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Corrections and Updates

This Errata section presents corrections and/or updates to the content of MedStudy products and categorizes them by Internal Medicine or Pediatrics specialities.

Click on the appropriate title below to view the associated Errata information.

Internal Medicine Products

Endocrinology: Page 7-11, Diagnosis of Hypothyroidism

Text currently reads:
Routine TRH stimulation test is generally done because management is the same: Replace thyroid hormone to achieve a normal FT4 level.

Text should read:

Routine TRH stimulation test is generally not done because management is the same: Replace thyroid hormone to achieve a normal FT4 level.

 

Cardiology: Page 5-39, Internal Carotid Artery Dissection

Text currently reads:

Suspect spontaneous dissection of the internal carotid artery (cervical area) in a patient with unilateral headache along with either TIAs or a dilated pupil.

Text should read:

Suspect spontaneous dissection of the internal carotid artery (cervical area) in a patient with unilateral headache along with either TIAs or a constricted pupil.

 

Cardiology: Page 5-24, Mechanical Complications after STEMI

Text currently reads:

You may (or may not) hear a short, early systolic murmur.

Text should read:

You may (or may not) hear a murmur (early, mid, to holosystolic) at the left sternal border to base of heart, and it may radiate to the back. Intensity of this murmur does not correlate with the severity of mitral regurgitation.

Infectious Disease, page 5-56, under Diagnosis

Text currently reads: Possible infective endocarditis is diagnosed with 1 major + 3 minor criteria.
Text should read: Possible infective endocarditis is diagnosed with either 1 major criterion + 1 minor criterion OR 3 minor criteria.

Endocrinology Section, Book 4, Page 7-41, Diabetes Mellitus section, middle of second column:
Currently reads: “Like GLP-1 antagonists, DPP4Is are reserved as 1st line drugs…”
This should instead read: “Like GLP-1 agonists, DPP4Is are served as 1st line drugs…”

Nephrology Section, Book 2, Page 4-19, Renal Tubular Acidosis section:
Currently reads: “Dietary restriction of sodium or bicarbonate administration may be sufficient treatment.” This should instead read: “Dietary restriction of potassium or bicarbonate administration may be sufficient treatment.”

Cardiology Section, Book 3, Pages 5-34 and 5-35:

Information in Tables 5-10 and 5-11 should be read across the 2 tables when side-by-side. Text in Table 5-11 is incorrect in several rows when reading across both tables.

Table 5-11 has been corrected.

Click here for pdf of tables >

Cardiology Section; Page 5-7, Murmurs section:
The text has been updated to read:
All valve murmurs increase in intensity when blood flow increases across the valve. Standing and the strain phase of Valsalva decrease right and left cardiac filling and cause the sound of most murmurs to decrease, but these actions increase the intensity of the murmurs of mitral valve prolapse (MVP) and hypertrophic cardiomyopathy (HCM; formerly IHSS). Squatting and lying down (or passive straight-leg raises if already supine) increase cardiac volume. This increased volume also increases intensity of all murmurs except, again, MVP and HCM.

Summary of the most useful maneuvers to differentiate murmurs:

•  Passive straight-leg raise (to 45 degrees, listen after 15 sec): increases venous return

•  Valsalva (hold for 20 sec, listen just before end): decreases venous return

•  Standing (squat for >30sec then quickly stand; listen during 1st 15 sec after standing):
decreases venous return

•  Transient arterial occlusion (bp cuff on both arms, inflated > 20 mm above systolic pressure):
increase systemic vascular resistance

•  Handgrip (isomeric; listen at end of 1 min max grip): increase systemic vascular resistance

•  Squatting: increases venous return and increases systemic vascular resistance but preload effect
is stronger than afterload effect

Explanation:
All valve murmurs are louder when blood flow increases across the valve.

Standing and the strain phase of Valsalva have similar effects in that they decrease right and left ventricular filling (= decrease preload, = decrease cardiac volume) and cause the sound of most murmurs to decrease, but these actions accentuate the murmurs of mitral valve prolapse (MVP) and hypertrophic cardiomyopathy (HCM). With HCM “accentuates” means gets louder. Note that standing produces better results than valsalva.

With MVP, “accentuates” means moving the click earlier (closer to S1) and prolonging the following murmur. Why does this happen? When the left atrial end diastolic pressure (preload) decreases due to these maneuvers, there is less backpressure on the MV and it closes earlier. So, with MVP, you will hear the click, caused by snapping of the cordae tendenae, shift earlier (closer to S1) and the following regurgitant murmur prolong.

Squatting and lying down (or passive straight-leg raises if already supine) increase right and left ventricular filling (= increase preload, = increase cardiac volume). Squatting also increases afterload to a lesser extent. These maneuvers accentuate all murmurs except it diminishes MVP and HCM (in MVP this means later systolic click (closer to S2) with a shorter following regurgitant murmur).

Sustained handgrip and transient arterial occlusion (BP cuff on both arms) boosts systemic vascular resistance and increases left ventricular volume and therefore decreases the murmurs of HCM (from increased left ventricular volume) and aortic stenosis (AS; from decreased flow across the aortic valve). This increased left ventricular pressure causes an increase in the left atrial end diastolic pressure and therefore also affects the findings with MVP, causing the click murmur to shift more toward S2, as with squatting.

All right-sided murmurs are louder during Inspiration and decrease during expiration. Breathing has little effect on left-heart filling. Typically this finding is used to help determine whether a murmur is right- or left-sided.

Best tests for increasing/decreasing specific systolic murmurs:
For HCM, use:

•  Standing (from squat): 95% get increased murmur.

•  Valsalva (if can’t do squat-to-stand): 65% get increased murmur.

•  Passive straight-leg raise or: 85% get decreased murmur

•  Handgrip: 85% get decreased murmur

For MVP, use:

•  Standing and valsalva: click-murmur moves earlier

•  Transient arterial occlusion: 80% click-murmur moves later

•  Handgrip: 70% click-murmur moves later

For VSD, use:

•  Standing and valsalva: murmur decreased

•  Transient arterial occlusion: 80% murmur increased

•  Handgrip: 70% murmur increased

For AS, use:

•  Transient arterial occlusion: murmur decreased

•  Handgrip: murmur decreased

Cardiology Section; Page 5-51, Quick Quiz box:
The third question currently reads: “How is BNP used to differentiate constrictive pericarditis from restrictive pericarditis?”
This should instead read: “How is BNP used to differentiate constrictive pericarditis from restrictivecardiomyopathy?”

Endocrinology Section; Page 7-35, middle of the second column:
Currently reads: “2 says you can consider one of these drugs in high-risk prediabetics.”
This should instead read: “AACE says you can consider one…”

Gastroenterology Section; Page 1-14, second column, last paragraph:
Currently reads: “If the gastrin level is elevated in a patient with gastric acid…”
This should instead read: If the gastrin level is elevated in a patient with gastric ulcer…”

General Internal Medicine Section; Page 10-47, first column, above Hearing Loss header:
Currently reads: Refer to be seen within 1-2 days:

•  Fetinal vein thrombosis,

This should instead read: Refer to be seen within 1-2 days:

•  Retinal vein thrombosis,

Hematology Section; Page 8-21, first column, last paragraph:
The last sentence currently reads: “Therefore, a mixing study that does maintain a sustained normalization…” 
This should instead read: “Therefore, a mixing study that does NOT maintain a sustained normalization…”

Hematology Section; Page 8-35, 2nd column, first paragraph under Aggressive Non-Hodgkin Lymphomas:
Third sentence of section currently reads: “…it may also develop in extranodal sights such as the lung or liver.” 
This should instead read: “…it may also develop in extranodal sites such as the lung or liver.”

Infectious Disease Section; Page 2-18, under sub-heading Listeria:
Currently reads: “Listeria monocytogenes, an anaerobic GNR, causes listeriosis…”
This should instead read: “Listeria monocytogenes, an anaerobic gram-positive rod, causes listeriosis…”

Nephrology Section; Page 4-29, middle of second column: Under the section for Prerenal AKI the bulleted list reads:
•  Drugs that cause vasoconstriction of the afferent and/or efferent arterioles:
– NSAIDs (afferent)
– ACEIs/ARBs (mainly efferent)
– Post-transplant immunosuppression drugs (afferent)

This should instead read:
•  Drugs that cause vasoconstriction of the afferent and/or efferent arterioles:
– NSAIDs (afferent)
– Post-transplant immunosuppression drugs (afferent)

Nephrology Section; Page 4-50; bottom of page first bullet point
•  Allow passage (if less than 0.5mm).

This should instead read:

•  Allow passage (if less than 5mm).

Neurology Section; Page 11-16, 1st column:
The statement currently reads: “Note: Oral contraceptives can increase the drug concentration of AED lamotrigine.”
This should instead read: “Note: Oral contraceptives can decrease the drug concentration of AED lamotrigine up to 50%!”

Neurology Section; Page 11-31, 1st column:
The first statement under the Quick Quiz currently reads: “Confirm the diagnosis of lumbar spinal stenosis with an MRI. Treatment is…”
This should instead read: “A presumptive diagnosis of spinal stenosis is made clinically. Neuroimaging (usually MRI) before treatment is not necessary for patients < 50 years old with no neurological deficits. In this group of patients, MRI is done only if there is worsening of symptoms during the first month of treatment or no improvement by the end of this first month. In patients > 50 years old and in those with neurological deficits, imaging is often done immediately to confirm the diagnosis before determining treatment. Treatment is…”

Rheumatoloy Section; Page 6-2, bottom of the first column:
Table 6-2: ANCAs: Table incorrectly lists Polyarteritis nodosa as anti-MPO–; PAN is anti-MPO+. This is discussed correctly in the text.

Infectious Disease Section, Book 1, Page 2-43, HIV and AIDS section, Quick Quiz question #2:
Currently reads: “What is the utility of measuring HIV DNA?”
This should instead read: “What is the utility of measuring HIV RNA?”.

Endocrinology Section, Book 4, Page 7-39, Diabetes Mellitus section, second column, next-to-last paragraph:
Currently reads: “Like GLP-1 antagonists, these drugs are reserved as 1st line drugs…”
This should instead read: “Like GLP-1 agonists, these drugs are served as 1st line drugs…”.

Answer #195
The correct answer should be: A. Dissection of the ascending aorta should be treated with aggressive medical therapy and close observation.

Add the following sentence to the beginning of the explanation: The patient has Marfan syndrome and is suffering a dissection of the aorta.

The Board Testing Point should read: Recognize the clinical characteristics of a dissection of the aorta in a patient with Marfan syndrome.

Question/Answer #255
Question and Answer/Explanation #255 in Infectious Disease topic should be moved to the Nephrology topic.
The scenario, answer choices, correct answer indication, and explanation are still valid.

Answer #271
The first paragraph in the explanation currently reads:
Alkalosis is generated when H+ is lost or bicarbonate is gained by the body or contraction of the plasma volume around a fixed amout of total body bicarbonate; i.e., loss of bicarbonate-free fluid. Less common causes of alkalosis generation are H+ shifts from the extracellular to the intracellular space. The alkalosis is then maintained by the inability of the kidneys to excrete excess bicarbonate in the urine (usually driven by aldosterone and decreased distal chloride delivery). The urinary chloride concentration is the most important lab test in the workup of metabolic acidosis. Chloride-responsive alkalosis (urine chloride < 10 mEq/L) is characterized by volume depletion; examples include vomiting, nasogastric suction, and contraction alkalsois (due to remote diuretic use).

The first paragraph in the explanation should read:
Alkalosis is generated when H+ is lost or bicarbonate is gained by the body or contraction of the plasma volume around a fixed amount of total body bicarbonate; i.e., loss of bicarbonate-free fluid. Less common causes of alkalosis generation are H+ shifts from the extracellular to the intracellular space. The alkalosis is then maintained by the inability of the kidneys to excrete excess bicarbonate in the urine (usually driven by aldosterone and decreased distal chloride delivery). The urinary chloride concentration is the most important lab test in the workup of metabolic alkalosis. Chloride-responsive alkalosis (urine chloride < 10 mEq/L) is characterized by volume depletion; examples include vomiting, nasogastric suction, and contraction alkalosis (due to remote diuretic use).

Answer #291
The explanation currently reads:
Answer: Na 136, K 5.0, Cl 102, HCO3 20, Serum Creatinine 3.5, Arterial pH 7.36, Urine pH 5.0. With a moderate glomerulonephritis, metabolic acidosis is usually mild, and the anion gap is only slightly elevated, if at all.

