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A 47-year-old woman is evaluated during a follow-up visit for a 2-year history of symptoms diagnosed 4 months ago as fibromyalgia. She reports ongoing widespread pain, fatigue, and difficulty concentrating. She does not have trouble falling asleep, but her sleep is nonrestorative. She was seen 3 months ago, and was given duloxetine and instructed to exercise. The medication produced a modest benefit, but she continues to have difficulty working as a housekeeper. She can only exercise to a limited extent without experiencing disabling pain for the next several days. On a 9-point pain scale, her pain was formerly an 8; after initiation of duloxetine, it decreased to a 5.
On physical examination, vital signs are normal. There is tenderness between the shoulder blades and at the occiput, trapezius, elbows, and hips bilaterally. There is no joint swelling.
Which of the following is the most appropriate treatment?
A) Add meloxicam
B) Add pregabalin
C) Discontinue duloxetine; start gabapentin
D) Discontinue duloxetine; start sertraline
B
Combination pharmacologic therapy that takes advantage of complementary mechanisms of action may be helpful in some patients with fibromyalgia.
A 32-year-old man is evaluated for an intermittent pruritic rash of 8 years' duration. Medical history is significant for mild persistent asthma. His only medications are an albuterol inhaler and an inhaled glucocorticoid.
On physical examination, vital signs are normal. There is mild xerosis with erythematous plaques on the bilateral antecubital fossae, volar wrists, and anterior lower legs. Lichenification is present on the dorsal hands. Linear excoriations are found within many of the erythematous plaques on the arms.
Which of the following is the most appropriate treatment?
A) Oral cephalexin
B) Oral prednisone
C) Topical glucocorticoids
D) Topical ketoconazole
E) Topical mupirocin
C
The initial treatment for atopic dermatitis consists of good skin care with mild cleansers and thick emollients along with topical glucocorticoids to decrease inflammation and pruritus.
A 33-year-old woman is evaluated after sustaining a needlestick puncture in an infusion clinic, where she works as a nurse. The needle was being placed for intravenous therapy and had blood on it; it is from a patient at the clinic who is known to have HIV infection and is taking antiretrovirals, but the recent viral load is unknown. The nurse has already cleaned her wound. Medical history is unremarkable, and she takes no medications.
On physical examination, vital signs are normal, and other examination findings are noncontributory.
Which of the following is the most appropriate immediate management?
A) Begin tenofovir and emtricitabine
B) Begin tenofovir, emtricitabine, and dolutegravir
C) Begin tenofovir, emtricitabine, and ritonavir-boosted darunavir
D) Determine source patient's viral load
B
Preferred HIV postexposure prophylaxis regimens include tenofovir disoproxil fumarate, emtricitabine, and either dolutegravir or raltegravir and are appropriate whether the exposure was occupational or nonoccupational.
A 29-year-old woman is evaluated before attempting pregnancy. Juvenile myoclonic epilepsy was diagnosed 11 years ago, at which time she started taking valproic acid; she has had no symptoms for 10.5 years. Her only other medication is an oral contraceptive agent. She is concerned about taking her medications if she becomes pregnant.
All physical examination findings are normal, as was her most recent electroencephalogram.
A plan is made to discontinue the oral contraceptive, start folic acid, and then taper the valproic acid.
Which of the following is the most appropriate additional step in treatment?
A) Gabapentin
B) Levetiracetam
C) Oxcarbazepine
D) Topiramate
E) No additional treatment is necessary
B
In a woman with childbearing potential, levetiracetam and lamotrigine are the most appropriate treatment options because of their relatively low risk of teratogenicity.
A 51-year-old man is evaluated during a routine follow-up visit for stage G4 chronic kidney disease and hypertension. He is asymptomatic. Medications are valsartan, amlodipine, and furosemide.
On physical examination, blood pressure is 140/70 mm Hg, and pulse rate is 70/min. BMI is 32. The remainder of the physical examination is noncontributory.
Laboratory studies:
HDL cholesterol: 32 mg/dL (0.83 mmol/L)
LDL cholesterol: 119 mg/dL (3.08 mmol/L)
Total cholesterol: 208 mg/dL (5.39 mmol/L)
Triglycerides: 289 mg/dL (3.27 mmol/L)
Which of the following is the most appropriate management for this patient's dyslipidemia?
