Quick Hits

Front 1

acute mono-articular arthritis in association with linear calcification (chondrocalcinosis) of the cartilage of the knee

Back 1

Pseudogout
(Calcium Pyrophosphate Dihydrate Deposition Disease)

Front 2

positive birefringent crystals

Back 2

Pseudogout
(Calcium Pyrophosphate Dihydrate Deposition Disease)

Front 3

hoarseness, breathing difficulty, and stridor

Back 3

acute epiglottitis

Front 4

most likely organism a/w acute epilottitis

Back 4

Haemophilus influenzae

Front 5

Ear pain and drainage in an elderly diabetic patient

Back 5

malignant external otitis

Front 6

MCC malignant external otitis

Back 6

P. aeruginosa

Front 7

Common causes of otitis media

Back 7

H. influenzae and M. catarrhalis

Front 8

hypertrophic, wartlike lesions around the anal area

Back 8

condylomata lata of secondary syphilis

Front 9

sore throat, bullous myringitis, and infiltrates on chest x-ray

Back 9

M. pneumoniae infection

Front 10

both upper and lower respiratory infection

Back 10

M. pneumoniae infection

Front 11

high titers of IgM cold agglutinins

Back 11

M. pneumoniae infection

Front 12

low hematocrit and elevated reticulocyte count

Back 12

hemolytic anemia

Front 13

Antibodies to I antigen on the erythrocyte membrane

Back 13

M. pneumoniae infection

Front 14

fever, pharyngitis, lymphadenopathy, and lymphocytosis

Back 14

infectious mononucleosis due to Epstein-Barr virus

Front 15

heterophile antibody test

Back 15

infectious mononucleosis due to Epstein-Barr virus

Front 16

atypical lymphocytes and a positive heterophile test

Back 16

infectious mononucleosis due to Epstein-Barr virus

Front 17

subacute bacterial endocarditis

Back 17

Viridans streptococci cause most cases of subacute bacterial endocarditis.

Front 18

fluctuant lesion and fistula over the mandible

Back 18

cervicofacial actinomycosis

Front 19

sickle cell anemia patient who presents with concomitant pneumonia and meningitis

Back 19

S. pneumoniae due to functional asplenia

Front 20

HIV-positive patient with a low CD4 count and visual blurring

Back 20

cytomegalovirus retinitis

Front 21

venereal warts caused by papillomavirus

Back 21

condyloma acuminatum

Front 22

organism has a tendency to produce skin lesions in exposed areas that become crusted, ulcerated, or verrucous

Back 22

Blastomycosis

Front 23

zygomycosis that originates in the nose and paranasal sinuses

Back 23

Mucormycosis

Front 24

Bronchial plugs, often filled with hyphal forms, result in repeated infiltrates and exacerbation of wheezing.

Back 24

allergic bronchopulmonary aspergillosis

Front 25

Sinus tenderness, bloody nasal discharge, and obtundation, usually occurring in the setting of diabetic ketoacidosis.

Back 25

Mucormycosis (a zygomycosis)

Front 26

facial nerve palsies, arthralgia, and first-degree AV block

Back 26

Facial nerve palsy has been increasingly recognized as a first manifestation of Lyme disease.

Front 27

serologic confirmation of Lyme disease

Back 27

antibody to Borrelia burgdorferi

Front 28

Used for protection against influenza A during the interim 2-week period before the influenza vaccine takes effect.

Back 28

Amantadine

Front 29

sputum sample showing many polymorphonuclear leukocytes and few squamous epithelial cells

Back 29

S. pneumoniae

Front 30

Gram stain that shows gram-positive lancet-shaped diplococci intracellularly

Back 30

pneumococcal infection
(S. pneumoniae)

Front 31

major factor in the development of multiple drug resistant tuberculosis (TB)

Back 31

Non-compliance or poor compliance with prescribed anti-TB medications

Front 32

hemorrhagic colitis with bloody diarrhea, acute renal failure, and death

Back 32

Escherichia coli 0157:H7

Front 33

ingestion of contaminated beef (in particular ground beef), ingestion of raw milk, and contamination via the fecal-oral route

Back 33

Escherichia coli 0157:H7

Front 34

leading causes of _____ include infections, malignancies, collagen vascular diseases, and granulomatous diseases

Back 34

fever of unknown origin (FUO)

Front 35

procedure in which prophylactic antibiotic therapy to prevent endocarditis is NOT recommended

Back 35

Prophylactic antibiotics are not currently
recommended for cardiac catheterization.

Front 36

Rabies incubation period

Back 36

The incubation period ranges from 4 days to many years, but is usually between 20 and 90 days.

Front 37

What should be done with nonimmunized animals that have bitten a human?

Back 37

Nonimmunized animals that have been bitten should be killed and their brains submitted for virus by immunofluorescent antibody examination.
A negative fluorescent test removes the need to treat the bite victim either actively or passively for rabies (rhabdovirus).

Front 38

agent responsible for erythema infectiosum

Back 38

Parvovirus B19 is the agent responsible for erythema infectiosum, also known as fifth disease.

Front 39

slapped-cheek rash, which may follow a prodrome of low-grade fever

Back 39

Parvovirus B19 is the agent responsible for erythema infectiosum, also known as fifth disease.

Front 40

Complications in adults include arthralgias, arthritis, aplastic crisis in patients with chronic hemolytic anemia, spontaneous abortion, and hydrops fetalis.

Back 40

Parvovirus B19 is the agent responsible for erythema infectiosum, also known as fifth disease.

Front 41

Desquamation of the skin usually occurs during or after recovery from infection by what organism?

Back 41

toxic shock syndrome (associated with a toxin produced by S. aureus)

Front 42

viral infection causing acute cerebellar ataxia

Back 42

The most common manifestation of CNS infection with varicella (chickenpox) is acute cerebellar ataxia.

Front 43

viral rash with vesicles that develop over a few hours

Back 43

varicella (chickenpox)

Front 44

vesiculation that develops over a period of days

Back 44

smallpox

Front 45

Lesions are typically all at the same stage of development

Back 45

smallpox

Front 46

vesicular fluid under electron microscopy show characteristic brick-shaped particles

Back 46

poxvirus

Front 47

scrapings of the base of the lesion reveal multinucleated giant cells

Back 47

chickenpox with Tzanck smear

Front 48

chronic central nervous system infection with an echovirus

Back 48

sex-linked or acquired agammaglobulinemia

Front 49

Malaise, irritability, and a high fever often associated with conjunctivitis with prominent tearing are common symptoms.

Back 49

measles

Front 50

duration of prodromal syndrome before the characteristic rash of measles develops

Back 50

Prodromal syndrome may last from 3 days to 1 week before the characteristic rash of measles develops.

Front 51

small, red, irregular lesions with blue-white centers may be visible on the mucous membranes and occasionally on the conjunctiva

Back 51

Koplik spots appear 1-2 days before the onset of the rash of measles

Front 52

viral rash will begin on the forehead and spread downward

Back 52

measles

Front 53

chest radiograph typically shows a diffuse bilateral interstitial pattern

Back 53

Pneumonia due to P. jiroveci (carinii )

Front 54

infection that may lead to blindness in an AIDS patient

Back 54

CMV retinitis

Front 55

chronic diarrhea in an AIDS patient that leads to malabsorption and wasting

Back 55

protozoan Cryptosporidium, diagnosed by direct examination of the stool with special concentration or staining techniques

Front 56

AIDS patient who present with seizures

Back 56

Toxoplasmosis
-or-
CNS lymphoma

Front 57

opportunistic pathogen in patients with AIDS causing bacteremia

Back 57

Salmonella

Front 58

Diarrhea in an AIDS patient diagnosed by direct examination of stool

Back 58

The protozoan Cryptosporidium may cause a chronic diarrhea that leads to malabsorption and wasting.

Front 59

How is trichomoniasis diagnosed?

Back 59

Trichomoniasis is usually diagnosed by a wet preparation microscopic examination or by culture

Front 60

papules, vesicles, and scabs in various stages of development

Back 60

chickenpox rash

Front 61

diagnosis of P. jiroveci (carinii) pneumonia?

Back 61

silver methenamine stain shows cystlike structures

Serology is not sensitive or specific enough for routine use. The organism does not grow on any media.

Front 62

There is no pleuritic chest pain or rigors and no sputum production. A
chest x-ray shows diffuse perihilar infiltrates. The patient worsens while
on erythromycin.

Back 62

P. jiroveci (carinii) pneumonia

Front 63

rash that spreads from the ankles and wrists to the trunk

Back 63

Rocky Mountain spotted fever (RMSF)

Front 64

North Carolina and East Tennessee have a relatively high index of disease

Back 64

Rocky Mountain spotted fever (RMSF)

RMSF is a rickettsial disease with the tick as the vector. The disease is most common in spring and summer.

Front 65

fiery red skin infection with a well-defined indurated margin that appears to be rapidly advancing

Back 65

Erysipelas, the cellulitis described, is typical of infection caused by S. pyogenes group A β-hemolytic streptococci.
There is often a preceding event such as a cut in the skin, dermatitis, or superficial fungal infection that precedes this rapidly spreading cellulitis.

Front 66

Anaerobic cellulitis is more often associated with?

Back 66

diabetes

Front 67

cellulitis that is usually more focal and likely to produce furuncles, or abscesses

Back 67

Staphylococcus aureus

Front 68

About half of all cases of nongonococcal urethritis are caused by?

Back 68

C. trachomatis

Front 69

An HIV-positive patient develops fever and dysphagia; endoscopic
biopsy shows yeast and hyphae.

Back 69

Candida albicans

Front 70

A 50-year-old develops sudden onset of bizarre behavior. CSF shows 80 lymphocytes; magnetic resonance imaging shows temporal lobe abnormalities.

Back 70

Herpes simplex encephalitis
(Herpes simplex type 1)

The bizarre behavior includes personality aberrations, hypersexuality, or sensory hallucinations.

Front 71

A patient with a previous history of tuberculosis now complains of hemoptysis. There is an upper lobe mass with a cavity and a crescent-shaped air-fluid level.

Back 71

Aspergillus flavus

The chest x-ray described is characteristic of a fungus ball—
almost always the result of an aspergilloma.

Front 72

A Filipino patient develops a pulmonary nodule after travel through the American Southwest.