The explanation should read:
Answer option “Na 136, K 5.0, Cl 102, HCO3 20, Serum Creatinine 3.5, Arterial pH 7.36, Urine pH 5.0” best fits the laboratory pattern of someone recovering from acute kidney injury due to glomerulonephritis. With a moderate glomerulonephritis, metabolic acidosis is usually mild, and the anion gap is only slightly elevated, if at all. The other answer options are incorrect for the following reasons: these choices portray a more severe metabolic acidosis; hypokalemia is not typically seen in acute glomerulonephritis; the presence of significant hyperkalemia would not be expected in a patient who is in renal recovery. In addition, a high urine pH with a mild metabolic acidosis signifies a tubulointerstitial process (i.e., distal RTA), whereas acute post-infectious glomerulonephritis is primarily a glomerular disease.

Question #7
The question currently reads:
A 40-year-old man undergoes endoscopy for heartburn and dysphagia. At endoscopy, he is found to have 3 small duodenal ulcers and LA class D reflux esophagitis. He is placed on esomeprazole. Because of this presentation, he undergoes fasting serum gastrin testing. His gastrin level is 600 pg/dL (upper limit normal is 110 pg/dL). He returns to your clinic.

This question should instead read:
A 40-year-old man undergoes endoscopy for heartburn and dysphagia. At endoscopy, he is found to have 3 small duodenal ulcers and LA class D reflux esophagitis. He is placed on esomeprazole. Three weeks later, he undergoes fasting serum gastrin testing. His gastrin level is 600 pg/dL (upper limit normal is 110 pg/dL). He returns to your clinic.

Question #10
The question currently reads:
A 21-year-old man is referred for abdominal pain for 5 years. He has had a workup from an outside gastroenterologist…

The question should read:
A 21-year-old man is referred for abdominal pain for 5 years. He has had a negative workup from an outside gastroenterologist…

Question #48
Response A currently reads: Neck circumference > 16 cm increases the risk of obstructive sleep apnea.
Response A should read: Neck circumference > 17 inches increases the risk of obstructive sleep apnea.

The explanation should read:

Answer: An apnea-hypopnea index (AHI) greater than 1 (one) is consistent with a diagnosis of OSA.

Obstructive sleep apnea (OSA) is due to repetitive obstruction of the upper airway that occurs during sleep. It is defined by the combination of total hypopneas (reduction in airflow > 50 %) and apneas (complete cessation of airflow) during sleep that is divided by the numbers of hours slept. This index is known as the apnea-hypopnea index (AHI). An AHI of 5–15 is associated with mild OSA, 16–35 with moderate OSA, and > 35 with severe OSA.Risk factors for OSA include obesity, neck circumference > 16 inches in women and > 17 inches in men, facial deformities, and menopause. The most common and effective treatment for OSA is CPAP (continuous positive airway pressure), which splints the airway open during sleep and allows for adequate airflow. OSA is associated with hypertension, coronary artery disease, cerebrovascular accidents, and glucose intolerance. Treatment with CPAP can reverse hypertension in certain cases without additional pharmacologic treatment.

Question #51:
The explanation currently reads: This patient has a moderately sized pleural effusion that is transudative in nature according to Light’s criteria. These…

The explanation should instead read: This patient has a moderately sized pleural effusion that you can determine is transudative in nature because it does not meet the criteria of an exudative effusion according to Light’s criteria. These…

Question #58
The question currently reads: A 36-year-old woman has had increasing dyspnea for 8 years. She has no cough or increased sputum production. On physical exam, there is hyperresonance to percussion in the bases. A chest radiograph reveals increased lung volumes with flattening of the diaphragmatic leaves bilaterally.

The question should instead read: A 36-year-old woman has had increasing dyspnea for 8 years. She has no cough or increased sputum production. No smoking history. On physical exam, there is hyperresonance to percussion in the bases. A chest radiograph reveals increased lung volumes with flattening of the diaphragmatic leaves bilaterally.

Answer #64
Add to the end of the explanation: HPOA is not associated with squamous cell carcinoma and is not typically associated with small cell lung cancer.

Answer #65
Add to the end of the explanation: Even so, evidence is lacking on whether response to treatment translates to a better outcome. The other answer choices do not indicate a response to treatment.

Question #68
The following image should have been included with the question:

IM-Cert-Pulmonary-150x150

Question #78
The Stem currently reads:
A 33-year-old woman in your clinic has a chest CT (see below). She has mild, worsening airflow limitation on serial spirometry. She has increasing exertional dyspnea that is now significantly limiting her activity. She had a small, spontaneous pneumothorax last year that resolved without intervention. She has never smoked, but her spouse does smoke.

It should instead read:
A 33-year-old woman in your clinic has a chest CT (see below). She has mild, worsening airflow limitation on serial spirometry. She has increasing exertional dyspnea that is now significantly limiting her activity. She had a small, spontaneous pneumothorax last year that resolved without intervention. Alpha-1 antitrypsin levels were normal when checked at that time. She has never smoked, but her spouse does smoke.

Question #197
The explanation currently reads:
Trimethoprim/sulfamethoxazole can be an effective replacement for ampicillin-sulbactam therapy on penicillin-allergic patients, but should be coupled with clindamycin to provide adequate coverage for the pathogens found in a human bite (specifically Eikenella ). Wound closure is not indicated in a wound this old. HBIG is not indicated because hepatitis B exposure in this situation is very unlikely. Hepatitis B vaccine, however, is indicated for certain subgroups of the population, including inmates of both juvenile detention and criminal detention facilities. Tetanus booster within 5 years is adequate even for contaminated wounds.

The explanation should instead read:
Hand wounds sustained in a bar fight are often due to contact with teeth and are treated as a human bite. Trimethoprim/sulfamethoxazole can be an effective replacement for ampicillin-sulbactam therapy on penicillin-allergic patients, but should be coupled with clindamycin to provide adequate coverage for the pathogens found in a human bite (specifically Eikenella ). Wound closure is not indicated in a wound this old. HBIG is not indicated because hepatitis B exposure in this situation is very unlikely. Hepatitis B vaccine, however, is indicated for certain subgroups of the population, including inmates of both juvenile detention and criminal detention facilities. Tetanus booster within 5 years is adequate even for contaminated wounds.

Question #223
The answer is incorrectly identified as option A (Benzathine penicillin G 2.4 million units IM q week x 3); the correct answer is option D (Benzathine penicillin G 2.4 million units IM).

Question #431
In the Laboratory Results under WBC differential, the table currently lists lymphocytes twice.
The WBC differential section of the Laboratory Results table should instead list: 88% neutrophils

10% lymphocytes

2% eosinophils.

Answer #449
The answer is incorrectly identified as option B. Oral decongestants.
The correct answer is option A. Nasal steroids.

The explanation currently reads:
Vasomotor rhinitis produces clear nasal discharge secondary to congestion of the nasal mucosa. Alternating exposure to dry and humid or to cold and warm environments can trigger this problem. Review of this scenario reveals no evidence of an infectious or allergic cause for this patient’s drainage. Steroids, antibiotics, and antihistamines are not primary treatments for vasomotor rhinitis. Nasal alpha-agonists run the risk of inducing rebound nasal congestion, rhinitis medicamentosa. Oral decongestants and modification of environmental exposures are the most appropriate interventions.

The explanation should read:
Vasomotor rhinitis produces clear nasal discharge secondary to congestion of the nasal mucosa. Alternating exposure to dry and humid or to cold and warm environments can trigger this problem. Review of this scenario reveals no evidence of an infectious or allergic cause for this patient’s drainage. Oral decongestants, antibiotics, and antihistamines are not primary treatments for vasomotor rhinitis. Nasal alpha-agonists run the risk of inducing rebound nasal congestion, rhinitis medicamentosa. Nasal steroids and modification of environmental exposures are the most appropriate interventions.

Question #518
Part of the answer explanation currently reads: “The key feature that identifies opiate withdrawal in this patient as the most likely cause is pinpoint pupils during the exam.”

This should instead read: “The key feature that identifies opiate withdrawal in this patient is the dilated eyes. Remember, pinpoint pupils = opiate usage; dilated pupils (mydriasis) = opiate withdrawal.”

Question #547
The Stem currently reads:
A 55-year-old woman with a history of hypothyroidism presents with increasing fatigue and bradycardia. Her TSH has risen from 4 (a year ago) to 45. Her meds are simvastatin, verapamil, warfarin, citalopram, calcium, and an MVI.

It should instead read:
A 55-year-old woman with a history of hypothyroidism previously treated effectively with levothyroxinepresents with increasing fatigue and bradycardia. Her TSH has risen from 4 (a year ago) to 45. Her meds are simvastatin, verapamil, warfarin, citalopram, calcium, and an MVI.

Cardiology Section; Pages 5-14 to 5-16:
There are five references on these three pages that currently read as “GP IIa/IIIb.” These should instead read as GP IIb/IIIa. The erroneous references are found on pg 5-14, column 2; pg 5-15, column 1; pg 5-15, Figure 5-4; pg 5-16, Figure 5-5; pg 5-16, column 1.

Cardiology Section; Page 5-43, Quick Quiz box:
The last question currently reads: “How is BNP used to differentiate constrictive pericarditis from restrictive pericarditis?”
This should instead read: “How is BNP used to differentiate constrictive pericarditis from restrictive cardiomyopathy?”

Endocrinology Section; Page 7-39, middle of column 2 under “Monitoring”:
The 1st bullet reads: “Microalbuminuria is > 300 mg/g.” It should instead read “Macroalbuminuria is > 300 mg/g.”

Gastroenterology Section; Page 1-13, middle of column 2:
The sentence currently reads: “COX-2 inhibitors (celecoxib-Celebrex®, meloxicam-Mobic®) appear to have decreased GI side effects (compared to conventional nonselective NSAIDS)…” should instead read: “COX-2 inhibitors (celecoxib-Celebrex®) appear to have decreased GI side effects (compared to conventional nonselective NSAIDS)…”

Gastroenterology Section; Page 1-14, middle of the second column:
Currently reads: “If the gastrin level is elevated in a patient with gastric acid…”
This should instead read: If the gastrin level is elevated in a patient with a gastric ulcer…”

Gastroenterology Section; Page 1-47, Quick Quiz box:
The second question currently reads: “Regarding HBsAg, HBcAg, and HBeAg: Which is the best marker for infectivity? What is the best marker for past infection?” This should instead read: “Regarding HBsAg, HBcAb, and HBeAg: Which is the best marker for infectivity? Which is the best marker for past infection?”

General Internal Medicine Section; Page 10-37, near top of column 2:
In describing heroin withdrawal, a statement currently reads: “Exam shows constricted pupils…” This should instead read: “Exam shows dilated pupils…”

General Internal Medicine Section; Page 10-50, 2nd column near bottom:
The sentence “HEELP syndrome is preeclampsia with elevated liver enzymes, low platelets, and microangiopathic hemolytic anemia.” should instead read “HELLP syndrome is preeclampsia with elevated liver enzymes, low platelets, and microangiopathic hemolytic anemia.”

General Internal Medicine Section; Page 10-51, middle of column 2:
The statement: “If the creatinine is < 2 and the patient with corticotropin-releasing factor (CRF) is not hypertensive, there is not an increased risk of abortion or malformation, and there is no increase in the rate of progression of the renal disease.” should instead read: “If the creatinine is < 2 and the patient with chronic kidney disease is not hypertensive, there is not an increased risk of abortion or malformation, and there is no increase in the rate of progression of the renal disease.”

Hematology & Hematologic Malignancies Section; Page 8-4, Image 8-11:
The caption given for this image is wrong. The caption should instead read:

Post splenectomy: Howell-Jolly bodies are the dense inclusion bodies in the RBCs. Also see target cells and a burr cell in this field.

Post splenectomy: Howell-Jolly bodies are the dense inclusion bodies in the RBCs. Also see target cells and a burr cell in this field.

Hematology Section; Page 8-19, second column, first paragraph:
The last sentence currently reads: “Therefore, a mixing study that does maintain a sustained normalization…”

This should instead read: “Therefore, a mixing study that does NOT maintain a sustained normalization…”

Hematology Section; Page 8-23, 2nd column, first paragraph under Aggressive Non-Hodgkin Lymphomas:
Third sentence of section currently reads: “…it may also develop in extranodal sights such as the lung or liver.” 
This should instead read: “…it may also develop in extranodal sites such as the lung or liver.”

Hematology Section; Page 8-36, 1st and 2nd columns near top, and in Table 8-10:
The terminology “monoclonal gammopathy of uncertain significance” (MGUS) should instead read “monoclonal gammopathy of undetermined significance.” This reflects current usage today.

