A 67-year-old male with a history of type II diabetes and hypertension is hospitalized with complaints of retrosternal chest pain that radiates to the left arm and jaw. In the ED, an electrocardiogram (ECG) showed S-T segment depressions in the inferior and lateral leads. He has been given the diagnosis of acute coronary syndrome and admitted to the coronary care unit for further evaluation and treatment. Admission laboratory values reveal a total cholesterol of 270, a lowdensity lipoprotein (LDL) of 190, and a high-density lipoprotein (HDL) of 28. He is currently smoking a pack of cigarettes per day and lives a sedentary life. He is clearly overweight and his blood pressure, despite medication, remains elevated at 150/88. His last HgbA1C less than a month ago was 9.8%. After being discharged from the hospital, which of the following cholesterol lowering regimens should be recommended to this patient?
A. Low fat diet and exercise four times per week should reduce his cholesterol profile to acceptable levels.
B. Starting a statin (3-hydroxy-3-methylglutaryl coenzyme A [HMG-CoA] reductase inhibitor) in addition to smoking cessation, diet, and exercise may reduce his risk of developing further cardiovascular complications.
C. Starting niacin and recommending smoking cessation classes should be the first-line therapy in order to increase his HDL and reduce his risk for further cardiovascular complications.
D. There is no role for cholesterol-lowering medications in secondary prevention of cardiovascular disease.
E. The role of cholesterol-lowering drugs in reducing the risk for CAD is not well established and routine recommendation of such therapy after acute coronary syndrome should be avoided.
Correct Answer: B Section: (none)
Explanation:
The history of acute coronary syndrome and diabetes places this patient at high risk for cardiovascular complications (MI or stroke). His diabetes, as well as all other risk factors, must be better controlled in order to decrease this risk. Statins (HMG-CoA reductase inhibitors) have been shown to lower cardiovascular morbidity and mortality in the primary and secondary prevention of cardiovascular complications. While niacin would indeed likely raise his HDL, data are still insufficient to recommend this as the main goal in reduction of cardiovascular events in patients with known CAD. The main goal at this point should be to lower LDL levels and total cholesterol to at least the recommended levels for patients at the highest risk for cardiovascular complication, with an emphasis on lowering the LDL to <100 mg/dL and total cholesterol to <200 mg/dL. Although both hypothyroidism and diabetes are well-known causes of secondary hyperlipidemia, the case makes no mention of depressed thyroid function in this patient. It would be unreasonable to start hormone supplementation without evidence of hypothyroid state. Although beneficial in cardiovascular disease and stroke, controlling blood pressure has no known direct effect on lipid profile. Controlling diabetes would therefore be the only choice that would directly contribute to positively affecting his lipid profile, by lowering LDL and TG levels and, therefore, decreasing total cholesterol. Sleeping, although healthy and beneficial to general well being, has no direct effect on lipid metabolism.
Question 32:
Ayoung college student is brought to your office by his fiancé for evaluation of weight loss. He tells you that, over the past few months, he seems to be unable to gain any weight despite having a ferocious appetite and that he is steadily losing weight. He has also noticed increased thirst and urination. Over the past few nights, he has awakened several times to go to the bathroom. You suspect that he may have developed diabetes.
Which of the following is a diagnostic criterion for diabetes mellitus (DM)?
A. a single fasting plasma glucose level of140 mg/dL in an asymptomatic person
B. a plasma glucose level of >175 mg/dL measured at least 8 hours after a meal
C. a plasma glucose level of >124 mg/dL measured at least 4 hours after a meal
D. a blood glucose level of 200 mg/dL, 2 hours after completing a glucose tolerance test with a 75-g oral glucose load
E. a serum glycosylated HgbA1C level higher than 7%
Correct Answer: D Section: (none)
Explanation: The symptoms of polydipsia, polyuria, and weight loss are suggestive of new-onset diabetes in this young man. Adiagnosis of DM can be made in any of the following ways: (1) A fasting plasma glucose level of at least 126 mg/dL; (2) a nonfasting plasma glucose level of at least 200 mg/dL in the presence of symptoms; or (3) an oral glucose tolerance test (OGTT) that yields a plasma glucose level of at least 200 mg/dL after 2 hours. Fasting is considered adequate at 8 hours. If unequivocal hyperglycemia is absent, testing should be repeated on a different day for confirmatory purposes before a diagnosis is made. Even though a glycosylated Hgb (A1C) of greater than 6% is suggestive of diabetes, the American Diabetes Association does not recommend the routine use of A1C in the diagnosis of diabetes.
