TABLE IV-114 Risk Factors for Active Tuberculosis Among Persons Who Have Been Infected With Tubercle Bacilli 7 page

FIGURE IV-246 Global distribution of schistosomiasis. A. S. mansoni infection (lightest shade) is endemic in Africa, the Middle East, South America, and a few Caribbean countries. S. intercalatum infection (darkest shade) is endemic in sporadic foci in West and Central Africa. B. S. haematobium infection (medium shade) is endemic in Africa and the Middle East. The major endemic countries for

S. japonicum infection (darkest shade) are China, the Philippines, and Indonesia. S. mekongi infection (black) is endemic in sporadic foci in Southeast Asia.

ГУ-247. The answer is D.(Chap. 219) This patient has Katayama fever caused by infection with Schistosoma mansoni. Approximately 4 to 8 weeks after exposure, the parasite migrates through the portal and pulmonary circulations. This phase of the illness may be asymptomatic but in some cases evokes a hypersensitivity response and a serum sickness-type illness. Eosinophilia is usual. Because there is not a large enteric burden of parasites during this phase of the illness, stool study results may not be positive, and serology may be helpful, particularly in patients from nonendemic areas. Praziquantel is the treatment of choice because Katayama fever may progress to include neurologic complications. Praziquantel remains the treatment for most helminthic infections, including schistosomiasis. Chloroquine is used for treatment of malaria; mebendazole for ascariasis, hookworm, trichinosis, and visceral larval migrans; metronidazole for amebiasis, giardiasis, and trichomoniasis; and thiabendazole for Strongyloides spp.

ГУ-248. The answer is B.(Chap. 219) Schistosoma mansoni infection of the liver causes cirrhosis from vascular obstruction resulting from periportal fibrosis but relatively little hepatocellular injury. Hepatosplenomegaly, hypersplenism, and esophageal varices develop quite commonly, and schistosomiasis is usually associated with eosinophilia. Spider nevi, gynecomastia, jaundice, and ascites are observed less commonly than they are in alcoholic and postnecrotic fibrosis.

ГУ-249. The answer is B.(Chap. 220) This patient has a new onset of seizures caused by neurocysticercosis from infection with Taenia solium (pork tapeworm). The computed tomography (CT) scan shows a parenchymal cysticercus with enhancement of the cyst and an internal scolex {arrow). The cyst represents larval oncospheres that have migrated to the central nervous system (CNS). Infections that cause human cystercicosis result from ingestion of T. solium eggs, usually from close contact with a tapeworm carrier who developed intestinal infection for ingestion of undercooked pork. Autoinfection may occur if an individual ingests tapeworm eggs excreted in their own feces. Cysticerci may be found anywhere in the body, but clinical manifestations usually arise from lesions in the CNS, cerebrospinal fluid (CSF), skeletal muscle, subcutaneous tissue, or eye. Neurologic manifestations are most common, including generalized or focal seizures from surrounding inflammation, hydrocephalus from CSF outflow occlusion, or arachnoiditis. As shown in Table IV-249. neuroradiologic demonstration of a cystic lesion containing a characteristic scolex is absolute criteria for diagnosis of cysticercosis. Intestinal infection may be detected by fecal examination for eggs. More sensitive enzyme-linked immunosorbent assay, polymerase chain reaction, and serologic testing is not currently commercially available. Treatment of neurocysticercosis after neurologic stabilization is with albendazole or praziquantel. Studies have shown faster resolution of clinical and radiologic findings compared with placebo. Initiation of therapy may be associated with worsening symptoms caused by inflammation that is treated with glucocorticoids. Intestinal T. solium infection is treated with a single dose of praziquantel. CNS cystic lesions (but without the visualized scolex) are typical of toxoplasmosis in patients with advanced HIV infection and are treated with pyrimethamine and sulfadiazine. However, in this case, the patient was documented HIV antibody negative, and the CT lesion was typical for cysticercosis. Viral testing for HIV would not be helpful because toxoplasmosis is seen in advanced cases, not acute infection. Echocardiography would be indicated for suspected staphylococcal (or other bacterial) endocarditis with systemic embolization.