Back 72

Coccidioides immitis (coccidioidomycosis)

Individuals from the Philippines have a higher incidence of the disease and are more likely to have complications of dissemination.

Front 73

A 35-year-old male who had a fever, cough, and sore throat develops chest pain after several days with diffuse ST segment elevations on ECG.

Back 73

Coxsackievirus B infection is the most likely cause of URI symptoms that evolve into a picture of myocarditis.

Front 74

rarely if ever attack the pericardium alone without involving the subepicardial myocardium

Back 74

Myocarditis caused by Enteroviruses

Front 75

Overwhelming pneumonia with adult respiratory distress syndrome
occurs on an Indian reservation in the Southwest following exposure to deer mice.

Back 75

Hantavirus pulmonary syndrome

Front 76

Begins with a prodromal illness of cough, fever, and myalgias that is difficult to distinguish from other viral illnesses such as influenza. However, the illness progresses to increased dyspnea, hypoxia, and hypotension.

Back 76

Hantavirus pulmonary syndrome

Front 77

infection should be suspected when a previously healthy adult develops unexplained pulmonary edema or ARDS without known causes

Back 77

Hantavirus pulmonary syndrome

Front 78

Transmission of the virus usually occurs through aerosolization of urine from infected rodents or through the bite of an infected rodent.

Back 78

Hantavirus

Front 79

A child develops an erythematous rash appearing as a slapped cheek.

Back 79

Human parvovirus

The slapped-cheek appearance in the child, previously called fifth dis-ease, is now known to be the result of a parvovirus B19. Its occurrence may be epidemic in nature. Children are usually not very ill, but adults can develop a polyarthralgia or true arthritis.

Front 80

symmetrical swelling and tenderness of the metacarpophalangeal (MCP) and wrist joints

Back 80

rheumatoid arthritis

Front 81

immunoglobulin directed against the Fc portion of IgG, is positive in about two-thirds of cases and is present early in the disease

Back 81

Rheumatoid factor

Front 82

A 40-year-old female complains of 7 weeks of pain and swelling in both wrists and knees. The patient notes that after a period of rest, resistance to movement is more striking.

Back 82

rheumatoid arthritis

Front 83

morning stiffness, swelling of the wrist or MCP, simultaneous swelling of joints on both sides of body, subcutaneous nodules

Back 83

rheumatoid arthritis

Front 84

gold, penicillamine, antimalarials, or methotrexate

Back 84

disease-modifying drugs for rheumatoid arthritis

Front 85

A 60-year-old female complains of dry mouth and a gritty sensation in her eyes. She states it is sometimes difficult to speak for more than a few minutes.

Back 85

Sjögren syndrome, an autoimmune disease with presenting symptoms of dry eyes and dry mouth. The disease is caused by lymphocytic infiltration and destruction of lacrimal and salivary glands.

Front 86

test used to measure dry eyes objectively in Sjögren syndrome

Back 86

Schirmer test, which measures the amount of wetness of a piece of filter paper when exposed to the lower eyelid for 5 minutes.

Front 87

auto-antibodies in Sjögren syndrome

Back 87

anti-Ro (SSA)

anti-La (SSB)

Front 88

sudden onset and severity of this monoarticular arthritis

Back 88

acute gouty arthritis, especially in a patient on diuretic therapy

Front 89

negatively birefringent crystals

Back 89

gout

Front 90

gout medication that causes nausea and diarrhea

Back 90

Colchicine

Front 91

monoarticular arthritis in a patient on diuretic therapy

Back 91

acute gouty arthritis

Front 92

A 70-year-old, non–sexually active male complains of fever and pain in his left knee. Several days previously, the patient skinned his knee while working in his garage. The knee is red, warm, and swollen. An arthocente-sis is performed, which shows 200,000 leukocytes/µL and a glucose of 20 mg/dL. No crystals are noted.

Back 92

acute septic arthritis

Front 93

most common organism to cause septic arthritis in adults

Back 93

S. aureus

Front 94

second most common organism to cause septic arthritis in adults

Back 94

β-hemolytic streptococci

Front 95

Treatment:

Acute mechanical low back pain

Back 95

Activity as tolerated with optional 2 days of bed rest is recommended along with adequate pain control and reassurance.

Front 96

Noninflammatory arthritis of weight-bearing joints

Back 96

Degenerative Joint Disease (Osteoarthritis)

Front 97

Crepitation over the involved joints and bony enlargements of the DIP joints

Back 97

Degenerative Joint Disease (Osteoarthritis)

Front 98

Pharmacologic Treatment:

Degenerative Joint Disease (Osteoarthritis)

Back 98

Intraarticular corticosteroid injections may be given two to three times per year for symptom reduction
Oral prednisone would be contraindicated

Front 99

Knee pain is relieved by rest and worsened by the movement. There is bony enlargement of the knees with mild inflammation.

Back 99

Degenerative Joint Disease (Osteoarthritis)

Front 100

Insidious onset of low back pain improved with exercise and worsened by rest. On exam the patient has loss of mobility with respect to lumbar flexion and extension.

Back 100

Ankylosing Spondylitis

Rheumatoid factor is negative in all the spondyloarthropathies.

Front 101

Ankylosing Spondylitis
Reiter Syndrome
Psoriatic Arthritis
Enteropathic Arthritis

Back 101

Spondyloarthropathies

Rheumatoid factor is negative in all the spondyloarthropathies.

Front 102

Insidious back pain occurring in a young male that improves with exercise.

Back 102

Spondyloarthropathies

Ankylosing Spondylitis
Reiter Syndrome
Psoriatic Arthritis
Enteropathic Arthritis

Front 103

leading causes of death due to ankylosing spondylitis

Back 103

Cervical fracture
Heart block
Amyloidosis

Front 104

fever, malar rash, and arthritis

Back 104

systemic lupus erythematosus

Front 105

thrombocytopenia, leukopenia, and positive antibody to native DNA

Back 105

Systemic Lupus Erythematosus (SLE)

Front 106

discoid rash, photosensitivity, oral ulcers, serositis, renal disorders (proteinuria or cellular casts), and neurologic disorder (seizures)

Back 106

Systemic Lupus Erythematosus (SLE)

Front 107

Raynaud’s phenomenon, arthralgia, and dysphagia

Back 107

Scleroderma (Systemic Sclerosis)

Rheumatoid factor is nonspecific and present in 20% of patients with scleroderma.

Front 108

Systemic vasculopathy of small and medium-sized vessels, excessive collagen deposition in tissues, and an abnormal immune system

Back 108

Scleroderma (Systemic Sclerosis)

Rheumatoid factor is nonspecific and present in 20% of patients with scleroderma.

Front 109

Highly specific serologic test for scleroderma

Back 109

Antinucleolar antibody (ANA) occurs in only 20 to 30% of patients with the disease, but a positive test is highly specific.

Front 110

Benign type of Scleroderma

Back 110

CREST Syndrome

Front 111

Polyarthritis that develops several weeks after an infection such as nongonococcal urethritis or gastrointestinal infection caused by Yersinia enterocolitica, Campylobacter jejuni, or Salmonella or Shigella species

Back 111

Reiter Syndrome
(Reactive Polyarthritis)

ANA and rheumatoid factor are usually negative.

Front 112

Oligoarticular arthritis, conjunctivitis, and urethritis

Back 112

Reiter Syndrome
(Reactive Arthritis)

ANA and rheumatoid factor are usually negative.

Front 113

A circinate balanitis is painless and occurs in 25 to 40% of patients. Other clinical features may include waxy papules on the palms and soles called keratoderma blenorrhagicum, spondylitis, myocarditis, and thrombophlebitis.

Back 113

Reiter Syndrome
(Reactive Arthritis)

ANA and rheumatoid factor are usually negative.

Front 114

Gene locus a/w Reiter Syndrome (Reactive Arthritis)

Back 114

HLA-B27 locus

Class I surface antigen encoded by the B locus in the major histocompatibility complex (MHC) on chromosome 6

Front 115

Unilateral headache and visual loss in this elderly patient with polymyalgia rheumatica (PMR)

Back 115

Temporal Arteritis

Evaluated by elevated ESR

Front 116

Temporal arteritis is highly a/w

Back 116

Polymyalgia Rheumatica (PMR)

should be evaluated for PMR with ESR

Front 117

Older patients who complain of diffuse myalgias and joint stiffness, particularly of the shoulders and hips

Back 117

Polymyalgia Rheumatica (PMR)

should be evaluated for PMR with ESR

Front 118

Acute mono-articular arthritis in association with linear calcification of the cartilage of the knee

Back 118

Pseudogout

Front 119

Most common presentation is hepatic cirrhosis in combination with hypopituitarism, cardiomyopathy, diabetes, arthritis, or hyperpigmentation

Back 119

Hemochromatosis

Front 120

Pseudogout may be a/w

Back 120

Hemochromatosis

Pseudogout has also been associated with hyperparathyroidism. A familial form of the disease has been localized to chromosomes 8q and 5p.

Front 121

Multiple tender points, associated sleep disturbance, and lack of joint or muscle findings

Back 121

Fibromyalgia

Front 122

Drug:

Fibromyalgia

Back 122

Tricyclic Antidepressants (Amitriptyline qHS) restore sleep

Biofeedback and exercise programs have been partially successful.

Front 123

A 70-year-old female with mild dementia complains of hip pain with some limitation of motion in the right hip.

The first step in evaluation?

Back 123

X-ray of right hip

Hip pain may result from fracture, bursitis, enthesitis, sacroiliac pain, sciatica, or pain referred from the lumbosacral spine.

Front 124

A 50-year-old drug abuser presents with fever and weight loss. Exam shows hypertension, nodular skin rash, and peripheral neuropathy. ESR is 100 mm/L, and RBC casts are seen on urinalysis.

Back 124

Polyarteritis nodosa

20-30% of patients have hepatitis B antigenemia. The disease is a necrotizing vasculitis of small and medium muscular arteries.

Front 125

An elderly male presents with pain in his shoulders and hands. ESR is 105 mm/L. History includes transient blindness and unilateral headache.

Back 125

Polymyalgia rheumatica

Front 126

A young male presents with leg swelling and recurrent aphthous ulcers of his lips and tongue. He has also recently noted painful genital ulcers. There is no urethritis or conjunctivitis. On exam, he has evidence of deep vein thrombophlebitis.

