Cardiology
ID
Nephro/urology
GI
Respiratory
100
A 65-year-old woman reports a one-hour history of acute-onset anterior chest pressure associated with shortness of breath.
She has a heart rate of 85 beats per minute, a blood pressure of 145/78 mm Hg, a respiratory rate of 24 breaths per minute, and an oxygen saturation of 89% while breathing ambient air. Inspiratory crackles extend more than halfway up both lung fields. She has no murmurs, but a third heart sound (S3 gallop) is audible. Her extremities are warm.
She is up to date with Covid-19 vaccinations, and testing for SARS-CoV-2 is negative. An electrocardiogram is obtained (figure).
In addition to aspirin and oxygen, which one of the following combinations of medications should be administered immediately to this patient?
A. Morphine and carvedilol
B. Nitroglycerin and morphine
C. Morphine and metoprolol
D. Nitroglycerin and metoprolol
Answer B
Given that an anterior myocardial infarction is not typically associated with right ventricular involvement, nitroglycerin use is appropriate. Morphine is the drug of choice for pain relief in patients with ST-segment elevation myocardial infarction, especially those whose course is complicated by heart failure or pulmonary edema as noted in this case. This drug can alleviate the work of breathing, reduce anxiety, and favorably affect ventricular loading conditions.
Key learning point: The two medication classes that should be avoided in a patient with decompensated heart failure and an acute myocardial infarction are beta-blockers and calcium-channel blockers.
A. Calcium-channel blockers and beta-blockers, such as metoprolol and carvedilol, are contraindicated in patients with myocardial infarction and heart failure, as these drugs may depress myocardial contractility.
C. Calcium-channel blockers and beta-blockers, such as metoprolol and carvedilol, are contraindicated in patients with myocardial infarction and heart failure, as these drugs may depress myocardial contractility. Beta-blockers are also contraindicated in patients who have an acute myocardial infarction with advanced (second- or third-degree) atrioventricular block.
E. An angiotensin-converting–enzyme inhibitor, such as lisinopril, is appropriate in this patient with an anterior myocardial infarction, but not in combination with a beta-blocker. Calcium-channel blockers and beta-blockers, such as metoprolol and carvedilol, are contraindicated in patients with myocardial infarction and heart failure, as these drugs may depress myocardial contractility.
100
An 81-year-old man is evaluated in a skilled nursing facility for a 2-day history of dysuria, urinary urgency, and incontinence. He also describes persistent pain localized to the lower abdomen and rectal area.
Three months ago, he underwent dilation of a urethral stricture, which was presumed to be related to an indwelling urinary catheter placed during a hospitalization for a heart failure exacerbation 4 months ago. He also has a history of hypertension, coronary artery disease, and ischemic cardiomyopathy. His current medications are carvedilol 12.5 mg twice daily, lisinopril 10 mg daily, furosemide 40 mg daily, and aspirin 81 mg daily.
He has a blood pressure of 138/74 mm Hg, a heart rate of 84 beats per minute, a respiratory rate of 18 breaths per minute, and a temperature of 38.1°C. Physical examination reveals jugular venous pressure of 8 cm of water, a regular cardiac rhythm with a grade 2/6 holosystolic murmur at the apex, clear lungs, a soft abdomen without tenderness to palpation, and perineal tenderness upon palpation.
In addition to routine urinalysis, which one of the following diagnostic tests is most appropriate?
A. Prostatic massage followed by culture of prostatic secretions
B. Urodynamic study
C. Urine testing for chlamydia trachomatis and Neisseria gonorrhoeae
D. Transrectal ultrasound of the prostate
E. Urine culture
Answer E
This patient’s presentation of dysuria, urinary urgency, new urinary incontinence, and fever along with perineal tenderness to palpation is consistent with acute prostatitis. Urine culture is the first step in diagnosing acute prostatitis, which develops suddenly and is usually due to enteric gram-negative bacilli but can also be caused by gram-positive bacteria, atypical pathogens, or nonbacterial factors. The history of urinary tract instrumentation in this patient does put him at risk for nosocomial or atypical infection.
Key learning point: In an older man with irritative urinary symptoms and perineal tenderness suggesting acute bacterial prostatitis, the most appropriate initial diagnostic test is urine culture.
A. Prostatic massage followed by culture of prostatic secretions is not necessary in acute prostatitis and may carry risks including bacteremia. It is a very helpful diagnostic maneuver in the setting of suspected chronic prostatitis, in which symptoms are prolonged or recurrent.
B. Urodynamic studies can be useful for evaluating urge incontinence due to overactive bladder, which is defined as the presence of urinary urgency with or without urinary incontinence in the absence of a urinary tract infection (UTI) or other obvious pathology. Urodynamic studies are not indicated in the setting of an acute UTI, and this patient cannot be considered to have overactive bladder given his current UTI. In addition, the symptoms of overactive bladder do not tend to manifest as suddenly as this patient’s symptoms did.
