocompromised patients (particularly with liver disease) after consumption of raw shellfish, such as oysters, or skin trauma incurred in warm sea waters, such as the Gulf of Mexico, or brackish water.

Answer 51

Ciprofloxacin + doxycycline Lacerations and puncture wounds sustained in aquatic environments, including fresh water and brackish water, particularly during warmer weather months, can result in wound infection. Aeromonas infections of the skin, soft tissue, and blood stream are more likely to occur in patients with underlying immunocompromising conditions such as cirrhosis and cancer.

Answer 52

-Tall (dominant) R wave in lead V1 -Persistent precordial S waves -Evidence of right atrial enlargement (P pulmonale) -Right axis deviation or indeterminate axis -rSr' in lead V1 -Right ventricular strain pattern (ST segment depression and asymmetric T wave inversions in leads V1 to V3)

Answer 53

Uric acid crystals can take on a variety of appearances, such as rhomboids, barrels, rosettes, needles, or hexagonal plates.

Answer 54

After failed NSAIDs

Answer 55

-severe/symptomatic: isotonic saline and calcitonin Bisphosphonates (zolendronic acid) take up to 4 days to work. Denosumab can be used when bisphosphonates are contraindicated (kidney failure) No furosemide unless heart or kidney failure

Answer 56

Chimeric antigen receptor T-cell therapies are highly effective; however, patients with a high disease burden may develop dangerous cytokine release syndrome. The clinical presentation of cytokine release syndrome can range from mild, with fever, malaise, and myalgia, to a severe inflammatory syndrome characterized by vascular leak, hypotension, pulmonary edema, cardiac dysfunction, kidney dysfunction, liver failure, coagulopathy, multiorgan system failure, and even death. Treatment protocols include early **supportive care **with antipyretics for lower grades of CRS and **high doses of glucocorticoids with cytokine-blocking monoclonal antibodies (e.g., tocilizumab) **for higher grades of CRS. The patient should also be evaluated for infection-related sepsis.

Answer 57

In patients not eligible for thrombolytic therapy, the blood pressure (BP) threshold for initiating antihypertensive therapy is greater than 220/120 mm Hg; reduction of BP by 15% during the first 24 hours may then be reasonable. A target blood pressure less than 130/80 mm Hg is considered a reasonable therapeutic target for most patients. In the first 48 hours, however, and especially in patients with symptomatic intracranial stenosis, lowering blood pressure is associated with neurologic worsening.

Answer 58

Chronic bisphosphonate therapy can be associated with atypical subtrochanteric femoral fracture. Increased femoral cortical width on plain radiography is a risk factor for the development of bisphosphonate-related atypical subtrochanteric femoral fracture.

Answer 59

Immunocompetent: >2 dermatomes OR vesicular lesions that cross the midline Immunocompromised: any dermatomal invomvement Precautions: airborne and contact

Answer 60

The presentation of an isolated VSD depends on the VSD size and pulmonary vascular resistance. Small VSDs are usually asymptomatic. A palpable systolic murmur (thrill) is often noted at the left sternal border, accompanied by a loud holosystolic murmur that obliterates the S2. Small VSDs do not cause left heart enlargement or pulmonary hypertension, and the ECG and chest radiograph reveal normal findings. VSD closure is not indicated for patients with a small left-to-right shunt and no chamber enlargement or valve disease, but periodic clinical evaluation and imaging are recommended. Patients with small VSDs do not require activity restrictions. An adult with an atrial septal defect (ASD) most often presents with dyspnea, atrial arrhythmias, or right heart enlargement. Physical examination findings include elevation in venous pressure, a right ventricular lift, fixed splitting of the S2, a pulmonary midsystolic flow murmur, and, when there is a large shunt, a tricuspid diastolic flow rumble. The ECG demonstrates right axis deviation and incomplete right bundle branch block, and the chest radiograph generally demonstrates features of right heart enlargement and enlarged pulmonary arteries with increased pulmonary blood flow.

Answer 61

The initial treatment of symptomatic hyponatremia is acutely increasing the serum sodium by 3 to 4 mEq/L (3-4 mmol/L) with 3% saline infusion. In the treatment of symptomatic hyponatremia, simultaneous administration of desmopressin with 3% saline infusion results in a more predictable and safer increase in serum sodium.

Answer 62

Omalizumab (anti-IgE) is indicated in patients with severe persistent asthma inadequately controlled with standard therapy who have **elevated IgE levels and sensitivity to multiple allergens**, as documented by skin testing, or elevated serum allergen-specific IgE.

Answer 63

Mepolizumab and reslizumab are anti-interleukin-5 mAbs: Severe asthma associated with **elevated eosinophil levels**, regardless of IgE level.

Answer 64

Amantadine (glutamate N-methyl-D-aspartate receptor antagonist) (Deep brain stimulation for refractory cases)

Answer 65

Typical strategies to address end-of-dose wearing-off phenomenon include increasing the dose of levodopa or adding a catechol-O-methyltransferase inhibitor (entacapone), a dopamine agonist (ropinirole), or a monoamine oxidase type B inhibitor (selegiline). All of these strategies, however, can aggravate the dyskinesia.

Answer 66

Type 1 (hypokalemic distal) renal tubular acidosis [defect in urine acidification] is characterized by a normal anion gap metabolic acidosis, hypokalemia, urine pH >6.0, and calcium phosphate kidney stones. Type 2 (proximal) renal tubular acidosis [defect in reclaiming bicarbonate] is characterized by a normal anion gap metabolic acidosis, hypokalemia, glycosuria (without hyperglycemia), low-molecular-weight proteinuria, and renal phosphate wasting. (This is known as Fanconi syndrome when all features are present.) Type 4 (hyperkalemic distal) RTA is due to aldosterone deficiency or resistance and is associated with a mild normal anion gap metabolic acidosis and hyperkalemia,

Answer 67

APL (acute promyelocytic leukemia)

Answer 68

**Pegloticase** Pegloticase is recombinant pegylated uricase administered intravenously every 2 weeks. All patients should be screened for glucose-6-phosphate dehydrogenase (G6PD) activity before administration of pegloticase; low activity of G6PD poses a risk for hemolytic anemia and methemoglobinemia, and pegloticase is contraindicated in that setting. Pegloticase rapidly lowers the serum urate level, and prophylactic therapy (colchicine, NSAIDs, or glucocorticoids) must be administered concurrently with treatment. Formation of antibody to pegloticase may occur (30%-50% of patients) and cause severe infusion reactions. Serum urate level must be checked before each infusion. After the initial dose, a serum urate level greater than 6.0 mg/dL (0.35 mmol/L) on two consecutive assessments indicates loss of efficacy due to antibody formation, necessitating discontinuation of pegloticase. Pegloticase should not be given with any other urate-lowering therapy so that interpretation of the serum urate level before each infusion is clear.

Answer 69

Typical findings of disseminated intravascular coagulation include thrombocytopenia, prolonged coagulation measures, hypofibrinogenemia, and elevated D-dimer level.

Answer 70

**Tenofovir disoproxil fumarate (TDF) and emtricitabine** Cabotegravir is another option (q2mo, ok in kidney disease) Once-daily tenofovir alafenamide (TAF) and emtricitabine is approved for HIV PrEP for men at high risk

Answer 71

Intubate (NOT BiPAP) In patients with asthma exacerbation, upright posture, inability to speak in full sentences, diaphoresis, flaring of the nares, and use of accessory muscles during inspiration are signs of impending respiratory failure. In patients with severe asthma, a normal or elevated PCO2 may signal impending respiratory failure and the need for intubation and mechanical ventilation.

Answer 72

In patients with gastric varices, c**ontrast-enhanced cross-sectional imaging** should be performed to determine the best treatment. For isolated gastric varices due to splenic vein thrombosis, splenectomy can be performed to decompress varices. If the portal vein is patent and a suitable splenorenal shunt is available, balloon-occluded retrograde transvenous obliteration of varices can be considered. If the anatomy of the hepatic veins and portal vein branches is favorable, a transjugular intrahepatic portosystemic shunt may be an option. To determine the best therapy, contrast-enhanced cross-sectional imaging is required.

Answer 73

Observation Synpharyngitic hematuria and hematuria after exertion are common and usually benign (unless increased creatinine, hypertension, or proteinuria) Steroids NOT indicated unless rapidly progressing renal insufficiency

Answer 74

UTI with *Proteus*, or other urea-splitting organisms such as *Klebsiella* or, less frequently, *Pseudomonas;* these bacteria secrete urease, which enzymatically hydrolyzes urea into carbon dioxide and ammonium, which markedly increases urine pH and results in the precipitation of m**agnesium ammonium phosphate**, also known as struvite. Struvite crystals are recognized by their **coffin-lid appearance.** Struvite crystals can rapidly form large stones in the renal pelvis and are responsible for the creation of **staghorn calculi**, which are stones that bridge two or more renal calyces. Patients with infection caused by urea-splitting organisms have the typical signs and symptoms of UTI. However, these stones may become persistently infected despite antibiotic therapy and are a source of significant morbidity and mortality due to sepsis. Percutaneous nephrolithotomy is the first-line treatment for most patients.

