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Endocarditis Prophylaxis


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Endocarditis Prophylaxis
Ankle Sprains
Diarrhea: Approach (Harrison)
General approach to the child with a limp
Feeding Birth to Maturity - ARTIFICIAL FEEDING

Endocarditis Prophylaxis

General Comments. Endocarditis can occur from transient bacteremia. Because a variety of health care procedures can result in bacteremia, prophylaxis against bacteria that can adhere to endocardium is recommended, particularly in patients at high risk for endocarditis. The frequency of bacteremia is highest subsequent to oral and dental procedures (because of the abundant oral flora), intermediate for genitourinary procedures, and lowest for diagnostic procedures of the gastrointestinal tract. It is important to give prophylactic antibiotics before a procedure because bacterial adhesion can occur within minutes after bacteremia develops.

Endocarditis Prophylaxis Recommended.
Cardiac conditions.
Prosthetic cardiac valves (including bioprosthetic, homograft, and mechanical).
Previous episode of bacterial endocarditis.
Most congenital cardiac defects (especially cyanotic congenital heart disease, patent ductus arteriosus, ventricular septal defects, and surgically repaired intracardiac defects with residual hemodynamic abnormalities).
Valvular heart disease resulting from rheumatic or other disease (aortic regurgitation and stenosis, mitral regurgitation and stenosis).
Hypertrophic cardiomyopathy.
Mitral valve prolapse with regurgitation.
Dental or surgical procedures.
Dental or surgical procedures that cause gingival or mucosal bleeding, including mechanical dental hygienic procedures.
Tonsillectomy or adenoidectomy.
Surgical procedures involving upper respiratory or gastrointestinal mucosa.
Rigid bronchoscopy.
Sclerotherapy of esophageal varices.
Esophageal dilatation.
Transesophageal echocardiography
Gallbladder surgery
Urethral catheterization or urinary tract surgery if infection present
Prostate surgery
I & D of infected tissue
Vaginal hysterectomy
Vaginal delivery in the presence of infection (chorioamnionitis, etc.)

Endocarditis Prophylaxis Not Recommended

Cardiac conditions.
Previous coronary artery bypass surgery.
Mitral valve prolapse without regurgitation. (If MPV is associated with thickening or redundancy of valve leaflets, may have increased risk of endocarditis, especially in men >45 years of age).
Functional or innocuous heart murmurs.
Cardiac pacemakers and implantable defibrillators.
Isolated secundum atrial septal defect.
6 months or more status postsurgical repair of PDA, VSD without residua.
Previous rheumatic heart disease or Kawasaki disease without valve dysfunction.
Dental or surgical procedures.
Dental procedures not likely to cause gingival bleeding such as fillings above the gum line, adjustment of orthodontic appliances.
Injection of intraoral anesthetics.
Shedding of primary teeth.
Tympanostomy tube insertion.
Endotracheal intubation, flexible bronchoscopy with or without biopsy specimens.
Cardiac catheterization.
Endoscopy with or without biopsy.
In absence of infection, urethral catheterization, D&C, uncomplicated vaginal delivery, abortion, sterilization procedures, insertion or removal of an IUD, or laparoscopy.

Standard Regimens

Dental, oral, upper respiratory tract. (Total children’s dose should not exceed adult dose).
For adults. Amoxicillin 2 g (children, 50 mg/kg) PO 1 hour before procedure.
In penicillin-allergic patients. Clindamycin 600 mg (children, 20 mg/kg) PO OR Cephalexin or Cefadroxil 2.0 g (children, 50 mg/kg) PO OR Azithromycin or Clarithromycin 500 mg (children, 15 mg/kg) PO 1 hour before procedure
If unable to take oral medications. Ampicillin 2.0 g (children 20 mg/kg) IV or IM 30 minutes before procedure. Alternative: clindamycin 600 mg (children 20 mg/kg) IV 30 minutes before procedure.
In the high-risk, penicillin-allergic patient. Vancomycin 1.0 g IV over 1 hour, starting 1 hour before surgery. A repeat dose is not necessary.
GI or GU procedures. (Total children’s dose should not exceed adult dose).
High risk. Ampicillin 2.0 g IV (children, 50 mg/kg) + Gentamicin 1.5 mg/kg IV (for adults and children, not to exceed 120 mg) 30 minutes before procedure, then amoxicillin 1.0 g (children, 25 mg/kg) PO 6 hours later, or ampicillin 1.0 g (children, 25 mg/kg) IV 6 hours after first dose.
High-risk, penicillin allergic. Vancomycin 1.0 g (children, 20 mg/kg) IV (over 1 hour) starting 1 hour before procedure + Gentamicin 1.5 mg/kg IV (both adults and children, not to exceed 120 mg) 1 hour before. Complete infusion 30 minutes before procedure.
Moderate or low-risk. Amoxicillin 2.0 g (children, 50 mg/kg) PO 1 hour before procedure. Or, Ampicillin 2.0 g (children 50 mg/kg) IM or IV 30 minutes before procedure.
Moderate or Low-risk, penicillin allergic. Vancomycin 1.0 g (children, 20 mg/kg) over 1 hour. Complete infusion 30 minutes before starting procedure.