C. Excluding sexually transmitted infections (STI) due to Chlamydia trachomatis and Neisseria gonorrhoeae is important in at-risk patients with suspected prostatitis. Although the risk of STI in an older resident of a skilled nursing facility is not zero, in this case, the risk factors of urethral stricture and urinary tract instrumentation strongly suggest acute bacterial prostatitis.
D. Transrectal ultrasound of the prostate is not indicated for evaluating acute prostatitis. It is commonly used to guide prostate needle biopsy in suspected cases of prostate cancer and is occasionally useful as a screening study to rule out prostate abscess after failed treatment of acute prostatitis
100
A 77-year-old woman presents for evaluation of urinary symptoms. She has a 6- to 8-month history of a strong urge to urinate and occasional leakage of urine before she can get to the bathroom. Her neurologic examination is unremarkable. Pelvic examination shows no evidence of mass or prolapse. Her BMI is 36. A urinalysis is normal.
Which one of the following evaluations is most appropriate for this patient?
A. Order a urodynamic study
B. Measure the postvoiding residual urine
C. Ask the patient to complete a voiding diary
D. Prescribe oxybutynin
Answer C
A common symptom of overactive bladder is urge urinary incontinence (UUI), as described in this case. Evaluating a patient with suspected UUI requires taking a complete history, conducting neurologic and pelvic examinations as part of the physical examination, and ordering a urinalysis. The next step is to then evaluate both subjective (patient-reported) and objective (bladder or voiding diary) outcomes, to assess the severity of the symptoms.
A voiding diary can help to quantify the patient's voiding and incontinence episodes, which can be useful for both the clinician and the patient. During the initial evaluation phase, the diary provides information that can help the clinician plan appropriate components of intervention, particularly behavioral intervention. Recording the times that the patient voids provides a foundation for determining voiding intervals in bladder training programs. The diary can also be used during the course of treatment to track the effectiveness of various treatment components and guide the intervention. Completing the diary can also help enhance patients' awareness of their voiding habits and help them recognize activities that trigger their incontinence.
Key learning point: The first step in evaluating a woman with urge urinary incontinence, no obstructive symptoms, and a normal physical examination and urinalysis is to ask her to complete a voiding diary.
A. Urodynamic studies are invasive tests that simulate the filling and emptying phases of micturition to assess for detrusor overactivity, bladder outlet obstruction, and detrusor sphincter dyssynergia. Given the invasive nature of this testing, it is not considered an appropriate study for initial evaluation of patients who present with UUI and OAB symptoms.
B. Measuring the post-void residual urine is not indicated in this patient, given the absence of obstructive urinary symptoms.
D. Pharmacologic therapy is not appropriate until precipitating factors are identified and remediated when possible.
E. Imaging of the pelvis is not warranted in this patient, given her normal findings on physical examination.
100
A 41-year-old man reports experiencing recurrent episodes of dysphagia and food impaction during the past several months. Use of over-the-counter omeprazole has not improved his symptoms. He has a history of food allergies, allergic rhinitis, and asthma. His physical examination is unremarkable.
Which one of the following diagnoses is the most likely cause of this patient’s recurrent food impactions?
A. Achalasia
B. Diffuse esophageal spasm
C. Reflux esophagitis
D. Eosinophilic esophagitis
E. Esophageal candidiasis
Answer: D
Eosinophilic esophagitis is responsible for about half the cases of recurrent food impaction in nonelderly men. The mechanism of dysphagia is likely related to an inflammatory response that causes remodeling of the esophagus, resulting in the development of rings and strictures. Eosiniophilic esophagitis is strongly associated with allergic conditions such as atopic dermatitis, rhinitis, asthma, and food allergies. Symptoms often occur for months or years before a diagnosis is made.
Key learning point: The most likely cause of recurrent food impaction in a nonelderly man with a history of food allergies, allergic rhinitis, and asthma is eosinophilic esophagitis.
A. Achalasia is a rare disorder that would be less likely in this case, especially given the patient’s risk factors for eosinophilic esophagitis.
B. Diffuse esophageal spasm can be associated with dysphagia but is typically accompanied by severe chest pain.
C. Acid reflux esophagitis can cause dysphagia and food impaction but is unlikely in patients for whom omeprazole has not improved symptoms.
E. Esophageal candidiasis is unusual in otherwise healthy individuals. It is typically associated with odynophagia and is unlikely to be chronic or to cause food impaction.
100
A 19-year-old woman presents for an office visit. She has seasonal allergies but no other chronic medical conditions. She plays on her college volleyball team and reports that 10 to 15 minutes into each practice, she experiences “coughing fits” characterized by chest tightness and shortness of breath. She practices with her team 5 days a week, and the practices can last up to 3 hours each, especially during volleyball season.