Answer 75

The American Diabetes Association (ADA) recommends initiation of insulin therapy for treatment for persistent hyperglycemia starting at a threshold of 180 mg/dL (target 140-180) Treatment consists of **basal, prandial, and correctional insulin **

Answer 76

**Resection ** Factors posing an increased risk for malignant transformation of hepatic adenomas include adenomas greater than 5 cm in diameter, adenomas with β-catenin activation, or adenomas found in men. Oral contraceptives should be discontinued in women with hepatic adenomas with follow-up CT or MRI at 6-month intervals to confirm stability or regression in the size of the lesion.

Answer 77

Oral contraceptives should be discontinued in women with hepatic adenomas with follow-up CT or MRI at 6-month intervals to confirm stability or regression in the size of the lesion.

Answer 78

**Lymphoma** Mucosa-associated lymphoid tissue lymphomas. Risk factors include parotid gland enlargement, depressed C4 complement level, elevated rheumatoid factor level, elevated anti-Ro/SSA and/or anti-La/SSB antibody levels, monoclonal gammopathy, and cryoglobulinemic vasculitis.

Answer 79

Patients with thyroid nodules and a suppressed thyroid-stimulating hormone level should be evaluated with thyroid scintigraphy with radioactive iodine uptake.

Answer 80

I: Intact skin with nonblanchable redness II: Partial-thickness loss of dermis; shallow open ulcer with red-pink wound bed without slough May also present as intact or ruptured serum-filled blister III: Full-thickness tissue loss; visible subcutaneous fat but not bone, tendon, or muscle May include undermining or tunneling IV: Full-thickness tissue loss with exposed bone, tendon, or muscle Unstageable: Full-thickness tissue loss in which base of the ulcer is covered by slough or eschar Suspected deep tissue injury: Purple or maroon localized area of discolored but intact skin, or blood-filled blister caused by damage of underlying soft tissue from pressure or shear

Answer 81

Remove line; start antibiotics tatgeting the most likely organism

Answer 82

Note: can rarely be transmitted via blood products (and can occur up to 6 months after transfusion) Fever, hemolysis (jaundice, hepatomegaly, splenomegaly) Hemolytic anemia, thrombocytopenia, elevated aminotransferses and alkaline phosphatase Intraerythrocytic rings are seen on a peripheral blood smear. Rx: azithromycin plus atovaquone

Answer 83

Diagnosing amyloidosis requires biopsy of the affected tissue that shows the characteristic pathologic findings; to avoid a more invasive biopsy, **abdominal fat pad or bone marrow biopsy** may be preferred initially.

Answer 84

1. preoperative chemotherapy 2. mastectomy 3. irradiation

Answer 85

**Epstein-Barr virus (EBV) **causes posttransplant lymphoproliferative disorder (PTLD). Patients can have fever, pancytopenia, generalized lymphadenopathy, and hepatosplenomegaly. PTLD risk is higher in patients with a history of pre-existing EBV infection treated with lymphocyte-depleting agents and in those receiving sirolimus and tacrolimus compared with those receiving mycophenolate and cyclosporine.

Answer 86

1.liposomal amphotericin-B + oral flucytosine 2. lumbar luncture

Answer 87

0.4-0.8 mg (no clear guidance on those at increased risk- 1? 4?)

Answer 88

Every pregnancy (between 27 weeks' and 36 weeks' gestation)

Answer 89

All nonbiologic disease-modifying antirheumatic drugs should be continued throughout the perioperative period in patients with rheumatologic disease undergoing elective arthroplasty. With the exception of patients with severe systemic lupus erythematosus, biologic agents should be withheld for one dosing cycle before arthroplasty, with surgery performed just after the next dose would have been due and resumed when the wound shows evidence of healing. Janus kinase inhibitors, such as tofacitinib, should be withheld for at least 3 days before surgery.

Answer 90

SubQ sumatriptan and oxygen

Answer 91

Initial treatment of a malignant pleural effusion in patients with expandable lung includes either an indwelling pulmonary catheter or chemical pleurodesis with talc. In patients with a malignant pleural effusion and a nonexpanding lung, an indwelling pulmonary catheter is the treatment of choice.

Answer 92

Gallbladder polyp size greater than 1 cm is a risk factor for malignancy; treatment for such polyps should be cholecystectomy. Gallbladder polyps associated with gallbladder stones or primary sclerosing cholangitis are more likely to be neoplastic regardless of the polyp size.

Answer 93

Atopic dermatitis is characterized by xerotic, pink, scaly skin and is most commonly seen on the periocular areas, posterior neck, antecubital and popliteal fossae, wrists, and ankles. Most localized Staphylococcus aureus infections associated with atopic dermatitis may be treated with a topical antibiotic such as mupirocin. More severe cases require systemic- TMP/SMX or doxycycline.

Answer 94

hyphal forms with acute-angle (45-degree) branching (on methenamine silver stain)

Answer 95

Calculate **Khorana score** In the absence of contraindications, outpatients with cancer at high risk of VTE (Khorana score of 2 or higher before starting a new systemic chemotherapy regimen) may be offered thromboprophylaxis with apixaban, rivaroxaban, or low-molecular-weight heparin.

Answer 96

Intravenous sodium bicarbonate administration is used to treat patients with salicylate toxicity, as it increases urinary elimination of salicylate (with a goal of a urine pH >7.5) and protects the patient from central nervous system toxicity.

Answer 97

Antidepressants with strong CYP2D6 inhibition, such as bupropion, fluoxetine, or paroxetine may decrease tamoxifen activation and should be avoided.

Answer 98

Overt hypercalciuria or high-normal levels of urine calcium can help distinguish primary hyperparathyroidism from familial hypocalciuric hypercalcemia, which typically presents with low urinary calcium excretion.

Answer 99

In patients with primary hyperparathyroidism, calcium levels are often only mildly elevated; parathyroid hormone levels may be frankly elevated or inappropriately normal. Overt hypercalciuria or high-normal levels of urine calcium can help distinguish primary hyperparathyroidism from familial hypocalciuric hypercalcemia, which typically presents with low urinary calcium excretion.

Answer 100

The treatment of mucosa-associated lymphoma tissue (MALT) lymphomas other than gastric MALT lymphoma may include **irradiation** for localized disease or **rituximab** when systemic therapy is required. Helicobacter pylori eradication therapy has only been definitively proven to be effective for H. pylori–associated gastric mucosa-associated lymphoma tissue lymphomas.

Answer 101

Hyperacute bacterial conjunctivitis is characterized by an abrupt onset and extensive purulent discharge. It is usually associated with gonococcal infection in a sexually active adolescent or adult. It is vision threatening, and emergent ophthalmology referral is necessary

Answer 102

Health care workers are at increased risk for pertussis and should receive the tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine regardless of when they received their last tetanus and diphtheria toxoids vaccine. In addition to pertussis, health care workers are also at increased risk for influenza, hepatitis B, measles, mumps, rubella, and varicella viruses and should receive the appropriate vaccinations.

Answer 103

Amoxicillin or doxycycline (An alternative treatment option would be monotherapy with a macrolide if local pneumococcal resistance is less than 25%.)

Answer 104

Cefuroxime and doxycycline or levofloxacin monotherapy

Answer 105

Roflumilast, a selective phosphodiesterase-4 inhibitor, can reduce symptoms and exacerbations in patients with severe COPD who have a chronic bronchitis phenotype or frequent exacerbations. Azithromycin, a macrolide antibiotic, can also be used for patients with COPD and persistent exacerbations, especially in those who are current nonsmokers.

Answer 106

Removal of a melanoma by biopsy alone is inadequate therapy; the excisional margins depend on melanoma depth. For nonulcerated melanomas less than 0.8 mm in Breslow depth, neither sentinel node sampling nor regional lymph node dissection is indicated. If the sentinel node is involved with metastatic melanoma, adjuvant systemic therapy (with either immunotherapy in all patients or with either immunotherapy or BRAF /MEK inhibitors in BRAF -mutated melanomas) would be considered, as data support an improvement in disease-free and overall survival. Completion axillary dissection in the presence of a positive sentinel node has not improved overall survival in randomized trials and is not necessary, although these patients do require ultrasound surveillance to detect nodal recurrence.

Answer 107

Monoclonal gammopathy of underdetermined significance is characterized by an M protein level less than 3 g/dL (or less than 500 mg/24 h of urinary monoclonal free light chains), clonal plasma cells comprising less than 10% of the bone marrow cellularity, and the absence of related signs and symptoms of end-organ damage. Patients with low-risk monoclonal gammopathy of undetermined significance can be clinically observed and do not require follow-up testing.

Answer 108

Thyroid nodule evaluation begins with a thyroid-stimulating hormone (TSH) measurement; if it is normal or elevated, ultrasonography and FNAB are performed. Repeat ultrasonography should be performed in 6 to 12 months for all high-suspicion thyroid nodules, 12 to 24 months for intermediate- and low-suspicion nodules, and 24 months or longer for very low-suspicion nodules. Repeat fine-needle aspiration biopsy is indicated for all high-suspicion thyroid nodules, nodules with concerning new sonographic findings, and intermediate or low-suspicion nodules that increase significantly in size.

Answer 109

1) initiate intravenous anticoagulation with unfractionated heparin 2) perform angiography, and 3) establish a plan for reperfusion of the leg.

