QUESTION: 9

A 59-year-old woman had a left modified radical mastectomy for intraductal carcinoma 2 years previously. She presents with confusion, lethargy, and thigh pain. X-rays reveal a lytic lesion in the shaft of the femur.

Which of the following is the most appropriate initial therapy?

radiotherapy to the femur
vigorous saline infusion
tamoxifen
chemotherapy
glucocorticoids

Answer(s): B

Explanation:

Hypercalcemia is a common complication of malignancy. Mechanisms include bone metastases, humoral secretion (e.g., osteoclast-activating factor), prostaglandin, or ectopic parathormone production and immobilization. Hypercalcemia is often manifested by confusion and lethargy. The other metabolic abnormalities usually are not associated with confusion. Therapy is directed at increasing renal calcium clearance and inhibiting further bone resorption. Saline infusion raises the glomerular filtration rate and decreases calcium reabsorption in the proximal tubule. Under life-threatening circumstances, the infusion may need to be aggressive, as much as 6 L of saline daily plus furosemide. Radiotherapy will do nothing for the calcium. Tamoxifen is an antiestrogen used in the treatment of breast carcinoma and other malignancies. When used in the presence of bone metastases, it may contribute to hypercalcemia.
Chemotherapy will not decrease the calcium levels. Glucocorticoids have an antitumor effect and reduce tumor production of humoral mediators, but act slowly.

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QUESTION: 10

A55-year-old retired policeman has had hypertension for about 15 years for which he takes hydralazine. He has a 35 pack-year tobacco history and continues to smoke one pack a day. On his visit, he complains about the appearance of his nose and asks if something can be done to decrease the redness.
Which of the following statements is correct?

Hydralazine does not play a role in his nasal erythema.
Smoking probably aggravates the dilatation of the blood vessels on his nose.
He should avoid alcohol and spicy foods.
There is no effective topical therapy.
Laser therapy will worsen the erythema.

Answer(s): C

Explanation:

He should avoid alcohol and spicy foods because these along with the heat, emotional stress, and hot temperature foods can aggravate rosacea. Hydralazine is a vasodilator and could worsen his nasal erythema. Smoking vasoconstricts rather than dilates blood vessels. Metronidazole gel is an effective topical therapy. Laser therapy is usually done after the other interventions have been tried

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QUESTION: 11

A46-year-old attorney is noted to have normal cholesterol levels but a very high fasting triglyceride level of 1600. He is otherwise healthy and has no risk factors for CAD. Which of the following statements is correct?

Hypertriglyceridemia is a strong independent risk factor for premature CAD.
Dietary modification is usually sufficient.
High triglyceride levels are associated with elevated high-density lipoprotein (HDL) levels.
Hypertriglyceridemia is usually associated with skin lesions.
Control of triglyceride levels can prevent attacks of acute pancreatitis in patients with extreme hypertriglyceridemia.

Answer(s): E

Explanation:

Hypertriglyceridemia has not been shown to be a strong independent risk factor for CAD, however, epidemiologic data do suggest a relationship. According to the National Cholesterol Education Program, when tirglycerides are above 200 mg/dL then non-HDL (total HDL) cholesterol becomes a pharmacologic treatment target. Severely elevated triglycerides (1000 mg/dL) are a recognized risk factor for attacks of acute pancreatitis, and control of the triglycerides can prevent these attacks. Diet alone is usually not sufficient at these high levels. A National Institutes of Health Consensus Conference has recommended that treatment be initiated in all patients with triglycerides greater than 500 mg/ 100 mL to prevent acute pancreatitis. Skin lesions are not present with hypertriglyceridemia.

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QUESTION: 12

A 60-year-old patient with long-standing diabetes has a creatinine of 3.6, which has been stable for several years. Which of the following antibiotics requires the most dosage modification in chronic renal failure?

tetracycline
gentamicin
erythromycin
nafcillin
chloramphenicol

Answer(s): B

Explanation:

Many drugs require dosage modifications in chronic renal insufficiency. Bioavailability, distribution, action, and elimination of drugs all may be altered. Drugs that are nephrotoxic may be contraindicated or used only with extreme care in renal insufficiency. The aminoglycosides, vancomycin, ampicillin, most cephalosporins, methicillin, penicillin G, sulfonamides, and trimethoprim all should be given in reduced dosage to patients with chronic renal failure. The aminoglycosides and vancomycin can be nephrotoxic and should be used with caution in renal insufficiency. The small group of antibiotics not needing dosage modification includes chloramphenicol, erythromycin, the isoxazolyl penicillins (nafcillin and oxacillin), and moxifloxacin.

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