Internal-Medicine

Answers: 54–75 301
few of such patients have a large pituitary
tumor that affects the visual pathways. Over
50% have a microadenoma, which is under 5 mm
in diameter. (Kasper, pp. 2135–2136)
66. (E) Elevated triglycerides are the most common
dyslipidemia in DM. However, the LDL particles
in DM are more atherogenic than in nondiabetics,
even though they are not elevated
by DM alone. DM frequently results in lower
HDL levels as well. (Kasper, pp. 2167–2168)
67. (D) The vertebral bodies in osteoporosis may
become increasingly biconcave because of
weakening of the subchondral plates. This
results in “codfish” vertebra. When vertebral
collapse occurs, the anterior height of the vertebra
is usually decreased. Plain x-rays are
insensitive diagnostic tools because up to 30%
of bone mass can be lost without any apparent
x-ray changes. Dual-energy x-ray absorptiometry
(DEXA) and CT scan are more sensitive
tests for bone loss, but their exact clinical role
has not been clearly established. (Kasper, pp.
2268–2269)
68. (B) Aspirin is given in low doses such as 325
mg/day, although the initial studies were done
with higher doses. Carotid endarterectomy is
the best treatment for stenoses of 70% or more.
(Kasper, pp. 2367–2377)
69. (C) Later symptoms of hypothyroidism include
loss of intellectual and motor activity, declining
appetite, dry hair and skin, and deepening
voice. In the elderly, hypothyroidism can be
misdiagnosed as due to aging or to other diseases
such as Parkinson’s disease, Alzheimer’s
disease, or depression. (Kasper, pp. 2108–2111)
70. (D) Radiation therapy in stage lA Hodgkin’s
disease has a very high cure rate. Patients must
be followed for hypothyroidism. The long-term
disease-free survival is 80%. Mantle irradiation
can result acutely in transient dry mouth,
pharyngitis, fatigue, and weight loss. The most
common long-term effect is hypothyroidism
(in 30% of cases), but radiation pneumonitis
and fibrosis or pericardial disease can occur.
Although radiotherapy alone would be acceptable
in this case, there is a trend to add
chemotherapy as well. (Kasper, pp. 654–655)
71. (A) PAN may be associated with hepatitis B
antigenemia in 30% of cases, suggesting
immunologic phenomena in the pathogenesis
of the disease. Aneurysmal dilatations along
involved arteries are characteristic and their
presence in small- and medium-sized arteries
in renal, hepatic, and visceral vasculature is
diagnostic. Biopsy of involved areas can also be
diagnostic. (Kasper, pp. 2007–2008)
72. (E) CMV can also cause neurologic complications
from CNS infection. Treatment is with
ganciclovir, foscarnet, or cidofovir. Relapse
rates are high with both drugs, and therefore
maintenance therapy is mandatory. (Kasper, pp.
1104–1123)
73. (B) Most patients have fever, pain, chills, elevated
alkaline phosphatase, as well as
increased conjugated bilirubin. Mechanical
obstruction is most commonly due to stones,
tumors, or strictures. For reasons that are
unclear, the serum bilirubin tends to plateau
and rarely exceeds levels of 600 mmol/L (25 mg/
dL). (Kasper, pp. 238–240)
74. (B) Dysplastic nevi and benign acquired nevi
are both most common on sun-exposed areas
such as the back. Atypical moles can occur on
the scalp, breasts, and buttocks, rare areas for
benign acquired nevi. Both lesions are usually
associated with similar lesions (10–40 on average
for benign nevi, often >100 in the case of
dysplastic nevi). Dysplastic nevi are larger
(>6 mm) and have irregular pigmentation and
borders. (Kasper, p. 501)
75. (E) Prerenal azotemia usually has urine osmolality
over 500, urine creatinine over 40, and
fractional excretion of sodium