Answer 110

Alcoholic ketoacidosis results in an increased anion gap metabolic acidosis and minimal ketones on urine dipstick analysis. Ethylene glycol, methanol, and isopropyl alcohol toxicities are associated with an increased osmolal gap. (Alcoholic ketoacidosis occurs in patients following an episode of acute intoxication; however, by the time of clinical evaluation, the ingested ethanol may be extensively metabolized, leading to low or absent serum ethanol levels. )

Answer 111

Ethylene glycol, methanol, and isopropyl alcohol toxicities are associated with an increased osmolal gap. The plasma osmolal gap is calculated as the difference between the measured osmolality and calculated osmolality, which is determined as follows: 2 × Serum Sodium (mEq/L) + Plasma Glucose (mg/dL)/18 + Blood Urea Nitrogen (mg/dL)/2.8

Answer 112

Treatment of hyperthyroidism during pregnancy is typically with medical management; **propylthiouracil is the drug of choice during the first trimeste**r. Radioactive iodine is contraindicated during pregnancy because it may cause destruction of the fetal thyroid.

Answer 113

-aspirin -statin -clopidogrel In patients who have experienced a transient ischemic attack, adding clopidogrel to aspirin for 21 days has been shown to be effective in reducing the risk for subsequent stroke compared with monotherapy with either agent alone. In patients treated with dual antiplatelet therapy following a transient ischemic attack or minor stroke, aspirin should be continued following discontinuation of clopidogrel at 21 days.

Answer 114

Myasthenia gravis is an autoimmune disease of the postsynaptic neuromuscular junction associated with antibodies to the postsynaptic acetylcholine receptors. Indications for **thymectomy** in myasthenia gravis include the presence of thymoma and the need to minimize immunotherapy requirements in patients without thymoma who have active disease and positivity for acetylcholine receptor antibodies, are younger than 65 years, and are within 3 years of diagnosis.

Answer 115

Dual antiplatelet therapy is recommended if started within 24 hours in select patients with transient ischemic attack or mild noncardioembolic ischemic stroke and continued for 21 and up to 90 days. Dual antiplatelet therapy for ischemic stroke **should not be extended beyond 90 days** given the lack of benefit and increased risk of bleeding. (Following completion of DAPT, the selection of a single antiplatelet agent should be individualized on the basis of patient risk factor profiles, cost, and tolerance. Aspirin versus clopidogrel monotherapy has been studied for the secondary prevention of the combined outcomes of ischemic stroke, peripheral artery disease, and myocardial infarction, and clopidogrel was associated with a 0.9% per year absolute benefit; however, the results of this trial were driven by peripheral artery disease outcomes. In this patient with ischemic stroke and peripheral artery disease, stopping aspirin in favor of clopidogrel is reasonable.)

Answer 116

In patients taking warfarin with a supratherapeutic INR less than 10 and no signs of bleeding, warfarin should be withheld until the INR returns to the therapeutic range. For INR elevation greater than 10 without bleeding, vitamin K is recommended in addition to withholding warfarin; if the INR is elevated and life-threatening bleeding is present, then warfarin is withheld, and vitamin K and a prothrombin complex concentrate should be administered.

Answer 117

**Tuberous sclerosis** Tuberous sclerosis complex (TSC) is a genetic disorder with mutations in the tumor-suppressing genes TSC1 or TSC2 and resulting tumors in many organs, primarily the brain, eyes, heart, kidney, skin, and lungs. Most patients have cutaneous findings, including hypopigmented macules (ash-leaf spots), angiofibromas, Shagreen patches, and fibrous forehead plaques. Epilepsy is present in most patients with tuberous sclerosis, and cognitive deficits, learning disabilities, and behavioral problems are also common.

Answer 118

In patients with essential thrombocythemia who have the JAK2 V617F mutation, hydroxyurea plus aspirin should be the initial treatment choice. Patients with essential thrombocythemia who are older than 60 years should be treated with aspirin and hydroxyurea regardless of mutation status.

Answer 119

If the platelet count remains greater than 30,000/μL (30 × 109/L), the pregnancy is not at risk. Patients should receive intravenous immune globulin or glucocorticoids at any time during pregnancy if the platelet count decreases to less than 30,000/μL (30 × 109/L). TP is a diagnosis of exclusion, although it is often difficult to distinguish from gestational thrombocytopenia when the thrombocytopenia is mild or noted later in pregnancy. However, features suggesting ITP include earlier presentation (first trimester), lower platelet count nadir (<70,000/μL [70 × 109/L]), and history of thrombocytopenia before pregnancy (even if it was only mild).

Answer 120

In the absence of a driver mutation (epidermal growth factor receptor, ALK, ROS1), **combination of pembrolizumab with chemotherapy** has been shown to improve survival in patients who have good performance with metastatic non–small cell lung cancer regardless of programmed cell death ligand-1 level. In the absence of a driver mutation (epidermal growth factor receptor, ALK, ROS1), pembrolizumab monotherapy is first-line therapy in patients with programmed cell death ligand-1 expression greater than 50%.

Answer 121

Hyperacute bacterial conjunctivitis is a potentially vision-threatening condition caused by Neisseria gonorrhea infection. It is characterized by rapid onset of profuse purulent discharge and diffuse bright red conjunctival hemorrhage. If untreated, it can progress to corneal ulceration

Answer 122

Gastroesophageal tumors should be evaluated for h**uman epidermal growth factor 2** overexpression. Adding trastuzumab to chemotherapy regimens for patients with metastatic gastroesophageal tumors and human epidermal growth factor 2 overexpression provides a modest survival benefit.

Answer 123

The most prominent feature of behavioral-variant frontotemporal dementia is an alteration in personality and behavior that typically develops years before the onset of cognitive impairment. **Selective serotonin reuptake inhibitors** have shown effectiveness in treating some of the symptoms of frontotemporal dementia, especially compulsive behaviors.

Answer 124

In patients with normal pressure hydrocephalus, the most predictive test for improvement with ventricular shunting is gait assessment before and after high volume cerebrospinal fluid removal.

Answer 125

Acquired hemophilia A is characterized by a prolonged activated partial thromboplastin time that fails to correct during a mixing study and by a low factor VIII activity. Treatment of acquired hemophilia A includes activated factor VII, activated prothrombin complex concentrate, or porcine-derived factor VIII concentrate. Treatment with activated factor VII or activated prothrombin complex concentrate is recommended because these agents activate factor X, located downstream from factor VIII in the coagulation cascade, thus bypassing the effect of the inhibitor. Treatment with factor VIII concentrate or fresh frozen plasma is ineffective because the inhibitor neutralizes the factor VIII activity in the administered product. Porcine-derived factor VIII is only partially cross- reactive with human factor VIII and can be effective therapy when the inhibitor titer is low; however, it is not widely available. Immunosuppressive therapy should be implemented to eliminate the inhibitor.

Answer 126

The North American Menopause Society recommends initiating nonhormonal therapies, such as daily **vaginal moisturizer and vaginal lubricants**, as first-line treatments for genitourinary syndrome of menopause before considering topical vaginal estrogen therapy. If nonhormonal treatments are not effective in the treatment of genitourinary syndrome of menopause, guidelines recommend the use of low-dose topical vaginal estrogen therapy rather than systemic estrogen therapy for patients whose only symptoms are related to vaginal atrophy.

Answer 127

Early-stage Hodgkin lymphoma is most commonly treated with **combination chemotherapy followed by radiation therapy.** Chemotherapy alone is a treatment option for early-stage Hodgkin lymphoma after a complete metabolic response assessed by interim PET/CT after two to three cycles of treatment (risk-adapted therapy).

Answer 128

Early-stage Hodgkin lymphoma is most commonly treated with **combination chemotherapy followed by radiation therapy.** (Combination chemo: doxorubicin, bleomycin, vinblastine, and dacarbazine) Chemotherapy alone is a treatment option for early-stage Hodgkin lymphoma after a complete metabolic response assessed by interim PET/CT after two to three cycles of treatment (risk-adapted therapy).

Answer 129

Cold agglutinins are IgM antibodies that can cause erythrocyte agglutination and hemolytic anemia, with extravascular hemolysis driven by complement fixation. In cold agglutinin disease, the direct antiglobulin test result is positive for anticomplement (C3) and negative for anti-IgG. Cold agglutinin hemolytic anemia can arise as a primary process or secondary to an underlying condition such as infection, lymphoproliferative disorders, or autoimmune disease. Mycoplasma pneumoniae is a common infectious issue associated with development of cold agglutinins. This may arise because the organism causes alterations in antigens on the erythrocyte membrane to which IgM autoantibodies are directed. The hemolysis associated with M. pneumoniae is often mild and self-limited. Based on her symptoms of cough and fever and their resolution with a macrolide, this patient may have had preceding M. pneumoniae infection. The presence of a cold agglutinin can be confirmed by checking a titer, whereby the ability of the patient's serum to agglutinate erythrocytes is evaluated through serial dilutions.