A) Gemfibrozil
B) Niacin
C) Omega-3 fish oil
D) Rosuvastatin
D
The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend treatment of dyslipidemia with a statin in patients aged ≥50 years with an estimated glomerular filtration rate <60 mL/min/1.73 m2, but not treated with chronic dialysis or kidney transplantation.
A 66-year-old woman is evaluated after developing five dental caries over the past year. She cannot eat crackers without accompanying water. She has lost two teeth due to caries. She also reports scratchy and itchy eyes for 2 years and intermittent joint pain, particularly of the small hand joints, for 1 year. She takes ibuprofen as needed for the joint pain, which provides relief.
On physical examination, vital signs are normal. Two molars are missing, and there is no salivary pooling below the tongue. Bilateral parotid and lacrimal enlargement is present. Mild tenderness without swelling of the second through fourth metacarpophalangeal joints bilaterally is noted.
Laboratory studies show positive rheumatoid factor, high-titer antinuclear antibodies, and high-titer anti-Ro/SSA antibodies.
A Schirmer test for ocular wetting is diminished at 3 mm. Chest radiograph is normal. Radiographs of the hands show no erosions.
Which of the following is the most appropriate treatment at this time?
A) Artificial tears and sugar-free candies
B) Methotrexate
C) Pilocarpine
D) Rituximab
E) Topical ophthalmic NSAID drops
A
Initial management of Sjögren syndrome typically involves treatment of sicca symptoms by restoring moisture of the eyes and mouth.
A 60-year-old woman is evaluated for follow-up treatment of long-standing psoriasis. Medical history is significant for hypertension and hypercholesterolemia. Family history includes multiple family members with psoriasis. She has no joint symptoms, and her medications are atenolol and simvastatin.
On physical examination, vital signs are normal. There is no joint swelling.
She has a total of 30% body surface area involvement with psoriasis without nail involvement.
Which of the following is the most appropriate treatment?
A) Methotrexate
B) Oral prednisone
C) Tacrolimus ointment
D) Topical calcitriol
A
Moderate to severe psoriasis is best treated with systemic agents; avoid prednisone as a therapy for psoriasis.
A 38-year-old woman undergoes follow-up evaluation in the office. She was evaluated in the emergency department 3 nights ago with fever and flank pain following 2 days of dysuria. A urine culture and two sets of blood cultures were collected. She was given intravenous ceftriaxone and discharged with a 7-day course of ciprofloxacin. She is now asymptomatic. Medications are ciprofloxacin and an oral contraceptive.
On physical examination, vital signs and other findings are normal.
Escherichia coli susceptible to ciprofloxacin was isolated from her urine culture and one blood culture.
Which of the following is the most appropriate management?
A) Completion of oral ciprofloxacin course
B) Completion of oral ciprofloxacin course with follow-up blood cultures
C) Extended oral ciprofloxacin therapy for 2 weeks
D) Intravenous ceftriaxone
E) Kidney ultrasonography
A
Acute, uncomplicated pyelonephritis can usually be managed with oral outpatient antimicrobial therapy, with the fluoroquinolones ciprofloxacin and levofloxacin being the preferred, first-line agents.
A 67-year-old man is evaluated for a carotid bruit detected on routine medical examination. He reports no history of previous focal neurologic symptoms or visual loss. He has type 2 diabetes mellitus and hyperlipidemia treated with metformin, moderate-intensity pravastatin, and aspirin.
On physical examination, blood pressure is 128/64 mm Hg, pulse rate is 78/min and regular, and respiration rate is 16/min. A left carotid bruit is heard on cardiac examination. All other physical examination findings, including those from a neurologic examination, are unremarkable.
Results of laboratory studies show an LDL cholesterol level of 82 mg/dL (2.12 mmol/L).
The carotid ultrasound report describes a mixed-density plaque at the origin of the left internal carotid artery with stenosis estimated to be 60% to 80%.
Which of the following is the most appropriate next step in management?
A) Carotid endarterectomy
B) Carotid stenting
C) Magnetic resonance angiography of the neck
D) Replacement of aspirin with clopidogrel
E) No further treatment or intervention
E
Statin therapy is indicated for asymptomatic carotid stenosis of 60% to 80%.
Magnetic resonance angiography (MRA) of the neck is inappropriate because an additional diagnostic test is unlikely to change medical management. The accuracy of MRA without contrast versus carotid ultrasound is likely similar, but neck MRA is associated with patient discomfort and a higher cost.