A 73-year-old diabetic white female presents with a 1-cm ulceration on the medial edge of the foot near the first metatarsal head. There is surrounding erythema of the skin and some exudative drainage is noted.

Which one of the following statements is true regarding this problem?

a.Povidone-iodine (Betadine) ointment should be applied continuously to the wound
b.Surgical debridement is important to promote healing
c.Anaerobic bacteria and gram-negative rods are seldom isolated
d.A swab of the ulcer for culture is likely to identify the invading pathogen


Neuropathy, ischemia, and infection commonly contribute to diabetic foot ulceration. Common pathogens include Staphylococcus, Streptococcus, and as part of a mixed infection, anaerobic bacteria and gram-negative rods. Swabs of superficial drainage are unreliable for identifying the infecting organism. A curettage specimen is more sensitive and specific. Thorough sharp debridement to remove debris, fibrin, and necrotic tissue is important to promote healing. Topical antibiotic ointments such as povidone-iodine promote maceration and are cytotoxic; therefore, they are not recommended.

A 67-year-old white female comes to your office complaining of a 1-month history of fatigue, weight loss, low-grade temperature elevation, and aching and stiffness in the upper back and shoulders. Physical examination confirms weakness in both shoulders with an otherwise normal musculoskeletal examination. Her temperature is 37.7° C (99.9° F).

Which one of the following would be the most appropriate diagnostic study?

a.Radiographs of the spine and shoulders
b.Erythrocyte sedimentation rate
c.Serologic titers for cytomegalovirus
d.Electromyographic studies of the shoulder girdle muscles
e.Febrile agglutinins


The symptoms described in this case are most consistent with a diagnosis of polymyalgia rheumatica, a subacute rheumatologic disorder affecting primarily the elderly. The erythrocyte sedimentation rate is the best diagnostic study and in most cases confirms the diagnosis. The disease does not cause radiographic changes. Cytomegalovirus infection would not be part of this differential. Electromyography would be unlikely to show changes in the absence of muscle weakness, and febrile agglutinins exhibit no relationship to this disease.

A 75-year-old white male with dementia of the Alzheimer's type presents with syncope. He often feels faint upon rising from his chair and occasionally passes out. His medication consists of thioridazine (Mellaril), 25 mg daily for agitation. The only pertinent abnormality found on examination is a 20-mm Hg fall in systolic blood pressure after standing for 1 minute.

Appropriate initial management would be to

a.prescribe fludrocortisone (Florinef), 0.1 mg daily
b.discontinue the thioridazine
c.instruct the patient to arise slowly from his bed or chair
d.encourage the patient to wear elastic stockings


This patient has orthostatic hypotension. Orthostatic hypotension is a symptomatic 20-mm Hg drop in systolic blood pressure or 10-mm Hg drop in diastolic blood pressure on assuming an upright posture. Initial therapy should include discontinuation of any drug that may be responsible for the orthostatic hypotension. In this patient the cause of the orthostatic hypotension is the thioridazine. Discontinuation of the drug is the only treatment he needs at this time. In the event the patient fails to improve with discontinuation of the offending drug, then he should be instructed to arise slowly from his bed or chair and encouraged to wear elastic stockings; if necessary, he can be started on fludrocortisone, 0.1 mg daily.

What is the single most important prognostic factor for survival in patients with vulvar squamous cell carcinomas?

A.tumor size
B.depth of invasion
C.tumor grade
D.Inguinal lymph node status


Inguinal lymph node status is the single most important prognostic factor in patients with squamous cell carcinomas. A study of 588 patients treated in two Gynecologic Oncology Group (GOG) trials reported a 5-year survival of 91% in those with negative inguinal lymph nodes. Five-year survival decreased to 75%, 36%, 24%, and 0% in patients with one or two, three or four, five or six, or seven or more positive lymph nodes, respectively. Patients with bilateral lymph node involvement had a survival rate of 25%, compared to 71% for those with unilateral lymph node involvement.
Other major prognostic factors include tumor size, depth of invasion, tumor grade, the presence of lymph-vascular space invasion, and extracapsular growth of lymph node metastases in the groin. These features correlate with one another, and are predictive of lymph node metastasis.
Source: The Diagnosis and Management of Vulvar Cancer.

