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AFP Journal Review. March 1, 2007. Articles. Preparation of the Cardiac Patient for Noncardiac Surgery Autoimmune Polyglandular Syndrome, Type II Iron Deficiency Anemia Asbestos-Related Lung Disease Erythema Nodosum. Strength of Recommendation Grades.

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Afp journal review

AFP Journal Review

March 1, 2007


Articles

Articles

  • Preparation of the Cardiac Patient for Noncardiac Surgery

  • Autoimmune Polyglandular Syndrome, Type II

  • Iron Deficiency Anemia

  • Asbestos-Related Lung Disease

  • Erythema Nodosum


Strength of recommendation grades

Strength of Recommendation Grades

  • A – Consistent, good quality patient oriented evidence

  • B – Inconsistent or limited quality patient oriented evidence

  • C – Consensus, disease oriented evidence, usual practice, expert opinion, or case series for studies of diagnosis, treatment, prevention, or screening


Preparation of the cardiac patient for noncardiac surgery

Preparation of the Cardiac Patient for Noncardiac Surgery

  • 20-40% of patients at high risk of cardiac-related morbidity develop MI perioperatively.

  • In 2002 ACC/AHA revised its evidence based guidelines.

  • Available for PDA - STAT Cardiac Clearance, www.statcoder.com/cardiac1.htm


2002 acc aha guidelines

2002 ACC/AHA Guidelines

  • Evaluation depends on:

    • Patient-specific risk factors

    • Surgery-specific risk factors

    • Exercise capacity.

  • Emergency surgery  OR

  • Recent cardiac evaluation (< 6 months in a stable pt) or revascularization and no change in symptoms  OR


Clinical predictors

Clinical Predictors

  • Major (unstable coronary syndromes, decompensated heart failure, significant arrhythmias, severe valvular disease)

  • Intermediate (mild angina, prior MI, compensated HF, DM, RF)

  • Minor (age > 75 yrs, abnormal EKG, non-sinus rhythm, low functional capacity, history of CVA, uncontrolled HTN)


Cardiac risk stratification for noncardiac surgery

Cardiac Risk Stratification for Noncardiac Surgery

  • High (risk > 5%) – Emergent operations in pts > 75 yrs, major vascular surgery, prolonged surgeries associated with large fluid shifts and/or blood loss.

  • Intermediate (risk 1-5%) – CEA, Head and neck, intraperitoneal and intrathoracic, orthopedic, prostate surgery.

  • *Low (risk < 1%) – Endoscopy, superficial, cataracts, breast surgery.

* Generally do not require further pre-op cardiac testing


Afp journal review

Minor or no clinical predictors

Clinical predictors

Moderate or

excellent (> 4 METs)

Functional capacity

Poor (<4 METs)

High surgical

risk procedure

Intermediate or low

surgical risk procedure

Surgical risk

Noninvasive

testing

Low risk

OR

Post-op risk stratification and risk factor reduction

High risk

Consider angiography

Subsequent care dictated by

Findings and tx results


Afp journal review

Intermediate clinical predictors

Clinical predictors

Moderate or

excellent (> 4 METs)

Functional capacity

Poor (< 4 METs)

Low risk

procedure

High risk

procedure

Intermediate

Risk procedure

Surgical risk

Noninvasive testing

Low risk

OR

High risk

Post-op risk stratification

and risk factor reduction

Consider angiography

Subsequent care

dictated by findings

tx results


Afp journal review

Major clinical predictors

Consider delay or

Cancel surgery

Consider angiography

Subsequent care dictated

by findings and treatment

results

Medical management

and risk factor modification


Other guides to assess cardiac risk

Other Guides to Assess Cardiac Risk

  • Goldman criteria

  • Detsky’s clinical risk index

  • Lee’s revised cardiac risk index

  • All available for PDA with MedRules


Sort key recommendations

SORT: Key Recommendations

  • Beta blockers should be given perioperatively to patients with known ischemic heart disease undergoing vascular surgery or who have previously taken beta blockers. – A

  • Beta blockers generally are NOT recommended for patients with low to moderate risk of peri-operative cardiovascular complications. – B


Sort key recommendations1

SORT: Key Recommendations

  • Statin use is associated with a reduction in perioperative risk in patients with preexisting CAD, although randomized trial data are lacking. – B

  • Alpha2-agonists such as clonidine (Catapres) are a possible alternative to beta blockers to reduce perioperative risk of cardiac complications in high-risk patients. – B


Autoimmune polyglandular syndrome type ii

Autoimmune Polyglandular Syndrome, Type II

  • Combination of

    • Autoimmune Adrenal Insufficiency

    • Autoimmune Thyroid disease

    • Type I Autoimmune Diabetes Mellitus


Epidemiology

Epidemiology

  • Incidence primary adrenal insufficiency is 5/100,000 in U.S.