Her physical examination is unremarkable.
In addition to encouraging the patient to continue exercising, what is the most appropriate next step in addressing her symptoms?
A. Prescribe a daily low-dose inhaled glucocorticoid and an as-needed inhaled short-acting beta2-agonist
B. Prescribe an inhaled short-acting beta2-agonist, to be used 15 minutes before exercise
C. Prescribe an inhaled short-acting beta2-agonist, to be used immediately after exercise
Answer A
Exercise-induced bronchoconstriction (EIB) is a narrowing of the lower airways that occurs during or immediately after strenuous exercise. The diagnosis should be suspected when a patient reports increased coughing, wheezing, or phlegm production in the context of physical activity. EIB is believed to stem from hyperpnea during exercise, which dries the airways and requires greater volumes of air to be humidified. The resulting water loss increases the osmolality of the airway surfaces, triggering a release of inflammatory mediators from mast cells, leading to bronchospasm. EIB is often associated with underlying asthma, but it also may occur on its own, as in this patient.
Use of a short-acting beta2-agonist before (not after) exercise has historically been the mainstay of therapy for EIB. However, evidence suggests that regular use of beta2-agonists without concurrent use of an inhaled glucocorticoid can increase airway responsiveness to bronchoconstrictor stimuli. Thus, current guidelines now recommend using a combination budesonide–formoterol inhaler before exercise to minimize symptoms, especially in those with mild asthma. This would be a reasonable option in this patient, but because she is a collegiate athlete who is exercising most days of the week, another reasonable option would be daily use of an inhaled glucocorticoid, with a short-acting beta2-agonist to be used as needed.
Key learning point: Patients with exercise-induced bronchoconstriction should use a combination budesonide–formoterol inhaler before exercise to minimize symptoms. For those who are competitive athletes and thus exercising most days of the week, another reasonable option would be daily use of an inhaled glucocorticoid, with a short-acting beta2-agonist to be used as needed.
B/C. Use of a short-acting beta2-agonist before (not after) exercise has historically been the mainstay of therapy for EIB. However, evidence suggests that regular use of beta2-agonists without concurrent use of an inhaled glucocorticoid can increase airway responsiveness to bronchoconstrictor stimuli. Thus, current guidelines now recommend using a combination budesonide–formoterol inhaler before exercise to minimize symptoms, especially in those with mild asthma. This would be a reasonable option in this patient, but because she is a collegiate athlete who is exercising most days of the week, another reasonable option would be daily use of an inhaled glucocorticoid, with a short-acting beta2-agonist to be used as needed.
D. Exercise-induced anaphylaxis may share features of EIB but would affect more than one organ system. Epinephrine and histamine blockade would be the indicated treatment.
E. Although oral glucocorticoids are important in treating asthma exacerbations, they are not recommended as preventive therapy for EIB. Moreover, long-term oral glucocorticoid use has many adverse effects. Prescribing medications in athletes requires consideration of doping regulations. Oral and intravenous glucocorticoids would require a therapeutic-use exception from the World Anti-Doping Agency.
200
A 65-year-old woman with hypertension is found to have a systolic ejection murmur. A transthoracic echocardiogram reveals a bicuspid aortic valve and a dilated ascending aorta.
A thoracic CT scan shows that the ascending aorta is 5.6 cm in diameter (reference, <3.5 cm).
Which one of the following management approaches is most appropriate for this patient?
A. Annual monitoring with transesophageal echocardiography
B. Annual monitoring with CT of the chest
C. Beta-blocker therapy and continued observation
D. Surgical repair
E. Endovascular repair
Answer D
Thoracic aortic aneurysms are usually asymptomatic until an acute, often catastrophic complication occurs (e.g., a dissection or rupture). In most patients, an ascending aortic aneurysm should be repaired surgically when it exceeds 5.5 cm in diameter or enlarges more than 0.5 cm per year. However, it should be repaired earlier (at 4.0 to 5.0 cm in diameter, depending on the condition) in patients with genetically mediated causes of aortic aneurysm (e.g., Marfan syndrome, Turner syndrome) because dissection or rupture may occur in these individuals with minimal aortic dilatation.
Key learning point: The most appropriate management approach for a patient with a bicuspid aortic valve who has an ascending aortic aneurysm > 5.5 cm in diameter is surgical repair of the aneurysm.
A. When surgical repair is not yet indicated, annual imaging of the thoracic aorta (with e.g., transesophageal echocardiography) is recommended.
B. When surgical repair is not yet indicated, annual imaging of the thoracic aorta (with e.g., CT) is recommended.
C. Beta-blocker therapy is used to slow the progression of aortic aneurysm dilation, but continued observation on beta-blocker therapy is not appropriate once surgical repair is indicated.