TABLE IV-249 Diagnostic Criteria for Human Cysticercosis-

1. Absolute criteria

a. Demonstration of cysticerci by histologic or microscopic examination of biopsy material

b. Visualization of the parasite in the eye by funduscopy

с Neuroradiologic demonstration of cystic lesions containing a characteristic scolex

2. Major criteria

a. Neuroradiologic lesions suggestive of neurocysticercosis

b. Demonstration of antibodies to cysticerci in serum by enzyme-linked immunoelectrotransfer blot
с Resolution of intracranial cystic lesions spontaneously or after therapy with albendazole or
praziquantel alone

3. Minor criteria

a. Lesions compatible with neurocysticercosis detected by neuroimaging studies

b. Clinical manifestations suggestive of neurocysticercosis

с Demonstration of antibodies to cysticerci or cysticercal antigen in cerebrospinal fluid by ELISA d. Evidence of cysticercosis outside the central nervous system (e.g., cigar-shaped soft tissue calcifications)

4. Epidemiologic criteria

a. Residence in a cysticercosis-endemic area

b. Frequent travel to a cysticercosis-endemic area

с Household contact with an individual infected with Taenia solium

-Diagnosis is confirmed by either one absolute criterion or a combination of two major criteria, one

minor criterion, and one epidemiologic criterion. A probable diagnosis is supported by the

fulfillment of (1) one major criterion plus two minor criteria, (2) one major criterion plus one minor

criterion and one epidemiologic criterion, or (3) three minor criteria plus one epidemiologic

criterion.

Abbreviation: ELISA, enzyme-linked immunosorbent assay.

Source: Modified from Del Brutto OH et al: Proposed diagnostic criteria for neurocysticercosis.

Neurology 57:177, 2001.

ГУ-250. The answer is B.(Chap. 220) Echinococcosis is usually caused by infection of Echinococcus granulosus complex or Echinococcus multilocularis transmitted to humans via dog feces. E. granulosus is found on all continents with high prevalence in China, central Asia, Middle East, Mediterranean region, Eastern Africa, and parts of South America. E. multi-locularis, which causes multiloculated invasive lung lesions, is found in alpine, sub-Arctic, or Arctic regions, including Canada, the United States, China, Europe, and central Asia. Echinococcal cysts, most commonly in the liver followed by the lung, are typically slowly enlarging and cause symptoms because of space-occupying effects. Cysts are often incidentally discovered on radiologic studies. Compression or leakage into the biliary system may cause symptoms typical for cholelithiasis or cholecystitis. Echinococcal cysts may be characterized by ultrasonography. Demonstration of daughter cysts within a larger cyst is pathognomonic. Serodiagnosis may be helpful in questionable cases for diagnosis of E. granulosus. Patients with liver cysts typically have positive serology in more than 90% (but not 100%) of cases. Up to 50% of patients with lung cysts may be seronegative. Biopsy is generally not

recommended for cysts close to the liver edge because of the risk of leakage. Small cysts may respond to medical therapy with albendazole or praziquantel. Percutaneous aspiration-injection-resaspiration (PAIR) therapy is recommended for most noncomplex nonsuperficial cysts. Surgical resection is recommended for complex cysts, superficial cysts with risk of leakage, and cysts involving the biliary system. Albendazole therapy is generally administered before and after PAIR or surgical therapy.

SECTION V

Disorders of the Cardiovascular System

QUESTION

DIRECTIONS: Choose the one best response to each question.

V-1. A 35-year-old woman is seen in clinic for evaluation of dyspnea. Which of the following physical findings would fit the diagnosis of idiopathic pulmonary arterial hypertension?

A. Elevated neck veins, normal S₁ and S₂, II/VI diastolic blowing murmur heard at the right upper

sternal border

B. Elevated neck veins; singular, loud S₂; II/VI systolic murmur left lower sternal border

C. Elevated neck veins; loud, fixed, split S₂; III/VI systolic murmur left lower sternal border

D. Elevated neck veins, expiratory splitting of S₂, II/VI harsh systolic murmur left upper sternal

border

E. Elevated neck veins, barrel chest, prolonged expiratory phase

V-2. A 75-year-old woman with widely metastatic non–small cell lung cancer is admitted to the intensive care unit with a systolic blood pressure of 73/25 mmHg. She presented complaining of fatigue and worsening dyspnea over the last 3–5 days. Her physical examination shows elevated neck veins. Chest radiograph shows a massive, water bottle–shaped heart shadow and no new pulmonary infiltrates. Which of the following additional findings is most likely present on physical examination?

A. Fall in systolic blood pressure greater than 10 mmHg with inspiration

B. Lack of fall of the jugular venous pressure with inspiration

C. Late diastolic murmur with opening snap

D. Pulsus parvus et tardus

E. Slow y-descent of jugular venous pressure tracing

V-3. A 78-year-old man is admitted to the intensive care unit with decompensated heart failure. He has long-standing ischemic cardiomyopathy. Electrocardiogram (ECG) shows atrial fibrillation and left bundle branch block. Chest radiograph shows cardiomegaly and bilateral alveolar infiltrates with Kerley’s B-lines. Which of the following is least likely to be present on physical examination?