Back 126

Behçet Syndrome

Iritis, uveitis, and nondeforming arthritis may also occur.

Front 127

A 19-year-old male complains of low back morning stiffness, pain, and limitation of motion of shoulders. He has eye pain and photophobia. Diastolic murmur is present on physical exam.

Back 127

Ankylosing spondylitis

-inflammatory disorder that affects the axial skeleton
-autoimmune disorder that has a close association with HLA-B27 histocompatibility antigen.

Front 128

Most common extraarticular complaint of ankylosing spondylitis

Back 128

Anterior uveitis

Front 129

Rheumatoid arthritis, splenomegaly, and leukopenia

Back 129

Felty Syndrome

- granulocytopenia

Front 130

Systemic features of rheumatoid disease such as nodules, skin ulcerations, the sicca complex, peripheral sensory and motor neuropathy, and arteritic lesions

Back 130

Felty Syndrome

- granulocytopenia

Front 131

Laboratory values demonstrate a white blood cell count of 2500/µL and a rheumatoid factor titer of
1:4096.

WBC differential in pt with Felty Syndrome is likely to reveal?

Back 131

Granulocytopenia

The leukopenia of Felty syndrome is related to a reduction in the number of circulating polymorphonuclear leukocytes.

Front 132

Drugs used in the treatment of rheumatoid arthritis are broadly classified as?

Back 132

anti-inflammatory
-or-
disease-modifying agents

Front 133

Rheumatoid Arthritis:

Most frequent side effect of Aspirin

Back 133

gastrointestinal distress

Front 134

Rheumatoid Arthritis:

Most frequent side effect of Gold therapy

Back 134

Dermatitis that may lead to exfoliative dermatitis if treatment is not discontinued, stomatitis, nephrotic syndrome, and bone marrow suppression.

Front 135

Rheumatoid Arthritis:

Most frequent side effect of Prednisone

Back 135

Prednisone has significant toxicity, including causing Osteoporosis

Front 136

Rheumatoid Arthritis:

Most frequent side effect of Chloroquine

Back 136

Retinopathy

Deposition of the drug in the pigmented layer of the retina.
Irreversible retinal degeneration may develop.

Front 137

Rheumatoid Arthritis:

Most frequent side effect of Hydroxychloroquine (Plaquenil)

Back 137

Less frequently associated with retinopathy than Chloroquine.

Ophthalmic examinations are required every 6 months during therapy.

Front 138

Involvement of the upper and lower respiratory tracts; a cause of glomerulonephritis

Back 138

Wegener’s granulomatosis

A granulomatous vasculitis of small arteries and veins that affects the lungs, sinuses, nasopharynx, and kidneys, where it causes a focal and segmental glomerulonephritis.

Front 139

Ecchymoses and necrosis in extremities in elderly patients

Back 139

Multiple Cholesterol Embolization Syndrome

After an endovascular procedure (such as vascular catheterization, grafting, or repair), some of the atheromatous material may embolize, usually to the skin, kidneys, or brain. This material is capable of fixing complement and thus causing vascular damage.

Front 140

Inflammation of small- to medium-sized muscular arteries, which may cause kidney, heart, liver, gastrointestinal, and muscular damage

Back 140

Polyarteritis nodosa

a multisystem necrotizing vasculitis that, prior to the use of steroids and cyclophosphamide, was uniformly fatal. In 30% of patients, antecedent hepatitis B virus infection can be demonstrated; immune complexes containing the virus have been found in such patients and are likely pathogenetic.

Front 141

Occurs in patients above the age of 55, who may experience fever, weight loss, scalp pain, headache, and visual changes

Back 141

Giant cell arteritis

Also referred to as temporal arteritis or cranial arteritis, is a disease of elderly patients that classically affects the temporal arteries.

Front 142

Inflammation of the aorta and its branches in young women; also known as pulseless disease

Back 142

Takayasu’s arteritis

A granulomatous inflammation of the aorta and its main branches. Symptoms are due to local vascular occlusion.

Front 143

Why is differentiation between cholesterol embolization and idiopathic vasculitis is important?

Back 143

Since not only is the former NOT steroid-sensitive, but there have been reports of increasing damage after the institution of steroid therapy.

Front 144

Antibodies found in most patients with Wegener's granulomatosis.

Back 144

Most patients with the disease develop antibodies to certain proteins in the cytoplasm of neutrophils called antineutrophil cytoplasmic antibodies (ANCA).

Front 145

Skin lesions (ecchymoses and necrosis) that look much like vasculitis

Back 145

Multiple Cholesterol Embolization Syndrome

Front 146

A multisystem necrotizing vasculitis that, prior to the use of steroids and cyclophosphamide, was uniformly fatal. In 30% of patients, antecedent hepatitis B virus infection can be demonstrated.

Back 146

Polyarteritis nodosa

Front 147

Granulomata that disrupt the internal elastica of the vessel, may present with headache, anemia, a high ESR, and occasionally polymyalgia rheumatica

Back 147

Giant Cell Arteritis

Also referred to as temporal arteritis or cranial arteritis.

Front 148

Stiffness, aching, and tenderness of the proximal
muscles. These patients describe weakness of the hip and shoulder girdles, but there is no objective weakness of the muscles, and the muscle enzymes are normal.

Back 148

Polymyalgia rheumatica

Front 149

Aortic regurgitation; systemic and pulmonary hypertension; and general symptoms of arthralgia, fatigue, malaise, anorexia, and weight loss may occur.

Back 149

Takayasu’s arteritis

A granulomatous inflammation of the aorta and its main branches.
Symptoms are due to local vascular occlusion.

Front 150

A very common disorder, particularly in middle-aged women, characterized by diffuse musculoskeletal pain, fatigability, and nonrestorative sleep.

Back 150

Fibromyalgia

Front 151

Diagnostic criteria for Fibromyalgia

Back 151

Identification of 11 specific trigger points (tender point sites)

Front 152

Associated with symptoms of irritable bladder, head-aches, and temporomandibular joint pain but not with classic symptoms of vasculitis. Patients may experience depression, anxiety, or hypochondriasis.

Back 152

Fibromyalgia

Front 153

A 35-year-old construction worker presents with complaints of nocturnal parasthesias of the thumb and the index and middle fingers. There is some atrophy of the thenar eminence. Tinel sign is positive.

Back 153

Carpal Tunnel Syndrome

Results from median nerve entrapment and is usually due to excessive use of the wrist.

Front 154

The process has been associated with thickening of connective tissue as in acromegaly, or with deposition of amyloid. It also occurs in hypothyroidism, rheumatoid arthritis, and diabetes mellitus.

Back 154

Carpal Tunnel Syndrome

Results from median nerve entrapment and is usually due to excessive use of the wrist.
Later in the process, atrophy of the abductor pollicis brevis becomes apparent.

Front 155

Parasthesia induced in the median nerve distribution by a reflex hammer hitting on the volar aspect of the wrist

Back 155

Positive Tinel Sign

-Carpal Tunnel Syndrome

Front 156

Focal wrist pain on the radial aspect of the hand and is due to inflammation of the tendon sheath of the abductor pollicis longus.

Back 156

De Quervain’s Tenosynovitis

-Negative Tinel Sign

Front 157

Distal muscle weakness that is diffuse and not focal, with diffuse atrophy and prominent muscle fasiculations.

Back 157

Amyotrophic Lateral Sclerosis

Front 158

clubbing of digits, periosteal new bone formation, and arthritis

Back 158

Hypertrophic Osteoarthropathy

A/w intrathoracic malignancy, suppurative lung disease, and congenital heart problems

Front 159

A 50-year-old patient with long-standing chronic obstructive lung disease develops the insidious onset of aching in the distal extremities, particularly the wrists bilaterally. There is a 10-lb weight loss. The skin over the wrists is warm and erythematous. There is bilateral clubbing. Plain film is read as periosteal thickening, possible osteomyelitis.

Back 159

Hypertrophic Osteoarthropathy

The first step in evaluation of this patient is to obtain a chest x-ray looking for lung infection and carcinoma.

Front 160

A patient with low-grade fever and weight loss has poor excursion on the right side of the chest with decreased fremitus, flatness to percussion, and decreased breath sounds all on the right. The trachea is deviated to the left.

Back 160

Pleural Effusion

A pneumothorax should result in hyperresonance of the affected side.

Front 161

Increased fremitus, flatness to percussion, bronchial breath sounds, and no tracheal deviation

Back 161

Consolidated Pneumonia

Atelectasis on the right side would shift the trachea to the right.

Front 162

A 60-year-old female with a history of urinary tract infection, steroid-dependent chronic obstructive lung disease, and asthma presents with bilateral infiltrates and an eosinophil count of 15%.

Back 162

Eosinophilic Pneumonia

Ddx: allergic bronchopulmonary aspergillosis, parasitic infections, drug reactions, and a category of idiopathic disease

Front 163

Which is not a cause of eosinophilic pneumonia?

-Bronchopulmonary aspergillosis
-Hypersensitivity pneumonitis
-Strongyloides hyperinfection syndrome
-Drug effect of nitrofurantoin

Back 163

Hypersensitivity pneumonitis may cause bilateral infiltrates, but does not of itself cause eosinophilia.

Front 164

Most likely location of an aspiration pneumonia

Back 164

The superior segment of the right lower
lobe is the one most likely to develop an aspiration pneumonia.

Front 165

A 40-year-old alcoholic develops cough and fever. Chest x-ray shows an air-fluid level in the superior segment of the right lower lobe. The most likely etiologic agent?

Back 165

The location of the infiltrate suggests aspiration, also making anaerobic infection most likely.

Front 166

Type of Pleural Effusion:

Congestive Heart Failure

Back 166

Right-sided effusion, protein 2.5 g/dL

Usually results in a transudative effusion

Front 167

Type of Pleural Effusion:

Tuberculosis

Back 167

Exudate, 100% lymphocytes

-Tuberculosis causes a hypersensitivity reaction to tuberculous protein
in the pleural fluid. It produces an exudative effusion with small lymphocytes.
-The diagnosis is now established by demonstrating high levels of TB markers such as adenosine deaminase or positive PCR for tuberculous DNA.

Front 168

This type of pleural effusion occurs when factors alter the formation or absorption of pleural fluid.

Back 168

Transudative Effusions

Front 169

This type of pleural effusion occurs when local factors produce an inflammatory process.