E. Endovascular repair for thoracic aortic aneurysms is not routinely recommended unless the patient is at prohibitive surgical risk.
200
An 85-year-old woman with end-stage kidney disease was admitted to the intensive care unit one week ago, after suffering an acute hemorrhagic cerebrovascular accident. She has been unable to wean from mechanical ventilation.
On hospital day 7, the patient was febrile to 38.4°C; she was hypotensive and required intermittent vasopressor support. Her physical examination was unchanged. Her leukocyte count was 19,000 per mm3 (reference range, 4500–11,000), and her chest radiograph was unremarkable. Blood cultures were obtained, and empiric antimicrobial therapy with vancomycin, cefepime, and ciprofloxacin was initiated. The patient was up to date with Covid-19 vaccinations, and testing for SARS-CoV-2 was negative.
On hospital day 8, the microbiology laboratory reported growth of oxidase-positive gram-negative rods in two sets of blood cultures.
Which one of the following organisms is the most likely cause of this patient’s infection?
A. Moraxella catarrhalis
B. Pseudomonas aeruginosa
C. Campylobacter jejuni
D. Escherichia coli
E. Klebsiella pneuomoniae
Answer B
Pseudomonas aeruginosa is a common cause of hospital-acquired infections, including bacteremia, pneumonia, and urinary tract infections. It is a gram-negative rod that can be distinguished from other gram-negative rods in the microbiology laboratory by its inability to ferment lactose and its ability to produce an oxidase enzyme.
Key learning point: The presence of an oxidase-positive gram-negative rod in blood cultures from a hospitalized patient is indicative of infection with Pseudomonas aeruginosa, a common cause of hospital-acquired infections.
A. gram-negative coccus
C. Campylobacter jejuni is also an oxidase-positive gram-negative rod, but it is an uncommon cause of health care–associated infections.
D. Klebsiella pneumonia and Escherichia coli are both gram-negative rods and common causes of hospital-acquired infections, but they are oxidase-negative.
E. Klebsiella pneumonia and Escherichia coli are both gram-negative rods and common causes of hospital-acquired infections, but they are oxidase-negative.
200
A 70-year-old woman reports a 2-month history of progressive leg swelling, mild intermittent abdominal discomfort, fatigue, 3.2 kg of unintended weight loss, and occasional visible hematuria. She reports no chest pain or dyspnea.
Her vital signs and cardiopulmonary examination are within normal limits, and her jugular venous pressure is not elevated. Her abdomen is not distended, and no masses are palpable. She has mild right-sided mid-abdominal tenderness to palpation, without rebound or guarding. Her extremities are notable for 2+ edema up to the hips, and her peripheral pulses are intact.
A urine dipstick is negative for proteinuria but 1+ positive for blood. The urine sediment shows 10 to 15 red cells per high-power field.
Which one of the following diagnoses is most likely in this case?
A. Ovarian cancer
B. Immunoglobulin A nephropathy
C. Renal-cell carcinoma
D. Amyloidosis
E. Renal vein thrombosis
Answer C. This patient’s hematuria, weight loss, fatigue, and abdominal tenderness raise suspicion for malignancy, specifically renal-cell carcinoma. Renal-cell carcinoma has a predilection for vascular invasion. Venous tumor thrombus extending into the renal vein or inferior vena cava (IVC) occurs in up to 10% of affected patients and into the right atrium in up to 1% of affected patients. Significant obstruction of IVC blood flow can cause lower-extremity edema and varicosities.
Key learning point: The findings of hematuria with weight loss and lower-extremity swelling are most typical of a diagnosis of inferior vena cava obstruction that is associated with renal-cell carcinoma.
A. Ovarian cancer should be considered in any woman with abdominal discomfort and weight loss. However, bloating and increasing abdominal size (and not leg edema) are more likely to be dominant presenting findings, and the visible and microscopic hematuria suggest renal cancer rather than ovarian cancer.
B. Immunoglobulin A nephropathy often manifests with hematuria (either visible or microscopic) and mild proteinuria. Occasionally, nephrotic-range proteinuria with edema occurs in immunoglobulin A nephropathy, but proteinuria is absent in this patient.
D. Renal amyloidosis commonly causes nephrotic-range proteinuria but not hematuria.
E. Renal-vein thrombosis can be associated with nephrotic syndrome; it would not manifest with edema in the absence of proteinuria.
200
An 81-year-old woman with a history of hypertension and hypothyroidism reports burning chest pain and intermittent dysphagia that have progressed during the past several weeks. Her current medications are hydrochlorothiazide, vitamin D, and levothyroxine.
A barium-swallow study shows a small degree of reflux with provocation and a small paraesophageal hernia. Her chest discomfort improves during 10 days of treatment with famotidine, but the dysphagia persists.
An electrocardiogram is normal.
Which one of the following next steps is most appropriate for this patient?
