Pics and Highlights COPY Flashcards

Question

Cards Highlighted Key/Trick Points

Answer 1

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

Answer 2

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

Answer 3

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

Answer 4

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

Answer 5

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

Answer 6

Septic embolic from IE

Answer 7

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

Answer 8

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

Answer 9

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

Answer 10

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

Answer 11

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

Answer 12

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

Answer 13

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

Answer 14

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

Answer 15

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

Answer 16

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

Answer 17

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

Answer 18

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

Answer 19

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

Answer 20

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

Answer 21

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

Answer 22

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

Answer 23

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

Answer 24

Narrow-Complex Tachycardia:

Answer 25

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

Answer 26

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

Answer 27

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

Answer 28

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

Answer 29

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

Answer 30

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

Answer 31

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

Answer 32

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

Answer 33

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

Answer 34

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

Answer 35

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

Answer 36

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

Answer 37

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

Answer 38

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

Answer 39

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

Answer 40

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

Answer 41

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

Answer 42

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

Answer 43

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

Answer 44

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

Answer 45

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

Answer 46

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

Answer 47

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

Answer 48

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

Answer 49

Do not prescribe dexamethasone for chronic AI replacement therapy.

Answer 50

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

Answer 51

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

Answer 52

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

Answer 53

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

Answer 54

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

Answer 55

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

Answer 56

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

Answer 57

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

Answer 58

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

Answer 59

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

Answer 60

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

Answer 61

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

Answer 62

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

Answer 63

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

Answer 64

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

Answer 65

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

Answer 66

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

Answer 67

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

Answer 68

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

Answer 69

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

Answer 70

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

Answer 71

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

Answer 72

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

Answer 73

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

Answer 74

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

Answer 75

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

Answer 76

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

Answer 77

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

Answer 78

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

Answer 79

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

Answer 80

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

Answer 81

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

Answer 82

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

Answer 83

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

Answer 84

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

Answer 85

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

Answer 86

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

Answer 87

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

Answer 88

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

Answer 89

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

Answer 90

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

Answer 91

Avoid opioids for the treatment of chronic pancreatitis.

Answer 92

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

Answer 93

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

Answer 94

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

Answer 95

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

Answer 96

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

Answer 97

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

Answer 98

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

Answer 99

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

Answer 100

Surgery is generally not indicated for asymptomatic gallstones.

Answer 101

Chest pain is common in patients with GERD, but a cardiac cause of chest pain must be ruled out first. * In patients without alarm features, GERD management consists of once-daily PPI; twice-daily PPI for 4-8 weeks is indicated in patients not responding to once- daily treatment.

Answer 102

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

Answer 103

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

Answer 104

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

Answer 105

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

Answer 106

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

Answer 107

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

Answer 108

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

Answer 109

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

Answer 110

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

Answer 111

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

Answer 112

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

Answer 113

Ten percent of rapid rectal bleeding has a UGI source.

Answer 114

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

Answer 115

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

Answer 116

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

Answer 117

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

Answer 118

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

Answer 119

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

Answer 120

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

Answer 121

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

Answer 122

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

Answer 123

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

Answer 124

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

Answer 125

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

Answer 126

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

Answer 127

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

Answer 128

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

Answer 129

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

Answer 130

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

Answer 131

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

Answer 132

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

Answer 133

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

Answer 134

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

Answer 135

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

Answer 136

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

Answer 137

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

Answer 138

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

Answer 139

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

Answer 140

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

Answer 141

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

Answer 142

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

Answer 143

Endometriosis does not cause fever or vaginal discharge.

Answer 144

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

Answer 145

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

Answer 146

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

Answer 147

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

Answer 148

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

Answer 149

Actinic Purpura Actinic purpura appears as purpuric macules or patches.

Answer 150

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

Answer 151

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

Answer 152

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

Answer 153

Tinea cruris spares the scrotum, whereas intertrigo does not.

Answer 154

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

Answer 155

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

Answer 156

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

Answer 157

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

Answer 158

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

Answer 159

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

Answer 160

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

Answer 161

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

Answer 162

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

Answer 163

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

Answer 164

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

Answer 165

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

Answer 166

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

Answer 167

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

Answer 168

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

Answer 169

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

Answer 170

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

Answer 171

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

Answer 172

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

Answer 173

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

Answer 174

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

Answer 175

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

Answer 176

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

Answer 177

Erythema Multiforme

Answer 178

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

Answer 179

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

Answer 180

Do not treat a red eye with topical glucocorticoids.