Infectious Disease Section; Page 2-3, 2nd column near bottom:
“1) Women can have false-positive urine pregnancy tests.” should instead read “1) Women can have false-positiveserum pregnancy tests.”

Nephrology Section; Page 4-1, 1st column near bottom:
Equation 2 for fractional excretion of sodium is currently displayed here as
FENa(%) = (sCr x uNa) / (sNa x uCr). This should instead be displayed as
FENa(%) = [(SCr x UNa) / (SNa x UCr)] x 100.

Neurology Section; Page 11-11, 2nd column near bottom:
The statement currently reads: “Note that oral contraceptives can increase the drug concentration of AED lamotrigine.”
This should instead read: “Note that oral contraceptives can decrease the drug concentration of AED lamotrigineup to 50%!”

Neurology Section; Page 11-24, 1st column:
The first statement under Table 11-5 currently reads: “Confirm the diagnosis of lumbar spinal stenosis with an MRI. Treatment is…”
This should instead read: “A presumptive diagnosis of spinal stenosis is made clinically. Neuroimaging (usually MRI) before treatment is not necessary for patients < 50 years old with no neurological deficits. In this group of patients, MRI is done only if there is worsening of symptoms during the first month of treatment or no improvement by the end of this first month. In patients > 50 years old and in those with neurological deficits, imaging is often done immediately to confirm the diagnosis before determining treatment. Treatment is…”

Pulmonary Medicine Section; Page 3-2, 1st column near bottom:
The statement: “This partial pressure 02 = 58.84 mmHg in the air surrounding us at sea level at 59° F.” should instead read: “This partial pressure 02 = 158.84 mmHg in the air surrounding us at sea level at 59° F.”

Nephrology Section; Page 4-29, 1st column near bottom:
The bullet currently reads: “·NSAIDs in the history: As we’ve discussed before on page 4-17, NSAIDs cause dilation of the efferent arteriole and decrease in GFR…”
This bullet should instead read: “·NSAIDs in the history: As we’ve discussed before on page 4-17, NSAIDs causeconstriction of the afferent arteriole and decrease in GFR…”

Pulmonary Medicine Section; Page 3-7, Figure 3-4:
The descriptive lines for the Obstructive volumes (bottom of the figure) were originally aligned with the Normal volumes. The corrected figure looks like this:

Pulm-Core-Errata

Pulmonary section; page 3-40, 1st paragraph, 2nd column:
The text currently reads:
Some experts advocate that bilateral effusions, equal in size and responsive to diuretics, in patients with well-established LV failure, cirrhosis, or nephritic syndrome, do not need thoracentesis because the overwhelming majority will be transudates.

The text should read:
Some experts advocate that bilateral effusions, equal in size and responsive to diuretics, in patients with well-established LV failure, cirrhosis, or nephrotic syndrome, do not need thoracentesis because the overwhelming majority will be transudates.

Rheumatology section; page 6-1, Table 6-1:
In the text adjacent to anti-U1-RNP “Specific for MCTD; also found in SLE—usually in association with anti-Sm” should read “Sensitive to exclude MCTD; also found in SLE—usually in association with anti-Sm.”

Rheumatoloy Section; Page 6-2, bottom of the first column:
Table 6-2: ANCAs: Table incorrectly lists Polyarteritis nodosa as anti-MPO–; PAN is anti-MPO+. This is discussed correctly in the text.

Rheumatology section; page 6-3, left column under “Anti-histone antibody”:
The text currently reads:
Anti-histone antibody is seen in SLE and drug-induced lupus, but the SLE patients usually have other ANA subtypes. Anti-histone antibody is very specific. If you encounter a patient with signs and symptoms of lupus, who is taking procainamide, hydralazine, chlorpromazine, or quinidine, who is ANA+ and anti-histone antibody+, but who has no other autoantibodies, you are dealing with drug-induced lupus.

The text should read:
Anti-histone antibody is seen in SLE and drug-induced lupus, but the SLE patients usually have other ANA subtypes. Anti-histone antibody is specific for drug-induced lupus when the patient has a high pre-test probability for disease (e.g., presents with a history of drug known for causing drug-induced lupus [procainamide, hydralazine, chlorpromazine, or quinidine] and does not test positive for other autoantibodies.) It is a very sensitive test in all patients; if the anti-histone antibody is negative, drug-induced lupus is not present.

Pulmonary Medicine: Card Number 458

Text currently reads:

Diagnosis is idiopathic pulmonary hemosiderosis. More often we see pulmonary-renal vasculitides present in adults. IPA is one of the rare causes of pulmonary hemorrhage that can present in young adults.

Text should read:

Diagnosis is idiopathic pulmonary hemosiderosis. More often we see pulmonary-renal vasculitides present in adults. IPH is one of the rare causes of pulmonary hemorrhage that can present in young adults.

 

Nephrology, Core Script card #371, On the Answer side

Currently reads: DX: Clinical + persistently low UOsm after water restriction; administration of ADH increases UOsm in nephrogenic DI, but does not increase UOsm in central DI.

Should read: Clinical + persistently low UOsm after water restriction; administration of ADH increases UOsm in central DI, but does not increase UOsm in nephrogenic DI.

 

Endocrinology Script Number 70:

The explanation currently reads: “Rarely, this disease can be confused with familiar hypercalcemic hypocalciuria…”
It should instead read: “Rarely, this disease can be confused with familial hypercalcemic hypocalciuria…”

Endocrinology Script Number 69:
The last bullet of the Script currently reads: “↓ Levels of glycoprotein alpha-subunits”
It should instead read:  “ Levels of glycoprotein alpha-subunits”

Endocrinology Script Number 70:
The explanation currently reads: “Rarely, this disease can be confused with familiar hypercalcemic hypocalciuria…”

It should instead read: “Rarely, this disease can be confused with familial hypercalcemic hypocalciuria…”

Endocrinology Script Number 75:
The 4th bullet of the Script currently reads: “↓ Serum Na+ and low urine specific gravity”
It should instead read: “ Serum Na+ and low urine specific gravity”

Nephrology Script Number 377
The illness script reports that “high” serum complement is found. This should be corrected to read that “low” serum complement is found.

As is:
• ↑ Serum complement

Should read:
• Low Serum complement

Explanation:
With a hypocomplementemic GN (like PIGN or lupus nephritis) that progresses to RPGN, the complement continues to remain low. On the other hand, if a disease like ANCA vasculitis or anti GBM disease, which have normal complement levels, progresses to RPGN the levels will continue to remain normal. The main features of RPGN is a) a crescent in the glomerulus (crescentic GN) on kidney biopsy along with b) rapidly worsening kidney function.

Question #20:
The answer explanation currently reads:
Explanation
… Note that controversy has recently occurred with the role of reflux in asthma—however, data consistently show that symptomatic reflux can exacerbate asthma. The conflicting new data suggest that people with asthma commonly have asymptomatic reflux and that treatment of asymptomatic reflux does NOT improve asthma symptoms or control.

They should instead read:
Explanation
… Data has shown that symptomatic reflux can exacerbate asthma and treatment is beneficial, especially if the asthma occurs at night. Newer data shows that people with asthma commonly have asymptomatic reflux and that treatment of asymptomatic reflux does NOT improve asthma symptoms or control.

Question #53:
The explanation currently reads: Choice B indicates very remote infection or more likely is immunization. Choice C indicates chronic active or acute disease.

The explanation should instead read:

In this explanation we use:
HBsAg = hepatitis B surface antigen which turns positive with hepatitis B infection and negative once it resolves; HBcAb = hepatitis B core antibody. HBcAb (IgM) is positive during acute infection only; HBcAb (IgG) is positive when a past infection occurred; HbsAb hepatitis B antibody-to-surface antigen which is positive with either past infection or vaccination.

In the correct answer, HBsAg is negative, HBcAb is positive, and HbsAb is positive. This indicates that hepatitis B infection has occurred (HBcAb (IgG) positive) but that it has resolved (HBsAg negative + and HbsAb positive).

Summary:
Neg Pos Pos = (this example, explained above) Past history of Hepatitis B infection. Resolved.

Neg Neg Pos = immunity due to Hepatis B vaccination—no HBcAb (IgG) which occurs in response to infection

Pos Pos Neg = Acute infection if HBcAb (IgM) is positive; Chronic infection if HBcAb (IgM) is negative.

Neg Neg Neg = No prior infection; No vaccination; Patient is susceptible to infection

Pos Pos Pos = infection with several different strains of hepatitis B or chronic infection in someone who later got immunized (the positive antibody to surface antigen)

Question #79:
The explanation currently reads:
Peritonsillar abscess is almost always due to either group A strep or anaerobes. Patients present with high fever, severe throat pain, trismus, “hot potato” voice, and deviation of the uvula laterally away from the abscess. Treatment is with penicillin and incision and drainage.

The explanation should read:
Peritonsillar abscess usually occur in older children, adolescents, and young adults. It is almost always due to either group A strep or anaerobes. Patients present with high fever, severe throat pain, trismus, “hot potato” voice, and deviation of the uvula laterally away from the abscess. Treatment is with penicillin and incision and drainage.

Retropharyngeal abscess usually occurs in infants and children < 5 years old. Symptoms are sore throat, neck stiffness, fever, dysphagia, and stridor. It can be difficult to see the swelling.

The epiglottis is the flap that closes off the trachea when swallowing. Epiglottitis is a soft tissue infection of this flap. Patients have swelling, dysphagia, drooling, and are at risk for pharyngeal obstruction with life-threatening respiratory compromise. Physical examination may need to be done in the operating room.

Question #230:
The description currently reads:
You are heading home from your long and grueling ABIM exam (which turned out to be quite easy, thanks to MedStudy), and you come across a woman at the local fast food hamburger store. She says her head hurts really badly. She is in line in front of you ordering 6 double burgers and mourning the death of Dave Thomas, the founder of Wendy’s. Her boyfriend says that she has not been herself since about 3 hours ago. She has had fever to 102° F and says that she had a “drooping of her left face.” She now complains of double vision.

The description should instead read:
A 32 year old woman is brought to the clinic by her boyfriend. She is complaining of a terrible headache and neck stiffness. Her boyfriend says that she has not been herself since about 3 hours ago. She has had fever to 102° F and says that she had a “drooping of her left face.” She now complains of double vision.

The answer options currently read:

A. Admit this patient to psychiatry and order a lipid profile

B. Get a STAT CT scan, then do a lumbar puncture, then give antibiotics if indicated

C. Give intravenous antibiotics followed by a lumbar puncture

D. Give oral antibiotics, then do a CT scan, then do a lumbar puncture if safe

E. Give the patient intravenous antibiotics, then do a CT scan, and then do a lumbar puncture if safe

The answer options should read:

A. Give IV antibiotics and then get a head CT followed by a lumbar puncture followed by IV dexamethazone.

B. Get a head CT, then do a lumbar puncture, then give antibiotics, then give dexamethasone.

C. Give dexamethasone then intravenous antibiotics followed by a lumbar puncture.

D. Give IV antibiotics, then do a head CT, then do a lumbar puncture if safe.

E. Give IV antibiotics, then do a lumbar puncture, then do a head CT.

The correct answer is D. Give IV antibiotics, then do a head CT, then do a lumbar puncture if safe.

The answer explanation currently reads:

She has bacterial meningitis with focal neurologic signs—double vision and “drooping of her left face.” She needs antibiotics quickly but needs a CT scan before you can do the LP. She likely has increased intracranial pressure and would herniate with an LP with these focal findings. Therefore, it is best to give her the antibiotics and then send her to CT scan.

The answer explanation should read:

This woman has bacterial meningitis with focal neurologic signs—double vision and “drooping of her left face.” The focal findings indicate that she may have increased intracranial pressure and might herniate with an LP. She needs antibiotics immediately but you must do a CT scan before you can do the LP.

Dexamethasone is appropriate in adults with suspected bacterial meningitis in developed countries where there is known or suspected pneumococcal meningitis who have a Glasgow coma scale of 8-11. Hers appears to be > 11. Additionally the dexamethasone is given before or at the same time as the antibiotics but NEVER after the antibiotics (worsens outcomes).

The board testing point currently reads:
Recognize that in a patient with acute meningitis and focal neurologic signs that an imaging study must be done before a lumbar puncture, but antibiotics still must be given immediately.

The board testing point should read:
Recognize that in a patient with acute meningitis and focal neurologic signs that an imaging study must be done before a lumbar puncture, but antibiotics still must be given immediately. Know when dexamethasone is given for bacterial meningitis.