Question 33:
A 53-year-old female has made an appointment to see you concerning the recent onset of menopause. Her last menstrual period was 8 months ago and, over the last year, she had noticed that her periods were becoming lighter and less frequent. In addition, she has developed frequent hot flashes, and her mood has become very labile. She wishes to know what your advice is regarding hormone replacement therapy (HRT). She has heard recent reports in the news concerning an increased risk of developing cardiovascular complications, especially heart attacks and strokes. Although she is in great health, her father died at age 50 of a massive heart attack. Her mother is alive and well, and there is no history of breast cancer among the females in her family
Which of the following would be the strongest argument to avoid HRT in this patient?
A. HRT is unlikely to relieve her hot flashes.
B. She has a positive family history of CAD.
C. She is at high risk for developing breast cancer.
D. She is at high risk for developing venous thromboembolism.
E. She probably would develop breast tenderness and bloating.
Correct Answer: B Section: (none)
Explanation: Despite recent findings from the Women's Health Initiative (WHI) study, which show that HRT may not be cardioprotective and may increase the risk for cardiovascular events (MI and stroke) in postmenopausal women with a known history of cardiovascular disease, HRT remains an effective way to treat and alleviate vasomotor instability and reduce the risk of osteoporosis and bone fractures (particularly hip fractures). In addition, there is evidence to support that this effect, along with improvement in affect and mood stability, is long lived and persists during the course of therapy. The incidence of endometrial cancer appears to be reduced in those taking HRT. The use of HRT in those with risk factors for cardiovascular disease must be made on an individual case base, with carefully considering the risks versus the potential benefits of the intervention.
The WHI study has demonstrated an added risk for developing cardiovascular events, such as MI and stroke, among those with known coronary disease or populations at high risk for CAD. A significant family history of CAD (father died at early age of an MI) would place this patient in the category of higher risk. Although patients taking HRT are at an increase risk for developing venous thromboembolism, this would not preclude its use unless the patient had a known history of the disease. The incidence of breast cancer in women on HRT remains controversial and, in our patient's case, we are told that there is a negative family history, hence making it less of a concern. Bloating and breast tenderness may develop in patients taking HRT, but its occurrence would not be a reason not to start therapy on our patient.
Question 34:
A 53-year-old female has made an appointment to see you concerning the recent onset of menopause. Her last menstrual period was 8 months ago and, over the last year, she had noticed that her periods were becoming lighter and less frequent. In addition, she has developed frequent hot flashes, and her mood has become very labile. She wishes to know what your advice is regarding hormone replacement therapy (HRT). She has heard recent reports in the news concerning an increased risk of developing cardiovascular complications, especially heart attacks and strokes. Although she is in great health, her father died at age 50 of a massive heart attack. Her mother is alive and well, and there is no history of breast cancer among the females in her family. Regarding postmenopausal HRT, which of the following statements would be correct?
A. Known benefits from HRT in postmenopausal women include a reduction in the incidence of osteoporosis and bone fractures (particularly hip fractures).
B. Known benefits from HRT in postmenopausal women include a cardioprotective effect, which reduces the incidence of coronary artery disease (CAD) and myocardial infarction (MI).
C. HRT increases the incidence of endometrial cancer in all patients.
D. Although HRT reduces vasomotor instability and hot flashes after menopause, this effect is short-lived and there is no effect in mood stability.
E. Despite recent press reports, any woman at risk for osteoporosis should take HRT, regardless of cardiovascular risk factors.
Correct Answer: A Section: (none)
Explanation:
Despite recent findings from the Women's Health Initiative (WHI) study, which show that HRT may not be cardioprotective and may increase the risk for cardiovascular events (MI and stroke) in postmenopausal women with a known history of cardiovascular disease, HRT remains an effective way to treat and alleviate vasomotor instability and reduce the risk of osteoporosis and bone fractures (particularly hip fractures). In addition, there is evidence to support that this effect, along with improvement in affect and mood stability, is long lived and persists during the course of therapy. The incidence of endometrial cancer appears to be reduced in those taking HRT. The use of HRT in those with risk factors for cardiovascular disease must be made on an individual case base, with carefully considering the risks versus the potential benefits of the intervention.