  • 44 - 94% due to autoimmune disease.

  • Prevalence of APS II is 1.4-2.0/100,000.

  • Most common in pts 30 – 40 years of age.

  • More common in women.

  • Half of pts with APS II have family history of autoimmune disorders.

  • Genetic determinant is HLA DR3 (DQB*0201) and DR4 (DQB1*0302)


Other associated conditions

Other Associated Conditions

  • Vitiligo

  • Chronic atrophic gastritis w or w/o pernicious anemia

  • Hypergonadotropic hypogonadism

  • Chronic autoimmune hepatitis

  • Alopecia

  • Hypophysitis

  • Myasthenia gravis

  • Rheumatoid arthritis

  • Sjogren’s syndrome

  • Thrombocytic purpura


Diagnosis of adrenal insufficiency

Diagnosis of Adrenal Insufficiency

  • Symptoms

    • Fatigue, weakness, anorexia, nausea, vomiting

    • Abdominal pain, salt craving, diarrhea, constipation, syncope

  • Signs

    • Weight loss, cutaneous and mucosal pigmentation, hypotension, hypoglycemia


Diagnosis

Diagnosis

  • A.M. cortisol level < 3 mcg/dL strongly suggestive.

  • If > 8 mcg/dL excludes diagnosis.

  • Cosyntropin (Cortrosyn) test has sn 95% and sp 97% and is the standard test. – C

    • 250 mcg of cosyntropin (ACTH) IM or IV and serum cortisol level measured 30-60 min later.

    • Normal serum cortisol > 14 mcg/dL.

    • Test can be done anytime of day.

    • Primary adrenal insufficiency confirmed by increased plasma ACTH level.


Diagnosis1

Diagnosis

  • Other Laboratory Abnormalities

    • Low sodium, bicarb, chloride

    • Low serum aldosterone levels

    • Increased potassium

    • Mild to mod increased calcium level

    • Normocytic anemia (uncommon)

  • Thyroid and Diabetes diagnosed in usual manner.

  • Autoimmune basis must be demonstrated.


Autoantibodies

Autoantibodies

  • Adrenal Insufficiency

    • adrenal Cortex Ab found early

    • 21-Hydroxylase Ab highly SN and SP

  • Hashimoto’s thyroiditis

    • thyroid peroxidase Ab

    • thyroglobulin Ab

  • Type I Diabetes

    • islet cell Ab occur in 80%

    • glutamic acid decarboxylase 65 Ab (GAD) highest diagnostic sensitivity


Treatment

Treatment

  • Each condition of APS II should be treated the same way as if they occurred separately. – C

  • Initiating treatment for autoimmune hypothyroidism in a patient with APS II and untreated adrenal insufficiency can precipitate a life-threatening adrenal crisis.


Treatment1

Treatment

  • Addisonian Crisis

    • Reverse hypotension and electrolyte problems with iv fluids (D5NS).

    • IV Steroids (hydrocortisone 100 mg or dexamethasone 2-4 mg) tapered over 3 days to maintenance dose of 15 – 20 mg po daily.

    • Fludrocortisone (Florinef) 0.1 mg given for primary adrenal insufficiency.


Iron deficiency anemia

Iron Deficiency Anemia

  • Most common nutritional deficiency worldwide.

  • Men and non-menstruating women lose 1 mg of iron per day.

  • Menstruating women can lose an extra 10 mg to 42 mg of iron per cycle.

  • Pregnancy takes 700 mg of iron

  • 2 packs of whole blood contains 250 mg of iron.


Iron deficiency anemia1

Iron Deficiency Anemia

  • Absorption occurs in jejunum

  • Two forms of dietary iron

    • Heme (found in meat) not affected by dietary factors

    • Nonheme (plant and dairy) requires acid digestion, enhanced by ascorbate, meat and inhibited by calcium, fiber, tea, coffee, wine


Iron deficiency anemia2

Iron Deficiency Anemia

  • Caused when demand not met by absorption from diet.

    • Inadequate dietary intake

    • Hampered absorption

    • Physiologic losses in woman of reproductive age

    • Blood loss, occult or known


Risk factors in u s

Risk Factors in U.S.