Back 169

Exudative Effusions

Front 170

-pleural fluid protein–to–serum protein ratio greater than 0.5
-pleural fluid LDH–to–serum LDH ratio greater than 0.6
-pleural fluid LDH more than two-thirds the normal upper limit for serum

Back 170

Exudative Effusions

Front 171

Type of Pleural Effusion:

Empyema

Back 171

Exudative effusion with pH less than 7.0 with a polymorphonuclear leukocyte predominance

Front 172

Type of Pleural Effusion:

Rheumatoid Arthritis

Back 172

Rheumatoid effusions are often exudative and may be lymphocytic, but they are best characterized by their very low glucose levels.

Pleural fluid glucose levels below 60 mg/dL also occur in malignancy and bacterial infections.

Front 173

Type of Pleural Effusion:

Mesothelioma

Back 173

Bloody Effusion

Mesotheliomas are primary tumors that arise from mesothelial cells that line the pleural cavity. They produce a very bloody effusion.

Front 174

Fever, shaking chills; sputum Gram stain showing gram-positive cocci in clusters

Back 174

Staphylococcus aureus Pneumonia

Cavities develop in association with lung infection when necrotic lung tissue is discharged into airways. Cavities greater than 2 cm are described as lung abscesses.

Front 175

Patient with shortness of breath and paroxysmal nocturnal dyspnea

Back 175

Congestive Heart Failure (CHF)

Signs of CHF on CXR include: cardiomegaly, bilateral infiltrates, and cephalization

Front 176

CXR showing cardiomegaly, bilateral infiltrates, and cephalization

Back 176

Congestive Heart Failure (CHF)

Front 177

Fever, night sweats for 1 year. CXR shows extensive apical and upper lobe scarring.

Back 177

Tuberculosis

Cavitary infiltrates in the posterior apical segments are very common. Mass lesions, interstitial infil-trates, and noncavitary infiltrates also occur.

Front 178

Patient with long-standing hypertension. CXR shows enlarged cardiac silhouette with a boot-shaped configuration.

Back 178

Left Ventricular Hypertrophy

Front 179

Neurologic deterioration and a petechial rash in the setting of fracture and hypoxia

Back 179

Fat Embolism

Occurs when neutral fat is introduced into the venous circulation after bone trauma or fracture. The latent period is 12 to 36 hours, usually earlier than a pulmonary embolus would occur after trauma.

Front 180

A 34-year-old black female presents to your office with symptoms of cough, dyspnea, and lymphadenopathy. Physical exam shows cervical adenopathy and hepatomegaly.

Back 180

Sarcoidosis

-CXR often shows symmetrical hilar lymphadenopathy
-20 to 30% of patients have hepatomegaly

Front 181

Diagnostic method of choice for Sarcoidosis

Back 181

Transbronchial biopsy, which will show a mononuclear cell granulomatous
inflammatory process.

ACE levels are elevated in two-thirds of patients, but false-positive values are common in other granuloma-tous disease processes.

Front 182

Pleural fluid is exudative if it has any one of the following 3 properties:

Back 182

1) ratio of concentration of total protein in pleural fluid to
serum greater than 0.5
2) an absolute value of LDH greater than 200 IU
3) a ratio of LDH concentration in pleural fluid to serum greater than 0.6

Front 183

Type of Effusion:

malignancy, pulmonary embolism, pneumonia, tuberculosis, abdominal disease, collagen vascular diseases, uremia, Dressler syndrome, and chylothorax

Back 183

Exudative Effusions

Front 184

Benign ovarian neoplasm with effusion

Back 184

Meigs Syndrome

Front 185

Provides an estimate of the rate at which oxygen moves by diffusion from alveolar gas to combine with hemoglobin in the red blood cells.

Back 185

Carbon Monoxide (CO) Diffusing Capacity

It is interpreted as an index of the surface area engaged in alveolar-capillary diffusion.

Front 186

Primary parenchymal disorders, anemia, and removal of lung tissue _____ the diffusing capacity.

Back 186

Primary parenchymal disorders, anemia, and removal of lung tissue DECREASE the diffusing capacity

Front 187

Polycythemia, congestive heart failure, and intrapulmonary hemorrhage tend to _____ the diffusing capacity.

Back 187

Polycythemia, congestive heart failure, and intrapulmonary hemorrhage tend to INCREASE the diffusing capacity.

Front 188

A 25-year-old male cigarette smoker has a history of respiratory infections and has also been found to have hematuria. A high value for diffusing capacity is noted during pulmonary function testing.

Back 188

Intrapulmonary Hemorrhage

In this patient, the possibility of Goodpasture syndrome would be considered.

Front 189

Asthma:

Indicative of exhaustion and respiratory muscle failure or fatigue and generally need to be aggressively treated with mechanical ventilation.

Back 189

Hypercapnia

Thoracoabdominal paradox (paradoxical respiration)

Front 190

Asthma:

Ominous finding on exam

Back 190

Silent chest is a particularly ominous finding, because the airway constriction is so great that airflow is insufficient to generate wheezing.

Front 191

Asthma:

Frequently seen with severe hypoxia or hypercapnia

Back 191

Altered mental status is frequently seen with severe hypoxia or hypercapnia, and ventilatory support is usually required.

Front 192

Normal range of pulsus paradoxus

Back 192

Pulsus paradoxus of up to 8 to 10 mmHg is considered normal.

Front 193

Asthma:

Abnormal pulsus paradoxus

Back 193

An increased pulsus paradoxus may also be a sign of severe asthma, as it increases with greater respiratory effort and generation of more negative intrathoracic pressures during inspiration. However, a pulsus paradoxus of up to 8 to 10 mmHg is considered normal.

Front 194

Community-acquired pneumonias in patients over the age of 35 are most likely due to?

Back 194

S. pneumoniae
Legionella species (e.g., pneumophila)
Haemophilus influenzae

Front 195

Pneumonia with short prodrome, shaking chills with rigor, fever, chest pain, sparse sputum production associated with cough, and a consolidated lobar infiltrate on chest x-ray.

Back 195

Pneumococcal Pneumonia

Front 196

Pneumonia with gram-positive diplococci on an adequate sputum (many white cells, few epithelial cells).

Back 196

Pneumococcal Pneumonia

Blood cultures are positive in only about 20% of patients, and, when positive, are indicative of a more severe case.

Front 197

Drugs:

Pneumococcal Pneumonia

Back 197

The fluoroquinolones or ceftriaxone are widely used as initial therapy for pneumococcal pneumonia.

Front 198

A 57-year-old man develops acute shortness of breath shortly after a 12-hour automobile ride. The patient consults his internist, and findings on physical examination are normal except for tachypnea and tachycardia. An electrocardiogram reveals sinus tachycardia but is otherwise normal.

Back 198

Pulmonary Embolic Disease

In greater than 80% of cases, pulmonary emboli arise from thromboses in the deep venous circulation (DVTs) of the lower extremities.

Front 199

ABG is usually abnormal, and a high percentage of patients exhibit hypoxia, hypocapnia, alkalosis, and a widening of the alveolar-arterial gradient.

Back 199

Pulmonary Embolism

Front 200

Most common ECG finding in pulmonary embolic disease

Back 200

The most common finding is sinus tachycardia, but atrial fibrillation, pseudoinfarction in the inferior leads, and right and left axis deviation are also occasionally seen.

Front 201

Initial treatment for suspected pulmonary embolic disease

Back 201

Prompt hospitalization and institution of intravenous heparin, provided there are no contraindications to anticoagulation.

Front 202

Used to rule out pulmonary embolus in patients with a low- or intermediate-probability scan

Back 202

Quantitative D-dimer enzyme-linked immunoabsorbent assay

--positive in 90% of patients with pulmonary embolus

Front 203

Most common symptom of an acute pulmonary embolus

Back 203

Tachypnea occurs in more than 90% of patients with pulmonary embolus.
Pleuritic chest pain occurs in about half of patients and is
less common in the elderly and those with underlying heart disease.
Hemoptysis and wheezing occur in less than half of patients.

Front 204

right-sided S3 with an acute pulmonary embolus

Back 204

A right-sided S3 is associated with large emboli that result in acute pulmonary hypertension.

Front 205

Prophylaxis of acute pulmonary embolus in patients who receive total hip replacement

Back 205

Warfarin is started preoperatively, and the daily dose is adjusted to maintain an international normalized ratio (INR) of 2 to 2.5.

--Low-molecular-weight heparin given twice daily subcutaneously is also a recommended regimen.

--Early ambulation and elastic stockings are also important in preventing thromboembolism, but are not adequate in themselves in this high-risk situation.

Front 206

How is asthma different from other obstructive lung diseases?

Back 206

Only in asthma is the airway obstruction reversible.

Front 207

Blood gas changes a/w:

Pulmonary Embolism

Back 207

The most consistent finding is acute respiratory alkalosis.

--Hypoxemia, although frequently found, need not be present

Front 208

Hypoxia; hypercapnia; and severe, uncompensated acidosis

Back 208

Hypoventilation

Front 209

What regulates respiration in the presence of long-standing lung disease?

Back 209

In the presence of long-standing lung disease, respiration may become regulated by hypoxia rather than by altered carbon dioxide tension and arterial pH, as in normal people.

--Unmonitored administration of oxygen may lead to respiratory suppression, that results in acute and chronic respiratory acidosis.

Front 210

What may administration of oxygen lead to in a patient with long-standing lung disease?

Back 210

In the presence of long-standing lung disease, respiration may become regulated by hypoxia rather than by altered carbon dioxide tension and arterial pH, as in normal people.

--Unmonitored administration of oxygen may lead to respiratory suppression, that results in acute and chronic respiratory acidosis.

Front 211

May occur secondary to respiratory depression after drug overdose

Back 211

Acute respiratory acidosis may occur secondary to respiratory depression after drug overdose.

Front 212

A 20-year-old man with diabetes mellitus comes to the emergency room with diffuse abdominal pain, tachypnea, and fever.