Question #233:
The answer options currently read:

A. E. coli, if cows were in the pastureland he ran in

B. Leptospirosis

C. Group A streptococcus

D. Pseudomonas aeruginosa

E. Lyme disease

The answer options should read:

A. Eschericia coli

B. Leptospirosa interrogans

C. Streptococcus pyogenes (Group A strep)

D. Pseudomonas aeruginosa

E. Staphylococcus aureus

Answer #246:
The explanation currently reads:
Patients with end-stage renal disease typically develop hyperparathyroidism in response to multiple factors, including hypocalcemia, primary hyperparathyroidism, and decreased production of 1,25 vitamin D3 by the kidney. Several therapeutic approaches, which should be initiated as renal function begins to deteriorate, are necessary. Phosphorus control is essential, and a diet that reduces phosphorus (750 mg/d) should be prescribed. Phosphate-binding agents are also usually necessary. In patients with minimal elevations of serum phosphorus, this can be accomplished with calcium-based therapy (calcium acetate or calcium carbonate), which will also supplement the obligatory dietary decrease in calcium intake that occurs with low phosphorus diets. An appropriate target for phosphorus in patients on dialysis is 5.5, well above the “normal” values. One of the most important issues is to control the calcium x phosphorus product. There is significant risk of metastatic calcification when the Ca x Phos product is greater than 60–70. This patient, therefore, has well-controlled phosphorus, an appropriate calcium and a Ca x Phos product below 70. She does, however, have secondary hyperparathyroidism. The target PTH value for dialysis patients should be approximately twice the normal range. Lower values may place patients at risk for adynamic bone disease. In this patient, therefore, there is no need to increase the calcium supplementation, which might only worsen her Ca x Phos product. If the phosphorus was poorly controlled, especially if the Ca x Phos product was high, sevelamer, which binds phosphorus but has little effect on calcium, would be appropriate. When the phosphorus is controlled and the calcium is not elevated, secondary hyperparathyroidism can be treated either with 1,25 vitamin D3 (calcitriol), or one of the new vitamin D analogs, 19-nor-1,25(OH2)D2, Zemplar® or 1α(OH)D2, Hectorol®. Hyperparathyroidism resistant to medical therapy or complicated by hypercalcemia, metastatic calcification, or fractures would be an appropriate indication for surgical referral. In this patient, therapy with a vitamin D analog is likely to effectively lower the PTH.

The explanation now includes KDOQI and KDIGO guidelines and should read:
Patients with end-stage renal disease typically develop hyperparathyroidism in response to multiple factors, including hypocalcemia, primary hyperparathyroidism, and decreased production of 1,25 vitamin D3 by the kidney. Several therapeutic approaches, which should be initiated as renal function begins to deteriorate, are necessary. Phosphorus control is essential, and a diet that reduces phosphorus (750 mg/d) should be prescribed. Phosphate-binding agents are also usually necessary. In patients with minimal elevations of serum phosphorus, this can be accomplished with calcium-based therapy (calcium acetate or calcium carbonate), which will also supplement the obligatory dietary decrease in calcium intake that occurs with low phosphorus diets. An appropriate target for phosphorus based on KDOQI guidelines for patients on dialysis is 5.5, well above the “normal” values. One of the most important issues is to control the calcium x phosphorus product. There is significant risk of metastatic calcification when the Ca x Phos product is greater than 55. This patient, therefore, has well-controlled phosphorus, an appropriate calcium and a Ca x Phos product. She does, however, have secondary hyperparathyroidism.

The target PTH value for dialysis patients should be two to nine times the upper normal limit for the intact PTH asay being used for the undergoing dialysis based on KDIGO guidelines. PTH targets based on KDOQI guidelines should be between 150–300. Lower values than 150 may place patients at risk for adynamic bone disease. In this patient, there is no need to increase the calcium supplementation, as serum phosphorus is well controlled. If the phosphorus was poorly controlled, especially if the Ca x Phos product was high or serum calcium was higher than 9.5, sevelamer (which binds phosphorus but has little effect on calcium) would be appropriate. When the phosphorus is controlled and the calcium is not elevated, secondary hyperparathyroidism can be treated either with 1,25 vitamin D3 (calcitriol), or one of the new vitamin D analogs, 19-nor-1,25(OH2)D2, Zemplar®, or 1α(OH)D2, Hectorol®. Hyperparathyroidism resistant to medical therapy or complicated by hypercalcemia, metastatic calcification, or fractures would be an appropriate indication for surgical referral or for use of a new drug called cinacalcet which is a calcimimetic and is effective in controlling parathyroid levels in secondary hyperparathyroidism. In this patient, therapy with a vitamin D analog is likely to effectively lower the PTH.

Question #270:
Question text states: “A U/A has a SG of 1.020, pH 5.2, and several urate crystals.” This should instead state: “A U/A has a SG of 1.020, pH 5.2, and several oxalate crystals.”/p>

Question #277:
The explanation currently reads:
This question requires you to know the contraindications for drugs that treat hyperglycemia.

The only correct answer from the list of possible answers is to stop metformin and begin repaglinide. Every answer that continues metformin is incorrect because she has an absolute contraindication to the drug. Metformin is not to be used in any man with creatinine ≥ 1.5 mg/dL or any woman with a creatinine ≥ 1.4 mg/dL. The woman in this scenario has a creatinine of 1.4 mg/dL. In addition, the thiazolidinediones—pioglitazone and rosiglitazone—are not approved for patients with stage III or IV CHF. Sh would be a good candidate for fast-acting insulins like insulin aspart or lispro with meals, but she refuses insulin.

The explanation should instead read:
Given current guidelines, the correct answer for board exams from the list of possible answers is to stop metformin and begin repaglinide. Every answer that continues metformin is incorrect because she has a contraindication to the drug. Metformin’s rate of elimination is decreased in renal insufficiency. Guidelines say not to be used in any man with a stable creatinine ≥ 1.5 mg/dL or any woman with a creatinine ≥ 1.4 mg/dL. The woman in this scenario has a creatinine of 1.5 mg/dL. In addition, the thiazolidinediones—pioglitazone and rosiglitazone—are not approved for patients with stage III or IV CHF. She would be a good candidate for fast-acting insulins like insulin aspart or lispro with meals, but she refuses insulin. But do know that many experts base the metformin decision on creatinine clearance (CCl) formulas that give a better estimation of GFR. Using these formulas, an estimated GFR < 30 mL/min is an absolute contraindication with 30-60 mL/min being an area during which patients are carefully watched and metformin dosage is decreased. CCl = 46.8 per the Cockcroft-Gault equation [(140-age) x lean body wt (kg)/(cr x 72)] (lean body weight in women is 0.85 x wt). For board exam questions, answer per the renal tests that are done (Cr vs GFR/CrCl).

Question #305:
Laboratory values: The TSH laboratory value currently reads: TSH 4.6 mU/L (0.5–5.0 mU/L). The TSH laboratory value should read: TSH 5.6 mU/L (0.5–5.0 mU/L). Added: Anti-thyroid antibodies positive.

The answer choice: Recommend a diet low in cholesterol and saturated fat should read: Start a statin.
The answer choice: Order a baseline bone density study to rule out osteoporosis should read: Order a pelvic ultrasound.

Answer #305:
The explanation currently reads:
This patient may very well have subclinical hypothyroidism. By definition, the diagnosis is very difficult and easily missed: The FT4 is normal and the TSH may be normal or minimally elevated. This diagnosis is important because of the implications. The Rotterdam study clearly showed that women ≥ 55 years of age with subclinical hypothyroidism have a significantly elevated risk of myocardial infarction and aortic atherosclerosis. Nevertheless, a clear benefit from treatment has not yet been published. However, hypothyroidism is well known to cause an elevated LDL, and her LDL is 195 mg/dL. No matter how few risk factors she has, her LDL goal is < 160 mg/dL at best, depending on all of her risk factors. Diet and exercise are not expected to reduce her LDL to within this range. It is premature to begin drug therapy, since treatment of hypothyroidism often reduces LDL levels. Starting a low-dose trial of thyroxine is very appropriate in this case. If her anti-thyroid antibodies (anti-TPO) are positive, I would continue her thyroxine therapy even if the LDL does not improve. If the LDL remains elevated, you should consider statin therapy. Because of her LDL elevation, a year is too long to wait for follow-up. And finally, her likelihood of having osteoporosis is very low, considering her level of physical activity and calcium supplementation.

The explanation should read:
This patient may very well have subclinical hypothyroidism. By definition, the diagnosis is very difficult and easily missed: The FT4 is normal and the TSH may be normal or minimally elevated. This diagnosis is important because of the implications. Positive anti-thyroid antibodies contribute to the diagnosis of subclinical hypothyroidism. The Rotterdam study clearly showed that women ≥ 55 years of age with subclinical hypothyroidism have a significantly elevated risk of myocardial infarction and aortic atherosclerosis. Nevertheless, a clear benefit from treatment has not yet been published. However, hypothyroidism is well known to cause an elevated LDL, and her LDL is 175 mg/dL. No matter how few risk factors she has, her LDL goal is < 160 mg/dL at best, depending on all of her risk factors.

It is premature to begin statin drug therapy, since treatment of hypothyroidism often reduces LDL levels. Starting a low-dose trial of thyroxine is very appropriate in this case. Since her anti-thyroid antibodies (anti-TPO) are positive, I would continue her thyroxine therapy even if the LDL does not improve. If the LDL remains elevated, you should consider statin therapy. A year-long revisit is too prolonged a follow-up to address both the lipid disorder and subclinical hypothyroidism. And finally, her likelihood of having an ovarian or uterine cancer in this post-menopausal patient without symptoms or an abnormal pelvic exam is very low. Therefore, the indication for a pelvic ultrasound is unnecessary.

Question #413:
The question currently reads: Which of the following is the initial treatment for mild rheumatoid arthritis?

The question should instead read: Which of the following is not be considered for treatment of mild rheumatoid arthritis?

The answer choices should be as follows:

A. Prednisone

B. Gold salts

C. Naproxen

D. Hydroxychloroquine

E. Methotrexate

The correct answer is B. Gold Salts

The explanation should now read:
Gold salts are no longer used for RA. Previously, treatment of RA followed a pyramid regimen consisting initially of NSAIDs and/or low dose-glucocorticoids—with DMARDs added only as the disease got progressively worse. Now we know that RA-associated disability can be drastically reduced when we treat early disease aggressively with DMARDs. Current treatment paradigms focus on early diagnosis and early aggressive therapy to allow patients a chance at remission. The goal is to try to initiate DMARD therapy within 3 months of symptoms and if needed, to titrate drugs (add additional DMARDs or biologic agents) to attain low disease activity or remission.

Question #419:
The question description currently reads:
A 50-year-old man presents with acute swelling of his first metatarsophalangeal joint. He admits to excessive alcohol intake and is on hydrochlorothiazide for hypertension. He is obese.

You tap the knee and discover urate crystals in the joint fluid.

Uric acid levels are normal.

The question description should read:
A 50-year-old man presents with acute swelling of his first metatarsophalangeal joint. He admits to excessive alcohol intake and is on hydrochlorothiazide for hypertension. He is obese.

You tap the joint and discover urate crystals in the joint fluid.

Uric acid levels are normal.

Question #541:
In the explanation, Incidence currently reads: The number of new cases of disease in the population at risk in a given time period; usually expressed as the number of new cases per 100,000 per population per year.

The Incidence should instead read: The number of new cases of disease in the population at risk in a given time period; usually expressed as the number of new cases per 100,000 population per year.

Cardiology Section; Page 5-18, middle of column 2:
While discussing Pletal® and PVD, the text currently reads “… resulting in a reversible platelet aggregation.”
Should read “… resulting in a reversible inhibition of platelet aggregation.”

Endocrinology Section; Page 7-5, column 2, 3rd paragraph under SIADH:
Sentence currently reads: “Consider hypertonic saline in cases of sudden, severe hypernatremia (usually Na < 120)
or when symptomatic (e.g., seizures).” This should instead read: “Consider hypertonic saline in cases of sudden,
severe hyponatremia (usually Na < 120) or when symptomatic (e.g., seizures).”

Endocrinology Section; Page 7-36, middle of column 1 under “Monitoring”:
The text currently reads: “Do a urine spot albumin:creatinine as a test for microalbuminuria (abnormal = 30–300 mg).” It should instead read: “Do a urine spot albumin:creatinine as a test for nephropathy (normal is < 30 mg/g; macroalbuminuria  is > 300 mg).”