A. Fourth heart sound

B. Irregular heart rate

C. Pulsus alternans

D. Reversed splitting of the second heart sound

E. Third heart sound

V-4. A 45-year-old man is admitted to the intensive care unit with symptoms of congestive heart failure.

He is addicted to heroin and cocaine and uses both drugs daily via injection. His blood cultures have yielded methicillin-sensitive Staphylococcus aureus in four of four bottles within 12 hours. His vital signs show a blood pressure of 110/40 mmHg and a heart rate of 132 beats/min. There is a IV/VI diastolic murmur heard along the left sternal border. A schematic representation of the carotid pulsation is shown in Figure V-4A. What is the most likely cause of the patient’s murmur?

FIGURE V-4A

A. Aortic regurgitation

B. Aortic stenosis

C. Mitral stenosis

D. Mitral regurgitation

E. Tricuspid regurgitation

V-5. A 72-year-old man seeks evaluation for leg pain with ambulation. He describes the pain as an aching to crampy pain in the muscles of his thighs. The pain subsides within minutes of resting. On rare occasions, he has noted numbness of his right foot at rest, and pain in his right leg has woken him at night. He has a history of hypertension and cerebrovascular disease. Four years previously had a transient ischemic attack and underwent right carotid endarterectomy. He currently takes aspirin, irbesartan, hydrochlorothiazide, and atenolol on a daily basis. On examination, he is noted to have diminished dorsalis pedis and posterior tibial pulses bilaterally. The right dorsal pedis pulse is faint. There is loss of hair in the distal extremities. Capillary refill is approximately 5 seconds in the right foot and 3 seconds in the left foot. Which of the following findings would be suggestive of critical ischemia of the right foot?

A. Ankle-brachial index less than 0.3

B. Ankle-brachial index less than 0.9

C. Ankle-brachial index greater than 1.2

D. Lack of palpable dorsalis pedis pulse

E. Presence of pitting edema of the extremities

V-6. A 24-year-old man is referred to cardiology after an episode of syncope while playing basketball. He has no recollection of the event, but he was told that he collapsed while running. He awakened lying on the ground and suffered multiple contusions as a result of the fall. He has always been an active individual but recently has developed some chest pain with exertion that has caused him to restrict his activity. His father died at age 44 while rock climbing. He believes his father’s cause of death was sudden cardiac death and recalls being told his father had an enlarged heart. On examination, the patient

has a III/VI midsystolic crescendo-decrescendo murmur. His electrocardiogram shows evidence of left ventricular hypertrophy. You suspect hypertrophic cardiomyopathy as the cause of the patient’s heart disease. Which of the following maneuvers would be expected to cause an increase in the loudness of the murmur?

A. Handgrip exercise

B. Squatting

C. Standing

D. Valsalva maneuver

E. A and B

F. C and D

V-7. Left bundle branch block is indicative of which of the following sets of conditions?

A. Atrial septal defect, coronary heart disease, aortic valve disease

B. Coronary heart disease, aortic valve disease, hypertensive heart disease

C. Coronary heart disease, aortic valve disease, pulmonary hypertension

D. Pulmonary embolism, cardiomyopathy, hypertensive heart disease

E. Pulmonary hypertension, pulmonary embolism, mitral stenosis

V-8. A 57-year-old man with long-standing ischemic cardiomyopathy is seen in the clinic for a routine visit. He reports good compliance with his diuretic regimen, but has seen his weight fall about 2 kg since his last visit. Routine chemistries are drawn and show a potassium value of 2.0 meq/L. The patient is referred to the emergency department for repletion of potassium. Which of the following is likely to be found on ECG before administration of potassium?

A. Diminution of P wave amplitude

B. Osborne waves

C. Prolongation of QT interval

D. Prominent U waves

E. Scooped ST segments

V-9. A 55-year-old woman from El Salvador is seen in the emergency department because of gradual onset of dyspnea on exertion. She denies chest pain, cough, wheezing, sputum, or fever. Her chest radiograph is notable for large pulmonary arteries and left atrial enlargement, but no parenchymal infiltrate. ECG shows a tall R in lead V₁ and right axis deviation. Which of the following is most likely

to be found on her echocardiography?