Which of the following risk factors found in pregnant women with chronic hypertension is associated with adverse neonatal outcomes independent of the development of preeclampsia:

A.smoking history
C.advanced maternal age race


Proteinuria, detected early in pregnancy, is an independent risk factor for adverse neonatal outcomes, independent of the development of preeclampsia in women with chronic hypertension. Preeclampsia was defined as proteinuria (urinary protein excretion of greater than or equal to 300mg per 24 hours) in women without proteinuria at baseline.
Source: Sibai BM, Lindheimer M, Hauth J, et al: Risk Factors for Preeclampsia, Abruptio placentae, and Adverse Neonatal Outcomes Among Women with Chronic Hypertension.

What is the standard treatment for HIV-infected pregnant women?

A.There is no standard treatment for HIV-infected pregnant women
B.combination therapy with zidovudine and lamivudine
C.Zidovudine monotherapy
E.Zalcitabine with Didanosine


There is no standard treatment for HIV-infected pregnant women. Many decisions about HIV therapy will be predicated on the stage of HIV disease in the mother. HIV-infected pregnant women should be offered a range of antiretroviral therapy options with discussion of the risks, both known and unknown, of exposing the baby in utero to the medications, particularly in the first trimester, balanced against the benefits of therapy to control HIV infection and improve immunologic status. If possible, pregnant women infected with HIV should be enrolled in clinical trials to ensure that all aspects of therapy and toxicities are carefully documented. Drug exposure should be reported to national pregnancy registries.
Source: Shah SS, McGowan JP.: Preventing HIV Transmission During Pregnancy. Infect Med. 2001;18:94-105.
1.US Public Health Service Perinatal HIV Guidelines Working Group. US Public Health Service Task Force recommendations for the use of antiretroviral drugs in pregnant women infected with HIV-1 for maternal health and for reducing perinatal HIV-1 transmission in the United States, 2000. Available at: Accessed August 6, 2001.

All the following statements regarding the treatment of patients with HIV infection are true EXCEPT

A use of zidovudine (ZDV) therapy during pregnancy reduces the risk of vertical transmission to less than 10 percent
B HIV RNA assays should not be relied upon in making decisions about changing a patient's antiviral regimen
C though a useful agent in antiviral therapy, zidovudine monotherapy is a suboptimal regimen
D primary prophylaxis of Mycobacterium avium complex has clearly demonstrated efficacy in preventing bacteremia and improving survival
E breast feeding is a potential mode of HIV transmission and should be discouraged in women who are HIV-infected

The answer is B
AIDS Clinical Trial Group 076 demonstrated that ZDV (AZT) administration to women reduced the rate of HIV transmission in neonates from 25 percent in the placebo group to 8 percent in ZDV recipients. Postnatal transmission of HIV from mother to infant via breast feeding has been clearly documented. A meta-analysis of several prospective trials indicated a risk of 7 to 22 percent. Certainly, in developed countries, breast feeding by an infected mother should be avoided. There is, however, disagreement regarding this recommendation in developing countries where breast milk is the only source of adequate nutrition for the infant. Plasma HIV RNA assays provide precise and compelling data on the relative magnitude and durability of antiretroviral therapy. Most authorities recommend the use of HIV RNA assays (viral load) and CD4+ counts to guide decisions regarding antiretroviral therapy. While zidovudine has proven benefit in patients with <500 CD4+ lymphocytes, its use as monotherapy is suboptimal and should be reevaluated in any patient receiving it. Rifabutin and macrolides have both demonstrated marked efficacy in the primary prophylaxis against Mycobacterium avium with a concomitant decrease in bacteremia and improvement in survival

Which drug is usually effective for treating lithium-induced tremor?

a. Benztropine
b. Triazolam
c. Propranolol
d. Verapamil
e. Valproic acid

The correct answer is c.
c. Lithium-induced postural tremor is probably the most common of the medication-induced postural tremors. Propranolol in the range of 20 to 160 mg daily, given in two or three divided doses, is generally effective for treating lithium-induced postural tremor.