Endocrinology Section; Page 7-42, end of column 1, in the Endocrinology Section Review:
The numbering sequence is off in the answer information for Single Best Answer question #8. Here is the correct answer information:

[1 (B) 2 (D; GHRH is, of course, growth hormone-releasing hormone.) 3 (C; LH is also controlled by GnRH.) 4 (A; CRH is corticotropin releasing hormone.) 5 (B and E) 6 (D and E; Okay! — I’ll try to keep the rest single best answer.) 7 (C; inhibin does not inhibit LH release.) 8 (A and D; secretion of GH is suppressed by hyperglycemia. I said I would try.) 9 (D; GH decreases the effect of insulin.) 10 (D. Checking IGF-1 level is a screen for acromegaly.)]

Gastroenterology Section; Page 1-12, bottom of column 1:
The sentence currently reads: “COX-2 inhibitors (celecoxib-Celebrex®, meloxicam-Mobic®) appear to have decreased GI side effects (compared to conventional nonselective NSAIDS)…” should instead read: “COX-2 inhibitors (celecoxib-Celebrex®) appear to have decreased GI side effects (compared to conventional nonselective NSAIDS)…”

Gastroenterology Section; Page 1-13 middle of the second column:
Currently reads: “If the gastrin level is elevated in a patient with gastric acid…”
This should instead read: If the gastrin level is elevated in a patient with gastric ulcer…”

Gastroenterology Section; Page 1-22, column 2, under subhead “Diabetes”, 3rd bullet:
The final text in parentheses currently reads: “(treat with metronidazole or amoxicillin-clavulanate)”. This should instead read: “(treat with metronidazole and amoxicillin-clavulanate)”.

Gastroenterology Section; Page 1-23, top of column 2, under MALABSORPTION—Overview, 3rd paragraph:
Text currently reads: “Low: albumin, Ca++, cholesterol, carotene, serum iron, and Prolonged PTT.” Prolonged PTT should be replaced with Prolonged PT.

Gastroenterology Section; Page 1-26, top of column 2:
While discussing bacterial overgrowth, the text currently reads: “Also remember the high folate levels with low B12 and microcytosis.” This should instead read: “Also remember the high folate levels with low B12 andmacrocytosis.”

Gastroenterology Section; Page 1-27, lower half of column 2 under COLON CANCER—OVERVIEW:
Text currently reads: “Also remember: Endocarditis caused by either Strep bovis or Clostridium septicus is often associated with colon cancer…”  Change Clostridium septicus to Clostridium septicum.

Gastroenterology Section; Page 1-42, Table 1-9:
In the “Interpretation” column where it currently reads “2) Chronic hep B (high AST)”, change this to “2) Chronic hep B (high ALT)”

Gastroenterology Section; Page 1-43, Quick Quiz box:
The second question currently reads: “Regarding HBsAg, HBcAg, and HBeAg: Which is the best marker for infectivity? What is the best marker for past infection?” This should instead read: “Regarding HBsAg, HBcAb, and HBeAg: Which is the best marker for infectivity? Which is the best marker for past infection?”

Gastroenterology Section; Page 1-47, column 2, 2nd paragraph under Drug- Related Chronic Hepatitis—Overview:
Text currently reads: “Drugs causing both toxic and idiopathic effects: Methyldopa, INH (isoniazid), and sodium valproate.” Change idiopathic to idiosyncratic.

General Internal Medicine Section; Page 10-16, 1st column, last paragraph:
Under “Stress Incontinence,” a statement currently reads: “Stress incontinence is initially best treated with behavioral therapy, especially Kegel exercises (perineal muscle contractions) and nightly application of conjugated steroid cream to the external urinary meatus.” Change conjugated steroid cream to conjugated estrogen cream.

General Internal Medicine Section; Page 10-44, 1st column, middle of page:
Under “Clues for X-linked inheritance,” the 2nd bullet currently reads: “If mother is a ‘carrier,’ she transmits gene to all sons (who are all affected) and 50% of daughters (who are usually unaffected).” This should instead read: “If mother is a ‘carrier,’ she has a 50% risk of transmitting the gene to her sons, and each son with a resulting abnormal X chromosome would therefore be affected. A ‘carrier’ mother has a 50% risk of transmitting the gene to her daughters. If a daughter receives the abnormal X chromosome, she is usually unaffected but becomes a potential carrier to future generations.”

Hematology Section; Page 8-1, beneath the middle photo on the bottom of the page:
The last sentence should read: “Many of the erythroid precursors have dark condensed nuclei.”

Hematology Section; Page 8-5, 2nd column, middle of page:
Last sentence of section currently reads: “Only the MMA is elevated in folate deficiency.”
Correction:
“Only homocysteine is elevated in folate deficiency.”

Hematology Section; Page 8-28, 2nd column, first paragraph under Aggressive Non-Hodgkin Lymphomas:
Third sentence of section currently reads: “…it may also develop in extranodal sights such as the lung or liver.” 
Correction: 
“…it may also develop in extranodal sites such as the lung or liver.”

Hematology Section; Page 8-31, 1st column:
The terminology “monoclonal gammopathy of uncertain significance” (MGUS) should instead read “monoclonal gammopathy of undetermined significance.” This reflects current usage today.

Infectious Disease Section; Page 2-50, Question #8:
The word “Coccidioidomycosis,” currently seen on answer option line “F,” should instead be listed on a separate line as answer option “G.”

Nephrology Section; Page 4-2, 1st column, at top:
An equation for fractional excretion of sodium is currently displayed here as
FENa(%) = (uNa/sNa)/(uCr/sCr) x 100 = (uNa x sCr)/(sNa x uCr) x 100. This should instead be displayed asFENa(%) = [(SCr x UNa) / (SNa x UCr)] x 100.

Nephrology Section; Page 4-17, column 1, 2nd paragraph from bottom:
This paragraph currently reads: “So if you see a hypertensive patient with hypokalemia and metabolic acidosis, don’t just jump to the diagnosis of hyperaldosteronism! Check symptoms, meds, and anion gap.” Disregard this paragraph; it is incorrect information.

Nephrology Section; Page 4-17, column 2, 1st paragraph under CALCIUM:
A sentence in the text currently reads: “For each decrease in albumin of 1, the total calcium decreases by .7, yet the ionized calcium level remains the same…” This should instead read: “For each decrease in albumin of 1, the total calcium increases by .7, yet the ionized calcium level remains the same…”

Nephrology Section; Page 4-17, column 2, 6th paragraph under CALCIUM:
A sentence in the text currently reads: “Renal failure results in a decreased renal conversion of 1-OH-D to the active 1,25-(OH)2-D (so there is an increased PTH in these patients).” This should instead read: “… conversion of25-OH-D to the active 1,25-(OH)2-D …”

Nephrology Section; Page 4-32, top of column 2:
The text currently reads: “Palpable purpura is the main presentation of mixed cryoglobulinemia. Do not forget this! Palpable purpura with hematuria/proteinuria → think mixed cryoglobulinemia and HIV.” This should instead read: “Palpable purpura is the main presentation of mixed cryoglobulinemia. Do not forget this! Palpable purpura with hematuria/proteinuria → think mixed cryoglobulinemia and HCV.”

Neurology Section; Page 11-1, bottom of column 1:
A sentence here currently reads: “If the comatose patient has neither doll’s eyes nor nonreactive ice water calorics, there is a problem in the midbrain or pons.” This should instead read: “If the comatose patient has neither doll’s eyes nor reactive ice water calorics, there is a problem in the midbrain or pons.”

Neurology Section; Page 11-4, near bottom of column 1:
Change subhead CAUSES OF DIZZINESS to CAUSES OF DEMENTIA.

Pulmonary Medicine Section; Page 3-6, Figure 3-4:
The descriptive lines for the Obstructive volumes (bottom of the figure) were originally aligned with the Normal volumes. The corrected figure looks like this:

Pulm-Core-Errata (1)

Pulmonary Medicine Section; Page 3-6, near top of column 2; also Figure 3-5 on page 3-7:
Figure 3-5 on page 3-7 and the “Restrictive disease” paragraph on page 3-6 as currently written are both incorrect. Here is a modified, corrected Figure 3-5:

IM-Core_Pulmo_Figure3-5

The “Restrictive disease” paragraph in column 2 on page 3-6 should now also be corrected to read as follows as it refers to the newly modified Figure 3-5 shown here:
“Notice, in Figure 3-5, restrictive lung diseases have reduced TLC compared to normal. Both vital capacity and residual volume are reduced. Flow-volume loops in intra- and extrathoracic restriction look similar, but intrathoracic restriction is often associated with a very decreased DLCO. Notice that the residual volume is increased even above normal in the obstructed loop.”

[This replaces the existing “Restrictive disease” paragraph on page 3-6 which reads: “Notice, in Figure 3-5, the two types of restrictive disease are overlaid on the previous graph. With parenchymal disease (i.e., interstitial lung disease), the TLC may be normal or higher than normal whereas with extrathoracic causes (e.g., obesity, kyphosis), the TLC is decreased and the restriction is due to the crimping of TLC.”]

Answer #68:
Add to the explanation: The other answer options do not cause this combination of findings.

Answer #70:
Add to the explanation: Influenza does not predispose a patient to any of the other answer options nearly as much as to S. aureus.

Question #75:
One answer option currently reads: “Azithromycin 500 mg 2 PO today, then 1 PO q day x 4 days.” This should instead read: “Azithromycin 250 mg 2 PO today, then 1 PO q day x 4 days.” This is the correct answer to Question #75, so make this change in both the Question presentation and the Answer text.

Answer #91:
This sentence in the explanation currently reads: In this case, the CO is already high, and the oxygen saturation with a pO2 of 85 is at least 90%.

The sentence should instead read: In this case, the CO2 is already high, and the oxygen saturation with a pO2 of 85 is at least 90%.

Question #156:
One answer option currently reads: “Pulmonary arterial hypertension, acquired via cor pulmonale.” This should instead read: “Pulmonary hypertension, acquired via cor pulmonale.” (I.e., delete the word “arterial.”) This is the correct answer to Question #156 so make this change in both the Question presentation and the Answer text. The Explanation accompanying this answer is correct as written.

Question #169:
In the second paragraph of the Answer/Explanation text, one sentence currently reads: “Rapid y descents are associated with tamponade.” This should instead read: “Rapid y descents are associated with constrictive pericarditis.”

Question #247
The Question and Answer/Explanation text for this question should be replaced with the following:

A 46-year-old alcoholic male is brought to the Emergency Room with altered mental status by a friend following a week of “heavy” drinking. He is found to have a glucose level of 45 and, with D50 administration, his mental status returns to normal. He has been drinking a quart of vodka a day for the past 12 years, but for the past week has doubled that amount. On examination, his blood pressure is 110/74, pulse 112, respiration 22; his hands are tremulous, and he has hepatomegaly with a liver span of 14 cm. His initial laboratory studies are: sodium 135, potassium 3.9, CO2 16, chloride 94, BUN 7, serum creatinine 0.8 mg/dL. His serum osmolality is 302. ABGs: pH 7.30, PCO2 30, HCO3 14. Hemoglobin is 11.3, HCT 35.1%, and WBC 8.7. He is given IV fluids (D5 ½N/S), vitamins, and lorazepam. Studies for hepatitis B and C are negative, and ultrasound of his liver shows no obstruction. CPK is 72,000. Clinically he seems to be improving, but 3 days later, his serum creatinine is noted to be 5.5. Urinalysis at this time: Sp Gr 1.1010, pH 5.5, 3+ blood, no glucose, trace protein, 0–1 RBCs/HPF, 3–5 hyaline casts, and 2–3 granular casts.

Which of the following is the most likely explanation for this rise in his creatinine?

A. Isopropyl alcohol intoxication

B. Acute renal failure secondary to ethylene glycol intoxication

C. Methanol intoxication

D. Acute renal failure secondary to rhabdomyolysis associated with hypophosphatemia

E. Hepatorenal syndrome

 

247.  Answer:  D

Answer: Acute renal failure secondary to rhabdomyolysis associated with hypophosphatemia.
This patient has alcoholic ketoacidosis (AKA) and presents with the classic constellation of findings of alcohol binging, hypoglycemia, an anion gap metabolic acidosis, and an extremely high CPK. These patients usually have hypophosphatemia, which can be severe, and hypomagnesemia. The hypophosphatemia can be severe enough to result in rhabdomyolysis. The diagnosis of alcoholic ketoacidosis may be missed, because these patients improve quickly with glucose administration, and the ketones are initially beta-hydroxybutyrate and are not detected in the serum until they are converted to acetoacetate. Recognition of the clinical syndrome allows one to monitor and appropriately replace phosphorus early in the hospitalization, to prevent complications such as rhabdomyolysis.