Answer 130

Cold agglutinins are **IgM antibodies** that can cause erythrocyte agglutination and **hemolytic anemia**, with extravascular hemolysis driven by complement fixation. In cold agglutinin disease, the **direct antiglobulin test result is positive for anticomplement (C3) and negative for anti-IgG**. Cold agglutinin hemolytic anemia can arise as a primary process or secondary to an underlying condition such as infection, lymphoproliferative disorders, or autoimmune disease. **Mycoplasma pneumoniae** is a common infectious issue associated with development of cold agglutinins. This may arise because the organism causes alterations in antigens on the erythrocyte membrane to which IgM autoantibodies are directed. The hemolysis associated with M. pneumoniae is often mild and self-limited. The presence of a cold agglutinin can be confirmed by checking a titer, whereby the ability of the patient's serum to agglutinate erythrocytes is evaluated through serial dilutions.

Answer 131

combined ITP and autoimmune hemolytic anemia

Answer 132

When an occupational lung disease is suspected, clinicians should request a Safety Data Sheet (SDS) from the patient's employer; the SDS details chemical properties and known health risks associated with substances at the workplace.

Answer 133

**Lamotrigine, gabapentin, and levetiracetam** are better-tolerated and equally effective seizure medications when compared with older antiepileptic drugs in treatment of older adults.

Answer 134

Empiric management of suspected health care–associated ventriculitis or meningitis should include **vancomycin and a β-lactam with antipseudomonal activity (such as cefepime or meropenem)** and **device removal**, if present.

Answer 135

The most common etiology of immune complex membranoproliferative glomerulonephritis is infectious, specifically hepatitis C virus infection.

Answer 136

Heart transplant

Answer 137

The American Society of Nephrology recommends that PICC line catheters should be avoided in patients with an estimated glomerular filtration rate <60 mL/min/1.73 m2.

Answer 138

24 hours or acute neurologic exam change

Answer 139

Apixaban All of the direct oral anticoagulants are at least partially eliminated through the kidney; however, apixaban has the lowest renal elimination and is approved for use in patients with advanced kidney disease undergoing dialysis. **Apixaban is the only DOAC approved for use in patients on dialysis.** Direct oral anticoagulants may be preferred to warfarin in patients with early stage chronic kidney disease (estimated glomerular filtration rate <60 mL/min/1.73 m2) and atrial fibrillation. (warfarin can also be used in HD)

Answer 140

The rapid development of a septic state following a nonspecific prodromal flu-like syndrome is characteristic of inhalational anthrax. Inhalational anthrax results in widening of the mediastinum and occasional bloody pleural effusions demonstrated on chest radiograph or CT scan.

Answer 141

Polycystic ovary syndrome is characterized by hyperandrogenemia, ovulatory dysfunction, and polycystic ovarian morphology on imaging. The diagnosis of polycystic ovary syndrome is confirmed when inclusion criteria are met and other diseases causing hyperandrogenemia are excluded.

Answer 142

In restrictive cardiomyopathy, reduced compliance is caused by abnormal elastic properties of the myocardium and/or intercellular matrix, whereas in constrictive pericarditis, reduced chamber compliance is imposed by the external pericardial constraint

Answer 143

Cardiac angiosarcomas are rare malignant cardiac tumors that typically arise within the right atrium and are commonly associated with sanguinous pericardial effusion. Metastasis to the lungs, liver, lymphatic system, bone, and adrenal glands is commonly present at the time of diagnosis. Surgical resection and adjuvant chemotherapy or radiotherapy should be considered, but survival rates are low even for patients in whom surgery is feasible.

Answer 144

In addition to continuing airway clearance, bronchiectasis exacerbations are treated with antibiotics tailored by previous sputum culture results. If sputum culture results are not available, empiric antibiotic therapy is recommended, often with a fluoroquinolone.

Answer 145

The classic presentation of episcleritis is an abrupt onset of unilateral eye redness due to dilated episcleral blood vessels, irritation, and tearing, with no pain, photophobia, or change in vision. The cardinal sign of scleritis is edema of the sclera often associated with an underlying violaceous discoloration of the sclera and intense dilation of the episcleral blood vessels, accounting for the red eye.

Answer 146

Superior labrum anterior and posterior (SLAP) lesions are often caused by repetitive overhead stress; patients present with deep anterolateral shoulder pain that worsens with abduction and external rotation.

Answer 147

Urgent surgical excision

Answer 148

The duration of the anticoagulant effect of the direct oral anticoagulants (DOACs) is limited because of their short half-life; in most cases of gastrointestinal bleeding, simply holding the DOAC is sufficient. For secondary prevention of cardiovascular disease, the risk of interrupting aspirin therapy (Option C) is substantial. Studies have shown that discontinuation of long-term low-dose aspirin therapy for secondary prevention is associated with a threefold increased risk for cardiovascular or cerebrovascular events, with 70% of such events occurring within 7 to 10 days of discontinuation. The American College of Gastroenterology and the British Society of Gastroenterology have recommended that to avoid thromboembolic events, aspirin for secondary prophylaxis in patients with established cardiovascular disease should not be discontinued in patients with lower gastrointestinal bleeding. If aspirin is discontinued, it should be restarted as soon as possible following hemostasis.

Answer 149

Patients with ulcers at high risk for rebleeding (active bleeding, active oozing, or nonbleeding visible vessel) receiving endoscopic therapy should receive high-dose proton pump inhibitor (PPI) therapy for 72 hours while hospitalized, followed by an oral PPI twice daily for a total of 2 weeks following the therapeutic endoscopy.

Answer 150

Annual lung cancer screening should be performed in patients aged 50 through 80 years who have no symptoms of lung cancer, have at least a 20-pack-year smoking history, and are current smokers or have quit within the last 15 years. Cessation of lung cancer screening should be considered in those who have not smoked in 15 years, those with limited life expectancy, and those who would not be candidates for or would not be willing to undergo surgery.

Answer 151

In men undergoing active surveillance for prostate cancer, a doubling time of less than 3 years is grounds for reassessment with a repeat biopsy.

Answer 152

Individuals with gastroesophageal reflux disease symptoms for 5 years or more and three or more risk factors (male sex, age >50 years, White race, obesity, tobacco use, and family history of Barrett esophagus or esophageal adenocarcinoma in a first-degree relative) should be screened for Barrett esophagus.

Answer 153

Recurrence prevention is recommended after the second episode of pneumothorax on the ipsilateral side in primary spontaneous pneumothorax and after the first occurrence in secondary spontaneous pneumothorax. Recurrence prevention is indicated following a first episode of pneumothorax in spontaneous primary pneumothorax in a patient with a high-risk occupation.

Answer 154

ACE or ARB

Answer 155

Patients with primary polycythemia vera should be treated with low-dose aspirin and phlebotomy to a target hematocrit of less than 45% to reduce the risk of adverse cardiovascular events. Patients with polycythemia vera and additional risk factors, including age older than 60 years or a history of thromboembolic event should receive cytoreductive therapy with hydroxyurea or interferon-α in addition to phlebotomy.

Answer 156

All seizure medications, but especially levetiracetam

Answer 157

If scaphoid fracture is suspected and radiographs are normal, thumb splinting and repeat radiography in 1 to 2 weeks or immediate advanced imaging (MRI or CT) is recommended.

Answer 158

In patients potentially exposed to anthrax spores and without local or systemic infection, prophylaxis with **doxycycline or ciprofloxacin plus anthrax immunization** should be provided. Initial multidrug antimicrobial therapy with a fluoroquinolone or doxycycline, a second active agent (e.g., penicillin, meropenem, vancomycin), and a protein synthesis inhibitor (e.g., linezolid, clindamycin) is standard treatment of anthrax with systemic manifestations.

Answer 159

Ceftriaxone (don't need to add doxycycline unless chlamydia not excluded)

Answer 160

Diabetic amyotrophy can occur in patients with well-controlled diabetes. Onset of diabetic amyotrophy is often acute or subacute, with asymmetric prominent pain followed by proximal weakness and muscle loss.

Answer 161

Condylomata acuminata (specifically HPV)

Answer 162

Acuminata: genital warts Lata: secondary syphilis

Answer 163

Patients with hyperosmolality who have submaximally concentrated urine without evidence of osmotic diuresis have diabetes insipidus by definition. Distinguishing between central and nephrogenic diabetes insipidus (DI) in a patient with hyperosmolality can be done by measuring **antidiuretic hormone levels** (patients with central DI have an inappropriately low level, whereas patients with nephrogenic DI have a normal to elevated level) or by evaluating the response to administering the vasopressor analogue desmopressin.

Answer 164

STARI presents with erythema migrans lesions identical to those seen in Lyme disease but without clinical progression or complications. STARI is associated with Amblyomma americanum, also known as the Lone Star tick, and occurs in the southeastern, south-central, and eastern United States; Lyme disease is transmitted by Ixodes ticks and is more likely to occur in the northeastern and north-central United States. No infectious cause of STARI has been confirmed. Therefore, diagnosis is based on clinical and geographic features. Because STARI and early-stage Lyme disease may be clinically indistinguishable, treatment with doxycycline is recommended.

Answer 165

Gout > infectious

Answer 166

5-ASA enemas

Answer 167

Ceftriaxone and levofloxacin are the recommended empiric treatment for acute epididymitis when the patient has risk factors for a sexually transmitted infection as well as enteric pathogens. A single dose of intramuscular ceftriaxone and a 10-day course of oral doxycycline is appropriate empiric antimicrobial therapy in patients with acute epididymitis who are at risk for sexually transmitted infections (STIs).

