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 7-42, 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 1-22, 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 and macrocytosis.”

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 1-47, 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."

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 4-17, 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 of 25-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, 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:

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.”]

Cardiology Section; Page 5-17, top 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."

Cardiology Section; Page 5-29, under PACEMAKERS, third paragraph:
Corrected: "DDD stands for dual chambers paced, dual chambers sensed, and dual response to sensing:
triggered and inhibited."

Cardiology Section; Page 5-33, last line of first paragraph:
“Synthetic natriuretic peptide drugs are being developed to boost the vasoconstrictive, diuretic, and natriuretic effects of these peptides.” should read “Synthetic natriuretic peptide drugs are being developed to boost the vasodilatory, diuretic, and natriuretic effects of these peptides.”

Endocrinology Section; Page 7-29, under subheading NORMAL CALCIUM PHYSIOLOGY, last line of first paragraph:
It reads: "PTH increases Ca+ from bone, increases renal tubular CA+ resorption, and renal tubular PO4 excretion." Replace this line with: "As mentioned above, PTH increases serum calcium levels by increasing resorption of bone and decreasing renal excretion of calcium. PTH stimulates renal secretion of phosphate which, in turn, enables calcium resorption."

Gastroenterology Section; Page 1-16, column 2, under “Treatment of UC”:
There is a discrepancy between the text in the second column and Table 1-3 regarding use of metronidazole in patients with fulminant UC. Although some physicians still use antibiotics in some cases, it has not been proven to be effective. For the Boards, metronidazole is not indicated in the treatment of mild-to-severe UC. It is indicated in the post-op Crohn patient because it helps prevent reanastomosis.

Gastroenterology Section; Page 1-20, top of column 2, under “Diabetic diarrhea may be caused by:”,  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 1-21, 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 1-24, half way down 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 1-29, column 1, under ACUTE MESENTERIC ISCHEMIA:
"Bowel infarction leads to acidosis, increased SGOT (ALT), and elevated amylase." ALT should be replaced with AST.

Gastroenterology Section; Page 1-36, Table 1-9:
The heading of the 1st column should be HBsAg (without the Anti-), the heading for the 2nd column should be Anti-HBc, and the heading for the 3rd column should be Anti-HBs. Also, 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 1-41, 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 10-6, column 2, paragraph 5:
A statement reads: "…it is very useful to use Table 10-5 in its stripped down form (Table 10-6)." The reference in the parentheses should be Table 10-7.

General Internal Medicine Section; Page 10-15, 1st column, paragraph beginning with number 2):
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 10-33, Quick Quiz #8:
Should read: "Know the eye movement associations with the 3rd, 4th, and 6th cranial nerves."

Infectious Disease Section; Page 2-21:
The references to "banana gametophyte" in the Quick Quiz box and in the text discussion of P. falciparum malaria should be "banana gametocyte."

Infectious Disease Section; Page 2-47, 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 4-12, column 2, 4th paragraph under CALCIUM:
A sentence in the text currently reads: “Renal failure results in a decreased renal conversion of 1-OH-D3 to the active 1,25-(OH)2-D3 (so there is an increased PTH in these patients).” This should instead read: “… conversion of 25-OH-D3 to the active 1,25-(OH)2-D3 …”

Nephrology Section; Page 4-34, column 1, under "Pregnancy and Renal Disease":
The last sentence of the 2nd paragraph should read: "Screen all pregnant lupus patients for lupus anticoagulant (spontaneous abortion) and SSA/SSB antibodies (neonatal heart block).

Neurology Section; Page 11-16, column 1, 6th paragraph:
Text currently reads: "Plasmacytomas: multiple melanoma (MM) can cause a demyelinating peripheral polyneuropathy." Correction: "Plasmacytomas: multiple myeloma can cause a demyelinating peripheral polyneuropathy."

Pulmonary Medicine Section; Page 3-10, Table 3-2 "Treatment of Asthma based on Severity Category":
3) Moderate persistent category
Column FEV1 or PEF should read: > 60%, < 80%

Pulmonary Medicine Section; Page 3-13, column2, sentence beginning "Criteria for starting continuous O2":
Should read:
resting PaO2 ≤ 55, or
O2sat (SaO2) ≤ 88%, or
PaO2 ≤ 59 mm Hg (O2sat ≤ 89%) with evidence of cor pulmonale or erythrocytosis (hematocrit > 55%).