Note that the answer option of acute renal failure secondary to ethylene glycol intoxication is incorrect. The most important clue to the diagnosis of either ethylene glycol or methanol intoxication is an osmolar gap greater than 10, but remember alcohol can also cause an osmolar gap as well. The osmolality is calculated as (2 x sodium) + (glucose/18) + (BUN/2.8). This calculated value will be significantly less than the measured osmolality in patients with alcohol, methanol, or ethylene glycol ingestion. With ethylene glycol ingestion you would expect the question to give you calcium oxalate crystals (not always present in the urine, but on Board exams is a rather important clue) and the CPK would not be this elevated. Treatment includes fomepizole (rarely, ethanol is used) administration, thiamine, and pyridoxine.

Could this patient have methanol intoxication? With methanol intoxication, an osmolar gap is usually present along with an anion gap acidosis, but again the CPK this high is inconsistent.  On Boards, these patients typically present with a fruity odor and blurred vision due to the degradation of methanol to formaldehyde and formic acid, which is toxic to the optic nerve. Treatment includes fomepizole (rarely, ethanol is used) administration and hemodialysis.

Isopropyl alcohol is metabolized to acetone and may result in ketosis; however, it does not cause an anion gap acidosis, which this patient had.

The diagnosis of hepatorenal syndrome should be suspected in patients with cirrhosis, portal hypertension, and ascites. Patients who develop acute renal failure in this setting must be evaluated for intravascular volume depletion—frequently associated with diuretics, vomiting, or bleeding—or conversely, they may develop acute renal failure due to acute tubular necrosis, related to many of the medications they receive. The diagnosis of HRS depends on demonstrating a benign urinalysis, extremely low fractional excretion of sodium, no response to volume repletion, and exclusion of obstruction or toxic causes.

Board Testing Point:
Know the clinical and laboratory features and therapy for rhabdomyolysis.

Question #390:
In the Answer/Explanation text for this question, one sentence currently reads: “The Weber test confirms this bilateralizing to the ear with the conductive hearing loss.” This should instead read: “The Weber test confirms thisby lateralizing to the ear with the conductive hearing loss.”

Question #409:
One answer option currently reads: “CT scan of joints.” This should instead read: “MRI of joints.” In the accompanying brief explanation, also change “CT scan of the SI joints” to “MRI of the SI joints.” This is the correct answer to Question #409, so make this change in both the Question presentation and the Answer text. (The reason underlying this correction is that CT scan is not used as often because of concern of gonadal radiation.)

Question # 246

This should read: “The correct answer is MPGN.” (Instead of “The
correct answer is cryoglobulinemia.”) The rest of the explanation is correct as it stands.

Question # 247
The Question and Answer/Explanation text for this question should be replaced with the following:

A 46-year-old alcoholic male is brought to the Emergency Room with altered mental status by a friend following a week of “heavy” drinking. He is found to have a glucose level of 45 and, with D50 administration, his mental status returns to normal. He has been drinking a quart of vodka a day for the past 12 years, but for the past week has doubled that amount. On examination, his blood pressure is 110/74, pulse 112, respiration 22; his hands are tremulous, and he has hepatomegaly with a liver span of 14 cm. His initial laboratory studies are: sodium 135, potassium 3.9, CO2 16, chloride 94, BUN 7, serum creatinine 0.8 mg/dL. His serum osmolality is 302. ABGs: pH 7.30, PCO2 30, HCO3 14. Hemoglobin is 11.3, HCT 35.1%, and WBC 8.7. He is given IV fluids (D5 ½N/S), vitamins, and lorazepam. Studies for hepatitis B and C are negative, and ultrasound of his liver shows no obstruction. CPK is 72,000. Clinically he seems to be improving, but 3 days later, his serum creatinine is noted to be 5.5. Urinalysis at this time: Sp Gr 1.1010, pH 5.5, 3+ blood, no glucose, trace protein, 0–1 RBCs/HPF, 3–5 hyaline casts, and 2–3 granular casts.

Which of the following is the most likely explanation for this rise in his creatinine?

A. Isopropyl alcohol intoxication

B. Acute renal failure secondary to ethylene glycol intoxication

C. Methanol intoxication

D. Acute renal failure secondary to rhabdomyolysis associated with hypophosphatemia

E. Hepatorenal syndrome

 

247.  Answer:  D

Answer: Acute renal failure secondary to rhabdomyolysis associated with hypophosphatemia.
This patient has alcoholic ketoacidosis (AKA) and presents with the classic constellation of findings of alcohol binging, hypoglycemia, an anion gap metabolic acidosis, and an extremely high CPK. These patients usually have hypophosphatemia, which can be severe, and hypomagnesemia. The hypophosphatemia can be severe enough to result in rhabdomyolysis. The diagnosis of alcoholic ketoacidosis may be missed, because these patients improve quickly with glucose administration, and the ketones are initially beta-hydroxybutyrate and are not detected in the serum until they are converted to acetoacetate. Recognition of the clinical syndrome allows one to monitor and appropriately replace phosphorus early in the hospitalization, to prevent complications such as rhabdomyolysis.

Note that the answer option of acute renal failure secondary to ethylene glycol intoxication is incorrect. The most important clue to the diagnosis of either ethylene glycol or methanol intoxication is an osmolar gap greater than 10, but remember alcohol can also cause an osmolar gap as well. The osmolality is calculated as (2 x sodium) + (glucose/18) + (BUN/2.8). This calculated value will be significantly less than the measured osmolality in patients with alcohol, methanol, or ethylene glycol ingestion. With ethylene glycol ingestion you would expect the question to give you calcium oxalate crystals (not always present in the urine, but on Board exams is a rather important clue) and the CPK would not be this elevated. Treatment includes fomepizole (rarely, ethanol is used) administration, thiamine, and pyridoxine.

Could this patient have methanol intoxication? With methanol intoxication, an osmolar gap is usually present along with an anion gap acidosis, but again the CPK this high is inconsistent.  On Boards, these patients typically present with a fruity odor and blurred vision due to the degradation of methanol to formaldehyde and formic acid, which is toxic to the optic nerve. Treatment includes fomepizole (rarely, ethanol is used) administration and hemodialysis.

Isopropyl alcohol is metabolized to acetone and may result in ketosis; however, it does not cause an anion gap acidosis, which this patient had.

The diagnosis of hepatorenal syndrome should be suspected in patients with cirrhosis, portal hypertension, and ascites. Patients who develop acute renal failure in this setting must be evaluated for intravascular volume depletion—frequently associated with diuretics, vomiting, or bleeding—or conversely, they may develop acute renal failure due to acute tubular necrosis, related to many of the medications they receive. The diagnosis of HRS depends on demonstrating a benign urinalysis, extremely low fractional excretion of sodium, no response to volume repletion, and exclusion of obstruction or toxic causes.

Board Testing Point:
Know the clinical and laboratory features and therapy for rhabdomyolysis.

Question # 290, Option C

This should read: “Fluid restriction to 800 cc/day” instead of “800
cc/hour.” In the Explanation for this question, the first sentence should
read: “The correct answer is fluid restriction to 800 cc/day” instead
of “800 cc/hour.”

The CD-ROM format for this product (IM Q&A vol 2) contains the same error.
However, the answer option in the CD program can vary as to letter A, B, C,
D, or E. In any event, “800 cc/hour” should be changed to “800
cc/day” in the answer option and in the first sentence of the explanation.

Pediatrics Products

Allergy & Immunology: Page 6-12, Phagocyte Disorders > Overview

Text currently reads:

  1. Neutropenia (< 1,000 PMN, severe = < 100):
    • Kostmann syndrome (AD)
    • Severe chronic neutropenia (AR)

Text should read:

  1. Neutropenia (< 1,000 PMN, severe = < 100):
    • Kostmann syndrome (AR)
    • Severe chronic neutropenia (AD)

 

Growth & Development: Page 1-1, Overview of Growth

Text currently reads:
Remember that 5% of the population have heights, weights, or head circumferences that normally lie outside of 2 standard deviations from the mean. (By definition, 2.5% are > 95th percentile, and 2.5% are < 5th percentile.)

Text should read:

Remember that 5% of the population have heights, weights, or head circumferences that normally lie outside of 2 standard deviations (SDs) from the mean. (By definition, 2.5% are > +2 SD and 2.5% are < –2 SD).

 

Cardiology: Page 12-26, Complete (d-) Transposition of the Great Arteries

Text currently reads:

Because the great arteries….and the pulmonary artery is connected to the left atrium instead of the right atrium.

Text should read:

Because the great arteries….and the pulmonary artery is connected to the left ventricle instead of the right ventricle.

 

Infectious Disease: Page 5-2, Gram-Positive Bacteria/Staphylococcus aureus

Text currently reads:

Mild: Patients with a fever, who are immunocompetent can sometimes be managed similarly to those with mild cases. Or, patients with moderate infections may require hospitalization if the area of involvement is extensive, if they have significant systemic symptoms, or if medication adherence is an issue.

Note: The D-test determines if there is macrolide-inducible clindamycin resistance. The test must be done when the S. aureus isolate is erythromycin-resistant but shows clindamycin susceptibility. If the D-test is positive, do not use clindamycin as treatment. Most microbiology laboratories perform this test routinely and report only clindamycin susceptibility based on its result.

Moderate: Previously healthy patients who have fever can be managed similarly to the mild cases. Or, they may require hospitalization and managed similar to severe cases if the area of involvement is extensive; if they have significant systemic symptoms; or if medication adherence is an issue.

Text should read:

Mild: Afebrile patients who are immunocompetent can sometimes be managed with incision and drainage alone. Often they require oral antibiotic therapy which includes trimethoprim/sulfamethoxazole, clindamycin, or doxycycline (if > 7 years old).

Note: The D-test determines if there is macrolide-inducible clindamycin resistance. The test must be done when the S. aureus isolate is erythromycin-resistant but shows clindamycin susceptibility. If the D-test is positive, do not use clindamycin as treatment. Most microbiology laboratories perform this test routinely and report only clindamycin susceptibility based on its result.

Moderate: Previously healthy patients who have fever can be managed similarly to the mild cases. Or, they may require hospitalization and managed similar to severe cases if the area of involvement is extensive; if they have significant systemic symptoms; or if medication adherence is an issue.

 

Growth & Development / Preventive Pediatrics: Page 1-19, Cholesterol and Lipid Screening

Text currently reads:

Consider pharmacologic therapy at 10 years of age in children with an LDL-C ≥ 190 mg/dL…

Text should read:

Consider pharmacologic therapy at 8 years of age in children with an LDL-C ≥ 190 mg/dL…

 

Adolescent Health and Gynecology: Page 4-27, Pelvic Inflammatory Disease

Text currently reads:

Recommended treatment:

  • Cefoxitin 2 gm IV every 6 hours, plus

Doxycycline 100 mg orally or IV every 12 hours for 14 days

Outpatient treatments for PID:

  • Other 3rd generation cephalosporins, plus
    Doxycycline 100 mg 2x/day for 14 days +/

Text should read:

Recommended treatment:

  • Cefoxitin 2 gm IV every 6 hours, plus

Doxycycline 100 mg 2x/day PO x 14 days

Outpatient treatments for PID:

  • Other 3rd generation cephalosporins, plus
    Doxycycline 100 mg 2x/day PO x 14 days +/

 

Metabolic Disorders: Page 10-6, Phenylalanine-Tyrosine Disorders, Tyrosinemia,
Hereditary Tyrosinemia Type I

Text currently reads: You can treat liver failure and Fanconi syndrome of hepatorenal tyrosinemia with 2-(nitro-4-trifuoro-methylbenzoyl)-1,3-cyclohexanedione…

Text should read: You can treat liver failure and Fanconi syndrome of hepatorenal tyrosinemia with 2-(2-nitro-4-trifluoro-methylbenzoyl)-1,3-cyclohexanedione…

 

Metabolic Disorders: Page 10-7, Sulfur-Containing Amino Acid Defects, Homocystinuria

Text currently reads: Classically, the term was used specifically to indicate disease due to a defect in the cystathionine β-synthetase enzyme.

Text should read: Classically, the term was used specifically to indicate disease due to a defect in the cystathionine β-synthase enzyme.

Infectious Disease: Card Number 568

Text currently reads:

It can be treated with macrolides, including doxycycline, erythromycin, or azithromycin.

Text should read:

It can be treated with macrolides, including erythromycin or azithromycin. Tetracyclines and fluoroquinolones are also effective.