The WHI study has demonstrated an added risk for developing cardiovascular events, such as MI and stroke, among those with known coronary disease or populations at high risk for CAD. A significant family history of CAD (father died at early age of an MI) would place this patient in the category of higher risk. Although patients taking HRT are at an increase risk for developing venous thromboembolism, this would not preclude its use unless the patient had a known history of the disease. The incidence of breast cancer in women on HRT remains controversial and, in our patient's case, we are told that there is a negative family history, hence making it less of a concern. Bloating and breast tenderness may develop in patients taking HRT, but its occurrence would not be a reason not to start therapy on our patient.
Question 35:
You are asked to interview a young couple who wish to conceive a child. Their first and only son was born with a rare, autosomal recessive glycogen storage disorder known as Pompe disease. Both parents are healthy and unaffected by this disease, but the father believes that he has heard of a distant cousin who also has this disease. They are concerned about the possibility that their next child will also be born with the affliction. In giving them advice about their chances of having a healthy child, you should:
A. Tell them not to worry about it; their next child will surely be healthy.
B. Tell them that their next child has a 25% chance of being born with the disease.
C. Tell them that there is a 50:50 chance that their next child will be affected.
D. Tell them that it is impossible to predict the likelihood that their next child will have the disease.
E. Advise them not to have any more children because they all will certainly be affected.
Correct Answer: B Section: (none)
Explanation:
We are dealing here with a rare disease and certainly one that you most likely will not encounter in clinical medicine. However, to answer the question correctly you must only recognize that we are dealing with an autosomal recessive disease (a positive family history in either side of the family and the mandatory unaffected parents are normally hints). In order to be unaffected by the disease and to have a child who is affected, both parents must be carriers of one copy of the autosomal recessive gene. If we call the recessive gene for this disorder "p" and the normal, dominant gene "P," then we can create a 2 × 2 table demonstrating the likelihood of having a child with the two recessive genes necessary to develop the disease.
We can see that there is a one-in-four chance of a child acquiring the two recessive genes necessary to develop the disease. All other answers are incorrect since they represent either an autosomal dominant disease (a 50:50 chance) or are inaccurate for recessive diseases (there is no chance that the child will be affected).
Question 36:
A 52-year-old male construction worker is seen in the emergency department (ED) at a local hospital with complaints of persistent cough for the past 4 months. He has been relatively healthy until a few months ago, when he lost his mother and developed severe depression which left him socially and professionally paralyzed. He has stopped doing any exercise or outdoor activity and spends most of his time at home eating, sleeping, and watching TV. In addition, he has noticed a 20-lb weight gain over this period but attributes it to his lack of exercise and increased food intake. His cough is worse at night, or any time when he lies down to sleep, and he notices a burning sensation in his throat associated with it. It is not associated with fever or chills, and his wife complains that he is constantly clearing his throat after meals. He smoked a few cigarettes per day as a young man in the Navy but quit more than 30 years ago. He denies recent travel or incarceration and has no recollection of any sick contacts. On examination, he is afebrile and appears mildly obese. His lung examination is clear. His oropharynx is red and mucosal membranes are dry and not inflamed. Which of the following therapies would be most beneficial in alleviating this patient's symptoms?
A. an inhaled, short-acting beta-2 agonist
B. a proton pump inhibitor (PPI)
C. an antitussive-expectorant syrup
D. weight loss and exercise
E. prolonged course of antibiotics
Correct Answer: B Section: (none)
Explanation: Although the most common cause of chronic cough in adults is the postnasal drip syndrome (not a choice in this question), the patient's cough is present only in the recumbent position and at night. This sign, as well as the fact that he has recently gained considerable amount of weight, point toward the correct diagnosis of GERD. All of the other answers are also potential causes of chronic cough among adults. The history and examination give some clues that point toward GERD (constant clearing of the throat, worse during recumbence, normal nasal mucosa, and worse after meals) and give some others that would make the alternative diagnoses less likely. While 4 months period is too long for a common cold, other infectious agents (including TB) are not likely given the lack of risk factors. It would be unusual for a patient to develop asthma at this age without other symptoms, and chronic bronchitis is even less likely given the remote history of smoking only a few cigarettes per day. Although nervous cough is also possible, this occurs more often as an escape from socially awkward situations or as a stress relieving method. Because the symptoms are due to GERD, they should be treated with a PPI as initial therapy. Although weight loss and exercise may be beneficial in relieving GERD symptoms, they should be considered additional therapies and not curative. Antibiotics are not necessary since the patient does not show signs or symptoms of bacterial or fungal infection. The use of cough suppressants and expectorants would temporarily improve the cough but would do nothing to address the underlying disorder. Inhaled bronchodilators such as beta-2 agonist play no role in the treatment of GERD, unless the patient was to develop pneumonitis and dyspnea.