Answer 168

The diagnosis of androgen deficiency should be made only when a patient has two separate early morning (8:00 AM) serum total testosterone levels less than 300 ng/dL (10.41 nmol/dL) combined with suggestive symptoms and/or signs. Free and bioavailable testosterone measurements should be reserved for patients with total testosterone levels in the low-normal range and for patients suspected of having alterations in sex hormone–binding globulin levels.

Answer 169

Hydromorphone NOT morphine

Answer 170

Smudge cells

Answer 171

**tenofovir disoproxil fumarate (TDF) and emtricitabine **(not recommended for persons with a creatinine clearance less than 60 mL/min, and dual-energy x-ray absorptiometry scanning is recommended in men older than 50 years and others at risk for osteoporosis) **tenofovir alafenamide (TAF) and emtricitabine** (lower risk of kidney and bone-related adverse effects, was approved in 2019 for use in men at high risk of HIV infection) **cabotegravir** (extended-release option for HIV PrEP. This intramuscular treatment allows dosing every 2 months (after the initial two doses) and is approved for use with kidney impairment)

Answer 172

The combination of tenofovir-emtricitabine, plus either raltegravir or dolutegravir is an HIV postexposure prophylaxis regimen to be given following a high-risk exposure

Answer 173

Well-differentiated neuroendocrine tumors are indolent, frequently discovered incidentally, and often initially only require observation and serial imaging. Somatostatin analogues are highly effective in controlling hormonal manifestations of gastrointestinal neuroendocrine tumors and should be given if hormone-related symptoms are present.

Answer 174

Polyuria is caused by either a water diuresis (dilute urine) or a solute diuresis (urine osmolality, 300-600 mOsm/kg H2O). Polyuria caused by an osmotic diuresis is caused by either an electrolyte diuresis or a nonelectrolyte diuresis (e.g., urea, glucose).

Answer 175

Thin glomerular basement membrane (GBM) disease (aka **benign familial hematuria**) is an autosomal dominant type IV collagen abnormality that causes thinning of the GBM, resulting in hematuria but usually without proteinuria or abnormal kidney function.

Answer 176

Thyroid ultrasonography with Doppler studies can help distinguish type 1 amiodarone-induced thyrotoxicosis (increased vascularity) from type 2 (decreased vascularity).

Answer 177

Therapy with **pirfenidone or nintedanib** decreases the rate of progression of idiopathic pulmonary fibrosis but is not curative. In patients with idiopathic pulmonary fibrosis, lung transplantation is a life-prolonging therapy for those without comorbidities that may otherwise limit life expectancy.

Answer 178

For patients with mild but disabling stroke symptoms, intravenous alteplase is indicated within 3 hours from symptom onset of symptoms and up to 4.5 hours in select patients who meet treatment criteria. Intravenous alteplase is recommended in patients with ischemic stroke whose blood pressure can be lowered safely to less than 185/110 mm Hg with antihypertensive agents.

Answer 179

Handheld fan

Answer 180

Leflunomide is highly teratogenic and absolutely contraindicated during any stage of pregnancy; during the preconception phase, leflunomide should be discontinued and cholestyramine used to remove its metabolite. Hydroxychloroquine can be continued throughout pregnancy.

Answer 181

Montelukast should be discontinued in patients with symptoms suggestive of depression.

Answer 182

Chronic interstitial nephritis in agricultural communities is most commonly observed in young- to middle-aged male agricultural workers and often progresses to end-stage kidney disease. Patients with chronic interstitial nephritis in agricultural communities may be hypertensive, and urinalysis may be normal or demonstrate pyuria and low-grade proteinuria.

Answer 183

The U.S. Preventive Services Task Force recommends screening women aged 21 to 65 years every 3 years with cytology; in women aged 30 to 65, primary high-risk human papillomavirus (hrHPV) testing (preferred) or cytology combined with hrHPV testing can be performed every 5 years. The American Cancer Society recommends initiating cervical cancer screening at age 25 years and prefers primary HPV testing every 5 years through age 65 years.

Answer 184

Infliximab

Answer 185

**Digital mammogram** Digital mammography is recommended as the breast cancer screening test for average-risk women with dense breasts. MRI is not recommended for either primary screening or as a supplemental test for average-risk women with increased breast density. However, women with dense breasts and other risk factors that impart a lifetime risk for breast cancer of 20% to 25% or higher, as calculated by models largely dependent on family history, should undergo breast MRI in addition to screening mammography.

Answer 186

Prepatellar bursitis presents as anterior knee pain and swelling; physical examination reveals a palpable fluid collection with preserved active and passive knee range of motion. Bursal aspiration is necessary to establish the cause of bursitis and determine the treatment plan. Treatment of noninfectious bursitis includes drainage of the fluid, compression to prevent re-accumulation, anti-inflammatory agents, and measures to avoid future trauma to the bursa. Antibiotics and drainage are indicated for septic bursitis.

Answer 187

Short-course dual therapy with isoniazid and rifampin or rifapentine is the preferred treatment for patients with latent tuberculosis infection. Daily isoniazid monotherapy for 6 or 9 months can be recommended for patients with latent tuberculosis who cannot take rifapentine or rifampin.

Answer 188

Polymyalgia rheumatica is characterized by symmetric proximal myalgia and stiffness, accompanied by constitutional symptoms and elevated inflammatory markers. For polymyalgia rheumatica, initiating prednisone at 12.5 to 20 mg/d is appropriate treatment.

Answer 189

Medical therapy with an aldosterone receptor blocker (spironolactone or eplerenone) is the treatment of choice for primary aldosteronism caused by idiopathic hyperaldosteronism (bilateral hyperplasia of adrenal glands) and in patients with aldosterone-producing adenoma who are not candidates for surgery. Aldosterone has direct inflammatory and fibrotic effects that are independent of its blood pressure effects.

Answer 190

Immediate surgery

Answer 191

Patent ductus arteriosus closure is indicated in patients with left-sided cardiac chamber enlargement even in the absence of symptoms, as long as pulmonary artery systolic pressure is less than 50% systemic.

Answer 192

Patients with hypertrophic cardiomyopathy who are receiving guideline-directed medical therapy but with New York Heart Association functional class III to IV heart failure symptoms or recurrent syncope believed to be related to left ventricular outflow tract (LVOT) obstruction and an LVOT gradient of 50 mm Hg (resting or provoked) or greater should be considered for septal reduction therapy.

Answer 193

In most patients with renal artery stenosis, the primary therapeutic intervention is medical management, including correction of modifiable cardiovascular risk factors. Patients who may benefit from percutaneous angioplasty or surgical intervention include those with a short duration of hypertension; atherosclerotic renovascular disease refractory to optimal medical therapy; severe hypertension or recurrent acute flash pulmonary edema; AKI following treatment with an ACE inhibitor or ARB; progressive impaired kidney function believed to be caused by bilateral renovascular disease; or unilateral stenosis affecting a solitary functioning kidney.

Answer 194

Empiric therapy for bacterial meningitis should include vancomycin, ceftriaxone or cefotaxime, and ampicillin in adult patients older than 50 years. Adjunctive dexamethasone is given concomitantly with the first dose of empiric antibiotic therapy for bacterial meningitis but should be discontinued promptly if the cause is not Streptococcus pneumoniae.

Answer 195

Varenicline

Answer 196

Perioperative prophylactic respiratory physiotherapy that includes increased mobility, sputum clearance, deep breathing exercise, and inspiratory muscle training reduces the incidence of postoperative pulmonary complications. There is no benefit of incentive spirometry, with or without deep breathing exercises, in preventing postoperative pulmonary complications.

Answer 197

NSAIDs are often the initial treatment of choice for osteoarthritis if used judiciously in low-risk patients, with minimizing and monitoring of adverse effects. Acetaminophen provides no benefit for hip or knee osteoarthritis; it may be considered as add-on therapy for short-term and episodic use but not as initial therapy.

Answer 198

Inclusion body myositis can be distinguished from other forms of idiopathic inflammatory myopathy by an insidious onset, slower progression, and involvement of distal muscle groups as well as proximal muscles.

Answer 199

No longer needed (if on or starting ART)

Answer 200

The key clinical features of thrombotic thrombocytopenic purpura are microangiopathic hemolytic anemia and thrombocytopenia. The initial treatment of thrombotic thrombocytopenia purpura includes plasma exchange, glucocorticoids, and rituximab.

Answer 201

Meningioma

Answer 202

Mild: folate Severe: splenectomy

Answer 203

iron overload–related heart failure and/or arrhythmias

Answer 204

Diuresis and IV nitroglycerin

Answer 205

Superficial, saucer-shaped ulcers with overlying crusts are the classic findings of classic ecthyma, which is a variant of impetigo. They almost always occur on the legs or feet and are usually caused by streptococci.

Answer 206

Acute pancreatitis is most commonly caused by biliary disorders, and patients should undergo transabdominal ultrasonography for the detection of gallstones. For patients with mild gallstone pancreatitis, **same-admission cholecystectomy** can reduce rates of gallstone-related complications compared with cholecystectomy 25 to 30 days after hospital discharge.

