Internal-Medicine

296 14: Comprehensive Review
encephalopathy include bilateral (but not necessarily
symmetrical) abductor weakness or
paralysis, horizontal diplopia, strabismus, and
nystagmus. The nystagmus is most frequently
horizontal or vertical gaze-evoked nystagmus.
(Kasper, p. 1636)
17. (E) Calcitonin is secreted by cells in the thyroid.
Calcitonin reduces bone resorption and
increases renal calcium clearance. The inhibition
of osteoclast-mediated bone resorption
and the stimulation of renal calcium clearance
are mediated by receptors on osteoclasts and
renal tubular cells. Other receptors to calcitonin
are present in the brain, GI tract, and immune
system. (Kasper, p. 2251)
18. (C) Major manifestations of rheumatic fever
include carditis, migratory polyarthritis,
chorea, erythema marginatum, and subcutaneous
nodules. Minor manifestations include
arthralgia, fever, elevated acute phase reactants
(ESR, C-reactive protein), and prolonged PR
interval. The diagnosis is made with two major
or one major and two minor criteria, and evidence
of group A streptococcal infection (positive
throat culture or rapid streptococcal
antigen test, or rising antibody titers). (Kasper,
p. 1978)
19. (C) Home parenteral nutrition is usually helpful
in extreme short-bowel syndrome, chronic
obstruction due to adhesions, and severe radiation
enteritis. Placement of a central venous
catheter, careful calculation of fluid and nutritional
requirements, and meticulous monitoring
are required in a long-term parenteral
nutrition program. (Kasper, p. 418)
20. (A) In selecting a heart for transplantation, size,
ABO match, negative lymphocyte cross-match,
and other disease states are important factors.
The presence of severe pulmonary hypertension
can result in intraoperative death. In the
United States, it is estimated that only 2000
potential donor hearts become available each
year for 20,000 potential recipients. This means
that careful recipient selection is very important.
The optimal candidates will have a high
likelihood of return to a high level of function,
to be mentally vigorous and medically compliant.
(Kasper, pp. 1378–1379)
21. (D) CLL is frequently discovered on routine
evaluation of elderly patients and may not
require treatment for several years.
Splenomegaly, when present, rarely leads to
symptoms. It is usually a disorder of B cells
and is very indolent in its course. Most therapeutic
regimens are designed for symptom
control, not cure. Common reasons for treatment
include hemolytic anemia, cytopenias,
disfiguring lymphadenopathy, symptomatic
organomegaly, or systemic symptoms.
Chlorambucil is easy to administer, but fludarabine
is considerably more effective. It
requires IV administration. Maintenance therapy
is not helpful. (Kasper, pp. 648–649)
22. (D) GI bleeding is the most common precipitating
factor for hepatic encephalopathy.
Furosemide, by causing hypokalemia, is
another common cause. Narcotics and sedatives
are also frequently implicated. (Kasper, pp.
1867–1868)
23. (C) Other causes of asymptomatic hematuria,
with or without proteinuria, include sickle cell
disease, Alport’s syndrome, resolving glomerulonephritis,
and thin basement disease. Berger’s
disease is characterized by immunoglobulin A
(IgA) deposits in the mesangium. It most commonly
affects older children and young adults,
and is more common in Blacks than Whites.
Macroscopic hematuria may occur with intercurrent
illness or vigorous exercise. The prognosis
is variable but tends to progress slowly.
Spontaneous remissions are more common in
children than in adults. About 20–50% of
patients develop end-stage renal disease within
20 years of diagnosis. (Kasper, p. 1690)
24. (E) Chronic obstructive pulmonary disease
(COPD) due to emphysema usually demonstrates
severe dyspnea, scanty mucoid sputum,
normal hematocrit, and decreased diffusing
capacity on pulmonary function testing.
Chronic bronchitis is characterized by milder
dyspnea, greater sputum production, more frequent
hypercarbia and polycythemia, and