  • Black

  • Blood donors > 2 Units/yr women and 3 Units/yr men

  • Low SES AND postpartum

  • Mexican ethnicity

  • Child and adolescent obesity

  • Vegetarian diet


Screening and primary prevention

Screening and Primary Prevention

  • USPSTF recommends screening pregnant women for IDA, but found insufficient evidence to recommend for or against routine screening in other asymptomatic persons.

  • High-risk infants six to 12 months of age should be given routine iron supplementation. – B

  • Dietary Reference Intakes (DRI) for iron is 8 mg/day for healthy non-menstruating adults; 18 mg for menstruating women; 16 mg for vegans, and 20 mg for blood donors.


High risk infants

High Risk Infants

  • Poverty

  • Black, Native American, or Alaskan Native

  • Immigrants from a developing country

  • Preterm or low birth weight

  • Primary dietary intake is unfortified cow's milk.


Definition of anemia

Definition of Anemia

Hemoglobin level


Differential diagnosis of microcytic anemia mcv 80 fl

Differential Diagnosis of Microcytic Anemia (MCV < 80 fL)

  • Iron deficiency

  • Thalassemia

  • Sideroblastic anemia

  • Chronic disease

  • Lead poisoning


Diagnostic tests for ida

Diagnostic Tests for IDA

  • Serum Ferritin <25 ng/ml

    • Falls before other indices

    • Most sensitive for IDA

    • Falsely elevated in Hepatitis

  • TIBC rises

  • Serum Iron

    • Falls after Serum Ferritin

    • Falls after TIBC

  • Transferrin Saturation decreases

    • Falls after Serum Ferritin

  • Serum transferrin receptor increased (normal levels in anemia of chronic disease)


Evaluation and treatment

Evaluation and Treatment


Sort key recommendations2

SORT: KEY Recommendations

  • Pts older than 65 with IDA should be screened for occult GI malignancy. – B

  • In men and postmenopausal women younger than 65, screening for occult GI malignancy should be done in absence of another cause for IDA. – B


Treatment of ida

Treatment of IDA

  • Consider transfusion for all pts who are symptomatic and for asymptomatic cardiac pts with Hgb < 10 g/dL.

  • Oral therapy is usually first line.

  • An increase in Hgb level of 1 g/dL should occur every 2-3 weeks.

  • Iron stores take up to 4 months to return to normal after Hgb has corrected.


Treatment of ida1

Treatment of IDA

  • FeSO4 300 mg provides 60 mg of elemental iron.

  • FeGluconate 325 mg provides 36 mg of elemental iron.

  • Bone marrow response to iron limited to 20 mg per day of elemental iron.

  • IV iron available

    • iron dextran (risk of anaphylaxis)

    • ferric gluconate (safer)

    • iron sucrose


Asbestos related lung disease

Asbestos-Related Lung Disease

  • Asbestos – a naturally occurring crystalline mineral used in many industries due to its flexibility, durability and resistance to heat and chemical corrosion.

  • Inhalation of asbestos fibers first linked to lung disease in 1890 and first deaths reported in 1907.

  • Legislation in U.S. enacted to limit exposure 1971.


Asbestos related lung disease1

Asbestos-Related Lung Disease

  • Asbestosis – Prevalence 200,000 and 2,000 deaths/yr

  • Lung Cancer – 2000-3000 deaths/yr

  • Mesothelioma – 2,000 deaths/yr

  • Pleural plaques – Among exposed 3-58%; general population 0.5-8%


Asbestos related lung disease2

Asbestos-Related Lung Disease

  • Risk of asbestos exposure should be assessed with occupational history. Screening should be considered in patients with a high risk of exposure. – C

  • CXR and PFTs should be performed every 3-5 yrs in pts with asbestos-related disease. – C


Potential sources of occupational and environmental asbestos exposure

Potential Sources of Occupational and Environmental Asbestos Exposure

  • Asbestos-containing products

    • Asbestos-containing flight materials: aircraft mechanics, aerospace and missile production, aircraft manufacturing

    • Asbestos-lined electrical products: electrical workers, electrical linemen, telephone linemen, and power plant workers

    • Asbestos shipping materials: shipyard workers (e.g., insulators, laggers, painters, pipe fitters, maintenance workers, welders), Coast Guard personnel, merchant mariners, longshoremen, U.S. Navy personnel, asbestos manufacturing plant workers, insulators, machinists, persons working at packing and gasket manufacturing plants, pipe fitters, and power plant workers