Pulmonary Medicine Section; Figure 3-6 on Page 3-6, top of column 2:
Figure 3-6 as currently drawn is incorrect. Here is a modified, corrected Figure 3-6:

Add the following explanatory paragraph:
“Notice, in Figure 3-6, 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.”

Rheumatology Section; Page 6-12, column 2, end of 6th paragraph (regarding SLE):
It reads: "Anti-Ro/SSA antibody is also associated with a significant (10-20%) risk of neonatal lupus, which occasionally (10% of this number) causes congenital heart block. Replace with this: "Anti-Ro/SSA is also associated with a significant (10-20%) risk of neonatal lupus, which occasionally (10%) causes congenital heart block. Anti-La/SSB has also been associated with some cases of neonatal lupus, although not as rigorously associated as SSA."

Endocrinology Section; page 7-29, under subheading NORMAL CALCIUM PHYSIOLOGY,
last line of first paragraph:
It reads: "PTH increases Ca+ deposition into bone, increases renal tubular CA+ resorption, and renal tubular PO4 excretion." Replace this line with: "As mentioned above, PTH increases serum calcium levels by increasing resorption of bone and decreasing renal excretion of calcium. PTH stimulates renal secretion of phosphate which, in turn, enables calcium resorption."

Gastroenterology Section; Page 1-18, near top of column 2, under “Diabetic diarrhea may be caused by:”, 
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 1-19, near 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 1-22, half way down 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 1-27, column 1, under ACUTE MESENTERIC ISCHEMIA:
Text currently reads: “If there is bowel perforation, chemistry may show acidosis, increased SGOT (ALT), and elevated amylase." ALT should be replaced with AST.

Gastroenterology Section; Page 1-34, Table 1-9:
The heading of the 1st column is correct with HBsAg, but the heading for the 2nd column should be Anti-HBc (not HBcAb), and the heading for the 3rd column should be Anti-HBs (not HBsAb). Also, 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 1-38, column 1, 2nd paragraph under Drug- related Chronic Hepatitis:
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 10-14, 1st column, paragraph beginning with number 2):
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 10-15, under "Treatment Options for ED":
"Tadalafil (Cialis) has the same mechanism of action as sildenafil and tadalafil" should read: "Tadalafil (Cialis) has the same mechanism of action as sildenafil and vardenafil."

Infectious Disease Section; Page 2-44, 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 4-12, column 2, 4th paragraph under CALCIUM:
A sentence in the text currently reads: “Renal failure results in a decreased renal conversion of 1-OH-D3 to the active 1,25-(OH)2-D3 (so there is an increased PTH in these patients).” This should instead read: “… conversion of 25-OH-D3 to the active 1,25-(OH)2-D3 …”

Pulmonary Medicine Section; Figure 3-6 on Page 3-6, top of column 2:
Figure 3-6 as currently drawn is incorrect. Here is a modified, corrected Figure 3-6:

Add the following explanatory paragraph:
“Notice, in Figure 3-6, 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.”

Pulmonary Medicine Section; Page 3-34, 3rd full paragraph:
It states that a health care worker with 10 mm diameter of induration (PPD result) is a candidate for treatment.
At the end of this Pulmonary Medicine section, review Question and Answer # 34 C indicates that a nurse with a PPD of 10mm does not need INH. The correct answer is that, for a PPD of 10 mm, the nurse should be treated. The guidelines for this group changed a few years ago, which is long enough for the question to now appear on the Boards.

Pulmonary Medicine Section; Page 3-27, middle of column 1:
It states: “As mentioned before, LMWH [Low Molecular Weight Heparin] is not used in pregnant women (yet).”
At the end of this Pulmonary Medicine section, review Question number 32 asks what the proper treatment is for a pregnant patient hospitalized for DVTs and PE, and who has been given IV heparin in the hospital. The correct answer to this question is given as B: “Adjusted-dose SQ heparin or LMWH until after delivery.”
Neither reference is wholly correct or wholly incorrect. Use of LMWH in pregnancy is standard in some centers, controversial in others. (As a result, this differentiation is unlikely to appear as a Board exam question.)

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.

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. 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

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 this by 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 # 255 should read:
"Which of the following is consistent with a patient with Type 1 RTA and recurrent nephrolithiasis?"
This question asks you to utilize the urine pH and anion gap to differentiate diarrhea from RTA.