 

Infectious Disease Flash Card #565, On the Answer side

Last bullet currently reads: Persons undergoing immunosuppressive therapy (equivalent to < 15 mg/day prednisone)
Last bullet should read: Persons undergoing immunosuppressive therapy (equivalent to > 15 mg/day prednisone)

Growth and Development / Preventive Pediatrics: Page 1-18, Cholesterol and Lipid Screening

Text currently reads:

Consider pharmacologic therapy at 10 years of age in children with an LDL-C ≥ 190 mg/dL…

Text should read:

Consider pharmacologic therapy at 8 years of age in children with an LDL-C ≥ 190 mg/dL…

 

Adolescent Health and Gynecology: Page 4-28, Pelvic Inflammatory Disease

Text currently reads:

Recommended treatment:

  • Cefoxitin 2 gm IV every 6 hours, plus

Doxycycline 100 mg orally or IV every 12 hours for 14 days

Outpatient treatments for PID:

  • Other 3rd generation cephalosporins, plus
    Doxycycline 100 mg 2x/day for 14 days +/

Text should read:

Recommended treatment:

  • Cefoxitin 2 gm IV every 6 hours, plus

Doxycycline 100 mg 2x/day PO x 14 days

Outpatient treatments for PID:

  • Other 3rd generation cephalosporins, plus
    Doxycycline 100 mg 2x/day PO x 14 days +/

 

Metabolic Disorders: Page 10-6, Phenylalanine-Tyrosine Disorders, Tyrosinemia, Hereditary tyrosinemia Type I

Text currently reads: You can treat liver failure and Fanconi syndrome of hepatorenal tyrosinemia with 2-(nitro-4-trifuoro-methylbenzoyl)-1,3-cyclohexanedione…

Text should read: You can treat liver failure and Fanconi syndrome of hepatorenal tyrosinemia with 2-(2-nitro-4-trifluoro-methylbenzoyl)-1,3-cyclohexanedione…

 

Metabolic Disorders: Page 10-7, Sulfur-Containing Amino Acid Defects, Homocystinuria

Text currently reads: Classically, the term was used specifically to indicate disease due to a defect in the cystathionine β-synthetase enzyme.

Text should read: Classically, the term was used specifically to indicate disease due to a defect in the cystathionine β-synthase enzyme.

StudyWise: Page 8, Exam Topics Chart
Text currently omits Metabolic Disorders topic, which belongs between Infectious Disease and Endocrine Disorders topics.

Text should read:

ABP Topic Exam % Core Curriculum book number and section
Metabolic Disorders 1.5% 3   Metabolic Disorders

Common Pediatric Disorders: Page 2-7, Under Color-vision Defects
Text currently reads:
Abnormal color vision occurs in ~ 8-10% of boys and < 0.5% of girls and is due to X-linked inheritance protan and deutan deficits (blue-green).
Text should read:
Abnormal color vision occurs in ~ 8-10% of boys and < 0.5% of girls and is due to X-linked inheritance protan and deutan deficits (red-green).

Common Pediatric Disorders: Page 2-7, Under Normal Visual Development
Text currently reads:
5) Most term infants are hyperopic (farsighted) at birth, while premature infants are myopic (nearsighted). The fovea reaches maturity at 4 years of age, and children reach 20/20 vision by 5 years. (Newborns start with 20/400—hmm, how do you get a newborn to do the wall chart?)

Text should read:
5) Most term newborns are nearsighted at birth with a visual acuity of approximately 20/400. Their vision trends toward farsightedness until age 7, generally passing through 20/20 around age 3–5 years. Maximum hyperopia (farsightedness) occurs at age 7 after which the visual acuity slowly decreases back to 20/20 or even myopia by about age 14. This trend slows but continues until the patient is about 30.Endocrinology; Page 15-6, Under Diabetes Insipidus > Diagnosis last paragraph:
Text currently reads:
With central DI, giving DDAVP® will raise serum and therefore urine osmolality (Figure 15-5).
Text should read:
With central DI, giving DDAVP® will increase urine osmolality and therefore decrease serum osmolality back toward normal values (~280 mOsm.kg).

Endocrinology; Page 15-34, Under Secondary Hyperaldosteronism last paragraph:
Text currently reads:
Gitelman syndrome is also a hyperaldosteronemic, hyperreninemic state without hypertension, but it presents at an older age with musculoskeletal signs/symptoms and hypocalcemia and hypomagnesemia.”
Text should read:
Gitelman syndrome is also a hyperaldosteronemic, hyperreninemic state without hypertension, but it presents at an older age with musculoskeletal signs/symptoms and hypocalciuria and hypomagnesemia.

Gastroenterology & Nutrition; Page 14-13, Under Pyloric Stenosis, end of first paragraph:
Text currently reads:
African-American children are 2-3x more likely to be affected than Caucasian children; Asian-Americans are rarely affected.
Text should read:
Caucasianchildren are 2-3x more likely to be affected than African-American children; Asian-Americans are rarely affected.

Growth and Development; Page 1-5, Under Note in the third paragraph in the column on the right:
Text currently reads:
“There has been a large increase in the number of cases of posterior plagiocephaly due to the recommendation that sleeping infants be placed on their backs to reduce SIDS.”
Text should read:
“There has been a large increase in the number of cases of positional plagiocephaly due to the recommendation that sleeping infants be placed on their backs to reduce SIDS.”

Hematology; Page 16-21, Under FXI Deficiency (Hemophilia C), middle of first paragraph:
Text currently reads:
Bleeding problems are less common than in those with Factor XIII or IX deficiency, and these patients usually do not get hemarthroses.
Text should read:
Bleeding problems are less common than in those with Factor VIII or IX deficiency, and these patients usually do not get hemarthroses.

Emergency Pediatrics Flash Card #213:
On the front of the card in the list of symptoms, the fourth bullet currently reads: Bronchorrhea/ronchospasm

It should instead read: Bronchorrhea/bronchospasm

Growth & Development Flash Card #452:
On the back of the card the explanation currently reads: The fastest rate of growth is between 0 and 3 months of age when the child grows at 0.5 cm/week (2 cm/month)!

It should instead read: The fastest rate of growth is between 0 and 2 months of age when the child grows at 0.5 cm/week (2 cm/month)!

Nephrology Flash Card #654:
On the back of the card the Answer currently reads: Anion Gap = Na + – (Cl- – HCO3-)

It should instead read: Anion Gap = Na + – (Cl- + HCO3-)

Flash Card #364, Gastroenterology & Nutrition, Explanation
The second sentence in the explanation currently reads: These 3 are caused by mutation on the PTEN tumor suppressor gene on chromosome 10g22-23.

This should instead read: These 3 are caused by mutation on the PTEN tumor suppressor gene on chromosome 10q23.

Common Pediatric Disorders Flash Card #127:
Answer is incorrect. Correct answer is “Nearsighted”

Explanation reads: “Most term newborns are hyperopic or farsighted at birth, while premature infants are nearsighted.”

It should instead read: “Most term newborns are nearsighted at birth with a visual acuity of approximately 20/400. Their vision trends toward farsightedness until age 7, generally passing through 20/20 around age 3–5 years. Maximum hyperopia (farsightedness) occurs at age 7 after which the visual acuity slowly decreases back to 20/20 or even myopia by about age 14. This trend slows but continues until the patient is about 30.”

Common Pediatric Disorders Flash Card #128:
The answer is correct, but the explanation should be expanded to read: “Most term newborns are nearsighted at birth with a visual acuity of approximately 20/400. Their vision trends toward farsightedness until age 7, generally passing through 20/20 around age 3–5 years. Maximum hyperopia (farsightedness) occurs at age 7 after which the visual acuity slowly decreases back to 20/20 or even myopia by about age 14. This trend slows but continues until the patient is about 30.”

Nephrology Flash Card #659:
Answer on the back of the card currently reads: Spironolactone is the potassium-sparing diuretic. It is an aldosterone agonist and can cause acidosis.

It should instead read: Spironolactone is the potassium-sparing diuretic. It is an aldosterone receptor antagonist and can cause acidosis.

Common Pediatric Disorders: Page 2-6, Under Color-vision Defects
Text currently reads:
Abnormal color vision occurs in ~ 8-10% of boys and < 0.5% of girls and is due to X-linked inheritance protan and deutan deficits (blue-green).
Text should read:
Abnormal color vision occurs in ~ 8-10% of boys and < 0.5% of girls and is due to X-linked inheritance protan and deutan deficits (red-green).

Growth & Development / Preventive Pediatrics Section; Page 1-25, near bottom of column 1:
A bulleted item currently reads: “History of high-dose (2 mg/kg/day or ≥ 20 mg/kg/day) oral corticosteroid use…” This should instead read: “History of high-dose (2 mg/kg/day or ≥ 20 mg/day) oral corticosteroid use…”

Endocrinology; Page 15-31, Under Secondary Hyperaldosteronism last paragraph:
Text currently reads:
Gitelman syndrome is also a hyperaldosteronemic, hyperreninemic state without hypertension, but it presents at an older age with musculoskeletal signs/symptoms and hypocalcemia and hypomagnesemia.”
Text should read:
Gitelman syndrome is also a hyperaldosteronemic, hyperreninemic state without hypertension, but it presents at an older age with musculoskeletal signs/symptoms and hypocalciuria and hypomagnesemia.

Gastroenterology & Nutrition; Page 14-12, Under Pyloric Stenosis, end of first paragraph:
Text currently reads:
African-American children are 2-3x more likely to be affected than Caucasian children; Asian-Americans are rarely affected.
Text should read:
Caucasian children are 2-3x more likely to be affected than African-American children; Asian-Americans are rarely affected.

Growth and Development; Page 1-4, Under Note in the second paragraph in the column on the right:
Text currently reads:
“There has been a large increase in the number of cases of posterior plagiocephaly due to the recommendation that sleeping infants be placed on their backs to reduce SIDS.”
Text should read:
“There has been a large increase in the number of cases of positional plagiocephaly due to the recommendation that sleeping infants be placed on their backs to reduce SIDS.”

Hematology; Page 16-20, Under FXI Deficiency (Hemophilia C), middle of first paragraph:
Text currently reads:
Bleeding problems are less common than in those with Factor XIII or IX deficiency, and these patients usually do not get hemarthroses.
Text should read:
Bleeding problems are less common than in those with Factor VIII or IX deficiency, and these patients usually do not get hemarthroses.

Endocrinology Section; Page 15-17, column 2, second subtopic:
Re: FHH, last sentence should read: “Serum calcium is elevated and urinary calcium is reduced.”

Endocrinology Section; Page 15-22 top of column 1:
Currently reads: “Also in 3ß-HSD, the ratio of 17-hydroxyprogesterone:17-hydroxypregnenolone is markedly high compared to the ratio in 21-hydroxylase deficiency, where it is low.”
Should read: “Also in 3ß-HSD, the ratio of 17-hydroxypregnenolone:17-hydroxyprogesterone is markedly high compared to the ratio in 21-hydroxylase deficiency, where it is low.”

Hematology Section; Page 16-20, Table 16-4:
Row 6b of Table currently reads: “Elevated bleeding time with normal platelet aggregation and decreased plt count.” Should read: “… with abnormal platelet aggregation…”

Metabolic Disorders Section; Page 10-24, column 2, under “Acute Intermittent Porphyria”:
Text currently reads: “This is an AR disorder seen most commonly in Scandinavians and British.”
Text should read: “This is an AD disorder seen most commonly in Scandinavians and British.”

Nephrology Section; Page 19-14, bottom of column 2:
Last sentence of the page should read: “For some families, there is an abnormality with collagen IV in this condition.”

Common Pediatric Disorders: Page 2-4, Under Color-vision Defects
Text currently reads:
Abnormal color vision occurs in ~ 8-10% of boys and < 0.5% of girls and is due to X-linked inheritance protan and deutan deficits (blue-green).
Text should read:
Abnormal color vision occurs in ~ 8-10% of boys and < 0.5% of girls and is due to X-linked inheritance protan and deutan deficits (red-green).

Gastroenterology & Nutrition; Page 14-12, Under Pyloric Stenosis, end of first paragraph:
Text currently reads:
African-American children are 2-3x more likely to be affected than Caucasian children; Asian-Americans are rarely affected.
Text should read:
Caucasian children are 2-3x more likely to be affected than African-American children; Asian-Americans are rarely affected.

Growth and Development; Page 1-5, Under Note in the middle of the column on the left:
Text currently reads:
“There has been a large increase in the number of cases of posterior plagiocephaly due to the recommendation that sleeping infants be placed on their backs to reduce SIDS.”
Text should read:
“There has been a large increase in the number of cases of positional plagiocephaly due to the recommendation that sleeping infants be placed on their backs to reduce SIDS.”