Back 212

Diabetic ketoacidosis (DKA)

--usually are maximally ventilating, as indicated by a very low arterial PCO2, however, they remain acidotic
--not hypoxic unless the underlying infection is pneumonia

Front 213

Pleural fluid, which is sterile, will contain a high level of lactic dehydrogenase and a low glucose concentration

Back 213

Rheumatoid Arthritis

--diffuse interstitial fibrosis and the occurrence of individual or clustered nodules in the lung parenchyma

Front 214

Most common lung infection in cystic fibrosis patient

Back 214

Mucoid strain of Pseudomonas aeruginosa

--Common pulmonary complications include bronchiectasis, severe hemoptysis, and allergic bronchopulmonary aspergillosis.

Front 215

Bronchiectasis and severe hemoptysis as frequent complications of clinical course

Back 215

Cystic fibrosis

Front 216

Presence of the mucoid strain of Pseudomonas aeruginosa

Back 216

Cystic fibrosis

Front 217

Development of severe liver disease that is usually associated with, but may be independent of, lung disease

Back 217

α1 Antitrypsin Deficiency

--Patients with liver disease secondary to α1 antitrypsin deficiency usually, but not always, have accompanying panacinar emphysema.

Front 218

Development of symptoms after ingestion of tartrazine yellow or aspirin

Back 218

Asthma

Certain chemicals, such as aspirin (but not sodium or magnesium salicylate) and tartrazine yellow, have been impli-cated in the development of bronchospasm in certain patients.

Front 219

Population groups predisposed to Sarcoidosis

Back 219

Blacks and Mediterranean peoples

Front 220

Most characteristic presentation of sarcoidosis

Back 220

Nonproductive cough with bilateral hilar adenopathy on chest x-ray

Front 221

chronic cough, hyperinflated lung fields, abnormal pulmonary function tests, and smoking history

Back 221

Chronic Bronchitis

Front 222

When is continuous low-flow oxygen indicated in chronic bronchitis

Back 222

Continuous low-flow oxygen becomes beneficial when arterial oxygen concentration falls below 55 mmHg.

Front 223

Fever, change in color of sputum, and increasing shortness of breath

Back 223

Acute exacerbations of chronic lung disease

Front 224

When are oral corticosteroids indicated in chronic lung disease?

Back 224

Oral corticosteroids are helpful in some patients, but are reserved for those who have failed inhaled bronchodilator treatments.

Front 225

Most characteristic exam findings of pneumothorax

Back 225

Hyperresonance and decreased breath sounds

--A tension pneumothorax may displace the mediastinum to the
unaffected side.
--Tactile fremitus would be decreased

Front 226

Tactile fremitus would be ____ in lung consolidation.

Back 226

Tactile fremitus would be INCREASED in lung consolidation.

Front 227

Most important single cause of adult respiratory distress syndrome

Back 227

Sepsis

Front 228

Pulmonary capillary wedge pressure in ARDS

Back 228

The pulmonary capillary wedge pressure would be normal or low in ARDS, but elevated in left ventricular failure.

Front 229

Pulmonary capillary wedge pressure in ventricular failure

Back 229

The pulmonary capillary wedge pressure would be normal or low in ARDS, but elevated in left ventricular failure.

Front 230

How can ARDS be distinguished from cardiogenic pulmonary edema?

Back 230

The pulmonary capillary wedge pressure would be normal or low in ARDS, but elevated in left ventricular failure.

Front 231

Most likely diagnosis in this young woman with dyspnea who has used appetite suppressants

Back 231

Primary pulmonary hypertension

--associated with fenfluramines

Front 232

A 35-year-old female complains of slowly progressive dyspnea. Her history is otherwise unremarkable, and there is no cough, sputum production, pleuritic chest pain, or thrombophlebitis. She has taken appetite suppressants at different times. On physical exam, there is jugular venous distention, a palpable right ventricular lift, and a loud P2 heart sound. Chest x-ray shows clear lung fields. ECG shows right axis deviation. A perfusion lung scan is normal with no segmental deficits.

Back 232

Primary Pulmonary Hypertension a/w appetite suppressants (eg, fenfluramines)

Front 233

What assessment is necessary in all patients with primary pulmonary hypertension?

Back 233

In all patients in whom primary pulmonary hypertension is confirmed, acute drug testing with a pulmonary vasodilator is necessary to assess the extent of pulmonary vascular reactivity.

--Inhaled nitric oxide, intravenous adenosine, or intravenous prostacyclin

Front 234

Patients with primary pulmonary hypertension who have a good response to the short-acting vasodilator are tried on _____.

Back 234

Long-acting calcium channel antagonist

Front 235

Daytime sleepiness and snoring at night

Back 235

Obstructive Sleep Apnea Syndrome

Front 236

Daytime sleepiness and frequent awakenings at night

Back 236

Frequent awakenings are more suggestive of central sleep apnea.

Front 237

Required to assess which type of sleep apnea syndrome is present.

Back 237

Polysomnography is required to assess which type of sleep apnea syndrome is present.

--The respiratory pattern is monitored to detect apnea and whether it is central or obstructive.

Front 238

Treatment:

Obstructive Sleep Apnea

Back 238

Nasal continuous positive airway pressure

--Weight loss is often helpful and should be recommended as well, but would probably not be sufficient.
--Uvulopalatopharyngoplasty has also been used in obstructive sleep apnea, but when applied to unselected patients is effective in less than 50%.

Front 239

Treatment:

Patient presents with unstable angina, a change from the previous chronic stable state in that chest pain has become more frequent and more severe.

Back 239

IV Heparin

--Subcutaneous administration of low-molecular-weight heparin (such as enoxaparin) is an alternative.

Front 240

Aggressive Treatment:

Unstable Angina

Back 240

Early interventional cardiac catheterization with angioplasty and/or stent placement, possibly in conjunction with glycoprotein IIb/IIIa inhibitors.

Front 241

Supplies most of the inferior myocardium and supplies the AV node in over 70% of patients.

Back 241

Right Coronary Artery

Front 242

Occlusion of this artery can cause ischemia of the AV node with AV block or bradycardia, as well as symptoms of an inferior MI.

Back 242

Right Coronary Artery

Front 243

15 to 20% of infarctions may be painless, with the greatest incidence in?

Back 243

Diabetics and the Elderly

--Diabetics are likely to have abnormal or absent pain response to myocardial ischemia due to generalized autonomic nervous system dysfunction.

Front 244

Cardiovascular medication likely to cause confusion in the elderly patient, for whom a lower dose of the drug should generally be given.

Back 244

Lidocaine

--Other potential adverse effects include tremor, convulsions, respiratory depression, bradycardia, and hypotension.

Front 245

Autoimmune pleuritis, pneumonitis, or pericarditis characterized by fever and pleuritic chest pain, with onset days to 6 weeks post cardiac injury.

Back 245

Post–cardiac Injury Syndrome

(Dressler Syndrome or Postmyocardial Infarction Syndrome)

Front 246

Mechanism of Post–cardiac Injury Syndrome

Back 246

Blood in the pericardial cavity, as after a cardiac operation, cardiac trauma, or MI.

Front 247

Treatment:

Post-cardiac Injury Syndrome (Dressler Syndrome)

Back 247

Nonsteroidal anti-inflammatory drug

--or occasionally a glucocorticoid

Front 248

Dyspnea, cough with sputum production, and rales on lung auscultation.

Back 248

Bacterial Pneumonia

Front 249

Method by which to organize the signs and symptoms for the diagnosis of congestive heart failure (CHF).

Back 249

Framingham Criteria

--8 major and 7minor criteria

Front 250

Framingham Major Criteria

Back 250

1) Paroxysmal Nocturnal Dyspnea
2) Neck Vein Distension
3) Rales
4) Cardiomegaly
5) Acute Pulmonary Edema
6) S3 Gallop
7) Increased Venous Pressure
8) Hepatojugular Reflux

Front 251

Framingham Minor Criteria

Back 251

1) Extremity Edema
2) Night Cough
3) Dyspnea On Exertion
4) Hepatomegaly
5) Pleural Effusion
6) Vital Capacity reduced by 1/3 from normal
7) Tachycardia of 120 or more bpm
8) Weight loss of 4.5 kg or more over 5 days of treatment (can be major criteria)

Front 252

Has been shown to prevent or retard the development of heart failure in patients with left ventricular dysfunction and to reduce long-term mortality when begun shortly after an MI.

Back 252

Angiotensin Converting Enzyme Inhibitor (ACEI)

Front 253

MOA of ACEI used after MI

Back 253

Inhibition of the renin-angiotensin system and reduction of preload and afterload.

Front 254

Treatment option in ACE inhibitor–intolerant MI patients

Back 254

Nitrate-Hydralazine Combination

Front 255

How many patients will recover from postpartum cardiomyopathy?

Back 255

Postpartum (or Peripartum) Cardiomyopathy may occur during the last trimester of pregnancy or within 6 months of delivery.
--About half of patients will recover completely, with most of the rest improving.
--Avoid future pregnancies due to risk of recurrence
--Treatment is as for other dilated cardiomyopathies, except that ACE inhibitors are contraindicated in pregnancy.

Front 256

Most common stress test–induced manifestation of myocardial ischemia

Back 256

ST Segment Depression

Front 257

On admission, his lungs were clear, and his heart revealed a grade II/VI systolic crescendo-decrescendo murmur at the upper right sternal border; cardiac enzymes were normal, and resting ECG showed right bundle branch block with less than 1 mm ST segment depression.

Back 257

Aortic Stenosis

Front 258

Exertional dyspnea, angina pectoris, and syncope.

Back 258

Aortic Stenosis

Front 259

Narrow pulse pressure and a harsh systolic crescendo-decrescendo murmur heard best at the upper right sternal border.

Back 259

Aortic Stenosis

Front 260

A diastolic decrescendo murmur heard at the mid-left sternal border.

Back 260

Aortic Insufficiency

Front 261

A holosystolic murmur heard best at the apex.

Back 261

Mitral Regurgitation

Front 262

A midsystolic click.

Back 262

Mitral Valve Prolapse

Front 263

Diastolic rumbling apical murmur.

Back 263

Mitral Stenosis

Front 264

Accentuated first heart sound and opening snap.

Back 264

Mitral Stenosis

Front 265

A 72-year-old male comes to the office with intermittent symptoms of dyspnea on exertion, palpitations, and cough occasionally productive of blood. On cardiac auscultation, a low-pitched diastolic rumbling murmur is faintly heard toward the apex.

Back 265

Mitral Stenosis

Front 266

Cause of dyspnea in Mitral Stenosis

Back 266

Dyspnea may be present secondary to pulmonary edema.

