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Elevated PTH is caused by a single parathyroid adenoma in approximately 80% of cases.

The criteria for diagnosing diabetes mellitus include any one of the following:  symptoms of diabetes (polyuria, polydipsia, weight loss) plus a casual glucose level ≥200 mg/dL; a fasting plasma glucose level ≥126 mg/dL; or a 2-hour postprandial glucose level ≥200 mg/dL after a 75 gram glucose load.  In the absence of unequivocal hyperglycemia the test must be repeated on a different day. The criteria for impaired glucose homeostasis include either a fasting glucose level of 100-125 mg/dL (impaired fasting glucose) or a 2-hour glucose level of 140-199 mg/dL on an oral glucose tolerance test.  Normal values are now considered <100 mg/dL for fasting glucose and <140 mg/dL for the 2-hour glucose level on an oral glucose tolerance test. Ref: American Diabetes Association: Diagnosis and classification of diabetes mellitus. Diabetes Care 2008;31(Suppl 1):S55-S60.

As a result of delays in diagnosis, perforation is found in over 65% of elderly patients at the time of diagnosis.

Clostridium difficile colitis is suggested by semiformed rather than watery stools and fecal leukocytes. Fecal leukocytes are not seen in viral gastroenteritis or sprue.

Simple renal cysts are incidentally seen on abdominal imaging studies in over 30% of people over age 50, and are present in up to 50% in some autopsy series. No further evaluation is indicated for cysts that meet ultrasound criteria (i.e., thin-walled, homogeneous, fluid-filled). With cysts that appear to be complex, a renal CT with contrast is indicated. MRI has been shown to be statistically superior to CT in correctly characterizing benign lesions, and may be helpful when results of a CT scan are equivocal.

Illegal drug use is currently the leading cause of new cases of hepatitis C. It is estimated that * 60% of new cases of hepatitis C in the United States are due to injection drug use. Intranasal cocaine use has been associated with hepatitis C, but its importance as a route of transmission is controversial and it occurs at a much lower frequency, if it all.

Hepatitis A vaccine should be administered to unvaccinated adolescents who plan to travel to or work in an area of high endemicity of hepatitis A virus infection, those who receive clotting factors, those who have chronic liver disease or use illegal drugs, and males who have sex with males.

Fluoroquinolones such as ciprofloxacin have been shown to significantly reduce the duration and severity of traveler’s diarrhea when given for 1–3 days. Sulfacetamide is available only in a topical form for use in the eye. Penicillin and erythromycin are not effective against the most common cause of traveler’s diarrhea, enterotoxigenic E. coli. * Alvin L Wiseman 11.8.39

The individual described in this case has symptomatic hyponatremia. Headache, mental confusion, nausea, and malaise are common. Seizures, stupor, and coma generally do not occur until sodium concentrations fall below 120 mEq/L. The presence of significant peripheral edema in this patient indicates extracellular fluid volume expansion, and his serum osmolality is low. In this situation, hyponatremia is usually a manifestation of an edematous state, such as hepatic cirrhosis, congestive heart failure, or the nephrotic syndrome. Although these patients have increased extracellular fluid, their intravascular fluid is depleted, and their body’s attempt to conserve sodium at the level of the kidney produces urine with a sodium concentration <20 mEq/L. They have appropriately increased arginine vasopressin (AVP) levels, resulting in a urine osmolality that is less than maximally dilute and often >100 mOsm/kg H2O. Patients with the syndrome of inappropriate antidiuretic hormone (SIADH) have normal volume status and urine sodium levels which are typically >20 mEq/L. Patients with primary polydipsia often have an underlying psychiatric disorder. They have normal volume status, and produce large volumes of very dilute urine (<50 mOsm/kg H2O). Patients with adrenal insufficiency typically have normal volume status, but may be dehydrated. Patients with salt-wasting nephropathy are typically dehydrated despite producing urine with a sodium concentration >20 mEq/L.