The most commonly recommended screening interval for cholesterol for adults under age 65 with no history of cardiac disease is

a. Yearly
b. Every 3 years
c. Every 5 years
d. Every 7 years
e. Every 10 years


In adults under age 65 with no cardiovascular disease, it is recommended that a serum cholesterol be done every 5 years. If the level is greater than 200 mg/dL, a complete fasting lipid profile should be ordered

In pt with >2 risk factors and total Ch>200, or <2 RF, total Ch>239, you do fsting lipoprotien analysis. If pt has <2 RF and is 200-239, recheck in 1-2 years.
Hope this help. In pt with >2 risk factors and total Ch>200, or <2 RF, total Ch>239, you do fsting lipoprotien analysis. If pt has <2 RF and is 200-239, recheck in 1-2 years.
Hope this help.

The number of community elderly people over age 65 who experience a fall is

a. 33%
b. 55%
c. 90%

The correct answer is a.
a. About one-third of community elderly people older than 65 years of age fall each year; this percentage increases to 50% by age 80 years. Most fallers experience multiple episodes. Although the results have been inconsistent, most studies have shown that the frequency of falling is similar in older men and women. Women, however, are about twice as likely to suffer a serious injury during a fall

What is the appropriate indication for influenza vaccine?

a. Adults over age 65 or those with chronic cardiac or pulmonary disease
b. All adults if not previously immunized within the past 10 years
c. Adults with sickle cell disease or splenic dysfunction
d. Staff and patients in dialysis unit


a.     Influenza vaccine is recommended for people over age 65 who have chronic cardiac or pulmonary disease as well as for younger patients with asthma

Which of the following conditions is not associated with smoking?

a. Peripheral vascular disease
b. Parkinson's disease
c. Complications of pregnancy
d. Cancer of the larynx
e. All of the above

The correct answer is b.
b. Peripheral vascular disease, complications of pregnancy, and cancer of the larynx are all associated with smoking. Other diseases related to smoking include coronary artery disease, cerebrovascular disease, lung, esophageal, oral, and bladder cancers, and chronic obstructive pulmonary disease. Parkinson's disease is not associated with smoking but may be inversely related to it

Which condition is predictive of cardiovascular events?

a. Hospitalization
b. Systolic hypertension
c. Diastolic hypertension
d. Antihypertensive medications
e. Normal-pressure hydrocephalus


Although the clinical treatment of hypertension has classically focused more on diastolic blood pressure levels, epidemiologic data indicates that for middle age and elderly adults, systolic blood pressure is more predictive of future cardiovascular disease than diastolic blood pressure. Elevation of systolic blood pressure continues to be the single strongest cardiovascular risk factor, but elevation of diastolic blood pressure is diminished substantially in terms of associated risk.

Systolic BP is a sensitive indicator of CVA/Adverse cardiovascular events, more than diastolic(particularly in gero population). However hospitalization is also an independent risk factor.

A 24-year-old, previously healthy woman presents with jaundice, confusion, and fever. Initial physical examination is unremarkable except for scattered petechiae on the lower extremities, scleral icterus, and disorientation on mental status examination. Laboratory examination discloses the following: hematocrit, 27 percent; white cell count, 12,000/L; platelet count, 10,000/L; bilirubin, 85 mol/L (5 mg/dL); direct bilirubin, 10 mol/L (0.6 mg/dL); urea nitrogen, 21 mmol/L (60 mg/dL); creatinine, 400 mol/L (4.5 mg/dL). Red blood cell smear discloses fragmented red blood cells and nucleated red blood cells. Prothrombin, thrombin, and partial thromboplastin times are all normal.
The most effective and appropriate therapeutic maneuver is likely to be

A plasmapheresis
B administration of aspirin
C administration of high-dose glucocorticoids
D administration of high-dose glucocorticoids plus cyclophosphamide
E splenectomy


she shows the pentad of TTP(thrombocytopenia, fever ,confusion, MAHA, renal dysfunction)

plasmapheresis is the mainstay of least 5days or for 2days after normalization of platelet count, resolution of neurologic signs
we can add methylprednisone 200mg IV qd.
antiplatelet agent (aspirin 325mg qd) in some cases
splenectomy- recurrent , refractory to plasma exchange

Which of the following statements best describes the role of polymerase chain reaction (PCR) in the diagnosis of HIV infection?