Question # 256:
Toward the end of the Answer/Explanation, the statement "therefore the urine Cl increases and the urine AG becomes positive" should instead read "therefore the urine Cl increases and the urine AG becomes negative"

Question # 260:

In the table listing urinalysis results, two of the Macro results read as follows:

These should instead read:

Please replace Question #278 and its associated explanation with the following corrected text:

Which of the following disease states is not caused by an abnormality in the adrenal gland itself?

A. Cushing disease
B. Pheochromocytoma
C. Aldosteronoma (Conn syndrome)
D. Adrenal tumor-secreting deoxycorticosterone (DOC)
E. Adrenal carcinoma

Answer: A. Cushing disease.

Explanation: Adrenal carcinomas, Conn syndrome, pheochromocytomas and adrenal deoxycorticosterone (DOC)-secreting tumors all arise within the adrenal gland.
Cushing disease, however, is caused by an ACTH-secreting pituitary adenoma. The ACTH stimulates cortisol release by the adrenal glands and resultant hypertension. Cushing disease is the most common cause of Cushing syndrome.

Board Testing Point: Recognize that Cushing disease is a secondary disorder of the adrenal gland (the primary lesion is in the pituitary gland).

Please replace question 291 in Internal Medicine Board-Style Questions & Answers Volume 4 (Books/CD-ROM/Download) with the question presented below. The ECG shown in the original question is incorrect and shows QT interval prolongation, which is consistent with HYPOcalcemia, not hypercalcemia. Additionally, portions of the explanation accompanying the original question are incorrect.

291.

A 74-year-old lethargic female is brought to the ED complaining of nausea, vomiting, and abdominal pain. She has been having vague muscle and joint pains for several days prior to admission. On exam, she has hyperreflexia, and you notice that she has fasciculations of the tongue. A cardiac tracing shows a shortened QT interval without significant change in the T wave.

Which of the following is the most likely diagnosis?

A. Hypercalcemia
B. Hypocalcemia
C. Hyperkalemia
D. Hypokalemia
E. Carbon monoxide poisoning

Answer: A. Hypercalcemia.

Hypercalcemia is most commonly caused by hyperparathyroidism or malignancy (usually breast or lung cancer or multiple myeloma), but can also be caused by sarcoidosis and other granulomatous diseases.

When caused by hyperparathyroidism, the hypercalcemia is usually mild; this is also known as primary hyperparathyroidism. This occurs more often in women, and its incidence increases with age. The increase in calcium is due to the hypersecretion of parathyroid hormone (PTH), which causes an increase in the absorption of calcium in the intestine, as well as decreased excretion of calcium at the renal tubule. The osteoclasts in the bones are not involved in this process.

When caused by cancer, the hypercalcemia is usually more severe. It is due to increased osteoclastic activity within the bone (non-PTH mediated). This affects men and women equally, and increases in incidence with increasing age (as does the occurrence of these tumors).

Symptoms of hypercalcemia include nausea, vomiting, abdominal pain, altered mentation, and lethargy. Some patients report muscle and joint pains. Physical findings may include hyperreflexia and tongue fasciculations, but usually physical findings are absent. Laboratory testing shows elevated calcium. An ECG may show a shortened QT interval.

The treatment is to rapidly correct the hypercalcemia. The prognosis depends on the underlying cause. If caused by a malignancy, the prognosis is usually poor.

Hyperkalemia usually causes peaked T waves and a shortened QT interval on ECG. As the condition worsens, the PR interval and QRS widens. Hyporeflexia and muscle weakness can be observed when levels exceed 7.0 meq/L.

Hypocalcemia is incorrect because low calcium levels are associated with circumoral paresthesias and tetany (not fasciculations). You normally see prolongation, not shortening, of the QT interval.

Hypokalemia is associated with muscle weakness that begins distally and progresses to the trunk, with abdominal pain, nausea, vomiting and muscle cramping or tetany. The ECG is variable (ectopy, bradycardia, AV blocks and ventricular arrhythmias). Major changes include ST segment depression and reduced amplitude T waves. On occasion, the rare lateral U wave can be seen. Shortening of the QT interval is not a common feature, however.

Carbon monoxide poisoning is not associated with this clinical presentation, and ECG traditionally shows evidence of ischemia or ventricular arrhythmias.

Board Testing Point: Recognize the clinical findings of hypercalcemia and interpret an electrocardiogram showing a shortened QT interval.