Potential sources of occupational and environmental asbestos exposure1

Potential Sources of Occupational and Environmental Asbestos Exposure

  • Brake linings and clutch pads: auto mechanics, those involved in brake and clutch manufacturing, and assembly workers

  • Building materials: building engineers, cement plant production workers, building material manufacturers, construction workers (including insulators, boilermakers, steelworkers, ironworkers, plumbers, steamfitters, plasterers, drywallers, cement and masonry workers, roofers, tile/linoleum installers, carpenters, and welders)

  • Other asbestos-containing products: railroad workers, steamfitters, refinery workers, sheet metal workers, refractory products plant workers, rubber workers, and warehouse workers


Potential sources of occupational and environmental asbestos exposure2

Potential Sources of Occupational and Environmental Asbestos Exposure

  • Asbestos removal

    • Removal of insulation, asbestos removal, and waste handling

    • Building demolition and ship breaking

  • Environmental exposure

    • Asbestos in public buildings (e.g., hospitals, libraries, schools); occurs when the asbestos is disturbed during building or maintenance work

    • Family members of persons exposed occupationally

  • Asbestos production

    • Asbestos mining; textile mill workers who weave asbestos into cloth

  • Asbestos transport

    • Packing and handling of asbestos


Asbestosis

Asbestosis

  • Fibrotic lung disease, or pneumoconiosis, resulting from inhalation of asbestos fibers. Currently no treatment alters course of disease.

  • Latent period of 20 to 30 yrs.

  • PFTs reveal decreased DLCO and exertional oxygen desaturation restrictive pattern with TLC and VC.

  • CXR and CT show interstitial markings lower lobes, pleural plaques.

  • Clinically similar to idiopathic pulmonary fibrosis, but slower progression.


Benign pleural disease

Benign Pleural Disease

  • Most common pathologic pulmonary response to asbestos exposure.

  • Deposition of collagen in the pleura, which calcify.

  • Usual asymptomatic and no evidence that they transform into malignant lesions.

  • Benign pleural effusions, unilateral, exudative most common 10-20 yrs after exposure. Diagnosis of exclusion.


Afp journal review

Figure 1. Computed tomographic scan of the chest demonstrating severe asbestosis. There is marked parenchymal remodeling and tissue destruction ("honeycombing" [arrow]), leading to restrictive lung disease (forced vital capacity: 56 percent of predicted) and decreased oxygen exchange.

Figure 2. Chest radiograph of a patient with previous asbestos exposure who has developed pleural plaques (arrows)). These plaques are characteristically located symmetrically along the lateral chest wall but also may occur on the domes of the diaphragm.


Lung cancer

Lung Cancer

  • Asbestos exposure significantly increases risk of small cell and non-small cell carcinoma.

  • Smoking increases this risk several-fold.

  • Evaluation of new non-calcified pulmonary nodule is the same with or without a history of exposure.


Diffuse malignant mesothelioma

Diffuse Malignant Mesothelioma

  • Aggressive tumor derived from mesothelial cells, most commonly of the pleura.

  • Uniformly fatal, median survival of 6 to 18 months from diagnosis. Surgery, radiation, chemo do not improve survival.

  • CXR and CT unilateral pleural effusion with irregular pleural thickening.

  • Advanced cases associated with superior vena cava syndrome, Horner’s syndrome, dysphagia, invasion of neighboring structures.


Afp journal review

Mesothelioma

Irregular diffuse pleural thickening / mass on left

Blunting of costophrenic angle

Loss of left diaphragmatic silhouette

Left hemithorax larger


Erythema nodosum a sign of systemic disease

Erythema Nodosum: A Sign of Systemic Disease

  • Most common panniculitis – painful disorder of subcutaneous fat

  • Prevalence 1-5/100,000; Women > Men (6:1)

  • Peak incidence 20-30 yrs

  • Usually cause is unknown, but can be sign of underlying systemic disease.

  • Type IV delayed hypersensitivity response to a variety of antigens.


Erythema nodosum

Erythema Nodosum

  • Basic Features

    • Painful, symmetric, red nodules

    • Anterior legs most common location

    • Involutes in weeks with bruise-like appearance

    • Does not ulcerate; tends to heal completely

    • Prodrome 1-3 weeks before onset of lesions; wt loss, malaise, fever, cough, arthralgia


Afp journal review

Erythema nodosum

Classically located on pretibial surface of lower extremity.


Clinical variants

Clinical Variants

  • Erythema nodosum migrans – persistent, minimally symptomatic, unilateral, migrate centrifugally.