A. Replace famotidine with carafate
B. Schedule esophageal manometry
C. Schedule esophagogastroduodenoscopy
D. Refer for surgical hernia repair
E. Replace famotidine with lansoprazole
Answer C
Many patients with paraesophageal hernias develop symptoms of gastroesophageal reflux. These symptoms are best managed with acid suppressants, such as famotidine or lansoprazole. As the paraesophageal hernia enlarges, it can produce symptoms secondary to hernia torsion. Dysphagia, as is reported in this case, is a more alarming symptom and should prompt a diagnostic esophagogastroduodenoscopy in a patient who has not had this test previously.
Key learning point: Paraesophageal hernias frequently manifest with symptoms of esophageal reflux; the presence of dysphagia requires additional evaluation with a esophagogastroduodenoscopy.
A. Carafate is less effective than treatment with acid suppressants and is not recommended.
B. Esophageal manometry is not likely to change the patient’s management and is not indicated.
D. Elective surgical hernia repair is reserved for failed medical management of symptoms, such as early satiety, postprandial pain, and vomiting attributable to the hernia.
E. Although proton pump inhibitors (e.g., lansoprazole) are more effective acid suppressants than H2 antagonists (e.g., famotidine), this patient reports decreased chest discomfort with famotidine. The persistent presence of dysphagia should prompt a diagnostic step first.
200
A 68-year-old man with a history of coronary artery disease, type 2 diabetes, hypertension, and chronic obstructive pulmonary disease (COPD) presents for initial evaluation of COPD. He has a 60-pack-year history of cigarette use and is currently smoking one pack of cigarettes per day. Four months ago, he was admitted to the hospital with increased cough and sputum production with severe shortness of breath and was found to have acute hypercapnic respiratory failure necessitating noninvasive positive pressure ventilation (NPPV) for one day. He was treated with prednisone and doxycycline and was discharged after 3 days. He was also admitted to the hospital about 6 months earlier with an exacerbation but did not require NPPV at that time.
Today, he reports mild dyspnea and an occasional nonproductive cough. He is able to walk comfortably on level ground but gets “winded" walking uphill. He can accomplish all of his activities of daily living without limitation. His current medications include carvedilol 6.25 mg twice daily, atorvastatin 40 mg daily, chlorthalidone 12.5 mg daily, potassium chloride 20 mEq daily, and inhaled albuterol as needed.
A transthoracic echocardiogram reveals a regional anterolateral wall-motion abnormality, a left ventricular ejection fraction estimated at 55% to 60%, and normal right ventricular function without evidence of pulmonary hypertension. There is no evidence of any significant valvular dysfunction. An electrocardiogram reveals normal sinus rhythm with left-axis deviation, a left anterior fascicular block, and a corrected QT interval of 507 msec.
Pulmonary function test results are as follows:
- FEV1 /FVC ratio: 58%
- FEV1 : 44% of predicted and without significant bronchodilator responsiveness
- Total lung capacity: 120% of predicted
- Carbon monoxide diffusing capacity: 79% of predicted
A complete blood count with differential shows an eosinophil count of 99 cells/mm3 (reference range, 0–350).
In addition to recommending smoking cessation, providing appropriate vaccinations, and referring to pulmonary rehabilitation, which one of the following pharmacologic therapies should be initiated?
A. Inhaled umeclidinium and vilanterol
C. Oral roflumilast
D. Inhaled tiotropium
E. Inhaled fluticasone propionate and salmeterol
Answer A
This patient’s symptoms and exacerbation history are consistent with group E chronic obstructive pulmonary disease (COPD) according to the latest Global Initiative for Chronic Obstructive Lung Disease (GOLD) classification system. Group E COPD, which is a combination of the two groups formerly referred to as C and D, is defined by a history of at least two moderate exacerbations or at least one exacerbation requiring hospitalization. The grouping is used to determine initial pharmacologic treatment, as shown in the “Initial pharmacological treatment of stable COPD” table.
For patients with group E COPD, as in this case, the preferred initial pharmacologic therapy is an inhaled combination of a long-acting muscarinic antagonist (LAMA) and a long-acting beta-agonist (LABA), such as umeclidinium and vilanterol. This is a new recommendation in the GOLD 2023 guidelines based on a Cochrane systematic review and meta-analysis that showed fewer exacerbations with combined therapy than with either agent alone.
Emerging data suggest that blood eosinophil counts can predict the magnitude of response to inhaled glucocorticoids, with counts ≥300 per mm3 suggesting responsiveness and counts <100 per mm3 suggesting a low likelihood of benefit. In patients with group E COPD and a blood eosinophil count ≥300 per mm3, initial therapy with a LABA–LAMA–inhaled glucocorticoid combination may be considered. This patient’s eosinophil count is <100 per mm3, so an inhaled glucocorticoid is not indicated.