Question 37:
A 52-year-old male construction worker is seen in the emergency department (ED) at a local hospital with complaints of persistent cough for the past 4 months. He has been relatively healthy until a few months ago, when he lost his mother and developed severe depression which left him socially and professionally paralyzed. He has stopped doing any exercise or outdoor activity and spends most of his time at home eating, sleeping, and watching TV. In addition, he has noticed a 20-lb weight gain over this period but attributes it to his lack of exercise and increased food intake. His cough is worse at night, or any time when he lies down to sleep, and he notices a burning sensation in his throat associated with it. It is not associated with fever or chills, and his wife complains that he is constantly clearing his throat after meals. He smoked a few cigarettes per day as a young man in the Navy but quit more than 30 years ago. He denies recent travel or incarceration and has no recollection of any sick contacts. On examination, he is afebrile and appears mildly obese. His lung examination is clear. His oropharynx is red and mucosal membranes are dry and not inflamed.
Which of the following statements describes the likely cause of his chronic cough?
A. The patient likely suffers from a common cold due to a viral infection and will improve with symptomatic medications.
B. The patient most likely suffers from chronic bronchitis exacerbated by a bacterial infection.
C. The patient has developed gastroesophageal reflux disease (GERD). D. The patient has developed late-onset occult asthma.
D. The patient has a "nervous" cough due to severe depression.
Correct Answer: C Section: (none)
Explanation:
Although the most common cause of chronic cough in adults is the postnasal drip syndrome (not a choice in this question), the patient's cough is present only in the recumbent position and at night. This sign, as well as the fact that he has recently gained considerable amount of weight, point toward the correct diagnosis of GERD. All of the other answers are also potential causes of chronic cough among adults. The history and examination give some clues that point toward GERD (constant clearing of the throat, worse during recumbence, normal nasal mucosa, and worse after meals) and give some others that would make the alternative diagnoses less likely. While 4 months period is too long for a common cold, other infectious agents (including TB) are not likely given the lack of risk factors. It would be unusual for a patient to develop asthma at this age without other symptoms, and chronic bronchitis is even less likely given the remote history of smoking only a few cigarettes per day. Although nervous cough is also possible, this occurs more often as an escape from socially awkward situations or as a stress relieving method. Because the symptoms are due to GERD, they should be treated with a PPI as initial therapy. Although weight loss and exercise may be beneficial in relieving GERD symptoms, they should be considered additional therapies and not curative. Antibiotics are not necessary since the patient does not show signs or symptoms of bacterial or fungal infection. The use of cough suppressants and expectorants would temporarily improve the cough but would do nothing to address the underlying disorder. Inhaled bronchodilators such as beta-2 agonist play no role in the treatment of GERD, unless the patient was to develop pneumonitis and dyspnea.
Question 38:
A 45-year-old male comes to your office for his first annual checkup in the last 10 years. On first impression, he appears overweight but is otherwise healthy and has no specific complaints. He has a brother with diabetes and a sister with high blood pressure. Both of his parents are deceased and his father died of a stroke at age 73. He is a long-standing heavy smoker and only drinks alcohol on special occasions. On physical examination, his blood pressure is 166/90 in the left arm and 164/88 in the right arm. The rest of the examination is unremarkable. He is concerned about his health and does not want to end up on medication, like his siblings Your patient returns to clinic a few weeks later for a follow-up appointment. Despite having lost 3 lbs and increasing his activity to walking 2 mi three times per week, his blood pressure remains elevated at 162/92. His initial evaluation revealed a fasting blood sugar of 156 and a hemoglobin (Hgb) A1C of 7.5. Along with starting hypoglycemic medications to control his diabetes, you recommend that he take an antihypertensive medication. At this point, you decide to start the patient on hypoglycemic medications to control his diabetes.
What other intervention is appropriate at this time?