A It should be used if the western blot is indeterminate
B It is a useful screening test
C It should be used if two consecutive serologic tests (ELISA) are positive
D It should be used if the initial serologic test is positive, but the second is negative
E It has no real role

The answer is A
The standard serologic test for HIV infection, the enzyme-linked immunosorbent assay (ELISA), has a sensitivity of over 99.5 percent. However, this test is not particularly specific in that low-risk patients are subject to a false-positive rate of over 10 percent. If the ELISA test is indeterminate or positive, the test should be repeated. If the repeat is positive or indeterminate, one should proceed to the next step, which is a western blot test. If the repeat ELISA is negative, then the person can be assumed not to have HIV infection. A western blot test involves the reaction of the serum with a strip impregnated with HIV-1 antigens. Binding of antibodies in the patient's serum to the antigens on the strip is detected with an enzyme-conjugated anti-human antibody. A positive western blot test requires the detection of antibodies to several HIV-1 gene products. If the western blot is indeterminate, perhaps due to infection in evolution or due to cross-reacting antibodies in the patient's serum, one should proceed to a PCR test and repeat the western blot in 1 month. If the PCR is negative and there is no progression on the western blot, the diagnosis of HIV infection is ruled out. The PCR test is extraordinarily sensitive, but the false-positive rate would be too high for use as a cost-efficient screening test. A DNA PCR test for HIV involves the isolation of DNA from blood mononuclear cells and incubation with primers from both the gag and LTR regions, followed by amplification and hybridization to detect HIV proviral DNA. An RNA PCR test can be used to monitor the level of HIV genome present in plasma.

DNA PCR estimates viral load and is an indicator of HAART response-should be zero within 4-6 months of therapy. Ultrasensitive tests are also there but only the PCR is FDA approved for F/U

All of the following statements regarding the epidemiology of HIV infection are correct EXCEPT

A the risk of transmission following skin puncture from a needle contaminated with blood from an HIV-infected patient is less than 0.5 percent

B most cases of AIDS are now among IV drug users

C the risk of transmission from a single donor unit of blood is approximately 1/500,000

D most pediatric cases of AIDS arise because of vertical transmission from an infected mother

E there is no convincing evidence that saliva can transmit HIV

The answer is B
Among U.S. cases of AIDS, male-to-male sexual contact represents the most frequently reported mode of HIV transmission among persons with AIDS. However, over the past few years, the number of newly reported cases of AIDS among other groups, including IV drug users and heterosexuals, from certain large cities have surpassed the number of newly reported cases among men who had sex with men. The proportion of new cases attributed to IV drug use and heterosexual sex has increased dramatically over the past ten years. There is a small but existent occupational risk of HIV transmission. Large, multi-institutional studies have indicated the risk of a penetrating injury, such as a needlestick from an HIV-infected person, to be approximately 0.3 percent. Risk posed by a mucocutaneous exposure is probably closer to 0.1 percent. Current measures used to screen donors now include p24 antigen testing which has resulted in a further decrease in the risk of being infected from a unit of blood to at most 1 in 450,000 to 1 in 660,000. Pediatric AIDS arises mainly from infants born to mothers who are HIV-infected. The remainder are generally exposed via blood transfusions. Although HIV can be rarely isolated from saliva, there is no convincing evidence that saliva can transmit HIV infection, either through kissing or other exposures, such as occupationally to health care workers.

NAT (genomic amplification testing) is also used by big centers, I think it is not yet FDA approved. It shortens the window period by 11 days.
Ref J.B. Henry: Clinical Diagnosis and Management by Laboratory Methods, 20th edition

Which is a risk factor for oral cancer?

a. Radiation to head and neck
b. Alcohol and tobacco abuse
c. Fair skin and sun exposure


most important predisposing risk factors for the primary head and neck ca. is the use of alcohol and tobacco,
the use of the two together is more than additive in enhancing carcinogenesis
other associated etiologic agents include viruses.(HPV 6,11,16,18), EBV, HIV genetic susceptibility

Which legal document most correctly defines an advanced directive?

a. Living will
b. Durable power of attorney for health care
c. Both
d. Neither


Advance directives are written documents intended to become effective when the patient has lost decision-making capacity. There are three forms of advance directives. The living will specifies medical treatment preference and the medical conditions in which those preferences should or should not be implemented. With the durable power of attorney a person is designated to act as a health care representative with the legal authority to make health care decisions for the patient. However, the decisions are not specified by the document. The third form of advance directive is a combination of the above two forms. A representative is designated with the responsibility to assure that the patient's written instructions concerning medical therapy are respected