In most patients with heavy gastrointestinal bleeding ( GI bleed) localizing the bleeding site, rather than diagnosing the cause of the bleeding, is the most important task. A lower GI series is usually nondiagnostic during heavy, active bleeding. A small-bowel radiograph may be helpful after the active bleeding has stopped, but not during the acute phase of the bleeding. A blood pool scan allows repeated scanning over a prolonged period of time, with the goal of permitting enough accumulation of the isotope to direct the arteriographer to the most likely source of the bleeding. If the scan is negative, arteriography would also be unlikely to reveal the active source of bleeding. It is also a more invasive procedure. Exploratory laparotomy may be indicated if a blood pool scan or an arteriogram is nondiagnostic and the patient continues to bleed heavily.

The American Academy of Pediatrics recommends initiating phototherapy for bilirubin levels based on the infant’s age:

15 mg/dL at 25–48 hours

18 mg/dL at 49–72 hours

20 mg/dL at 72 hours or more.

The criteria for severe preeclampsia specify a blood pressure of 160/110 mm Hg or above on two occasions, 6 hours apart. Other criteria include proteinuria above 5 g/24 hr, thrombocytopenia with a platelet count <100,000/mm3, liver enzyme abnormalities, epigastric or right upper quadrant pain, and alteration of mental status.

The use of automated external defibrillators (AEDs) by lay persons, trained and otherwise, has been quite successful, with up to 40% of those treated recovering full neurologic and functional capacity.

ACE inhibitors are the preferred drugs for congestive heart failure due to left ventricular systolic dysfunction, because they are associated with the lowest mortality. The combination of hydralazine/isosorbide dinitrate is a reasonable alternative, and diuretics should be used cautiously. It is not known whether digoxin affects mortality, although it can help with symptoms.

In pregnant women with severe hypertension, the primary objective of treatment is to prevent cerebral complications such as encephalopathy and hemorrhage. Intravenous hydralazine, intravenous labetalol, or oral nifedipine may be used. Sublingual nifedipine can cause severe hypotension, and reserpine is not indicated. Nitroprusside can be used for short intervals in patients with hypertensive encephalopathy, but fetal cyanide toxicity is a risk with infusions lasting more than 4 hours.

Clinical trials support the treatment of systolic hypertension in the older person with a systolic blood pressure of at least 160 mm Hg. (Systolic hypertension is defined as systolic blood pressure of at least 140 mm Hg and a diastolic blood pressure of less than 90 mm Hg.) The studies most strongly support the use of thiazide diuretics and long-acting calcium channel blockers as first-line therapy.

Causes of secondary dyslipidemia include diabetes mellitus, hypothyroidism, obstructive liver disease, chronic renal failure, and some medications.

A 34-year-old white female at 32 weeks' gestation develops a venous thromboembolism. Following 5 days of intravenous heparin in the hospital, which one of the following regimens would be most appropriate? (check one)
A. Warfarin (Coumadin) throughout the remainder of her pregnancy 
B. Subcutaneous heparin every 12 hours until delivery 
C. Outpatient intravenous heparin every 6 hours until delivery 
D. Aspirin twice a day until delivery 
Heparin does not cross the placenta and is safe for the fetus, whereas coumarin derivatives can cause fetal bleeding and are teratogenic during weeks 6–12. Therefore, pregnant women with venous thromboembolism should receive intravenous heparin for 5 days, followed by adjusted-dose subcutaneous heparin every 12 hours until delivery. Increasingly, low–molecular-weight heparins are being used instead of unfractionated heparin because of ease of administration and the reduced need for coagulation monitoring. Intravenous heparin is not necessary after the patient leaves the hospital, and aspirin has not been shown to be beneficial. Ref: Ginsberg JS, Greer I, Hirsh J: Use of antithrombotic agents during pregnancy. Chest 2001;119(1 Suppl):122S-131S. 2) Andres RL, Miles A: Venous thromboembolism and pregnancy. Obstet Gynecol Clin North Am 2001;28(3):613-630.