Front 267

Cause of palpitations in Mitral Stenosis

Back 267

Palpitations are often related to atrial arrhythmias (PACs, PAT, atrial flutter or fibrillation).

Front 268

Cause of hemoptysis in Mitral Stenosis

Back 268

Hemoptysis may occur as a consequence of pulmonary hypertension with rupture of bronchial veins.

Front 269

Etiology of Mitral Stenosis

Back 269

The etiology of mitral stenosis is usually rheumatic fever, rarely congenital.

--2/3 of patients afflicted are women.

Front 270

Holosystolic murmur at the mid-left sternal border.

Back 270

Ventricular Septal Defect (VSD)

Front 271

Murmurs enhanced by exercise and diminished by amyl nitrite.

Back 271

Ventricular Septal Defect (VSD)
&
Mitral Regurgitation

Front 272

A systolic crescendo-decrescendo murmur heard best at the upper right sternal border with radiation to the carotids; the murmur is augmented with transient exercise.

Back 272

Aortic Stenosis

Front 273

A systolic murmur at the pulmonic area and a diastolic rumble along the left sternal border.

Back 273

Atrial Septal Defect (ASD)

Front 274

A continuous murmur through systole and diastole at the upper left sternal border.

Back 274

Patent Ductus Arteriosus (PDA)

Front 275

What do unifocal PVCs suggest?

Back 275

Occasional unifocal PVCs do not suggest any of the underlying diseases described.

PVCs are common in patients with and without heart disease, and are detected in 60% of adult males on Holter monitoring.

Front 276

Best management for premature atrial contractions (PACs)

Back 276

Minimally symptomatic PVCs do not require treatment (just observaton).

--Antiarrhythmic therapy in this setting has not been shown to reduce sudden cardiac death or overall mortality.
--A beta blocker would be the best choice if symptoms began to interfere with daily activities.

Front 277

Pharmacologic Treatment:

Stroke Patient (no A-fib)

Back 277

Aspirin alone

Front 278

Pharmacologic Treatment:

Stroke Patient with Atrial Fibrillation

Back 278

In patients with atrial fibrillation, in whom the risk of stroke approaches 30%, therapeutic anticoagulation with warfarin (Coumadin) reduces the incidence of future stroke to a greater extent than the use of aspirin.

Front 279

Performed to exclude the presence of left atrial thrombus.

Back 279

Transesophageal Echocardiogram (TEE)

Front 280

A medical procedure by which an abnormally fast heart rate or cardiac arrhythmia is converted to a normal rhythm, using electricity or drugs.

Back 280

Cardioversion

Front 281

Narrow QRS complex without clearly discernable P waves.

Back 281

Paroxysmal Supraventricular Tachycardia (SVT) due to AV Nodal Reentry

--rate in the 160 to 190 range

Front 282

Sawtooth pattern of P waves

Back 282

Atrial Flutter

AV conduction ratios most commonly 2:1 or 4:1, leading to ventricular rates of 150 or 75/min.

Front 283

Irregularly Irregular Rhythm

Back 283

Atrial Fibrillation

Front 284

Wide QRS complexes

Back 284

Ventricular Tachycardia

Front 285

Vagotonic Maneuvers for Supraventricular Tachycardia (SVT)

Back 285

Carotid Massage

Valsalva Maneuver

Front 286

Drug of Choice:

Supraventricular Tachycardia (SVT)

Back 286

ADENOSINE
--excellent safety profile and extremely short half-life
--initial dose of 6 mg. Dosage can be repeated if necessary a few minutes later at 12 mg

Verapamil is the next alternative.

Front 287

Medication useful in ventricular, not supraventricular, arrhythmias.

Back 287

Lidocaine

Front 288

Also known as Wenckebach Phenomenon

Back 288

Mobitz Type I Second-degree AV Block (Wenckebach)

Front 289

Progressive PR interval prolongation prior to block of an atrial impulse.

Back 289

Mobitz Type I Second-degree AV Block (Wenckebach)

Front 290

Therapy:

Mobitz Type I Second-degree AV Block (Wenckebach)

Back 290

This rhythm generally does not require therapy. It may be seen in normal individuals; other causes include inferior MI and drug intoxications such as from digoxin, beta blockers, or calcium channel blockers. Even in the post-MI setting, it is usually stable, although it has the potential to progress to higher-degree AV block with consequent need for pacemaker.

Front 291

First step in Adult Basic Life Support (CPR)

Back 291

First determine responsiveness by tapping or gently shaking the victim and shouting, “Are you OK?” Then proceed with the ACLS approach. Shout or phone for help, then position the victim and yourself.

Front 292

ABCDs of Adult Basic Life Support (CPR

Back 292

ABCDs
--establishing the Airway
--assessing Breathing
--assessing Circulation
--managing any need for Defibrillation

Front 293

The standard approach to ventricular fibrillation or pulseless ventricular tachycardia.

Back 293

Defibrillation with 200 joules, then 300, then 360, followed if needed by Epinephrine 1 mg IV push every 3 to 5 min.

Front 294

Persistent ventricular fibrillation or pulseless ventricular tachycardia leads to consideration of?

Back 294

Amiodarone 300 mg IV push
or
Lidocaine 1.0 to 1.5 mg/kg IV push

Front 295

May be given in torsade de pointes or when arrhythmia due to hypomagnesemia is suspected.

Back 295

Magnesium Sulfate 1 to 2 g IV

Front 296

Given to patients with intermittent return of a pulse or non-VF rhythm, but then recurrence of VF/VT.

Back 296

Procainamide
--up to 50 mg/min
--maximum total 17 mg/kg

Front 297

A 55-year-old African American female presents to the ER with lethargy and blood pressure of 250/150. Her family members indicate that she was complaining of severe headache and visual disturbance earlier in the day. They report a past history of asthma but no known kidney disease. On physical exam, papilledema and retinal hemorrhages are present.

Back 297

Malignant Hypertension with Hypertensive Encephalopathy

Front 298

Pharmacologic Treatment:

Malignant Hypertension

Back 298

Immediate therapy with nitroprusside is indicated in the ICU setting, although it would be avoided if renal insufficiency were present.

Other options include intravenous nitroglycerin or intravenous enalaprilat (active metabolite of enalapril).

Front 299

Contraindication:

Nitroprusside for Malignant Hypertension

Back 299

Renal Insufficiency

Front 300

Intravenous labetalol is often used in hypertensive urgencies, but, as a beta blocker, it is relatively contraindicated in?

Back 300

Asthma

Front 301

Arthritis, fever, murmur, subcutaneous nodules.

Back 301

Rheumatic Fever

Group A β-hemolytic Streptococci (Streptococcus pyogenes)

Front 302

An 18-year-old male complains of fever and transient pain in both knees and elbows. The right knee was red and swollen for 1 day the week prior to presentation. On physical exam, the patient has a low-grade fever but appears generally well. There is an aortic diastolic murmur heard at the base of the heart. A nodule is palpated over the extensor tendon of the hand. There are pink erythematous lesions over the abdomen, some with central clearing.

Back 302

Rheumatic Fever

Group A β-hemolytic Streptococci (Streptococcus pyogenes)

Front 303

The rash is usually pink with clear centers and serpiginous margins.

Back 303

Erythema Marginatum

Front 304

Elevated lab value that typically occurs in rheumatic fever?

Back 304

Elevated Erythrocyte Sedimentation Rate (ESR)

Front 305

ECG change with Rheumatic Fever

Back 305

First-degree AV Block

Front 306

Antibody present in Rheumatic Fever

Back 306

An antistreptolysin O (ASO) antibody is necessary to diagnose the disease by documenting prior streptococcal infection.

Front 307

Most experts recommend the use of _____ when carditis is part of the picture of rheumatic fever.

Back 307

Glucocorticoids + Penicillin

Therefore, in patients with first-degree AV block, corticosteroids would be indicated.

Front 308

Pharmacologic Treatment:

Group A β-hemolytic Streptococci

Back 308

Penicillin

Front 309

P waves and QRS complexes are completely independent of each other, i.e., dissociated.

Back 309

Complete Heart Block

Front 310

Treatment:

Complete heart block in the setting of acute myocardial infarction

Back 310

Requires at least temporary, and often permanent, transvenous pacemaker placement.

Atropine may be used as a temporary measure.

Front 311

Cardiac medications contraindicated in complete heart block in the setting of acute myocardial infarction.

Back 311

You would certainly want to avoid digoxin, beta blockers, or any other medication that promotes bradycardia.

Lidocaine would be relatively contraindicated in that it might suppress the ventricular pacemaker, leading to asystole.

Front 312

Reduce pain, limit infarct size, and decrease ventricular arrhythmias.

Back 312

Beta Blockers

Front 313

No role for _____ in this acute setting; in fact, it may increase myocardial oxygen consumption and increase infarct size.

Back 313

Digoxin

Front 314

Indicated for pain control for substernal chest pain.

Back 314

Nitroglycerin and Morphine

Front 315

ECG shows ST segment elevation in inferior leads II, III, and aVF with reciprocal ST depression in aVL.

Back 315

Acute Inferior MI

Front 316

_____ MI would produce ST segment elevation in the precordial leads.

Back 316

Anterior MI

Front 317

Pleuritic chest pain and diffuse ST segment elevation (except aVR) on ECG.

Back 317

Pericarditis

Costochondritis, esophageal reflux, cholecystitis, and duodenal ulcer disease can all cause the symptoms of substernal chest pain, but not these ECG findings.

Front 318

The most common cause of refractory hypertension.

Back 318

Nonadherence to the medication regimen

A history from the patient is useful, and pill count is the best compliance check.

Front 319

Cushing’s disease, coarctation of the aorta, renal artery stenosis, and primary aldosteronism are secondary causes of _____.

Back 319

Refractory Hyptertension

Front 320

Substernal chest pain aggravated by inspiration and relieved by sitting up.

Back 320

Pericarditis

A pericardial friction rub may initially be present, then disappear, with the heart sounds becoming fainter as an effusion develops.

Lung sounds are typically clear.

Front 321

An enlarged cardiac silhouette without other chest x-ray findings of heart failure.

Back 321

Pericardial Effusion

Front 322

Most sensitive, specific way of determining whether pericardial fluid is present.

Back 322

Echocardiography

The effusion appears as an echo-free space between the moving epicardium and stationary pericardium.