  • Subacute nodular migratory panniculitis – nodules on legs coalesce into large plaques.

  • Chronic erythema nodosum – join to form larger plaques, less inflamed


Causes of erythema nodosum

Causes of Erythema Nodosum

  • Common

    • Idiopathic (up to 55 percent)

    • Infections: streptococcal pharyngitis (28 to 48 percent), Yersinia spp. (in Europe), mycoplasma, chlamydia, histoplasmosis, coccidioidomycosis, mycobacteria

    • Sarcoidosis (11 to 25 percent) with bilateral hilar adenopathy

    • Drugs (3 to 10 percent): antibiotics (e.g., sulfonamides, amoxicillin), oral contraceptives

    • Pregnancy (2 to 5 percent)

    • Enteropathies (1 to 4 percent): regional enteritis, ulcerative colitis


Causes of erythema nodosum1

Causes of Erythema Nodosum

  • Rare (less than 1%)

    • Infections

      • Viral: herpes simplex virus, Epstein-Barr virus, hepatitis B and C viruses, human immunodeficiency virus

      • Bacterial: Campylobacter spp., rickettsiae, Salmonella spp., psittacosis, Bartonella spp., syphilis

      • Parasitic: amoebiasis, giardiasis

    • Miscellaneous: leukemia or lymphoma, other malignancies


Diagnosis2

Diagnosis

  • CBC w/diff; ESR and C-reactive protein levels

  • Evaluation for strep infection (i.e., throat culture for group A streptococci, rapid antigen test, ASO, and polymerase chain reaction assay)

  • Excisional biopsy (when clinical diagnosis is in doubt); key histologic findings are septal panniculitis, lymphocytic infiltrate with neutrophils, actinic (Miescher's) radial granulomas, absence of vasculitis, and no organisms

  • Clinical suspicion of chronic disease (e.g., sarcoidosis, tuberculosis); PPD, CXR

  • Stool culture, O&P in patients with gastrointestinal symptoms; consider evaluation for inflammatory bowel disease


Differential diagnosis

Differential Diagnosis

  • Most common

    • Alpha1-antitrypsin deficiency

    • Cytophagic histiocytic panniculitis (a lymphoma)

    • Lupus erythematosus profundus (lupus panniculitis)

    • Nodular fat necrosis

  • Occasional

    • Necrobiosis lipoidica

    • Necrobiotic xanthogranuloma

    • Scleroderma

    • Subcutaneous granuloma


Differential diagnosis1

Differential Diagnosis

  • Rare

    • Cold panniculitis

    • Infectious panniculitis

    • Leukemic fat infiltrates

    • Lipodystrophies

    • Poststeroid panniculitis

    • Povidone panniculitis

    • Scleroderma neonatorum

    • Sclerosing panniculitis

    • Subcutaneous fat necrosis of the newborn


Treatment2

Treatment

  • Self-limited

  • Treat any underlying disorder

  • Supportive, bed rest, avoid contact irritation of affected areas.

  • NSAIDs for pain

  • Oral potassium iodide 400-900 mg per day effective if begun at onset.

  • Prednisone 1 mg/kg daily


Sort key recommendations for practice

SORT: KEY RECOMMENDATIONS FOR PRACTICE

  • The most important step in the management of erythema nodosum is treatment of the underlying disorder. – C

  • Antitubercular therapy should be started presumptively for erythema nodosum in patients with a positive PPD skin test result with or without a positively identified focus of infection. – C

  • In patients with erythema nodosum, pain can be managed with NSAIDs. – C


Sort key recommendations for practice1

SORT: KEY RECOMMENDATIONS FOR PRACTICE

  • Systemic steroids at a dosage of 1 mg/kg daily may be used until resolution of erythema nodosum if underlying infection, risk of bacterial dissemination or sepsis, and malignancy have been excluded by a thorough evaluation. – C

  • Colchicine may be considered in patients with erythema nodosum and coexistent Behçet's syndrome. – C


Afp journal review

Quiz

1. Which one of the following statements about perioperative risk assessment and intervention in cardiac patients undergoing noncardiac surgery is correct?

A. Emergency surgery should be delayed until a formal risk stratification can be completed.

B. Most patients will benefit from beta blockade or alpha agonists.

C. Functional status and exercise tolerance are important factors in decision making.

D. There is strong evidence from prospective trials that starting a statin before surgery improves outcomes.


Afp journal review

Quiz

2. Which one of the following medications has been shown in prospective trials to improve outcomes in high-risk perioperative patients?