A. allow more time for the patient to practice lifestyle modifications
B. start treatment with an angiotensinconverting enzyme (ACE) inhibitor only
C. start treatment with a thiazide diuretic only
D. start treatment with a beta-blocker only
E. start treatment with a two-drug combination
Correct Answer: E Section: (none)
Explanation:
Although this is the first time that your patient has been noted to have an elevated blood pressure reading, given his family history and obesity, it is important to consider the coexistence of other cardiovascular risk factors. His evaluation should include, among other things, screening for DM and dyslipidemia along with an ECG. It is reasonable to ask the patient to submit himself to a strict diet (low in fat and salt) and to increase his exercise and activity, since these lifestyle modifications will likely result in weight loss, decreased blood pressure, and improve his risk profile for cardiovascular disease. Nonetheless, it is rarely enough to normalize blood pressure in all but the earliest stages of hypertension. Provided that no other comorbidities exist, the patient should return to clinic in no more than 2 months for a repeat blood pressure check. There is no need to consider secondary causes of hypertension, given his age and presentation.
You should not start antihypertensive medications until further evaluation is completed, and a second elevated reading confirms your diagnosis of hypertension. In the initial evaluation of hypertension (as per the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure [JNC-7], 2003), it is important to evaluate the patient for end-organ damage. This should include the heart, kidneys, eyes, and nervous system. It is recommended to obtain a urinalysis to assess for proteinuria, glucosuria, or hematuria; to obtain an ECG to evaluate the heart for potential hypertrophy or early signs of cardiovascular disease; to obtain a fasting lipid profile, particularly after the age of 35, to assess the cardiovascular risk profile; and to check the patient's renal function to assess for damage or dysfunction. Thyroid function tests are only indicated in the workup of secondary causes of hypertension. According to the JNC-7, this patient's blood pressure falls into the stage 2 hypertension classification in which either systolic blood pressure (SBP) is at least 160 mmHg or diastolic blood pressure (DBP) is at least 100 mmHg.
Stage 1 hypertension is characterized by a SBP of 140159 mmHg and a DBP of 9099 mmHg. Prehypertension is characterized by a SBP of 120139 mmHg and a DBP of 8089 mmHg. Normal blood pressure is characterized by a SBP of less than 120 mmHg and a DBP of less than 80 mmHg. In classifying a patient's blood pressure and determining appropriate therapy, the higher of the two categories corresponding to the SBP and DBP is the one that is used. Per JNC-7 guidelines, treatment of stage 2 hypertension should involve the consideration of a two-drug regimen initially. The goal blood pressure in patients with diabetes is a SBP less than 130 mmHg and a DBP less than 80 mmHg. An ACE inhibitor should be used as the drug class has been shown to slow the progression of diabetic nephropathy and reduce albuminuria. Thiazide diuretics, betablockers, and calcium channel blockers are appropriate choices to consider in this patient in addition to an ACE inhibitor.
Question 39:
A 45-year-old male comes to your office for his first annual checkup in the last 10 years. On first impression, he appears overweight but is otherwise healthy and has no specific complaints. He has a brother with diabetes and a sister with high blood pressure. Both of his parents are deceased and his father died of a stroke at age 73. He is a long-standing heavy smoker and only drinks alcohol on special occasions. On physical examination, his blood pressure is 166/90 in the left arm and 164/88 in the right arm. The rest of the examination is unremarkable. He is concerned about his health and does not want to end up on medication, like his siblings Which of the following describes the patient's blood pressure status?
A. normal blood pressure
B. prehypertension
C. stage 1 hypertension
D. stage 2 hypertension
E. stage 3 hypertension
Correct Answer: D Section: (none)
Explanation:
Although this is the first time that your patient has been noted to have an elevated blood pressure reading, given his family history and obesity, it is important to consider the coexistence of other cardiovascular risk factors. His evaluation should include, among other things, screening for DM and dyslipidemia along with an ECG. It is reasonable to ask the patient to submit himself to a strict diet (low in fat and salt) and to increase his exercise and activity, since these lifestyle modifications will likely result in weight loss, decreased blood pressure, and improve his risk profile for cardiovascular disease. Nonetheless, it is rarely enough to normalize blood pressure in all but the earliest stages of hypertension. Provided that no other comorbidities exist, the patient should return to clinic in no more than 2 months for a repeat blood pressure check. There is no need to consider secondary causes of hypertension, given his age and presentation.