Front 323

Jugular venous distention, hypotension, electrical alternans on ECG.

Back 323

Cardiac Tamponade

Pericardial fluid under increased pressure impedes diastolic filling, resulting in reduced cardiac output and hypotension.

Front 324

Pulsus paradoxus, a greater than normal (10 mmHg) inspiratory decline in systolic arterial pressure, is indicative of?

Back 324

Cardiac Tamponade

In contrast to pulmonary edema, the lungs are usually clear.

Front 325

Pulmonary hypertension and consequent right ventricular dysfunction.

Back 325

Cor Pulmonale

Its causes include diseases leading to hypoxic vasoconstriction, as in cystic fibrosis; occlusion of the pulmonary vasculature, as in pulmonary thromboembolism; and parenchymal destruction, as in sarcoidosis.

Front 326

Tall, peaked P waves in leads II, III, and aVF

Back 326

Right Atrial Enlargement

Front 327

Tall R waves in leads V1 to V3 and a deep S wave in V6 with associated ST-T wave changes.

Back 327

Right Ventricular Hypertrophy (RVH)

Front 328

ECG Findings:

--Right atrial enlargement
--Right ventricular hypertrophy
--Right axis deviation
--RBBB (15%)

Back 328

Cor Pulmonale

In the presence of a chronic increase in afterload, the right ventricle becomes hypertrophic, dilates, and fails.

Front 329

Atrial rate of 250 to 350/min

Back 329

Atrial Flutter

Front 330

Every fourth atrial depolarization is conducted through the AV node, resulting in a ventricular rate of 75/min.

Back 330

4:1 Atrioventricular (AV) Block

Front 331

Abnormality of the valve’s connective tissue with secondary proliferation of myxomatous tissue.

Back 331

Mitral Valve Prolapse

The redundant leaflet(s) prolapses toward the left atrium in systole, which results in the auscultated click and murmur and characteristic echocardiographic findings.

Front 332

What maneuvers cause the click and murmur of mitral valve prolapse to occur earlier in systole?

Back 332

Any maneuver that reduces left ventricular size, such as standing or the Valsalva maneuver, allows the click and murmur to occur earlier in systole.

Front 333

What maneuvers cause the click and murmur of mitral valve prolapse to occur later in systole?

Back 333

Conditions that increase left ventricular size, such as squatting or propranolol administration, delay the onset of the click and murmur.

Front 334

Treatment of Mitral Valve Prolapse (MVP)

Back 334

Most patients with MVP have a benign prognosis, and, in the absence of mitral regurgitation or arrhythmias (beta blocker), reassurance is the key point in management.

Front 335

When is antibiotic prophylaxis indicated in mitral valve prolapse (MVP)?

Back 335

Antibiotic prophylaxis to prevent endocarditis is reserved for those with the systolic murmur of mitral regurgitation and/or thickening of mitral valve leaflets on echocardiography.

Front 336

When are beta blockers indicated in mitral valve prolapse (MVP)?

Back 336

Beta blocker therapy is reserved for symptoms, including those related to arrhythmias.

Front 337

Marfan syndrome, prosthetic heart valves, coarctation of the aorta, aortic valve disease, ventricular septal defect, mitral insufficiency, and patent ductus arteriosus.

High risk for development of what cardiac condition?

Back 337

Infective Endocarditis

Front 338

Conditions considered to entail very low risk of infective endocarditis.

Back 338

Atrial septal defect
Syphilitic aortitis
Cardiac pacemakers

Front 339

Inspiration increases blood return to the right side of the heart, pulmonic closure is delayed.

Back 339

Normal Splitting of S2

Front 340

Splitting of S2 that is narrowed with inspiration.

Back 340

Paradoxical Splitting of S2

--S2 that is narrowed instead of widened with inspiration consequent to a delayed aortic closure.
--Can result from any electrical or mechanical event that delays left ventricular systole.

Front 341

Splitting of S2 that is widened with inspiration.

Back 341

Normal Splitting of S2

Front 342

Most common cause of paradoxical splitting.

Back 342

Left Bundle Branch Block delays electrical activation of the left ventricle.

--Right Bundle Branch Block results in a wide splitting of S2 that widens further during inspiration.

Front 343

S3 Heart Sound

Back 343

An S3 is typically heard with congestive heart failure (CHF).

Front 344

S4 Heart Sound

Back 344

An S4 is typically heard with hypertension.

Front 345

Opening snap.

Back 345

Mitral Stenosis

Front 346

Type of Splitting:

--Aortic Stenosis
--Hypertension
--Acute Ischemia from Angina or Acute Myocardial Infarction

Back 346

Paradoxical Splitting of S2

--Aortic stenosis and hypertension, which increase resistance to systolic ejection of blood, delay closure of the aortic valve.

--Acute ischemia from angina or acute myocardial infarction also can delay ejection of blood from the left ventricle.

Front 347

High-pitched, blowing, decrescendo diastolic murmur; widened arterial pulse pressure.

Back 347

Aortic Regurgitation

Front 348

Holosystolic murmur at left sternal border; increased murmur on inspiration; prominent V wave in neck.

Back 348

Tricuspid Regurgitation

The neck veins are usually distended with prominent V waves and signs of right-sided heart failure.

Front 349

Crescendo-decrescendo systolic murmur beginning well after S1, heard best at the lower left sternal border; rapidly rising carotid arterial pulse.

Back 349

Hypertrophic Cardiomyopathy

These patients have diffuse left ventricular hypertrophy with preferential hypertrophy of the interventricular septum and a dynamic LV outflow tract pressure gradient.

Front 350

Unless it is very minor in magnitude, the murmur will be accompanied by peripheral signs such as widened pulse pressure.

Back 350

Aortic Regurgitation

Front 351

Medication:

Two-hour history of chest pain; acute ST segment elevation in leads 2, 3, and AVF; sinus bradycardia at rate of 40 with hypotension.

Back 351

Atropine

Sinus bradycardia is a common rhythm disturbance in acute inferior MI, secondary to vagal tone. With associated hypotension, atropine should be given.

Front 352

Sinus bradycardia is a common rhythm disturbance in _____, secondary to vagal tone.

Back 352

Acute Inferior MI

Front 353

Medication:

Sudden onset of chest pain at night; ST segment elevations in precordial leads that resolve with sublingual nitroglycerin.

Back 353

Calcium Channel Blockers

Classically, the syndrome is caused by coronary artery spasm, often in smokers and in a younger age group than typical angina patients.

Front 354

Medication:

Development of accelerated idioventricular rhythm post–myocardial infarction, with rate of 80.

Back 354

This is usually considered a benign rhythm, and only observation is necessary.

--Develops in up to 25% of post-MI patients.

--Enhanced automaticity of Purkinje fibers is considered the most likely etiology.

Front 355

Medication:

Shortness of breath, palpitations, bifid apical beat, and increased intensity of systolic murmur on Valsalva maneuver.

Back 355

Propranolol

Physical findings strongly suggest the diagnosis of hypertrophic cardiomyopathy.

β-adrenergic agents have been used extensively and are considered the agents of choice, especially in the setting of palpitations.

Front 356

Calcium channel blockers indicated in hypertrophic cardiomyopathy?

Contraindicated?

Back 356

Among the calcium channel blockers, diltiazem and verapamil (but not nifedipine) may be helpful.

Front 357

Most common side effect of ACEIs (eg, Captopril)

Back 357

Captopril which inhibits the angiotensin converting enzyme, is a potent antihypertensive agent because it prevents the generation of angiotensin II, a vasoconstrictor, and inhibits the degradation of bradykinin, a vasodilator.

It may cause membranous glomerulopathy, the nephrotic syndrome, and leukopenia. The most common side effect is cough.

Front 358

Most common side effect of this class of antihypertensive medication is cough.

Back 358

Captopril which inhibits the angiotensin converting enzyme, is a potent antihypertensive agent because it prevents the generation of angiotensin II, a vasoconstrictor, and inhibits the degradation of bradykinin, a vasodilator.

It may cause membranous glomerulopathy, the nephrotic syndrome, and leukopenia. The most common side effect is cough.

Front 359

Cardiac medication that may cause bronchospasm in susceptible patients.

Back 359

Propranolol is a nonselective beta blocker and may therefore cause bronchospasm in susceptible patients.

Beta blockers, as a class, may reduce HDL cholesterol and increase serum triglyceride levels.

Front 360

Cardiac medication that may reduce HDL cholesterol and increase serum triglyceride levels.

Back 360

Beta blockers, as a class, may reduce HDL cholesterol and increase serum triglyceride levels.

Front 361

2 Antihypertensive medications that my cause gynecomastia.

Back 361

Spironolactone, a potassium-sparing diuretic

Methyldopa, a centrally acting antiadrenergic agent

Front 362

Antihypertensives that may cause first-dose syncope.

Back 362

Alpha blockers such as terazosin may rarely (in <1%) cause first-dose syncope.

Front 363

Cardiac medication a/w rebound hypertension.

Back 363

Clonidine

Front 364

Cardiac medication a/w volume retention.

Back 364

Minoxidil

Front 365

Cardiac medication a/w lupus-like syndrome.

Back 365

Hydralazine

Front 366

ECG Finding:

Flattening of the T wave and prominent U waves.

Back 366

Hypokalemia

Hypokalemia typically increases automaticity of myocardial fibers, which results in ectopic beats or arrhythmias

Front 367

Electrolyte Disturbance:

Increases automaticity of myocardial fibers, which results in ectopic beats or arrhythmias.

Back 367

Hypokalemia

Electrocardiography in hypokalemia reveals flattening of the T wave and prominent U waves.

Front 368

Electrolyte Disturbance:

Decreases the rate of spontaneous diastolic depolarization in all pacemaker cells.

Back 368

Hyperkalemia decreases the rate of spontaneous diastolic depolarization in all pacemaker cells. It also results in slowing of conduction.

One of the earliest electrocardiographic signs of hyperkalemia is the appearance of tall, peaked T waves.

More severe elevations of the serum potassium result in widening of the QRS complex.

Front 369

Electrolyte Disturbance:

Tall, peaked T waves

Back 369

One of the earliest electrocardiographic signs of hyperkalemia is the appearance of tall, peaked T waves.

More severe elevations of the serum potassium result in widening of the QRS complex.