A. Calcium channel blockers.

B. Nitrates.

C. Beta blockers.

D. Statins.


Afp journal review

Quiz

3. Which one of the following statements about treatment of autoimmune polyglandular syndrome, type II is correct?

A. To avoid precipitating adrenal crisis, thyroid hormone therapy should be given before treating adrenal insufficiency.

B. Cortisone usually can be tapered over weeks to months.

C. Dexamethasone (Decadron) should be avoided because it interferes with steroid measurement during adrenocorticotropic hormone testing.

D. Fludrocortisone (Florinef) should be used to treat primary adrenal insufficiency.


Afp journal review

Quiz

4. Which one of the following groups is at highest risk of iron deficiency anemia?

A. Non-Hispanic white women.

B. Men 70 years and older.

C. Black women.

D. Mexican women living in the United States.


Afp journal review

Quiz

5. Which of the following is the preferred initial diagnostic test in women with a low mean corpuscular volume and suspected iron deficiency anemia?

A. Serum iron.

B. Serum ferritin.

C. Transferrin saturation.

D. Serum transferrin receptor level.


Afp journal review

Quiz

6. Which one of the following is the most common pathologic pulmonary response to asbestos inhalation?

A. Malignant mesothelioma.

B. Pleural effusion.

C. Small cell lung carcinoma.

D. Asbestosis.

E. Pleural plaques.


Afp journal review

Quiz

7. Which one of the following statements about asbestosis is correct?

A. It progresses more rapidly than idiopathic pulmonary fibrosis.

B. It often has mild clinical symptoms.

C. Decreased vital capacity typically occurs before decreased diffusion capacity.

D. Honeycombing is an early radiographic manifestation.

E. Lung biopsy is necessary to diagnose asbestosis


Afp journal review

Quiz

8. A 30-year-old woman with a history of Crohn's disease presents with diarrhea and skin lesions. Erythema nodosum and a recurrence of inflammatory bowel disease are diagnosed. Which one of the following symptoms best supports a diagnosis of erythema nodosum?

A. Ulcerating lesions on the shin.

B. Painless red nodules.

C. Asymmetric lesions on flexor surface of arms.

D. Healing lesions in some areas with bruise-like appearance.


Afp journal review

Quiz

9. A 25-year-old woman reports fatigue, cough, fever, and joint aches beginning two weeks earlier. She now has painful red nodules on her shins. Which one of the following tests should be performed in the initial work-up for erythema nodosum?

A. Punch biopsy.

B. Antistreptolysin-O titer.

C. Computed tomography of the chest.

D. Blood cultures.


Afp journal review

Quiz

10. According to the 2006 update of the American College of Cardiology/American Heart Association guidelines, perioperative beta blockade is recommended for which of the following groups of patients?

A. High-risk patients undergoing vascular surgery.

B. Low- to moderate-risk patients undergoing non-vascular surgery.

C. Patients currently taking a beta blocker for another indication.

D. Low- to moderate-risk patients undergoing vascular surgery


Afp journal review

Quiz

11. Which of the following statements about the standard cosyntropin (Cortrosyn) test, a diagnostic test for adrenal insufficiency, is/are correct?

A. It can be performed at any time of day.

B. Serum cortisol levels greater than 14 mcg per dL (390 nmol per L) indicate a normal result.

C. The result must be compared with a basal cortisol level.

D. Cortisol levels must be at least double for the test to be considered positive


Afp journal review

Quiz

12. Lower endoscopic evaluation is recommended in which of the following groups of patients with iron deficiency anemia with no obvious benign cause?

A. Men of all ages.

B. Premenopausal women.

C. Postmenopausal women.

D. Infants and children.


Afp journal review

Quiz

13. A 65-year-old man presents with a complaint of dyspnea. His occupational history reveals that for many years he renovated buildings. This work included asbestos removal. Which of the following tests should be included in the initial assessment?

A. High-resolution computed tomography.

B. Chest radiography.

C. Spirometry.

D. Pleural biopsy.


References

References

  • FLOOD F. Preparation of the Cardiac Patient for Noncardiac Surgery. AFP. March 1 2007.

  • MAJERONI B. Autoimmune Polyglandular Syndrome, Type II. AFP. March 1 2007.

  • Killip S. Iron Deficiency Anemia. AFP. March 1, 2007.

  • O'REILLY K. Asbestos-Related Lung Disease. AFP. March 1, 2007.

  • SCHWARTZ R. Erythema Nodosum: A Sign of Systemic Disease. AFP. March 1 2007.


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