Answer 181

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

Answer 182

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

Answer 183

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

Answer 184

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

Answer 185

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

Answer 186

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

Answer 187

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

Answer 188

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

Answer 189

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

Answer 190

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

Answer 191

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

Answer 192

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

Answer 193

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

Answer 194

Acral Melanoma Acral melanoma on the toe.

Answer 195

Do not order hormone levels to diagnose menopause.

Answer 196

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

Answer 197

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

Answer 198

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

Answer 199

True hip joint pain usually presents as groin pain.

Answer 200

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

Answer 201

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

Answer 202

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

Answer 203

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

Answer 204

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

Answer 205

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

Answer 206

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

Answer 207

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

Answer 208

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

Answer 209

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

Answer 210

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

Answer 211

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

Answer 212

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

Answer 213

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

Answer 214

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

Answer 215

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

Answer 216

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

Answer 217

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

Answer 218

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

Answer 219

Never select systemic glucocorticoids for the treatment of psoriasis.

Answer 220

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

Answer 221

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

Answer 222

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

Answer 223

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

Answer 224

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

Answer 225

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

Answer 226

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

Answer 227

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

Answer 228

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

Answer 229

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

Answer 230

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

Answer 231

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

Answer 232

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

Answer 233

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

Answer 234

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

Answer 235

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

Answer 236

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

Answer 237

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

Answer 238

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

Answer 239

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

Answer 240

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

Answer 241

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

Answer 242

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

Answer 243

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

Answer 244

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

Answer 245

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

Answer 246

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

Answer 247

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

Answer 248

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

Answer 249

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

Answer 250

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

Answer 251

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

Answer 252

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

Answer 253

* Reticulocytosis (e.g., secondary to hemolysis) can increase the MCV. * Vitamin B12 deficiency can present with subacute combined degeneration of the nuclear lobes. Consider vitamin B12 or folate deficiency (megaloblastic anemia). spinal column (weakness, paresthesias, ataxia) without anemia or macrocytosis. * Folate supplementation can improve the anemia of B12 deficiency but does not prevent the associated neurologic sequelae.

Answer 254

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

Answer 255

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

Answer 256

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

Answer 257

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

Answer 258

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

Answer 259

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

Answer 260

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

Answer 261

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

Answer 262

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

Answer 263

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

Answer 264

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

Answer 265

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

Answer 266

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

Answer 267

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

Answer 268

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

Answer 269

* Do not use cryoprecipitate to treat vWD because of its increased transfusion infection risk.

Answer 270

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

Answer 271

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

Answer 272

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

Answer 273

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

Answer 274

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

Answer 275

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

Answer 276

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

Answer 277

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

Answer 278

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

Answer 279

Treat chlamydial infection with azithromycin or doxycycline.

Answer 280

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

Answer 281

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

Answer 282

Trimethoprim-sulfamethoxazole should not be used FOR uti if it was taken in the preceding 3 months.

Answer 283

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

Answer 284

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

Answer 285

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

Answer 286

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

Answer 287

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

Answer 288

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

Answer 289

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

Answer 290

Do not stop ART in the setting of IRIS.

Answer 291

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

Answer 292

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

Answer 293

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

Answer 294

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

Answer 295

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

Answer 296

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

Answer 297

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

Answer 298

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

Answer 299

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

Answer 300

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

Answer 301

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

Answer 302

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

Answer 303

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

Answer 304

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

Answer 305

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

Answer 306

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

Answer 307

Cellulitis Cellulitis is characterized by demarcated areas of tender erythema.

Answer 308

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

Answer 309

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

Answer 310

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

Answer 311

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

Answer 312

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

Answer 313

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

Answer 314

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

Answer 315

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

Answer 316

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

Answer 317

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

Answer 318

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

Answer 319

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

Answer 320

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

Answer 321

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

Answer 322

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

Answer 323

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

Answer 324

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

Answer 325

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

Answer 326

Glomerulonephritis Erythrocyte casts consistent with glomerulonephritis.

Answer 327

The absence of erythrocyte casts does not rule out glomerulonephritis.

Answer 328

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

Answer 329

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

Answer 330

Significant hyperkalemia associated with a normal ECG suggests pseudohyperkalemia.