Question #340: An elaboration. In the U.S., most physicians would give chemotherapy because of the size of this tumor (> 2 cm); however, data suggest in this setting of postmenopause, 3-cm, node-negative, hormone receptor-positive breast cancer that chemotherapy does not add much benefit compared to hormonal therapy alone. In any case, this is controversial and unlikely to appear on the current ABIM exam for General Internal Medicine.

Question # 173
The ECG shown in question #173 is more consistent with constrictive pericarditis, but the clinical scenario is more consistent with pulmonary embolism. (The answer currently given as correct is pulmonary embolism.) Please replace the ECG in question #173 with this ECG for pulmonary embolism, which shows the classic: S wave in lead I, Q wave in lead III, and inverted T wave in lead III (S1Q3T3).

Question # 393 in book format; # 402 in the software format
The Explanation for the answer to this question includes the sentence: "Remember Parkinson's does not have a resting tremor."

This sentence should read: "The tremor associated with Parkinson's Disease has a characteristic appearance. The tremor is most obvious when the hand, arm or leg is at rest, but it subsides with movement - unlike this patient's presentation. It is also important to remember that a hand tremor can take the form of a back-and-forth motion of the thumb and forefinger, as though rolling a small object between them. This is sometimes called "pill rolling."

Question # 405, CD-ROM
The question is truncated when it displays. The full text of the question should read: "A 56-year-old comatose obese woman is brought to the ED by her husband. She has had several days of headache, and has been "sleepy." On the day of admission, she became unresponsive. On exam, she has hyperreflexia on the left (arm and leg), spasticity in the left upper and lower extremity, and seems to withdraw from painful stimuli, less well on the left. There is no atrophy or fasciculations of the muscles in the left arm or leg. Funduscopic exam shows bilateral papilledema; the right pupil is large and unreactive, while the left is midpoint and reacts to light."
(The question appears correctly in the book format of IM Q&A vol 3, where it is Question number 396.)

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. 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

 

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.

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."

Endocrinology Section; Page 8-11, Table 8-2:
The last row of the table states that a low TSH and low T4 indicate pituitary hyperthyroidism; it actually indicates pituitary hypothyroidism.
In the line directly above the last row in the same table (low TSH and normal T4), it should read: Incipient/subclinical hyperthyroidism, not hypothyroidism.

Endocrinology Section; Page 8-21, column 2, highlighted area:
Currently reads: “Also in 3ß-HSD, the ratio of 17-hydroxyprogesterone:17-hydroxyprenenolone 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-hydroxyprenenolone:17-hydroxyprogesterone is markedly high compared to the ratio in 21-hydroxylase deficiency, where it is low.”

Genetics Section; Page 7-3, Figure 7-4:
The figure on this page should be replaced by the following figure:

Hematology Section; Page 14-20, Table 14-4:
Row 6b of Table currently reads: “Elevated bleeding time with nl plt aggregation and decreased plt count.” Should read: “… with abnormal plt aggregation…”

Metabolic Disorders Section; Page 6-25, column 1, 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 13-5, bottom of column 2:
Text should read: "therefore, the pH tells you what the primary abnormality is:
< 7.35 indicates acidemia.
> 7.45 indicates alkalemia."

Nephrology Section; Page 13-20, bottom of column 2:
Text currently reads: “Overall, acute tubular necrosis is very serious, even”
Complete text should read: “Overall, acute tubular necrosis is very serious, even with dialysis (death, however, if it occurs, is usually because of multiple other complicating factors). For those who improve, 90% do so within 3 weeks, 99% within 6 weeks.”

Nephrology Section; Page 13-21, bottom of column 2:
The 2 lines of text at the bottom of this column are repeated at top of Page 13-22. This is a simple redundancy.

Nephrology Section; Page 13-28, bottom of column 1:
Text currently reads: “Severe phimosis can impede”
Complete text should read: “Severe phimosis can impede urinary flow.”

Nephrology Section; Page 13-29, Quick Quiz #2:
Text currently reads: “How is phimosis treated?”
Text should read: “How is paraphimosis treated?”

Neurology Section; Page 18, Figure 18-2:
Figure 18-2 should be labeled Syringomyelia, not Spina Bifida

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 #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 # 199

The 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, high urine osmolality, and low serum sodium are consistent with inappropriate secretion of ADH.”

Question # 512