A 44-year-old nonsmoking woman presents to your office with a productive cough. She has had asthma since childhood, with several exacerbations requiring hospitalization over the past 10 years. She comes to you for treatment of poorly controlled asthma. She complains of daily productive cough, frequently expectorating brown mucus plugs, and with dyspnea, wheezing, fever, and chills. She currently is on an albuterol inhaler, inhaled beclomethasone, theophylline, and occasional short courses of prednisone for exacerbations. She denies allergies, pets, or travel. She denies postnasal drip, heartburn, and chest pain.
Physical examination reveals a woman in no respiratory distress. Head and neck examination is normal. Lung examination reveals diffuse inspiratory and expiratory wheezing with crackles in the right upper lung field. A chest radiograph reveals a right-upper-lobe infiltrate with subsegmental atelectasis and central bronchiectasis. A room air ABG shows pH 7.45, pCO2 35 mmHg, and pO2 80 mmHg. Hematocrit is 40%, leukocyte count is 15,000 mm3, segmented neutrophils 60%, lymphocytes 20%, and eosinophils 15%. Serum IgE level is 3500. Sputum analysis reveals hyphae consistent with aspergillus. A skin test for aspergillus reveals an immediate wheal and flare response.
The most likely diagnosis of this patient is allergic bronchopulmonary aspergillosis.
Which of the following is the most appropriate therapy for this patient?

a. Itraconazole
b. Amphotericin B
c. Prednisone
d. Surgical resection
e. No specific therapy is required


ABPA- allergen avoidance and intermittent use of corticosteroids
Pulmonary aspergilloma-observation and surgical resection for the patients with massive hemoptysis
Invasive aspergilloma- serious invasion:amphotericin B(1mg/kg/day for 2.0-2.5g total)
mild to moderate invasion-Itraconazole(600mg po qd for 4days, then 200-400mg po qd for 1 year)

Which of the following patients should undergo operative excision of an abdominal aortic aneurysm and replacement with a vascular graft?

A: A 58-year-old man with a 8-cm abdominal aneurysm who sustained a myocardial infarction 3 months ago

B: A 65-year-old man with a 7-cm aneurysm who sustained a myocardial infarction 1 year ago

C: A 65- year- old woman with a 4-cm aneurysm and no prior history of heart or lung disease

D: A 58-year-old man with a 7-cm aneurysm and FEV1 of 0.8 L

E: A 67- year- old man with an 8-cm aneurysm and creatinine 3.2 mg/dL

The answer is B
The vast majority of aortic aneurysms are due to atherosclerosis; 75 percent of such aneurysms are located in the distal aorta below the renal arteries. Although these aneurysms are typically asymptomatic, rupture may occur with devastating consequences. The prognosis is related to the size of the aneurysm as well as the presence of coexistent vascular diseases. Patients with aneurysms exceeding 6 cm who are not treated surgically have 50 percent mortality in 1 year, while those with lesions between 4 and 6 cm have 25 percent mortality during the first year. Surgical excision and replacement with a prosthetic graft are indicated for patients with aneurysms greater than 6 cm in diameter as well as in symptomatic patients or those with rapidly enlarging aneurysms regardless of the absolute diameter. Depending on the degree of operative risk, surgery also may be recommended in those with aneurysms with diameters between 5 and 6 cm. Contraindications to elective reconstruction include myocardial infarction within the past 6 months, intractable congestive heart failure, ongoing severe angina pectoris, severe obstructive lung disease, severe chronic renal failure, history of stroke with residual neurologic deficits, and life expectancy less than 2 years. An extensive preoperative evaluation including assessment of coronary disease, renal failure, and pulmonary function studies should be carried out, and if abnormalities are found, they should be ameliorated when possible. For patients in whom the diameter of the aneurysm is less than 6 cm or in whom there is significant operative risk, serial ultrasound may be helpful in defining a group that more urgently requires surgical intervention based on expansion of 0.5 cm or more.

Is a stool ova and parasites (stool O&P) recommended in cases of acute diarrhea?

A. Yes
B. No


Because this laboratory evaluation isn't cost-effective in cases of acute diarrhea, it is not recommended. However, the American College of Gastroenterology Practice Parameters Guideline Committee (ACG PPGC) recommends ordering the study if there is a high suspicion of parasitic infection; if the patient hasn't been treated empirically for parasites; or if one of the following conditions exists:
• persistent diarrhea in a patient with AIDS or who is a homosexual male;
• diarrhea following travel to Russia, Nepal, or mountainous regions;
• exposure to infants attending daycare centers;
• persistent diarrhea associated with a community outbreak; or
• bloody diarrhea with negative fecal leukocyte test results.

at first,ask about fever, tenesmus, abdominal pain hx.of diet, travel ,antibiotics use ,sexual exposure ,other disease
if say 'no' - rehydration with oral or IV and observe
if say 'yes' -stool exam and culture..

A 77-year-old male with COPD has a non-Q wave MI. Should this patient receive a beta-blocker?