Hematology; Page 16-20, Under FXI Deficiency (Hemophilia C), middle of first paragraph:
Text currently reads:
Bleeding problems are less common than in those with Factor XIII or IX deficiency, and these patients usually do not get hemarthroses.
Text should read:
Bleeding problems are less common than in those with Factor VIII or IX deficiency, and these patients usually do not get hemarthroses.

Adolescence Question #39 and Answer #39
Question answer choice E. currently reads: Ceftriaxone 250 mg IM in a single dose plus azithromycin 1 g orally in a single dose
This should instead read: E. Ceftriaxone 250 mg IM in a single dose plus doxycycline 100 mg orally twice daily

In Answer book, #39, correct answer currently reads: Ceftriaxone 250 mg IM in a single dose plus azithromycin 1 g orally in a single dose
This should instead read: Ceftriaxone 250 mg IM in a single dose plus doxycycline 100 mg orally twice daily

In the answer explanation, 2nd sentence currently reads: “Combination therapy with ceftriaxone 250 mg intramuscularly and either azithromycin 1 gm orally as a single dose or doxycycline 100 mg orally twice daily for 7 days…”
This should instead read: “Combination therapy with ceftriaxone 250 mg intramuscularly and doxycycline 100 mg orally twice daily for 10 days…”

Question #109
The current explanation reads: …Following the clinical diagnosis of erythema multiforme, a workup should be initiated to attempt to identify a concurrent or recent infection, medication, or an underlying disorder responsible for the cutaneous findings.

The corrected explanation should read: …Following the clinical diagnosis of erythema nodosum, a workup should be initiated to attempt to identify a concurrent or recent infection, medication, or an underlying disorder responsible for the cutaneous findings.

Question #144
The current answer options are:

A. Valporic acid

B. Phenylephrine

C. Diphenhydramine

D. Guanfacine

E. Promethazine

The corrected answer options should be:

A. Valporic acid

B. Phenylephrine

C. Diphenhydramine

D. Baclofen

E. Promethazine

The current explanation reads: … Within minutes of treatment with diphenhydramine, 1–2 mg/kg IM or IV, motor abnormalities begin to resolve. Although dystonic reactions may be dose related, most are idiosyncratic. A dystonic reaction may occur within minutes following ingestion of the offending drug. Half of all reactions occur within 48 hours of onset of treatment while up to 90% occur within 5 days of initiation of treatment. Dystonic reactions are rarely life threatening, although emergent airway management is required when contractions of the laryngeal and/or pharyngeal muscles place the patient at risk of respiratory compromise.

The corrected explanation should read: … Diphenhydramine and baclofen are anticholinergics used to treat dystonic reactions. Valproic acid and phenylephrine do not cause dystonic reactions. Within minutes of treatment with diphenhydramine, 1–2 mg/kg IM or IV, motor abnormalities begin to resolve. Although dystonic reactions may be dose related, most are idiosyncratic. A dystonic reaction may occur within minutes following ingestion of the offending drug. Half of all reactions occur within 48 hours of onset of treatment while up to 90% occur within 5 days of initiation of treatment. Dystonic reactions are rarely life threatening, although emergent airway management is required when contractions of the laryngeal and/or pharyngeal muscles place the patient at risk of respiratory compromise.

 

Question #219
The last sentence in the question currently reads: Serum alkaline phosphatase (ALT) and γ-glutamyl transpeptidase (GGT) levels are in the high-normal range.
The corrected sentence should read: Serum alkaline phosphatase (ALP) and γ-glutamyl transpeptidase (GGT) levels are in the high-normal range.

The last sentence of the second paragraph in the explanation currently reads: ALT and γ-GGT levels are generally in the high-normal to mildly elevated range except in cases of autoimmune cholangiopathy in which levels may be more markedly elevated.
The corrected sentence should read: ALP and γ-GGT levels are generally in the high-normal to mildly elevated range except in cases of autoimmune cholangiopathy in which levels may be more markedly elevated.

 

Question #251
The explanation currently reads: The patient has clinical findings consistent with Pierre Robin syndrome… A U-shaped or V-shaped cleft palate occurs in as many as 90% of patients with Pierre Robin syndrome. Many conditions are associated with this syndrome, most notably Stickler syndrome… In addition to its common association with Pierre Robin syndrome, Stickler syndrome…

Infants with Pierre Robin syndrome…

The explanation should instead read: The patient has clinical findings consistent with Pierre Robin sequence… A U-shaped or V-shaped cleft palate occurs in as many as 90% of patients with Pierre Robin sequence. Many conditions are associated with this syndrome, most notably Stickler syndrome… In addition to its common association with Pierre Robin sequence, Stickler syndrome…

Infants with Pierre Robin sequence

The Board Testing Point currently reads: Recognize Pierre Robin syndrome… The Board Testing Point should instead read: Recognize Pierre Robin sequence

 

Question #305
The corrected explanation should read: To update this answer put in new explanation and BTP:
Children with a history of severe immediate reactions (e.g., generalized urticaria, respiratory distress, hypotension) following egg ingestion should not receive either the inactivated or live-attenuated influenza vaccine. These children should be seen by a physician with expertise in allergic conditions. Children with a only a family history of severe egg allergy may be vaccinated with either the inactivated or live-attenuated vaccine. There is no egg-free recombinant tetravalent form of vaccine for children (RIV3 is only for 18-49 years old).

Although the MMR vaccine is derived from chicken embryo tissue, children with a history of a hypersensitivity reaction to eggs (even when severe) are at low risk of anaphylaxis and may receive the vaccine. Skin testing is not recommended prior to administration of the MMR or MMRV vaccine as it is not predictive of an allergic reaction following vaccination. Hypersensitivity reactions following MMR or MMRV are likely due to gelatin, neomycin, or other vaccine components rather than to egg proteins.

The yellow fever vaccine also contains egg protein. Skin testing is recommended for those patients with a history of egg hypersensitivity who require this vaccine prior to travel to an endemic area.

Board Testing Point: Recall which vaccines and vaccine types are contraindicated in children with severe anaphylactic-like reactions following egg ingestion.

Question #42:
Question currently reads: Which of the following cutaneous findings is, in some circumstances, associated with the chronic use of certain illicit substances?

The question should instead read: Which of the following cutaneous findings is, in some circumstances, associated with chronic inhalant abuse?

The Board Testing Point currently reads: Recall specific clinical findings that may be associated with chronic use of illicit substances.

The Board Testing Point should read: Recall specific clinical findings that may be associated with chronic inhalant abuse.

Question #46:
Both answer options A (Shigella flexneri) and B (Campylobacter jejuni) are acceptable.

Question #132:
Explanation currently reads: A large hematoma may be complicated…

The explanation should instead read: A large hemangioma may be complicated…

Question #137:
In the Answer/Explanation text for this question, there is text that incorrectly reads:
47,XYY is Klinefelter syndrome.

This should instead read: 47,XXY is Klinefelter syndrome.

Question #198:
In the Answer Option C, the text incorrectly reads: “Both breasts are usually involved”

This should instead read: “Both breasts are equally involved”

Question # 202
In the Question and the Answer/Explanation text for this question, the text for one of the response options (which is also the correct response) currently reads: “Begin IV D5W at 4-8 mg/kg/hr.”

This should instead read: “Begin IV D5W at 4-8 mg/kg/min.”

Question #206:
The current question asks:

What labs need to be drawn to determine if she has had exogenous insulin administered as cause of her hypoglycemia?

This question should instead read:

What labs need to be drawn to distinguish endogenous from exogenous sources of insulin as a cause of her hypoglycemia?

Question #263
The explanation currently reads: Spondylolysis is a stress fracture of the pars due to an overuse…

The explanation should instead read: Spondylolysis is a stress fracture of the pars interarticularis due to an overuse…

Question #305:
The correct answer, D, currently reads, “Elevated levels of serum copper”

This should read: “Elevated levels of urine copper”

Additionally, the second sentence in the explanation currently reads: “Elevated serum transaminases, decreased serum levels of ceruloplasmin—the major carrier of copper in the serum, and elevated serum and urinary concentrations of copper are characteristic of Wilson disease.”

This should instead read: “Elevated serum transaminases, decreased serum levels of ceruloplasmin (the major carrier of copper in the serum), decreased serum copper and increased urinary concentrations of copper are characteristic of Wilson disease.”

Question #322:
The current correct answer reads: Send the patient for an urgent barium enema.
The correct answer should read: Send the patient for an urgent contrast enema.

The 4th sentence in the explanation currently reads: Barium enema in these cases…
The sentence should read: Contrast enema in these cases…

The Board Testing Point currently reads: Recognize intussusception and realize that the best diagnostic and therapeutic intervention is to perform a barium enema.
The Board Testing Point should read: Recognize intussusception and realize that the best diagnostic and therapeutic intervention is to perform a contrast enema.

Question #614:
The correct response, A, currently reads, “Lower motor neuron dysfunction of the right 7th cranial nerve”

This should read: “Lower motor neuron dysfunction of the left 7th cranial nerve”

Question #659
The entire original question should be replaced with the following update:

While attending the delivery of a term child who has been demonstrating late decelerations during labor, heavy meconium staining with particulate is noted in the amniotic fluids.

The most important step to reduce the complications of meconium aspiration is:

A.     Suctioning of the oropharynx on the perineum

B.     Intubation with suctioning below cords

C.     A short course of intravenous hydrocortisone

D.     None of the choices are correct

Answer: D: None of the choices are correct.

Aspiration of meconium or meconium-stained fluids is most common in term or post-term newborns with perinatal stresses. This occurs when the amniotic fluid is stained or contains frank meconium particles. The most effective intervention to avoid meconium aspiration was thought to be suctioning of the oropharyngeal cavity of the child before the first breath has been initiated—this has been proven to be ineffective. Intubation and airway suctioning has also been shown to be ineffective. Oxygen therapy may be required if symptoms of meconium aspiration develop but does not avert the development of respiratory complications. Hydrocortisone has no benefit in this condition. The best measures are supportive care and making sure the infant is well oxygenated.

Board Testing Point: Recall how to manage meconium aspiration.

Question #83
In the Question and the Answer/Explanation text for this question, the text for one of the response options (which is also the correct response) currently reads: “A systolic murmur heard best at the apex and left lower sternal border, which increases in intensity when moving from an upright to a supine position.” This should instead read: “A systolic murmur heard best at the apex and left lower sternal border, which decreases in intensity when moving from an upright to a supine position.” The remaining text for question, answer options, and explanation is correct as written.

Question # 189
One of the answer options for this question currently reads: “Give insulin glargine every 3 hours according to his sliding scale.” This should instead read: Give rapid-acting or very-rapid-acting insulin (lispro, aspart, glulisine) every 3 hours according to his sliding scale. The remaining text for question, answer options, and explanation is correct as written.

Question #442:
The answer option shown as correct for this question is not in fact the correct answer. Currently, the answer option “Hyper IgM syndrome” is indicated as correct; however, the correct answer option is “Hyper IgE syndrome.” The Answer explanation is correct. The Board Testing Point should read, “Recognize that hyper IgEsyndrome is primarily a neutrophil abnormality.”

Question #631
In the Answer/Explanation text for this question, the 2nd sentence currently reads: “Therefore, a fluoride supplement is recommended for the breastfed infant shortly after birth or no later than 6 months of age.” This should instead read: “Therefore, a fluoride supplement is recommended for the breastfed infant starting at 6 months of age. It is not recommended before 6 months of age because of increased risk of fluorosis.” The remaining text of the explanation is correct as written.

Question #199The last sentence of the question stem currently reads “The urine osmolality is 450 mOsm/L (normal, 600 mOsm/L).” This should instead read: “The urine osmolality is 750 mOsm/L (normal, 600 mOsm/L).”
The last sentence of the explanation currently reads: “Weight gain, low urine osmolality, and low serum sodium are consistent with inappropriate secretion of ADH.” This should instead read: “Weight gain, high urine osmolality, and low serum sodium are consistent with inappropriate secretion of ADH.”
The Board Testing Point currently reads: “Recognize that weight gain, low urine osmolality, and low serum sodium are consistent with inappropriate secretion of ADH.” This should instead read: “Recognize that weight gain, highurine osmolality, and low serum sodium are consistent with inappropriate secretion of ADH.”

Question #512

One answer option for this question currently reads: “Check an upright and supine spot urine to plasma-creatinine ratio.” Change plasma-creatinine ratio to protein-creatinine ratio. (Note that this is the correct answer to Question 512, so make the change where this appears in both the Questions and the Answers content.)