Front 370

Electrolyte Disturbance:

More severe elevations result in widening of the QRS complex

Back 370

One of the earliest electrocardiographic signs of hyperkalemia is the appearance of tall, peaked T waves.

More severe elevations of the serum potassium result in widening of the QRS complex.

Front 371

Electrolyte Disturbance:

Prolongation of the QT interval.

Back 371

Hypocalcemia results in prolongation of the QT interval.

Low serum calcium levels may also be associated with a decrease in myocardial contractility.

Front 372

Electrolyte Disturbance:

May also be associated with a decrease in myocardial contractility.

Back 372

Hypocalcemia results in prolongation of the QT interval.

Low serum calcium levels may also be associated with a decrease in myocardial contractility.

Front 373

ECG changes a/w Hypernatremia

Back 373

At serum sodium levels compatible with life, neither hyponatremia nor hypernatremia results in any characteristic electrocardiographic abnormalities.

Front 374

Serum osmolarities above what value produce lethargy or coma?

Back 374

When severe hyperglycemia and dehydration increase serum osmolarity above 380 mOsm/L, lethargy or coma occurs.

Front 375

Serum Osmolarity Formula

Back 375

(Glu/18) + 2(Na+K) + (BUN/2.8)

Front 376

Major determinant of serum osmolarity?

Back 376

Serum osmolarity depends mostly on the concentration of sodium.

(Glu/18) + 2(Na+K) + (BUN/2.8)

Front 377

Primary treatment for hyperosmolar nonketotic states.

Back 377

Fluid replacement, usually normal saline over the first 2 to 3 h.

Hypotonic saline may be given for severe hypernatremia or congestive heart failure.

Front 378

The best possible coordination of calorie intake, weight loss, and exercise. It emphasizes modification of risk factors for hypertension and hyperlipidemia, not just weight loss and calorie restriction.

Back 378

Medical Nutrition Therapy

Front 379

A 30-year-old female complains of palpitations, fatigue, and insomnia. On physical exam, her extremities are warm and she is tachycardic. There is diffuse thyroid gland enlargement and proptosis. There is a thickening of the skin in the pretibial area.

Back 379

Thyrotoxicosis 2/2 Graves’ Disease

Most patients with thyrotoxicosis have increases in total and free concentrations of T3 and T4. (Some may have isolated T3 or T4 increases.) Most thyrotoxicosis results in suppression of pituitary TSH secretion, so low TSH levels can also confirm the diagnosis.

Front 380

Decreased TSH, increased total thyroxine.

Back 380

Thyrotoxicosis

Most patients with thyrotoxicosis have increases in total and free concentrations of T3 and T4. (Some may have isolated T3 or T4 increases.) Most thyrotoxicosis results in suppression of pituitary TSH secretion, so low TSH levels can also confirm the diagnosis.

Front 381

Accounts for 60 to 80% of all thyrotoxicosis.

Back 381

Graves’ Disease

Front 382

Characteristic dermopathy of Graves’ Disease

Back 382

Pretibial Myxedema

The extrathyroidal manifestations of the diseases are due to immunologically activated fibroblasts in extraocular muscles and skin.

Front 383

Produces thyrotoxicosis caused by benign, functionally autonomous tumors.

Back 383

Toxic Multinodular Goiter

Does not produce the proptosis or dermopathy (pretibial myxedema) of Graves’ disease.

Front 384

Produces a transient hyperthyroidism followed by hypothyroidism. The thyroid gland is tender.

Back 384

Subacute Thyroiditis (de Quervain’s) is probably caused by a viral infection.

It produces a transient hyperthyroidism followed by hypothyroidism. The thyroid gland is tender.

Front 385

Drug of Choice:

Graves' Disease

Back 385

Methimazole

Antithyroid drugs are considered by most to be the treatment of choice in a patient with Graves’ disease when the underlying illness may remit.

Front 386

A 30-year-old female complains of fatigue, constipation, and weight gain. There is no prior history of neck surgery or radiation. Her voice is hoarse and her skin is dry. Serum TSH is elevated and T4 is low.

Back 386

Hypothyroidism

Hypothyroidism is almost always caused by autoimmune disease, thyroid damage from surgery, or radiation therapy.

Front 387

Autoimmune thyroiditis with a goiter.

Back 387

Autoimmune thyroiditis may be present with a goiter (Hashimoto’s thyroiditis) or with minimal residual thyroid tissue (atrophic thyroiditis).

Front 388

Autoimmune thyroiditis with minimal residual thyroid tissue.

Back 388

Atrophic Thyroiditis

Autoimmune thyroiditis may be present with a goiter (Hashimoto’s thyroiditis) or with minimal residual thyroid tissue (atrophic thyroiditis).

Front 389

T/F

Thyroid cancer may cause hypothyroidism.

Back 389

Thyroid cancer does NOT cause hypothyroidism. It presents with neck mass, hoarse voice, or expanding nodule.

Front 390

Autoimmune thyroiditis can be confirmed by?

Back 390

Thyroid Peroxidase Antibody (TPO), which is present in 90 to 95% of patients with autoimmune hypothyroidism.

Front 391

On routine physical exam, a young woman is found to have a thyroid nodule. There is no pain, hoarseness, hemoptysis, or local symptoms. Serum TSH is normal. The next step in evaluation is?

Back 391

Fine needle aspiration of thyroid

If the TSH is normal, as it is in this patient, then fine needle aspirate biopsy is indicated and will distinguish cysts from benign lesions or neoplasms.

Front 392

A 30-year-old woman has cervical fat pad, purple striae, and hirsutism.

Back 392

Cushing’s Disease produces hypercortisolism secondary to excessive excretion of pituitary ACTH. It often affects women in their child-bearing years.

Also a/w muscle wasting, easy bruising, amenorrhea, and psychiatric disturbances.

Front 393

What can a thyroid scan show?

Back 393

Thyroid scan can show a hot nodule, which would be reassuring that the nodule is benign; however, a biopsy would be necessary for cold nodules.

Thyroid sonography seldom can rule out malignancy in palpable nodules.

Front 394

Produces hypercortisolism secondary to excessive excretion of pituitary ACTH.

Back 394

Cushing’s Disease

Cervical fat pad, purple striae, and hirsutism are characteristic features, as well as muscle wasting, easy bruising, amenorrhea, and
psychiatric disturbances.

It often affects women in their child-bearing years.

Front 395

A nonpregnant woman has bitemporal hemianopsia, irregular menses, and galactorrhea.

Back 395

Prolactinoma (Prolactin-secreting Adenoma)

Serum prolactin levels are usually over 250 ng/mL, often distinguishing them from other causes of hyperpro-lactinemia such as renal failure.

Front 396

An obese hypertensive woman has chronic headaches and normal pituitary function.

Back 396

Empty Sella Syndrome

Enlargement of the sella turcica from CSF pressure compressing the pituitary gland. It is likely to occur in obese, hypertensive women.

Front 397

Empty sella syndrome is likely to occur in what type of patients?

Back 397

Obese hypertensive woman

Enlargement of the sella turcica from CSF pressure compressing the pituitary gland.

Front 398

In a diabetic with claudication or
abnormal femoral pulses, injection of _____ into the corpora cavernosa can test vascular insufficiency as the cause of impotence.

Back 398

Papaverine

A normal response is an erection within 10 min.

Front 399

In the evaluation of impotence, a decreased libido suggests?

Back 399

A decrease in libido would suggest testosterone deficiency. Serum testosterone should then be measured, and, if low, serum gonadotropins should be measured.

Front 400

Loss of all erectile function suggests what type of cause?

Back 400

Loss of all erectile function suggests an organic cause for the disease.

Front 401

A 90-year-old male complains of hip and back pain. He has also
developed headaches, hearing loss, and tinnitus. On physical exam the skull appears enlarged, with prominent superficial veins. There is marked kyphosis, and the bones of the leg appear deformed. Plasma alkaline phosphatase is elevated. A skull x-ray shows sharply demarcated lucencies in the frontal, parietal, and occipital bones. X-rays of the hip show thickening of the pelvic brim.

Back 401

Paget’s Disease of Bone

Front 402

Excessive resorption of bone is fol-lowed by replacement of normal marrow with dense, trabecular, disorganized bone. Hearing loss and tinnitus are due to direct involvement of the ossicles of the inner ear.

Back 402

Paget’s Disease of Bone

Alkaline phosphatase is a marker of bone formation and does not rise in pure lytic lesions such as multiple myeloma.

Front 403

Etiology of Paget's Disease of Bone

Back 403

The cause of Paget’s disease remains unknown. Some intranuclear inclusions resemble the nucleocapsids of viruses. No known endocrinopathy has been suggested, and Paget’s disease does not involve malignant cells.

Front 404

Medication:

Paget's Disease of Bone

Back 404

Calcitonin or Bisphosphonates (eg, Alendronate)

Calcitonin restores normal bone modeling.

Bisphosphonates bind to hydroxyapatite crystals to decrease bone turnover.

Front 405

Medication:

Restores normal bone modeling.

Back 405

Calcitonin

Front 406

Medication:

Bind to hydroxyapatite crystals to decrease bone turnover.

Back 406

Bisphosphonates (eg, Alendronate)

Front 407

A 24-h urine for free cortisol would be used in the workup of?

Back 407

Cushing Syndrome

Front 408

Hypertension with hypokalemia
syndrome.

Back 408

Excessive inappropriate aldosterone production.

The hypertension is due to increased sodium absorption.

Front 409

Hypersecretion of aldosterone increases distal tubular exchange of _____ for _____ with progressive depletion of body _____.

Back 409

Hypersecretion of aldosterone increases distal tubular exchange of SODIUM for POTASSIUM with progressive depletion of body POTASSIUM.

Front 410

What causes hypertension in hyperaldosteronism?

Back 410

The hypertension is due to increased sodium absorption.

Front 411

Very low plasma renin that fails to increase with appropriate stimulus (such as volume depletion) suggests the diagnosis of?

Back 411

Very low plasma renin that fails to increase with appropriate stimulus (such as volume depletion) and hypersecretion of aldosterone suggest the diagnosis of PRIMARY HYPERALDOSTERONISM.

Front 412

Suppressed _____ activity occurs in about 25% of hypertensive patients with essential hypertension.

Back 412

Suppressed RENIN activity occurs in about 25% of hypertensive patients with essential hypertension.