Because there is no clear evidence that clopidogrel is superior to aspirin for the primary prevention of stroke in the setting of asymptomatic internal carotid artery stenosis, replacing this patient's aspirin with clopidogrel is unwarranted.
A 28-year-old man is evaluated in the emergency department for acute right-sided flank pain and blood in the urine. He reports no prior episodes of hematuria or flank pain. He takes no medications.
On physical examination, vital signs are normal. Costovertebral angle tenderness is noted. The abdomen is soft and nontender.
Urinalysis shows 3+ blood, trace protein, and too numerous to count erythrocytes.
A kidney ultrasound shows normal-appearing kidneys, no hydronephrosis, and no nephrolithiasis.
Which of the following is the most appropriate test to perform next?
A) Contrast MRI
B) Contrast-enhanced helical abdominal CT
C) Kidney, ureter, and bladder plain radiography
D) Noncontrast helical abdominal CT
D
Noncontrast helical CT is the gold standard for diagnosis of nephrolithiasis.
A 55-year-old man is evaluated for a 3-week history of progressive joint pain, swelling of the ankles, and occasional dry cough. He also reports a 2-day history of low-grade fever and painful red lumps on his shins. He has no other significant history and takes no medications.
On physical examination, temperature is 37.8 °C (100.0 °F); other vital signs are normal. The chest is clear to auscultation. Swelling and warmth of the ankles are noted. There are three raised, erythematous, and indurated subcutaneous nodules on the right anterior shin and one on the left anterior shin.
Laboratory studies show a normal complete blood count and an erythrocyte sedimentation rate of 70 mm/h.
Chest radiograph shows bilateral hilar adenopathy but is otherwise normal.
Which of the following is the most appropriate management?
A) Biopsy of the hilar node
B) Biopsy of a shin lesion
C) Rheumatoid factor testing
D) Synovial fluid cultures
E) No further testing
E
The presence of acute arthritis, bilateral hilar lymphadenopathy, and erythema nodosum is 95% specific for Löfgren syndrome.
A 43-year-old woman is evaluated for painful wheals on the upper legs and back that have been present for 2 weeks. Individual lesions resolve with bruising in 3 to 4 days. The patient also reports some associated joint pain, particularly of the small joints in her hands. Medical history is unremarkable, and she takes no medications.
On physical examination, vital signs are normal. There are polycyclic edematous plaques on the back and upper legs. The remainder of the examination, including joint examination, is normal.
Which of the following is the most appropriate management?
A) Epicutaneous patch testing
B) Ice cube provocation test
C) Oral prednisone
D) Skin biopsies
E) Topical triamcinolone
D
Skin biopsies should be performed to evaluate for urticarial vasculitis when individual urticarial lesions are present for longer than 24 hours.
A 19-year-old man is evaluated in the emergency department for fever, cough producing blood-tinged sputum, shortness of breath, and headache. He attended a political rally on his college campus 4 days ago. Six other people have been hospitalized with similar symptoms. Medical history is unremarkable, and he takes no medications.
On physical examination, the patient is alert and oriented. Temperature is 39.1 °C (102.4 °F), blood pressure is 98/58 mm Hg, pulse rate is 110/min, and respiration rate is 24/min. Oxygen saturation is 92% breathing oxygen 2 L/min by nasal cannula. Neurologic examination is nonfocal, and no meningeal signs are present. Dyspnea, bilateral pulmonary rhonchi, and tubular breath sounds are noted on pulmonary examination. No rash is present, and the abdomen is nontender.
Sputum Gram stain reveals many polymorphonuclear cells and abundant gram-negative coccobacilli demonstrating bipolar staining.
A chest radiograph shows bilateral patchy infiltrates.
Which of the following is the most appropriate treatment?
A) Ceftriaxone and azithromycin
B) Ciprofloxacin
C) Gentamicin
D) Piperacillin-tazobactam and levofloxacin
C
First-line treatment for primary pneumonic plague is either streptomycin or gentamicin.
A 58-year-old man is evaluated in the emergency department for a 3-week history of worsening pain in the middle back and a 2-day history of increasing leg weakness that has made ambulation difficult. He has metastatic prostate cancer treated with leuprolide.