A. Aortic regurgitation

B. Aortic stenosis

C. Low left ventricular ejection fraction

D. Mitral stenosis

E. Tricuspid stenosis

V-10. A 29-year-old woman is in the intensive care unit with rhabdomyolysis due to compartment syndrome of the lower extremities after a car accident. Her clinical course has been complicated by

acute renal failure and severe pain. She has undergone fasciotomies and is admitted to the intensive care unit. An ECG is obtained (shown in Figure V-10). What is the most appropriate course of action at this point?

A. 18-lead ECG

B. Coronary catheterization

C. Hemodialysis

D. Intravenous fluids and a loop diuretic

E. Ventilation/perfusion imaging

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FIGURE V-10

V-11. Acute hyperkalemia is associated with which of the following electrocardiographic changes?

A. Decrease in the PR interval

B. Prolongation of the ST segment

C. Prominent U waves

D. QRS widening

E. T-wave flattening

V-12. The ECG shown below (Figure V-12) was most likely obtained from which of the following patients?

A. A 33-year-old female with acute-onset severe headache, disorientation, and intraventricular
blood on head CT scan

B. A 42-year-old male with sudden-onset chest pain while playing tennis

C. A 54-year-old female with a long history of smoking and 2 days of increasing shortness of breath
and wheezing

D. A 64-year-old female with end-stage renal insufficiency who missed dialysis for the last 4 days

E. A 78-year-old male with syncope, delayed carotid upstrokes, and a harsh systolic murmur in the
right second intercostal space

FIGURE V-12

V-13. You are evaluating a new patient in your clinic who has brought in the ECG shown below ( Figure V-13) to the visit. The ECG was performed on the patient 2 weeks ago. What complaint do you expect to elicit from the patient?

A. Angina

B. Hemoptysis

C. Paroxysmal nocturnal dyspnea

D. Pleuritic chest pain

E. Tachypalpitations

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FIGURE V-13

V-14. All the following ECG findings are suggestive of left ventricular hypertrophy EXCEPT:

A. (S in V₁ + R in V₅ or V₆) greater than 35 mm

B. R in aVL greater than 11 mm

C. R in aVF greater than 20 mm

D. (R in I + S in III) greater than 25 mm

E. R in aVR greater than 8 mm

V-15. Based on the electrocardiogram below (Figure V-15), treating which condition might specifically improve this patient’s tachycardia?

A. Anemia

B. Chronic obstructive pulmonary disease (COPD)

C. Myocardial ischemia

D. Pain

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FIGURE V-15

V-16. Doppler echocardiography is most useful for diagnosis of which of the following cardiac lesions?

A. Determination of cardiac mass in a patient with an audible “plop” on examination

B. Determination of left ventricular ejection fraction in a patient with a history of myocardial
infarction

C. Diagnosis of myocardial ischemia in a patient with atypical chest pain

D. Diagnosis of pericardial effusion

E. Diastolic filling assessment in a patient with suspected heart failure with preserved ejection
fraction

V-17. A 75-year-old man is undergoing routine cardiac catheterization for evaluation of stable angina that has not responded to medical therapy. He is inquiring about the risks associated with the procedure. Which of the following is the most common complication of cardiac catheterization and coronary angiography?

A. Acute renal failure

B. Bradyarrhythmias

C. Myocardial infarction

D. Tachyarrhythmias

E. Vascular access site bleeding

V-18. Which of the following patients is an appropriate candidate for right heart catheterization?

A. A 54-year-old woman with dyspnea of unclear etiology; a loud, fixed split second heart sound;
normal chest radiograph; and evidence of bidirectional shunt across her interatrial septum

B. A 54-year-old man with an episode of sustained monomorphic ventricular tachycardia while at
the casino terminated with bystander defibrillation. After arrival in the emergency department, the
patient is hemodynamically stable.

C. A 63-year-old woman with a history of tobacco abuse, hypercholesterolemia, and Type 2
diabetes mellitus with chest pain at rest, a normal ECG, and mild elevation in serum troponin value

D. A 66-year-old man with a history of diabetes and hyper-cholesterolemia brought to the
emergency department with 1 hour of substernal chest pain and shortness of breath. His blood
pressure is 95/60 mmHg with a heart rate of 115 beats/min. An ECG shows a new left bundle branch
block since his prior ECG 1 month ago.