A. Yes
B. No

Yes. According to a retrospective review of 201,752 patients with myocardial infarction published in the August 20, 1998 issue of the New England Journal of Medicine, mortality was lower across every subgroup of patients treated with beta-blockade compared with untreated patients, including those with heart failure, chronic pulmonary disease, advanced age, and non-Q wave infarction.

A 25-year-old woman presents with brownish discoloration of the face. She is 6 months pregnant and reports that the areas of hyperpigmentation developed as her pregnancy progressed. What is the most likely diagnosis?

A. Solar Lentigines
B. Pityriasis versicolor
C. Café au lait Spots
D. Melanoma
E. Melasma


Melasma gravidarum (chloasma gravidarum). This form of melasma (chloasma), a fairly trivial cause of skin hyperpigmentation, generally presents in pregnant women as a tan or brownish discoloration on the face. These blotches often proceed as far up as the hairline and extend down to the jawline. The hyperpigmented areas of skin are typically symmetric and localized to the forehead and chin, but may also manifest on the areolae, axilae, and genitals. The condition is more prevalent among dark-skinned individuals and worsens on sun exposure. Levels of progesterone and estrogen -- both of which stimulate melanin formation -- rise during pregnancy, implicating a role for these hormones in the etiology of this pigmented lesion. Although melasma gravidarum usually fades after delivery, it may persist for many years.

A diabetic patient well-known to you has a BP reading of 150/90mmHg at his latest office visit. What is the target BP recommended for patients with diabetes?

A. 130/80 mmHG
B. 120/80 mmHG
C. 120/90 mmHG
D. 130/90 mmHG


According to the guidelines for management of hypertension (JNC-VI) which were revised in November of 1997, patients with diabetes should have a BP less than 130/80mmHG.
Other revisions include an emphasis on classification; the previous terms of 'mild,' 'moderate,' and 'severe' hypertension have been replaced with 'Stages 1, 2, and 3.' Because of its small size, Stage 4 hypertension (from JNC V) has been deleted, with Stage 3 now encompassing patients with BP readings greater than 180mmHg systolic and/or greater than 110mmHg diastolic. Prognostic implications of systolic hypertension are more important than those of diastolic hypertension.

Is testing for H pylori recommended in patients with no prior history of ulcer disease and who are not at increased risk of NSAID-induced ulcer complications?

A. Yes
B. No


In a patient with no history of ulcer disease and who otherwise is not at increased risk of NSAID-induced ulcer complications, testing for H pylori is not recommended at this time.

Immunocompromised children should be vaccinated against varicella?

A. yes
B. no

No. The American Academy of Pediatrics currently recommends that most of these children not receive the vaccine routinely. The results of administering the vaccine under research protocols show that around 40% of those with acute lymphocytic leukemia (ALL) developed a small rash consisting of vesicular lesions that often congregated around the site of injection.[1] Many of these patients needed treatment with acyclovir, and some required admission to the hospital for IV administration.
There is, however, an ongoing study in which children with ALL are receiving the vaccine. The manufacturer makes free vaccine available -- through a research protocol -- to any physician for use in patients who have ALL and who meet certain eligibility criteria.[2] This is also true for renal transplantation patients. The CDC now recommends giving the vaccine to children with HIV who are asymptomatic and have CD4+ age-specific T-lymphocyte percentage of >/= 25%.[3] However, a 2-dose regimen is recommended.

contraIx.of VZV vaccination severe immunocompromised patient , patient receiving gammaimmunoglobulin, during pregnancy, acute febrile illness , hypersensitivity to certain antibiotics(erythromycin..), poor general condition due to renovascular disease, renal disease, and liver disease

high risk group like immunocompromised with chickenpox-
acyclovir 500mg/m2/8hours)

What is the most common pattern of dyslipidemia in patients with type 2 diabetes?

A. elevated triglyceride levels and decreased HDL cholesterol
B. elevated triglyceride levels
C. elevated triglyceride levels and increased high-density lipoprotein (HDL) cholesterol
D. elevated triglyceride levels and increased HDL cholesterol levels
E. elevated triglyceride levels and increased LDL cholesterol levels


Dyslipidemia in patients with type 2 diabetes is most commonly manifested by elevated triglyceride levels and decreased high-density lipoprotein (HDL) cholesterol. Although the concentration of low-density lipoprotein (LDL) cholesterol is usually not significantly different from that of nondiabetic individuals, patients with type 2 diabetes typically have a higher prevalence of small denser LDL particles, which have been reported to be more atherogenic.
The American Diabetes Association defines optimal lipoprotein levels for adults with diabetes as LDL cholesterol < 100 mg/dL (2.60 mmol/L) and an HDL cholesterol > 45 mg/dL (1.15 mmol/L). The desirable level of triglycerides is < 200 mg/dL (2.30 mmol/L).