On physical examination, vital signs are normal. Muscle strength testing shows 4/5 weakness in the hip flexors. Reflexes are 3+ in both legs.
An MRI of the thoracic spine shows a contrast-enhancing mass originating in the T8 vertebral body with invasion into the epidural space that causes moderate cord compression.
After administration of high-dose glucocorticoids, which of the following is the most appropriate next step in management?
A) Decompressive surgery with radiation
B) Laminectomy
C) Radiation only
D) Spinal angiography
A
Spinal cord compression from metastatic disease requires emergent use of high-dose glucocorticoids and urgent surgical decompression followed by radiation.
A 57-year-old man is evaluated during a routine visit. History is significant for hypertension. Medications are hydrochlorothiazide, 25 mg/d, and amlodipine, 5 mg/d.
On physical examination, blood pressure is 135/86 mm Hg, and pulse rate is 70/min; other vital signs are normal. There is 1+ bilateral ankle edema. The remainder of the examination is normal.
Laboratory studies show a serum creatinine level of 1.0 mg/dL (88.4 µmol/L), a serum potassium level of 3.6 mEq/L (3.6 mmol/L), and an estimated glomerular filtration rate >60 mL/min/1.73 m2.
Which of the following is the most appropriate treatment?
A) Add hydralazine
B) Add losartan
C) Double the amlodipine dose
D) Double the hydrochlorothiazide dose
B
Three strategies can be used for antihypertensive dose adjustment in the treatment of hypertension: (1) maximize the medication dose before adding another; (2) add another class of medication before reaching the maximum dose of the first; and (3) start with two medication classes separately or as fixed-dose combinations.
Increasing the amlodipine or hydrochlorothiazide dose is not appropriate because there is diminishing return in blood pressure lowering if the dose is titrated up from 50% to 100% of maximum.
Hydralazine is not the best option because it is a thrice-daily medication and may pose problems with adherence, considering that once-daily medication options have not been exhausted in this patient.
A 73-year-old woman is hospitalized for symptoms of heart failure, with progression occurring over the past 2 weeks. She also reports a 6-week history of arm aching that is worse with lifting and reaching, hip aching, morning stiffness, fever, and malaise. She reports no headache or jaw claudication.
On physical examination, temperature is 37.5 °C (99.5 °F), blood pressure is normal but systolic pressure is 16 mm Hg less on the right arm than the left arm, pulse rate is 90/min, respiration rate is 20/min, and oxygen saturation is 93% breathing ambient air. There is no rash. There is no temporal tenderness. A bruit is heard over the right supraclavicular fossa. The right radial pulse is reduced. A diastolic decrescendo murmur is heard in the upper right sternal border. Bibasilar crackles are heard. Painful range of motion is noted in the shoulders and hips. No joint swelling is present.
Transthoracic echocardiogram shows aortic valve regurgitation with normal leaflets, dilated aortic root, and dilated left ventricle.
Which of the following is the most likely diagnosis?
A) Kawasaki disease
B) Polyarteritis nodosa
C) Subcranial giant cell arteritis
D) Takayasu arteritis
C
Giant cell arteritis can affect the great vessels of the chest causing upper extremity claudication and/or aortitis; aortitis may lead to aortic root dilation, aortic regurgitation, and heart failure.
A 50-year-old man is evaluated for a several month history of itchy, scaly feet. It has persisted despite the application of a moisturizing lotion. He has no significant medical history and takes no medications.
On physical examination, vital signs are normal. There are erythematous scaly patches on the sides of the feet and maceration between toes. Toenails are normal. Microscopic examination using potassium hydroxide preparation shows branching hyphae in the keratin (scale).
Which of the following is the most appropriate treatment?
A) Imidazole cream
B) Nystatin cream
C) Oral ketoconazole
D) Topical betamethasone and clotrimazole
A
Treatment of tinea of non–hair-bearing skin includes topical antifungal agents such as imidazole, miconazole, clotrimazole, ketoconazole, ciclopirox, or terbinafine; topical nystatin is not effective, and oral ketoconazole should be avoided.
Combination therapy with potent topical glucocorticoids, such as betamethasone, and antifungal creams, such as clotrimazole, should be avoided because of an increased risk of treatment failures, development of skin atrophy with prolonged use, and increased cost without increased efficacy.