Answer 207

Tocilizumab

Answer 208

**Cefotetan or cefoxitin plus doxycycline** or combination **ceftriaxone plus doxycycline plus metronidazole** are the preferred parenteral antibiotic regimens for patients hospitalized with pelvic inflammatory disease.

Answer 209

Surveillance should be conducted with ultrasonography (US), with or without alpha-fetoprotein (AFP) testing, every 6 months

Answer 210

Major criteria include carditis, arthritis, chorea, erythema marginatum, and subcutaneous nodules; minor criteria include prolonged PR interval, arthralgia, fever, and elevated inflammatory markers (erythrocyte sedimentation rate ≥ 60 mm/h and/or C-reactive protein level ≥ 3.0 mg/dL [30 mg/L]).

Answer 211

A positive result on the fourth-generation HIV-1/2 antigen/antibody combination assay but negative result on HIV antibody differentiation is tested for HIV RNA by nucleic acid amplification testing; if positive, acute HIV infection is confirmed, and a negative result identifies a false-positive combination assay. Postexposure prophylaxis should be started as soon as possible after exposure; it is not recommended if more than 72 hours have passed.

Answer 212

Morphea, a type of localized scleroderma, is an inflammatory disorder of unknown cause that leads to sclerotic changes in the skin and is distinct from systemic sclerosis. Clinical features that help distinguish between systemic sclerosis and morphea are a lack of Raynaud phenomenon, absence of mat-like telangiectasias on the hands and face, and lack of internal organ involvement in morphea compared with systemic sclerosis.

Answer 213

Pregnant patients *with risk factors* for type 2 diabetes mellitus should be screened at the time of their positive pregnancy test using standard screening tests. Pregnant patients with risk factors for type 2 diabetes mellitus who have a negative screening test at the time of their positive pregnancy test should be rescreened between 24 and 28 weeks' gestation using an oral glucose tolerance test.

Answer 214

Chronic bacterial prostatitis commonly manifests as recurrent lower urinary tract infections with the same organism. Patients with chronic bacterial prostatitis require an extended course (at least 4-6 weeks) of antimicrobial therapy that has good prostatic tissue penetration and covers the causative organism.

Answer 215

For patients receiving high-emetic-risk chemotherapy, standard antiemetic treatments include a **four-drug combination** of an NK1 receptor antagonist, a 5-hydroxytryptamine-3 receptor antagonist, dexamethasone, and olanzapine. Olanzapine, when added to standard antiemetic regimens, has been found to be effective for the treatment of delayed chemotherapy-induced nausea and vomiting.

Answer 216

Bacterial prostatitis is associated with acute onset of local symptoms (dysuria, urinary frequency and urgency, suprapubic and/or perineal pain) and systemic symptoms (fevers, chills, nausea/vomiting, malaise). Oral trimethoprim-sulfamethoxazole or an oral fluoroquinolone (ciprofloxacin, levofloxacin) is an appropriate empiric antibiotic for acute bacterial prostatitis. Antibiotic therapy should be initiated after a urine sample is obtained for analysis and culture and should be continued for 2 to 4 weeks; some experts recommend up to 6 weeks. Treatment can be modified on the basis of results of the urine culture.

Answer 217

Opioid-induced constipation requires prophylactic and ongoing pharmacologic therapy with an osmotic laxative, such as polyethylene glycol; stimulant laxatives are often needed in addition. Peripherally acting μ-opioid receptor antagonists are recommended for opioid-induced constipation refractory to first-line treatment with laxatives.

Answer 218

Bidirectional endoscopy

Answer 219

Allergic rhinitis should be suspected if rhinitis symptoms (sneezing, congestion, rhinorrhea) are associated with a season, environment, or exposure. Guidelines recommend intranasal glucocorticoid monotherapy as first-line treatment for seasonal allergic rhinitis.

Answer 220

The evaluation of patients with likely cardiac amyloidosis includes testing for underlying monoclonal plasma cell dyscrasia for light-chain amyloid amyloidosis and 99m-technetium pyrophosphate scintigraphy for transthyretin amyloid amyloidosis.

Answer 221

Increased or decreased muscle mass can alter the serum creatinine level in the absence of kidney disease. **Serum cystatin C** is more sensitive in identifying milder decrements in kidney function than serum creatinine.

Answer 222

Cystitis in pregnant individuals is considered a complicated urinary tract infection and requires a urine culture and prompt treatment with antibiotics such as **cefpodoxime proxetil, cephalexin, cefdinir, and amoxicillin-clavulanate.** Follow-up urine cultures after treatment of urinary tract infections are indicated in pregnant patients.

Answer 223

Loop (not thiazide)

Answer 224

Patients with severe malaria should be treated initially with intravenous **artesunate** and then transitioned to an oral antimalarial regimen when clinically stable.

Answer 225

In patients with multiple sclerosis with ambulatory dysfunction, **dalfampridine** can improve gait speed and endurance. The benefit of disease-modifying therapies is reducing risk for future relapses, MRI activity or disability progression, not symptomatic improvement of existing disability.

Answer 226

In patients with dermatomyositis, initiation of methotrexate or azathioprine at diagnosis or after an early initial response to glucocorticoids is the most appropriate next step to achieve long-term disease control and to allow effective tapering of the prednisone dose. Physical therapy may help maintain muscle function and should be used in all patients with inflammatory myopathy.

Answer 227

In patients undergoing major surgery, warfarin should be withheld a minimum of 5 days before surgery to normalize the INR. In patients on chronic warfarin therapy, warfarin should be restarted within 12 to 24 hours of surgery, pending adequate hemostasis. Bridging can be considered for patients at highest risk for devastating thromboembolic disease (recent pulmonary embolism, prior stroke, high-thrombotic-risk mechanical heart valve, CHA2DS2-VASc score ≥7).

Answer 228

Chorea gravidarum

Answer 229

Exemestane may be used as a preventive measure in women who are at high risk of breast cancer with a previous history of venous thromboembolic disease.

Answer 230

Nonimmune persons exposed to hepatitis A virus (HAV) should receive postexposure prophylaxis with **HAV vaccine** as soon as possible after exposure. Postexposure prophylaxis with both HAV vaccine and HAV immune globulin may be considered for nonimmune patients older than 40 years.

Answer 231

In adults with respiratory symptoms, fractional exhaled nitric oxide levels above 50 ppb correlate with eosinophilic airway inflammation and predict response to inhaled glucocorticoids. Serial measurement of fractional exhaled nitric oxide may be helpful to monitor patient response to inhaled glucocorticoid therapy.

Answer 232

Osteomalacia Vitamin D deficiency may result in osteomalacia, which is characterized by diffuse bone pain, bone tenderness to palpation, and proximal muscle weakness; however, early osteomalacia may present only with low bone mass on dual-energy x-ray absorptiometry and may be indistinguishable from osteoporosis without further testing. Vitamin D deficiency is characterized by mild hypocalcemia, mild hypophosphatemia, increased alkaline phosphatase and parathyroid hormone levels, and a decreased serum 25-hydroxyvitamin D level.

Answer 233

If symptoms of gastroesophageal reflux disease (GERD) do not respond to proton pump inhibitor treatment or if symptoms recur, upper endoscopy is indicated to evaluate for signs of GERD and to rule out other abnormalities.

Answer 234

Beads on a string

Answer 235

Bullous has tense and firm bullae Pemphigus has flaccid

Answer 236

For patients with chronic insomnia refractory to cognitive behavioral therapy for insomnia (CBT-I) or who decline to participate in CBT-I, either low-dose **doxepin** or a nonbenzodiazepine benzodiazepine receptor agonist (e.g., zolpidem, zaleplon, eszopiclone) is recommended after a discussion of risks and benefits.

Answer 237

A TST reaction of 5 mm or greater is considered positive in persons at high risk, such as those with HIV, recent or known contacts of a person with active tuberculosis, persons with chronic fibrotic changes on chest radiography consistent with old tuberculosis, patients who have undergone solid organ transplantation, and other persons who are immunosuppressed. A TST reaction of 10 mm or greater should be considered positive in recent arrivals (<5 years) from high-prevalence countries; persons who inject drugs; residents or employees of high-risk settings, hospitals, other health care facilities, and homeless shelters; persons with clinical conditions that put them at high risk for active disease; and children younger than 4 years or those exposed to adults in high-risk categories. In patients with no known risk factors for tuberculosis, a reaction of 15 mm or greater is considered a positive result.

Answer 238

In patients who have upper extremity thrombosis associated with a central venous catheter that is removed, guidelines recommend 3 months of anticoagulation. In patients who have upper extremity thrombosis that is associated with a central venous catheter that is not removed, guidelines recommend that anticoagulation be continued as long as the central venous catheter remains in place.

Answer 239

Aromatase inhibitors are associated with bone loss and an elevated risk of fracture; patients on aromatase inhibitors should have bone density studies every 2 years.

Answer 240

reatment is indicated for SVT when the thrombus is 5 cm or greater in length or is close to the deep venous system or if other thrombophilic risk factors are present. Anticoagulation for 6 weeks is indicated.