Key learning point: The first-line treatment in group E chronic obstructive pulmonary disease is an inhaled long-acting muscarinic antagonist and a long-acting beta-agonist.
B. An inhaled LABA (e.g., salmeterol) may be considered as initial long-acting bronchodilator therapy in patients with GOLD group A COPD (minimal symptoms and 0 to 1 moderate exacerbations not requiring hospitalization). However, this patient has group E COPD and requires a combination of LABA and LAMA, not a single agent like salmeterol.
C. Roflumilast can be considered in patients who have frequent exacerbations despite optimal medical therapy. However, this patient has not yet tried an optimal regimen of inhaled therapies; thus, initiating roflumilast would be premature.
D. An inhaled LAMA (e.g., tiotropium) may be considered as initial long-acting bronchodilator therapy in patients with GOLD group A COPD (minimal symptoms and 0 to 1 moderate exacerbations not requiring hospitalization). However, for patients with group E COPD, the preferred initial pharmacologic therapy is a combination of a LAMA and a LABA, not a single agent like tiotropium.
E. Emerging data suggest that blood eosinophil counts can predict the magnitude of response to inhaled glucocorticoids, with counts ≥300 per mm3 suggesting responsiveness and counts <100 per mm3 suggesting a low likelihood of benefit. In patients with group E COPD and a blood eosinophil count ≥300 per mm3, initial therapy with a LABA–LAMA–inhaled glucocorticoid combination may be considered. This patient’s eosinophil count is <100 per mm3, so an inhaled glucocorticoid, such as fluticasone, is not indicated.
300
An 82-year-old left-handed woman with type 2 diabetes, hypertension, and hyperlipidemia reports 6 months of intermittent dizziness, blurry vision, and occasional diplopia while vacuuming. She denies any chest discomfort, palpitations, or orthostatic symptoms.
Her heart rate is 78 beats per minute. Her blood pressure is 138/79 mm Hg in the right arm and 100/75 mm Hg in the left arm. Her cardiovascular examination is notable for normal first and second heart sounds, a soft grade 1/6 systolic ejection murmur at the aortic area, and a bruit over her left supraclavicular and lower carotid areas.
An electrocardiogram shows normal sinus rhythm and left ventricular hypertrophy.
What is the most likely diagnosis in this case?
A. subclavian steal syndrome
B. type B aortic dissection
C. carotid stenosis
D. carotid dissection
E. aortic stenosis
Answer A
This patient’s symptoms of dizziness and vision changes are consistent with vertebrobasilar ischemia. Provocation of symptoms with use of the left arm (e.g., while vacuuming) and the presence of a bruit over the left supraclavicular region suggest subclavian steal syndrome caused by subclavian stenosis.
The initial test of choice is duplex ultrasonography, which can estimate the severity of subclavian stenosis and identify vertebral artery flow reversal using pulsed-wave Doppler technology. Notably, although many patients with subclavian stenosis have retrograde vertebral artery flow, the diagnosis of subclavian steal syndrome requires the presence of concomitant symptoms such as vertebrobasilar ischemia or arm claudication.
Key learning point: The best initial test for evaluating a patient who has symptoms of exertional dizziness and blurred vision as well as discrepant upper-extremity blood pressures is duplex ultrasonography of the subclavian artery.
B. Type B aortic dissection affects the distal aorta (beyond the left subclavian artery) and usually manifests with chest or back pain; it would not cause discrepant blood-pressure readings in the upper extremities.
C and D. Blurry vision and diplopia are manifestations of ischemia in the territory of the posterior cerebral circulation; they are not typical features of carotid artery disease.
E. The classic symptoms of severe aortic stenosis are angina, syncope or presyncope, and heart failure, not the neurologic symptoms experienced by this patient. In addition, hemodynamically important aortic stenosis is unlikely with only a grade 1 outflow murmur and with preserved intensity of the second heart sound.
300
A 36-year-old woman presents to the emergency department with abdominal pain, a fever of 38.3°C, diarrhea, and hematochezia. One week earlier, she went on vacation to Mexico and had taken ciprofloxacin for prophylaxis against travelers' diarrhea. Her brother has been diagnosed with Crohn disease.
The patient’s vital signs are stable. Her abdominal examination reveals slight tenderness without any rebound or guarding. A plain-film radiograph of the abdomen is unremarkable. Stool cultures are negative for Shiga toxin and Clostridioides difficile toxin. A flexible sigmoidoscopy reveals diffuse colitis. Histologic review of a biopsy from the sigmoid colon demonstrates acute colitis with flask-shaped ulcers (figure) and no features of chronicity.
Which one of the following treatments is most appropriate for this patient?