E. A 79-year-old man seen in the cardiology clinic for evaluation of severe aortic stenosis found on
echocardiography performed for evaluation of dyspnea

V-19. A 55-year-old woman is undergoing evaluation of dyspnea on exertion. She has a history of hypertension since age 32 and is also obese with a body mass index (BMI) of 44 kg/m². Her pulmonary function tests show mild restrictive lung disease. An echocardiogram shows a thickened left-ventricular wall, left-ventricular ejection fraction of 70%, and findings suggestive of pulmonary hypertension with an estimated right-ventricular systolic pressure of 55 mmHg, but the echocardiogram is technically difficult and of poor quality. She undergoes a right heart catheterization that shows the following results:

What is the most likely cause of the patient’s dyspnea?

A. Chronic thromboembolic disease

B. Diastolic heart failure

C. Obstructive sleep apnea

D. Pulmonary arterial hypertension

E. Systolic heart failure

V-20. Which of the following is a risk factor for the development of thromboembolism in patients with the tachycardia-bradycardia variant of sick sinus syndrome?

A. Age greater than 50 years

B. Atrial enlargement

C. Diabetes mellitus

D. Prothrombin 20210 mutation

E. None of the above; there is no increased risk of thromboembolism with the tachycardia-
bradycardia variant of sick sinus syndrome.

V-21. A 38-year-old man is evaluated for the recent onset of feeling fatigued. He is a busy executive and active triathlete. He competed a challenging course 1 week earlier without difficulty but feels tired at other times. Laboratory examination, including hematocrit and TSH, are unremarkable. Because his wife reports occasional snoring, a sleep study is recommended. There are no notable apneas, but ECG monitoring during the night shows sinus bradycardia. His heart rate varies between 42 and 56 while sleeping. His resting heart rate while awake is 65–72 beats/min. Which of the following is the most appropriate management for his bradycardia?

A. Carotid sinus massage

B. Intermittent nocturnal wakening

C. Measurement of free T₄

D. No specific therapy

E. Referral for pacemaker placement

V-22. All of the following are reversible causes of sinoatrial node dysfunction EXCEPT:

A. Hypothermia

B. Hypothyroidism

C. Increased intracranial pressure

D. Lithium toxicity

E. Radiation therapy

V-23. A 58-year-old man is admitted to the hospital after experiencing 2 days of severe dyspnea. Three weeks ago he had an ST elevation myocardial infarction that was treated with thrombolytics. He reports excellent adherence to his medical regimen that includes atorvastatin, lisinopril, metoprolol, and aspirin. On examination, his heart rate is 44 beats/min, his blood pressure is 100/45 mmHg, his lungs have bilateral crackles, and his cardiac examination is notable for elevated neck veins, bradycardia, and 2+ bilateral leg edema. There are no gallops or new murmurs. ECG shows sinus bradycardia and evidence of the recent infarct, but no acute changes. Which of the following is the most appropriate next management step?

A. Begin dopamine

B. Hold metoprolol

C. Measure TSH

D. Refer for pacemaker placement

E. Refer for urgent coronary angiography

V-24. A 23-year-old college student home for the summer is evaluated in the emergency department for dizziness that began within the last 3 days. He reports a rash on his right leg that looked like a target several days ago, but is otherwise healthy. Physical examination shows bradycardia at 40 beats/min and blood pressure of 88/42 mmHg; oxygen saturation is normal. His examination is otherwise unremarkable except for a bulls-eye rash over the right upper thigh. ECG shows third-degree AV block. Which of the following laboratory studies is most likely to reveal the etiology of his signs and symptoms?

A. ANA

B. HLA B27 testing

C. Borrelia burgdorferi ELISA

D. RPR

E. SCL-70

V-25. In the tracing below (Figure V-25), what type of conduction abnormality is present and where in the conduction pathway is the block usually found?

A. First-degree AV block; intranodal

B. Second-degree AV block type 1; intranodal

C. Second-degree AV block type 2; infranodal

D. Second-degree AV block type 2; intranodal

FIGURE V-25 V-26. A 47-year-old woman with a history of tobacco abuse and ulcerative colitis is evaluated for

intermittent palpitations. She reports that for the last 6 months every 2–4 days she notes a sensation of her heart “flip-flopping” in her chest for approximately 5 minutes. She has not noted any precipitating factors and has not felt lightheaded or had chest pains with these episodes. Her physical examination is normal. A resting ECG reveals sinus rhythm and no abnormalities. Aside from checking serum electrolytes, which of the following is the most appropriate testing?

A. Abdominal CT with oral and IV contrast

B. Event monitor

C. Holter monitor

D. Reassurance with no further testing needed

E. Referral for EP study

V-27. After further testing, the patient in question V-26 is found to have several episodes of atrial premature contractions. Which of the following statements regarding the dysrhythmia in this patient is true?

Date: 2016-04-22; view: 865