Answer 241

Medical anti-platelet therapy indication symptomatic patients drugs clopidogrel aspirin plus dipyridamole statins indication for all patients Operative carotid artery revascularization indication stenosis > 70% post-transient ischemic attack or stroke surgeries carotid endarterectomy (CEA) first-line for patients who can tolerate surgery carotid artery stenting for patients unable to tolerate CEA

Answer 242

Serologic testing for **anti-phospholipase A2 receptor antibodies** is a noninvasive test that approaches 100% specificity for primary membranous nephropathy. Serologic testing for anti-phospholipase A2 receptor antibodies can eliminate the need for kidney biopsy in patients with preserved kidney function and no evidence of secondary causes as well as in patients with a clear contraindication to kidney biopsy.

Answer 243

Membranous nephropathy

Answer 244

n patients with splanchnic vein thrombosis (portal vein, splenic vein, hepatic vein, or mesenteric vein thrombosis), evaluation for evidence of a myeloproliferative neoplasm should be considered, including evaluation for the JAK2 tyrosine kinase mutation. Evidence of a myeloproliferative neoplasm is discovered in approximately 50% of patients with Budd-Chiari syndrome, even when the complete blood count is normal.

Answer 245

An incidentally found ground-glass (subsolid) pulmonary nodule 6 mm or larger necessitates follow-up chest CT at 6 to 12 months; if it persists but is unchanged in size, CT should be repeated at 2-year intervals for 5 years.

Answer 246

An incidentally found ground-glass (subsolid) pulmonary nodule 6 mm or larger necessitates follow-up chest CT at 6 to 12 months; if it persists but is unchanged in size, CT should be repeated at 2-year intervals for 5 years.

Answer 247

Tinea cruris, a dermatophyte infection of the groin, pubic region, and thighs, manifests with an erythematous, well-demarcated edge; an annular lesion with a slight scale; and incomplete central clearing. Tinea can be suspected based on clinical presentation and pruritus; however, diagnosis is based on visualization by microscopic examination of branching hyphae in the keratin (scale) using a potassium hydroxide preparation.

Answer 248

CBT and lisdexamfetamine

Answer 249

Disk space aspiration/biopsy

Answer 250

**Terbinafine** Recommended treatment of localized tinea on non–hair-bearing skin is terbinafine or imidazole creams, such as miconazole, clotrimazole, and ketoconazole.

Answer 251

Empiric therapy for ventilator-associated pneumonia should include coverage for Staphylococcus aureus, Pseudomonas aeruginosa, and other gram-negative bacilli. Empiric treatment for antibiotic-resistant organisms is recommended for patients with ventilator-associated pneumonia who have risk factors for antibiotic resistance, including intravenous antibiotics within 90 days and more than 5 days in the hospital before diagnosis.

Answer 252

**Factor VIII** Empiric therapy for ventilator-associated pneumonia should include coverage for Staphylococcus aureus, Pseudomonas aeruginosa, and other gram-negative bacilli. Empiric treatment for antibiotic-resistant organisms is recommended for patients with ventilator-associated pneumonia who have risk factors for antibiotic resistance, including intravenous antibiotics within 90 days and more than 5 days in the hospital before diagnosis.

Answer 253

Ethylene glycol and methanol toxicity should be treated with **fomepizole**. Indications for hemodialysis in the setting of ethylene glycol or methanol toxicity include severe anion gap metabolic acidosis and end-organ involvement (kidney impairment, visual changes)

Answer 254

Subacute cutaneous lupus erythematosus is a photosensitive rash occurring especially on the arms, neck, and upper trunk, usually sparing the central face and consisting of erythematous annular/polycyclic or patchy papulosquamous lesions. Fewer than 25% of patients with subacute cutaneous lupus erythematosus have systemic lupus erythematosus.

Answer 255

First-line diagnostic tests for Cushing syndrome include the overnight low-dose dexamethasone suppression test, 24-hour urine free cortisol measurement, and late-night salivary cortisol measurement; two of three tests must be abnormal. After the diagnosis of Cushing syndrome has been established, the most appropriate diagnostic test to perform next is adrenocorticotropic hormone measurement to determine whether the patient has adrenocorticotropic hormone-dependent or -independent Cushing syndrome.

Answer 256

IV levothyroxine

Answer 257

Resting pulse oximetry is helpful in screening patients for in-flight hypoxemia. Patients not using baseline oxygen and with a resting SpO2 less than 92% should be prescribed supplemental oxygen during air travel without additional testing.

Answer 258

Patients typically have a basilar lymphocytic meningitis associated with cranial neuropathies (particularly involving cranial nerve VI) and hypoglycorrhachia. Patients with a high suspicion for central nervous system tuberculosis should be treated empirically with rifampin, isoniazid, pyrazinamide, and ethambutol plus adjunctive dexamethasone.

Answer 259

Doxycycline plus ceftazidime

Answer 260

Treatment guidelines for patients with multiple myeloma recommend that those treated with proteasome inhibitors (e.g., bortezomib) should receive antiviral prophylaxis (acyclovir, valacyclovir) to avoid herpes zoster virus reactivation.

Answer 261

Itraconazole can be used as monotherapy for patients with mild to moderate disease caused by histoplasmosis. The treatment of choice for disseminated histoplasmosis is liposomal amphotericin B

Answer 262

Prophylactic cranial irradiation reduces the incidence of brain metastases in patients with either limited or extensive-stage small cell lung cancer who have responded to their initial therapy. Prophylactic cranial irradiation improves overall survival in patients with limited-stage small cell lung cancer who have responded to their initial therapy.

Answer 263

In a woman with childbearing potential, lamotrigine and levetiracetam are the safest antiepileptic drug options.

Answer 264

High-dose glucocorticoids alone are not sufficient for induction and maintenance treatment of ANCA-associated vasculitis. High-dose glucocorticoids plus rituximab are the preferred treatment for induction of remission in severe organ-threatening or life-threatening granulomatosis with polyangiitis.

Answer 265

Deep brain stimulation

Answer 266

Central: T4 Peripheral: TSH

Answer 267

In patients with an abdominal aortic aneurysm (AAA) diameter smaller than 4.0 cm, surveillance with duplex ultrasonography every 2 to 3 years is recommended, whereas in patients with AAA diameter of 4.0 to less than 5.5 cm, surveillance with CT angiography or duplex ultrasonography should be performed every 6 to 12 months. In patients with an abdominal aortic aneurysm greater than 5.5 cm, either endovascular aneurysm repair or open surgery is indicated, and the choice is driven by the location of the aneurysm among other factors. Once the aortic diameter meets the threshold for aortic repair (≥5.5 cm), CT angiography or MR angiography is indicated to determine the exact location of the AAA (suprarenal, juxtarenal, or infrarenal) for planning repair.

Answer 268

In patients with suspected bacterial meningitis, perform a head CT before lumbar puncture to evaluate for elevated intracranial pressure if any of the following are present: focal neurologic findings, altered mental status, papilledema, new-onset seizure, history of central nervous system disease, and immunocompromise.

Answer 269

Patients with sickle cell disease, particularly hemoglobin SS disease, benefit from preoperative simple transfusion to achieve a hemoglobin level of 10 g/dL (100 g/L).

Answer 270

Corticobasal degeneration is a Parkinson-plus syndrome characterized by severely asymmetric parkinsonism, fixed dystonia, myoclonus, cortical sensory deficits, apraxia, and cognitive deficits.

Answer 271

Symptomatic intracranial arterial stenosis of greater than 70% is associated with a high risk for recurrent stroke and should be treated with aggressive medical therapy, including dual antiplatelet therapy for up to 90 days, followed by aspirin monotherapy. Stenting of intracranial stenosis is not recommended because of a higher risk for subsequent stroke or death compared with medical therapy alone.

Answer 272

In 2019, the FDA issued a warning that gabapentinoids such as gabapentin may cause serious breathing difficulties in patients with respiratory risk factors, including opioid use and chronic obstructive pulmonary disease (COPD).

Answer 273

For pregnant patients with a mechanical valve prosthesis, warfarin is the preferred anticoagulant during the first trimester if the dosage is 5 mg/d or less; warfarin is the preferred anticoagulant during the second and early third trimesters. Direct oral anticoagulants are not recommended in patients with a mechanical valve prosthesis.

Answer 274

-bupropion -tramadol -clozapine -cefepime

Answer 275

Full-thickness rectal tumors (stage II) and/or those with involved lymph nodes (stage III) routinely require irradiation, chemotherapy, and surgery. Surgery followed by irradiation is avoided when feasible for rectal tumors because of greater toxicity and a higher risk of tumor recurrence in the irradiated field than when irradiation is given before surgery.

Answer 276

pH (< 7.2)

Answer 277

A ventilation/perfusion scan is recommended for all patients with pulmonary hypertension to rule out chronic thromboembolic pulmonary hypertension. For patients with suspected chronic thromboembolic pulmonary hypertension and an abnormal ventilation/perfusion scan, right heart catheterization and pulmonary angiography will confirm pulmonary hypertension, exclude competing diagnoses, and provide vital information related to potential therapy.

Answer 278

A chylothorax is diagnosed by a triglyceride level greater than 110 mg/dL (1.24 mmol/L), and it is typically a lymphocytic predominant exudative effusion. The most common nontraumatic cause of chylothorax is malignancy, of which lymphoma is the most common.

Answer 279

Travelers' diarrhea prophylaxis with **rifaximin** is recommended in patients with underlying conditions that place them at higher risk of infection or disease complications (e.g., immune compromise, inflammatory bowel disease, chronic kidney disease).