A. Oral glucocorticoid
B. Loperamide and a BRAT diet ( bananas, rice, applesauce and toast)
C. Azithromycin
D. Ciprofloxacin and metronidazole
E. Metronidazole followed by paromomycin
Answer E
Entamoeba histolytica — a parasite often seen in Central and South America, Africa, and Asia — is thought to infect up to 50 million people per year worldwide. The incubation period is 7 to 21 days. This infection is characterized by the presence of flask-shaped enteric ulcers on microscopic evaluation of an intestinal biopsy.
The most appropriate treatment of entamoeba infection is a course of metronidazole for the amebic colitis, followed by a luminal agent such as paromomycin to prevent recurrent infection. Paromomycin is not recommended as concurrent treatment with metronidazole because it causes diarrhea in many individuals.
Key learning point: The most appropriate treatment for intestinal amebiasis is metronidazole followed by paromomycin.
A. The acute presentation is unlikely to represent inflammatory bowel disease, so treatment with glucocorticoids is not appropriate.
B. Treatment with loperamide can increase the risk for intestinal perforation in a patient with acute colitis and is not recommended.
C. This patient had already taken a course of ciprofloxacin for prophylaxis against travelers' diarrhea, and a recurrence is unlikely. Thus, both ciprofloxacin and azithromycin would be inadequate.
D. This patient had already taken a course of ciprofloxacin for prophylaxis against travelers' diarrhea, and a recurrence is unlikely. Thus, both ciprofloxacin and azithromycin would be inadequate.
300
A 56-year-old woman with hypertension, hyperlipidemia, and a history of kidney stones presents for follow-up 5 days after a visit to the emergency department (ED) for right-sided flank pain and nausea. She was visiting her son in Arizona at the time, and a CT scan of her abdomen showed a small, solitary kidney stone in the right ureter. She received intravenous fluids and a dose of pain medication before being discharged; she passed the stone on her own one day later.
This is her third episode of kidney stones. The first occurred at age 44 and also involved an ED visit. The second occurred 2 months ago when she had right-sided pain and then passed a small stone 3 hours later while she was at home.
Today, she feels well and reports no hematuria, flank pain, nausea, vomiting, or diarrhea. Her only complaint is a sore right heel from taking long hikes with her son. She reports that she has lost 3 kg during the past 4 months, which she attributes to dietary changes, including eating more leafy greens such as spinach and abstaining from red meat and alcohol.
On physical examination, her blood pressure is 117/72 mm Hg, and her heart rate is 80 beats per minute. She has a regular heart rhythm with no murmurs, and her lungs are clear to auscultation. She has no flank tenderness on palpation and no peripheral edema.
A basic metabolic panel yields the following results:
Sodium (mEq/liter)138 (136–145)
Potassium (mEq/liter)4.6 (3.5–5.0)
Chloride (mEq/liter)104 (98–106)
Bicarbonate (mEq/liter)25 (21–30)
Blood urea nitrogen (mg/dL)18 (10–20)
Creatinine (mg/dL)0.9 (0.6–1.1)
Random glucose (mg/dL)97 (<140)
Calcium (mg/dL)9.7 (9.0–10.5)
Phosphorus (mg/dL)3.2 (3.0–4.5)
What is the best next step in evaluating this patient’s recurrent nephrolithiasis?
A. 24-hour urine studies
B. Measurement of parathyroid hormone
C. Measurement of 25-hydroxyvitamin D
E. Measurement of uric acid
Answer A
In patients with recurrent kidney stones, the goal of evaluation is to identify the type of stone to inform a plan for preventing further recurrence. The evaluation should include a focused history, metabolic panel, radiographic imaging with CT, stone analysis (if a stone is available), and 24-hour urine studies. In this case, the patient has already undergone the first three components of evaluation, and her history provides some possible clues to the recent recurrence:
• Her recent dietary changes, including increased intake of spinach, would have led to a higher oxalate intake, which could have led to the formation of calcium oxalate crystals.
• Her recent visit to Arizona, which has a hot, dry climate, may have predisposed her to volume depletion, which is another risk factor for kidney stone precipitation.
The next step is to conduct 24-hour urine studies to assess urine volume, pH, and excretion of calcium, uric acid, citrate, oxalate, sodium, potassium, magnesium, phosphate, and creatinine.
Stone retrieval for analysis would have been ideal but is not currently possible in this patient as she has already passed the stone. She should be advised to bring in any stones that she passes in the future so that they can be analyzed.
Key learning point: Evaluation of patients with recurrent kidney stones should include a focused history, metabolic panel, CT, 24-hour urine studies, and stone analysis.
B. Measuring parathyroid hormone levels is not indicated at this point because the patient’s calcium and creatinine levels are within normal limits. If the 24-hour urine collection reveals hypercalciuria, then measurement of the parathyroid hormone level would be appropriate.
C. Measurement of 25-hydroxyvitamin D is not needed but would be appropriate if there were hypercalciuria, hypophosphatemia, or hyperparathyroidism.