A 33-year-old woman is evaluated in the emergency department in January with a 3-day history of fever, headache, stiff neck, and photophobia. She was previously well, and medical history is negative for recent travel; she takes no medications.
On physical examination, temperature is 38.5 °C (101.3 °F), blood pressure is 136/86 mm Hg, pulse rate is 100/min, and respiration rate is 18/min. The general medical examination is unremarkable. On neurologic examination, she shows photophobia, and a nondilated funduscopic examination shows no papilledema. The remainder of the examination is nonfocal.
Cerebrospinal fluid evaluation shows a leukocyte count of 324/µL (324 × 106/L) with 60% neutrophils, glucose level of 58 mg/dL (3.2 mmol/L), and protein level of 125 mg/dL (1250 mg/L). Gram stain of the cerebrospinal fluid is negative, and culture is pending.
Which of the following is the most likely cause of this patient's symptoms?
A) Enterovirus
B) Herpes simplex virus type 2
C) Mumps virus
D) West Nile virus
B
Herpes simplex virus type 2 can cause acute aseptic meningitis year round and is the most common cause of recurrent viral meningitis.
A 55-year-old man is evaluated for increasing difficulty keeping track of tasks and performing his job adequately. The patient works as an accountant and lately has been making frequent calculation errors. He also has noticed some word-finding difficulties and marked difficulty with short-term memory. Symptoms have progressed over the past 18 months but recently have become more prominent. The patient has a 15-year history of multiple sclerosis and also has depression, which has been in remission. Medications are glatiramer acetate, vitamin D3, and fluoxetine.
On physical examination, vital signs are normal. On neurologic examination, the patient can recall only one of three objects at 3 minutes, skips “August” when reciting the months backward, and makes one error when subtracting serial sevens.
Which of the following is the most appropriate treatment?
A) Cognitive rehabilitation
B) Increased dosage of fluoxetine
C) Memantine
D) Methylphenidate
A
Cognitive rehabilitation approaches, such as the development of accommodative strategies and training with challenging cognitive tasks, have been shown to improve symptoms of cognitive deficits in patients with multiple sclerosis.
A 50-year-old man is evaluated for elevated blood pressure measurements despite an increase in his hydrochlorothiazide dose 1 month ago. History is significant for hypertension and hyperlipidemia. Medications are hydrochlorothiazide and atorvastatin.
On physical examination, blood pressure is 150/92 mm Hg, and pulse rate is 69/min. BMI is 30. The remainder of the examination is normal.
Laboratory studies show a serum creatinine level of 1.0 mg/dL (88.4 µmol/L), a serum potassium level of 3.4 mEq/L (3.4 mmol/L), and a urine albumin-creatinine ratio of 550 mg/g.
In addition to weight loss, which of the following is the most appropriate management?
A) Add amlodipine
B) Add losartan
C) Add spironolactone
D) Schedule a follow-up visit for 3 months
B
An ACE inhibitor or angiotensin receptor blocker is an agent of choice for treatment of hypertension in a patient with chronic kidney disease.
A 35-year-old woman is hospitalized for left-sided pleuritic chest pain and dyspnea that began 1 day ago. Four weeks ago, she began to experience fever once or twice a day, pharyngitis, intermittent rash on the trunk and proximal extremities that occurs with the fever, severe joint pain, and myalgia. She gave birth 10 weeks ago to a healthy female infant.
On physical examination, temperature is 39.0 °C (102.2 °F), pulse rate is 90/min, and respiration rate is 22/min. Enlarged cervical lymph nodes, hepatomegaly, and splenomegaly are present. A pleural friction rub is heard. A pink maculopapular rash is present on the trunk. Tenderness and swelling of the wrists, knees, and ankles are noted.
Laboratory studies:
Erythrocyte sedimentation rate: 90 mm/h
Hemoglobin: 10 g/dL (100 g/L)
Leukocyte count: 20,000/µL (20 × 109/L), 90% neutrophils
Alanine aminotransferase: 80 U/L
Aspartate aminotransferase: 70 U/L
Ferritin: 6000 ng/mL (6000 µg/L)
Urinalysis: Normal
Chest radiograph shows a small left-sided pleural effusion.
Which of the following is the most likely diagnosis?