Answer 331

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

Answer 332

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

Answer 333

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

Answer 334

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

Answer 335

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

Answer 336

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

Answer 337

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

Answer 338

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

Answer 339

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

Answer 340

* Dipstick urinalysis does not detect immunoglobulin light chains associated with multiple myeloma. * Because moderately increased albuminuria may go undetected by dipstick, direct quantification using a random (spot) protein-creatinine ratio or albumin- creatinine ratio is required when screening patients at high risk.

Answer 341

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

Answer 342

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

Answer 343

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

Answer 344

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

Answer 345

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

Answer 346

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

Answer 347

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

Answer 348

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

Answer 349

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

Answer 350

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

Answer 351

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

Answer 352

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

Answer 353

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

Answer 354

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

Answer 355

Warfarin is the only approved drug for valvular AF.

Answer 356

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

Answer 357

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

Answer 358

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

Answer 359

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

Answer 360

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

Answer 361

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

Answer 362

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

Answer 363

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

Answer 364

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

Answer 365

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

Answer 366

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

Answer 367

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

Answer 368

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

Answer 369

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

Answer 370

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

Answer 371

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

Answer 372

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

Answer 373

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

Answer 374

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

Answer 375

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

Answer 376

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

Answer 377

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

Answer 378

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

Answer 379

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

Answer 380

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

Answer 381

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

Answer 382

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

Answer 383

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

Answer 384

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

Answer 385

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

Answer 386

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

Answer 387

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

Answer 388

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

Answer 389

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

Answer 390

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

Answer 391

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

Answer 392

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

Answer 393

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

Answer 394

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

Answer 395

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

Answer 396

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

Answer 397

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

Answer 398

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

Answer 399

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

Answer 400

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

Answer 401

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

Answer 402

* Radioiodine is not taken up by C cells and is not a treatment option for medullary thyroid cancer. * Chemotherapy does not prolong or improve the quality of life for patients with metastatic thyroid carcinoma.

Answer 403

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

Answer 404

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

Answer 405

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

Answer 406

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

Answer 407

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

Answer 408

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

Answer 409

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

Answer 410

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

Answer 411

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

Answer 412

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

Answer 413

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

Answer 414

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

Answer 415

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

Answer 416

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

Answer 417

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

Answer 418

* Do not confuse obesity-hypoventilation syndrome with OSA. Obesity- hypoventilation syndrome is usually associated with COPD and always with elevated arterial PCO2 levels when awake. * Obesity-hypoventilation syndrome may coexist with OSA. * Overnight oximetry has not been validated as a screening tool for OSA.

Answer 419

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

Answer 420

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

Answer 421

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

Answer 422

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

Answer 423

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

Answer 424

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

Answer 425

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

Answer 426

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

Answer 427

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

Answer 428

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

Answer 429

Do not treat asymptomatic pulmonary sarcoidosis.

Answer 430

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

Answer 431

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

Answer 432

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

Answer 433

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

Answer 434

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

Answer 435

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

Answer 436

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

Answer 437

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

Answer 438

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

Answer 439

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

Answer 440

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

Answer 441

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

Answer 442

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

Answer 443

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

Answer 444

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

Answer 445

* Suspect glucocorticoid-induced myopathy in patients with continued or new- onset worsening of proximal muscle weakness despite normalization of muscle enzyme levels. * Always check TSH levels when evaluating myopathy.

Answer 446

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

Answer 447

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

Answer 448

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

Answer 449

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

Answer 450

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

Answer 451

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

Answer 452

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

Answer 453

* A negative rheumatoid factor does not exclude RA; anti-CCP antibody assay may be positive, or the patient may have seronegative RA. * A positive rheumatoid factor alone is not diagnostic of RA. * Fluctuations in rheumatoid factor do not mirror disease activity, and serial testing is not indicated. * Not all symmetric arthritis is RA.

Answer 454

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

Answer 455

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

Answer 456

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

Answer 457

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

Answer 458

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

Answer 459

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

Answer 460

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

Answer 461

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

Answer 462

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

Answer 463

NSAIDs may result in worsening of associated IBD.

Answer 464

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

Answer 465

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

Answer 466

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

Answer 467

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

Answer 468

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

Answer 469

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

Answer 470

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

Answer 471

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

Answer 472

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

Answer 473

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

Answer 474

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

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