You should not start antihypertensive medications until further evaluation is completed, and a second elevated reading confirms your diagnosis of hypertension. In the initial evaluation of hypertension (as per the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure [JNC-7], 2003), it is important to evaluate the patient for end-organ damage. This should include the heart, kidneys, eyes, and nervous system. It is recommended to obtain a urinalysis to assess for proteinuria, glucosuria, or hematuria; to obtain an ECG to evaluate the heart for potential hypertrophy or early signs of cardiovascular disease; to obtain a fasting lipid profile, particularly after the age of 35, to assess the cardiovascular risk profile; and to check the patient's renal function to assess for damage or dysfunction. Thyroid function tests are only indicated in the workup of secondary causes of hypertension. According to the JNC-7, this patient's blood pressure falls into the stage 2 hypertension classification in which either systolic blood pressure (SBP) is at least 160 mmHg or diastolic blood pressure (DBP) is at least 100 mmHg.
Stage 1 hypertension is characterized by a SBP of 140159 mmHg and a DBP of 9099 mmHg. Prehypertension is characterized by a SBP of 120139 mmHg and a DBP of 8089 mmHg. Normal blood pressure is characterized by a SBP of less than 120 mmHg and a DBP of less than 80 mmHg. In classifying a patient's blood pressure and determining appropriate therapy, the higher of the two categories corresponding to the SBP and DBP is the one that is used. Per JNC-7 guidelines, treatment of stage 2 hypertension should involve the consideration of a two-drug regimen initially. The goal blood pressure in patients with diabetes is a SBP less than 130 mmHg and a DBP less than 80 mmHg. An ACE inhibitor should be used as the drug class has been shown to slow the progression of diabetic nephropathy and reduce albuminuria. Thiazide diuretics, betablockers, and calcium channel blockers are appropriate choices to consider in this patient in addition to an ACE inhibitor.
Question 40:
A 14-year-old boy is brought to the emergency department for evaluation of fever and headache. The mother relates that her son has had a worsening headache for 56 days. She says that she took him to a walk-in clinic, and he was put on amoxicillin for a sinus infection. His headaches have been getting worse and that he is now having fevers as high as 103.6°F . The mother says that he normally is very active and that he currently has a summer job at a local park clearing out underbrush. Since he has become ill, he has had such a decrease in energy that he cannot go to work. He has had a decrease in his appetite and has been sleeping more. He denies any sore throat, abdominal pain, chest pain, dysuria, vomiting, or diarrhea. On examination, he is an uncomfortable young man whose vital signs are: temp 101.9°F, RR 26, HR 124, and BP 79/56. is head, ear, eye, nose, and throat examination reveals normal TMs, a mildly erythematous hypopharynx, and some shotty cervical lymphadenopathy. His lungs are clear. His cardiac examination is normal. His liver edge is palpable just below the right costal margin and is mildly tender. His spleen is not palpable. His skin examination is normal with the exception of scattered petechiae around his ankles and wrists. A CBC reveals WBC 13,000 with 65% segs and 22% lymphs, hematocrit of 35, and platelet count of 95,000. His electrolytes reveal a Na 125, K 5.1, Cl 102, and bicarbonate 21. His BUN and Cr are normal.
What is his most likely diagnosis?
A. enteroviral encephalitis
B. measles
C. Still disease
D. RMSF
E. Kawasaki syndrome
Correct Answer: D Section: (none)
Explanation: Typical symptoms include a summertime fever, headache, petechial rash, thrombocytopenia, and hyponatremia. This may be mistaken for a systemic enteroviral infection, or enteroviral encephalitis, but the presence of thrombocytopenia and hyponatremia would exclude this diagnosis. Still disease (systemiconset JRA) would have an elevation of acute-phase reactants, including the WBC and platelet count. Fourteen years old is an unlikely age for Kawasaki disease, and the acute phase reactants would likewise also be elevated.
RMSF is a very serious infectious illness. Appropriate antimicrobial therapy, usually doxycycline, needs to be started as soon as the diagnosis is seriously considered, as this can prevent some of the more severe sequelae. The use of systemic corticosteroids has no place in the management of RMSF. Confirmation of RMSF is serologic. Rising IgG titers or the presence of IgM titers to R. rickettsii is a confirmation of RMSF.
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