A) Adult-onset Still disease
B) Cryoglobulinemic vasculitis
C) Lymphoma
D) Microscopic polyangiitis
E) Systemic lupus erythematosus
A
Adult-onset Still disease is characterized by spiking fever, an evanescent salmon-colored rash on the trunk and extremities that occurs in conjunction with fever, arthritis, lymphadenopathy, and leukocytosis; an extremely high serum ferritin level is characteristic.
A 40-year-old man is evaluated during a follow-up visit for an extremely pruritic skin eruption for several months that was recently diagnosed as dermatitis herpetiformis. He denies gastrointestinal symptoms and is otherwise healthy and takes no medications.
On physical examination, vital signs are normal. There are numerous excoriations on elbows, knees, and buttocks with rare intact vesicles.
In addition to a gluten-free diet, which of the following is the most appropriate treatment for this patient?
A) Betamethasone valerate
B) Dapsone
C) Diphenhydramine
D) Prednisone
E) Sulfasalazine
B
Dapsone should be used in conjunction with a gluten-free diet as first-line treatment of dermatitis herpetiformis.
A 42-year-old man is evaluated in the hospital for increased pain and drainage from a previously healed surgical wound over the left fibula. He underwent open reduction and internal fixation of a fracture 4 weeks ago. The patient has undergone incision and surgical debridement of the wound. A bone culture revealed methicillin-sensitive Staphylococcus aureus. Medical history is otherwise noncontributory, and his only medication is ibuprofen for pain.
On physical examination, vital signs are normal. A surgical wound over the left lateral leg is well approximated with no erythema or drainage.
A plain radiograph before debridement shows nonunion of the fracture with screws and K-wires in place.
Which of the following is the most appropriate treatment?
A) Cefazolin
B) Cefazolin and rifampin
C) Ceftaroline
D) Vancomycin and rifampin
B
Rifampin should be used in combination with another antistaphylococcal agent when managing Staphylococcus aureus osteomyelitis in the setting of orthopedic hardware if the hardware cannot be removed.
A 35-year-old man is evaluated for a 3-year history of epilepsy. Seizures typically occur twice monthly, last 2 minutes, and are characterized by staring, lip smacking, and confusion; approximately once every 6 months, the patient experiences a whole-body convulsion marked by incontinence and prolonged confusion for several hours. Treatment with oxcarbazepine and lamotrigine, although initially reducing seizure frequency, has been largely ineffective. He no longer drives or works because of the seizures. He also has migraines, which are well controlled by sumatriptan.
On physical examination, vital signs are normal. All other physical examination findings, including those from a neurologic examination, are unremarkable.
Results of routine outpatient electroencephalography (EEG) are normal. An MRI of the brain shows right hippocampal atrophy.
Which of the following is the most appropriate next step in management?
A) Levetiracetam
B) Topiramate
C) Vagus nerve stimulation
D) Video EEG monitoring
D
Video electroencephalography is first step in determining candidacy for epilepsy surgery in patients with medically intractable epilepsy.
Although levetiracetam and topiramate are reasonable options for treating this seizure type, and topiramate has the added benefit of migraine prophylaxis, the chance of seizure freedom from an additional drug is only approximately 5% to 10%. Additionally, this patient's migraines are already well controlled, so a prophylactic agent is not required.
Use of a vagus nerve stimulator is a palliative measure, is unlikely to result in freedom from seizures, and should be offered only if resection is not an option.
A 52-year-old woman is hospitalized for a toe ulcer and foot pain occurring for 1 month. History is significant for stage G4 chronic kidney disease (estimated glomerular filtration rate , 22 mL/min/1.73 m2) and type 2 diabetes mellitus. Medications are lisinopril, sevelamer, sodium bicarbonate, insulin glargine, and insulin aspart.
On physical examination, vital signs are normal. A foul-smelling toe ulcer is present. Probe-to-bone test is positive.
A plain radiograph shows changes compatible with osteomyelitis. The patient undergoes wound débridement and bone biopsy.
Bone cultures are pending, and empiric antibiotic therapy is to be administered.
Which of the following is the most appropriate venous access strategy?
A) Arteriovenous graft creation followed by peripherally inserted central catheter placement in opposite arm
B) Peripherally inserted central catheter in the dominant arm
C) Peripherally inserted central catheter in the nondominant arm
D) Tunneled internal jugular central venous catheter
D
Peripherally inserted central catheter placement before or after hemodialysis initiation is associated with adverse vascular access outcomes in patients with chronic kidney disease.