What is the definitive therapy for decompression illness in divers?

A. Hyperbaric oxygen (HBO) treatment
B. Nitrogen treatment
C. 100% oxygen at 30 FSW for 90 minutes bid
D. No definite treatment is available


Hyperbaric oxygen (HBO) treatment is gaining popularity as the definitive therapy for a growing number of disorders, including decompression illness, arterial gas embolism, carbon monoxide poisoning, clostridial infections, crush injuries, diabetic leg ulcers, skin graft failures, refractory osteomyelitis, thermal burns, necrotizing soft tissue infections, and osteoradionecrosis.
In the US, hyperbaric oxygen therapy for decompression sickness is guided by the Navy Treatment Tables. The prescribed treatments are very effective, especially when recompression is begun promptly. The purpose of the therapy is two-fold: to promote inert gas elimination and to help cause a decrease in bubble size. The treatment outlined by the tables also provides oxygen to the damaged tissues, treats platelet and clotting damage and allows excretion of harmful metabolites. The oxygen reduces CNS edema and provides a high oxygen gradient (2000 mm Hg) for the ischemic tissues.

Should patients with total hip arthroplasty (THA) receive antibiotic prophylaxis for dental procedures?

A. Yes
B. No


Perioperative antibiotics are not necessary in routine dental procedures in nonimmunocompromised patients who have total hip implants. However, they should be used in any post-THA patients undergoing extensive dental procedures involving periodontal work, extractions, and relatively high blood loss.
In a retrospective study of 3000 patients with THA over 14 years from 1982 to 1995, 52 (1.7%) late infections of THA were identified. Of those, 3 patients (6% of those infected) were found to have infections related to a dental procedure both temporally and bacteriologically.

A 55-year-old healthy white postmenopausal female presents to your office with complaints of low back pain. She takes no drugs and does not smoke. Would you recommend that she get a bone density scan?

A. Yes
B. No

Yes. Because of her gender, advancing age (she is postmenopausal and not taking estrogen), and complaints of back pain (which may be due to weakened vertebrae), this patient should be evaluated for osteoporosis. Diagnosis of osteoporosis is based on measurement of bone mineral density, which correlates with fracture risk.
The absence of risk factors, such as family history or the use of certain medications, including anticonvulsants or corticosteroids, which can promote osteoporosis, does not guarantee that this patient does not have the disease; up to 35% of all women with no documented risk factors will develop osteoporosis. And osteopenia may be present in more than half the postmenopausal women seen in a typical primary care setting. Therefore, bone mineral density testing should be considered in any patient with at least one risk factor for osteoporosis, a history of hyperthyroidism/hyperparathyroidism, a chronic disease that can cause bone loss, and in all postmenopausal women who are not taking estrogen replacement therapy. Dual energy x-ray absorptiometry is the most widely used imaging technique for measuring bone mineral density.

A 65-year-old cirrhotic male with a history of hepatitis C virus (HCV) infection presents to clinic. What is the recommended screening strategy for assessing this patient for hepatocellular carcinoma (HCC)?

A. ultrasound every six months
B. alpha-feto protein (AFP) every six months
C. ultrasound and alpha-feto protein (AFP) every three months
D. ultrasound and alpha-fetp protein (AFP) every six months.
E. No screening is recommended

Answer is C.
According to a report from the American College of Gastroenterology Annual Scientific Meeting (held October 15-20, 1999, in Phoenix, Ariz), for patients at 'extremely high risk' of developing HCC, such as those with cirrhosis associated with active ethanol ingestion and HCV infection, ultrasonography and serum alpha-fetoprotein (AFP) measurements should be performed every 3 months.
HCC is the most common primary liver cancer and has a worldwide distribution. This malignancy is associated with many underlying conditions and events, including hepatitis B virus (HBV) and HCV infection (with or without cirrhosis); end-stage liver diseases due to ethanol ingestion, hemochromatosis, and alpha-1-antitrypsin deficiency; exposure to environmental toxins, such as aflatoxin; and administered medications, such as anabolic steroids.
Establishing a proper screening strategy first requires determination of who should be screened. All patients with at-risk disorders should be considered for screening. In most cases, this means screening those with cirrhosis, especially when HBV, HCV, ethanol, or alpha-1-antitrypsin deficiency are causative diseases.

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