A 73-year-old male with COPD presents to the emergency department with increasing dyspnea. Examination reveals no sign of jugular venous distention. A chest examination reveals decreased breath sounds and scattered rhonchi, and the heart sounds are very distant but no gallop or murmur is noted. There is +1 edema of the lower extremities. Chest radiographs reveal cardiomegaly but no pleural effusion. The patient’s B-type natriuretic peptide level is 850 pg/mL (N <100) and his serum creatinine level is 0.8 mg/dL (N 0.6–1.5). Which one of the following would be the most appropriate initial management? (check one)
A. Intravenous heparin 
B. Tiotropium (Spiriva) 
C. Levalbuterol (Xopenex) via nebulizer 
D. Prednisone, 20 mg twice daily for 1 week 
E. Furosemide (Lasix), 40 mg intravenously 
B-type natriuretic peptide (BNP) is secreted in the ventricles and is sensitive to changes in left ventricular function. Concentrations correlate with end-diastolic pressure, which in turn correlates with dyspnea and congestive heart failure. BNP levels can be useful when trying to determine whether dyspnea is due to cardiac, pulmonary, or deconditioning etiologies. A value of less than 100 pg/mL excludes congestive heart failure as the cause for dyspnea. If it is greater than 400 pg/mL, the likelihood of congestive heart failure is 95%. Patients with values of 100–400 pg/mL need further investigation. There are some pulmonary problems that may elevate BNP, such as lung cancer, cor pulmonale, and pulmonary embolus. However, these patients do not have the same extent of elevation that those with acute left ventricular dysfunction will have. If these problems can be ruled out, then individuals with levels between 100–400 pg/mL most likely have congestive heart failure. Initial therapy should be a loop diuretic. It should be noted that BNP is partially excreted by the kidneys, so levels are inversely proportional to creatinine clearance. Ref: Maisel AS, Zoorob R: B-type natriuretic peptide in congestive heart failure: Diagnosis and management. CME Bulletin 2004;3(3). 2) Maisel AS, Mehra MR: Understanding B-type natriuretic peptide and its role in diagnosing and monitoring congestive heart failure. Clin Cornerstone 2005;7(Suppl 1):S7-S17.

Which one of the following is the medical treatment of choice for acute delirium in the intensive care unit? (check one)
A. Intravenous haloperidol (Haldol) in increasing doses every 30 minutes as needed 
B. Intravenous droperidol (Inapsine) every 6–8 hours 
C. Intravenous lorazepam (Ativan) 
D. Intramuscular chlorpromazine (Thorazine) 
E. Intramuscular diphenhydramine (Benadryl) 
Intravenous haloperidol has been found to be more effective than lorazepam and has minimal physiologic side effects. Chlorpromazine can worsen confusion and lower blood pressure. Droperidol can cause akathisia. Diphenhydramine can increase confusion due to its anticholinergic effects. Ref: Stoudemire A, Fogel BS, Greenberg DB (eds): Psychiatric Care of the Medical Patient, ed 2. Oxford University Press, 2000, pp 302-305.

A 72-year-old male with a history of previous inferior myocardial infarction sees you prior to surgery for symptomatic gallstones. He denies chest pain or dyspnea. His current medications include aspirin, 81 mg daily; ramipril (Altace), 10 mg daily; and pravastatin (Pravachol), 40 mg daily. He is in good health otherwise and has no other health complaints. He has been cleared for surgery by his cardiologist. Which one of the following should be considered before and after surgery, assuming no contraindications? (check one)
A. Atenolol (Tenormin) 
B. Verapamil (Calan, Isoptin) 
C. Digoxin 
D. Transdermal nitroglycerin 
E. Intravenous nitroglycerin 
A recent development in the prophylaxis of surgery-related cardiac complications is the use of beta-blockers perioperatively for patients with cardiac risk factors. In a randomized, double-blind, placebo-controlled trial involving 200 patients who were undergoing elective noncardiac surgery that required general anesthesia, the effect of atenolol on perioperative cardiac complications was evaluated. Patients were eligible for beta-blocker therapy if they had known coronary artery disease or two or more risk factors. Atenolol was not used if the resting heart rate was <55 beats/min, systolic blood pressure was <100 mm Hg, or there was evidence of congestive heart failure, third degree heart block, or bronchospasm. A 5-mg dose of intravenous atenolol was given 30 minutes before surgery and then again immediately after surgery. Oral atenolol, 50–100 mg, was then given until hospital discharge or 7 days postoperatively. The results of the study showed that mortality from cardiac causes was 65% lower in the patients receiving atenolol. Another study showed similar perioperative benefit using the beta-blocker bisoprolol. Ref: Auerbach AD, Goldman L: Beta-blockers and reduction of cardiac events in noncardiac surgery. JAMA 2002;287(11):1435-1444.