Answer 280

Erythrasma, a superficial skin infection, manifests as thin, atrophic, finely wrinkled pink-brown plaques in the intertriginous areas; Wood lamp evaluation reveals a soft coral-red or pink fluorescence. Symptoms of erythrasma are limited to mild pruritus, and treatment for localized disease is topical erythromycin.

Answer 281

Candida species demonstrate pseudohyphae and budding yeast forms. Aspergillus fumigatus shows acutely branching hyphae with septations. Blastomyces dermatitidis is seen as large, round, budding yeast with a broad base. Coccidioides immitis is identified by evidence of thick-walled, round structures. Mucor species have broad, irregularly branched hyphae without septations.

Answer 282

Fluoroquinolones (ciprofloxacin for 7 days or levofloxacin for 5 days for uncomplicated infections, 10-14 days in complicated infections) are the only oral agents recommended for empiric outpatient treatment of pyelonephritis. Patients with pyelonephritis who are acutely ill, hypotensive, nauseated, or vomiting should be hospitalized to receive intravenous fluids and empiric therapy with a fluoroquinolone, an extended-spectrum cephalosporin or penicillin, or an aminoglycoside.

Answer 283

Allogeneic hematopoietic stem cell transplantation is used for consolidation therapy in patients with high-risk acute myeloid leukemia who respond to induction therapy.

Answer 284

Presence of the HLA-B*58:01 allele has been associated with a higher incidence of allopurinol hypersensitivity and is more prevalent in persons of Korean, Han Chinese, Thai, and African descent. Testing for the HLA-B*58:01 allele is recommended in high-risk populations before initiation of allopurinol given the potential severity of a hypersensitivity reaction.

Answer 285

Abacavir is a nucleoside analog used in the treatment of HIV infection. Abacavir is associated with a severe hypersensitivity reaction in individuals identified by the HLA-B*57:01 allele. Patients who are prescribed abacavir must first undergo testing to show they are HLA-B*57:01 negative in order to reduce the risk for a hypersensitivity reaction. As with allopurinol, absence of the allele does not protect patients from hypersensitivity reactions, and appropriate counseling should be provided.

Answer 286

The American Diabetes Association recommends that insulin therapy should be initiated for treatment for persistent hyperglycemia starting at a threshold of 180 mg/dL (10.0 mmol/L) with a target glucose range of 140 to 180 mg/dL (7.8-10.0 mmol/L)

Answer 287

Acute infection with chikungunya virus is heralded by the abrupt onset of severe, polyarticular arthralgia, high temperature, rash, and conjunctivitis and often with bilaterally symmetric polyarticular arthritis. Chikungunya virus can be detected polymerase chain reaction for 1 week after onset of symptoms; specific IgM antibody is detectable in 5 to 10 days after symptom onset and remains positive for up to 2 to 3 months.

Answer 288

Low-dose CT (preferred) and PET-CT are recommended as the initial imaging procedure for patients with a monoclonal gammopathy because of increased sensitivity for the detection of lytic lesions. A whole-body low-dose CT scan negative for smoldering myeloma should be followed by a whole-body MRI.

Answer 289

Remove When candidemia is likely to be the result of an intravenous catheter, the catheter must be removed promptly because it serves as a nidus for ongoing candidemia. An echinocandin (micafungin, caspofungin, or anidulafungin) is typically the preferred empiric agent for all patients with candidemia.

Answer 290

Nothing “Hot tub” folliculitis is a self-limited skin infection associated with the use of hot tubs, swimming pools, saunas, and whirlpools containing Pseudomonas aeruginosa.

Answer 291

Symptomatic hypermagnesemia (serum magnesium level >4.8 mg/dL [2.0 mmol/L]) is immediately treated with intravenous calcium gluconate while awaiting hemodialysis.

Answer 292

First-line empiric treatment regimens for uncomplicated cystitis in nonpregnant persons are a 5-day course of nitrofurantoin, a 3-day course of trimethoprim-sulfamethoxazole, and a single dose of fosfomycin.

Answer 293

High-risk gastrointestinal stromal tumors should be treated with surgery and 3 years of adjuvant **imatinib**.

Answer 294

Screening for the JAK2 V617F mutation is recommended in patients with unprovoked splanchnic vein thrombosis. polycythemia vera

Answer 295

A 3-year colonoscopy interval is appropriate for patients with larger adenomas (≥10 mm), 5 to 10 tubular adenomas less than 10 mm, adenomas with tubulovillous or villous histology, or adenomas with high-grade dysplasia; a 3- to 5-year interval is appropriate for three or four tubular adenomas less than 10 mm. A 7- to 10-year colonoscopy interval is appropriate for patients with one or two small (<10 mm) tubular adenomas.

Answer 296

Orbital cellulitis can be distinguished from preseptal cellulitis (periorbital cellulitis) by the presence of pain with eye movements, ophthalmoplegia, proptosis, and vision impairment as orbital cellulitis involves the extraocular muscle and fatty tissue whereas preseptal cellulitis does not. The diagnosis of orbital cellulitis is suspected clinically and can be confirmed by CT of the orbits and sinuses.

Answer 297

Radiation therapy is the preferred treatment for localized tumors of the larynx, avoiding the potential morbidity of surgery, including loss of voice. Combined chemotherapy and radiation therapy is a standard treatment for more locally advanced laryngeal cancer.

Answer 298

In patients with Paget disease of bone, a bone scan followed by focused radiography of abnormal areas of radionuclide uptake is used to identify the extent of disease.

Answer 299

Daptomycin is bound by surfactant, and it is not effective in treating pneumonia.

Answer 300

The diagnosis of Peutz-Jeghers syndrome (PJS) is based on the presence of two of the following three criteria: two or more PJS-type hamartomatous polyps in the gastrointestinal tract; multiple melanotic macules in the mouth, buccal mucosa, nose, eyes, genitalia, or fingers; and family history of PJS.

Answer 301

ACE/ARB Tolvaptan can slow kidney function decline in adults at risk for progressive autosomal dominant polycystic kidney disease.

Answer 302

During pregnancy, the levothyroxine dosage is typically increased in the first trimester, with a possible total increase of 30% to 50%. During pregnancy, thyroid-stimulating hormone levels should be maintained in the lower half of the trimester-specific reference range, or less than 2.5 µU/mL (2.5 mU/L).

Answer 303

Lung volume reduction surgery improves quality of life, exercise tolerance, pulmonary function, and survival in selected patients with emphysema. Ideal patients for lung volume reduction therapy are those with upper-lobe-predominant emphysema, FEV1 and DLCO of 20% of predicted or higher, and low exercise tolerance after completion of pulmonary rehabilitation.

Answer 304

For patients with metastatic prostate cancer, combining a gonadotropin-releasing hormone agonist such as leuprolide with either docetaxel or an androgen receptor pathway inhibitor can result in improved progression-free and overall survival.

Answer 305

The non-steroidal mineralocorticoid antagonist finerenone is recommended in patients with type 2 diabetes mellitus and chronic kidney disease who have persistent albuminuria despite maximal renin-angiotensin system inhibition and sodium-glucose cotransporter 2 inhibitor treatment, normal serum potassium levels (<4.8 mEq/L [4.8 mmol/L]), and an estimated glomerular filtration rate ≥25 mL/min/1.73 m2, but care must be taken to avoid hyperkalemia.

Answer 306

Fluconazole (for life if meningitis)

Answer 307

Treatment of high-altitude pulmonary edema focuses on promptly reducing the pulmonary artery pressure; the patient should be given supplemental oxygen and advised to descend to a lower altitude as soon as possible and to limit physical exertion and cold exposure.

Answer 308

According to guidelines from the American Heart Association/American College of Cardiology and American Diabetes Association, moderate-intensity statin therapy should be initiated in adults aged 40 to 75 years with diabetes mellitus; high-intensity statin therapy should be considered in those with additional ASCVD or diabetes-specific risk factors.

Answer 309

Patients with chronic hepatitis B infection who will be receiving immunosuppressive therapy should begin antiviral therapy (entecavir or tenofovir) to prevent reactivation. In patients with chronic hepatitis B infection, antiviral therapy should be initiated at the time of transplantation and be continued indefinitely afterward.

Answer 310

Anal cancer is often curable with combined irradiation and chemotherapy; surgery is typically not indicated.

Answer 311

Certain therapies used to treat systemic lupus erythematosus, including mycophenolate mofetil, belimumab, and methotrexate, should be avoided in patients contemplating pregnancy because they are teratogenic; cyclophosphamide is associated with age- and dose-dependent infertility and should not be used in patients contemplating pregnancy without compelling life- or organ-threatening indications.

Answer 312

For metastatic non–small cell lung cancer with an ALK translocation, initial treatment should be with alectinib.

Answer 313

Amitryptiline

Answer 314

The initial step in the management of newly diagnosed membranous nephropathy (MN) is to evaluate for secondary forms of the disease, and cancer screening is particularly important in evaluating for secondary forms of MN in patients >65 years of age. Testing for phospholipase A2 receptor (PLA2R) antigen is used to help distinguish primary (PLA2R antigen–positive) from secondary (PLA2R antigen–negative) forms of membranous nephropathy.

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