D. Although radiographic imaging can be used to assess stone burden in patients with recurrent stones, CT is preferred over radiographs and has already been completed in this case.
E. Measuring the uric acid level would be helpful if this patient had a history of gout or other conditions that predisposed her to an acidic urine (e.g., chronic diarrhea, diabetes mellitus, or metabolic syndrome) as uric acid is more likely to precipitate in urine with a low pH. However, her history is more consistent with calcium oxalate stones, and a 24-hour urine study would be more helpful.
300
A 40-year-old woman reports a 3-day history of mouth soreness without retrosternal pain or odynophagia. She uses a daily inhaled glucocorticoid for mild persistent asthma. In addition, she took a course of antibiotics one week ago for a urinary tract infection.
On examination, she has nonadherent white plaques on the posterior aspect of her tongue. Testing for HIV infection is negative.
Which one of the following treatments is most appropriate for this patient?
A. Clotrimazole troches/lozenges
B. Oral fluconazole tablets
C. Oral itraconazole solution
D. Oral itraconazole tablet
E. Topical glucocorticoid
Answer A
The presence of nonadherent white plaques on the buccal mucosa, palate, or tongue indicates oropharyngeal candidiasis. Risk factors include immunosuppression, inhaled glucocorticoid use, and recent antibiotic use.
First-line therapy for mild oropharyngeal candidiasis is clotrimazole troches or miconazole mucoadhesive buccal tablets. Nystatin suspension or pastilles are alternative choices. For more severe disease or if there is no response to local therapy, oral fluconazole is recommended. This agent can also be used as first-line therapy for esophageal candidiasis, which would manifest with odynophagia or retrosternal pain. Itraconazole is usually reserved for fluconazole-refractory candidiasis.
Key learning point: First-line therapy for oropharyngeal candidiasis is clotrimazole troches or miconazole mucoadhesive buccal tablets.
B. For more severe disease or if there is no response to local therapy, oral fluconazole is recommended. This agent can also be used as first-line therapy for esophageal candidiasis, which would manifest with odynophagia or retrosternal pain.
C. Itraconazole is usually reserved for fluconazole-refractory candidiasis.
D. Itraconazole is usually reserved for fluconazole-refractory candidiasis.
E. Topical glucocorticoids are first-line treatments for patients with symptomatic oral lichen planus, which can cause adherent white plaques and can be confused with candidiasis. Topical glucocorticoids worsen oral candidiasis
300
A 65-year-old man with heart failure and chronic atrial fibrillation reports a 4-month history of progressive dyspnea on exertion. His medications, which have not changed during the past year, include aspirin, furosemide, amiodarone, and metoprolol.
His blood pressure is 112/64 mm Hg, his heart rate is 85 beats per minute with an irregular rhythm, his respiratory rate is 19 breaths per minute, and his oxygen saturation is 85% while he is breathing ambient air.
Jugular venous pulsations are barely visible just above the clavicles, with the patient’s chest positioned at an elevation of 45 degrees. He has diffuse inspiratory crackles. The cardiac examination reveals a grade 1/6 midsystolic outflow murmur at the base and no third heart sound. He has mild bilateral, symmetric pedal edema.
Chest radiography and CT are performed (figures).
What is the most appropriate next step in this patient's care?
A. Treat with methylprednisolone and methotrexate
B. Increase the furosemide dose
C. Administer a 7-day course of levofloxacin
D. Discontinue the amiodarone, and begin treatment with prednisone
E. Discontinue the amiodarone and observe
Answer D
Pulmonary toxic effects from amiodarone are characterized by dyspnea, hypoxemia, and both reticulonodular changes and ground-glass opacities on chest imaging.
This patient is receiving long-term amiodarone therapy, which is the most likely cause of his symptoms and radiographic changes. The most appropriate next step is to discontinue the amiodarone; if an antiarrhythmic agent is still required, an alternative agent should be used.
In case reports, severely symptomatic patients with hypoxemia and diffuse lung involvement appear to benefit from a course of prednisone therapy. Although no large-scale clinical trials have been performed to evaluate this approach, oral prednisone is typically started in 40- to 60-mg daily doses and then tapered slowly.
Key learning point: Severely hypoxemic patients with amiodarone-induced lung toxicity should be treated with prednisone.
A. There is no role for methotrexate in the treatment of amiodarone-induced lung toxicity.
B. The findings on physical examination and chest imaging are not typical of a patient with advancing congestive heart failure; thus, treatment with additional furosemide is not indicated.
C. The presenting features are not consistent with a diagnosis of an acute pulmonary infection; thus, treatment with levofloxacin is not indicated.
E. This patient is receiving long-term amiodarone therapy, which is the most likely cause of his symptoms and radiographic changes. The most appropriate next step is to discontinue the amiodarone; if an antiarrhythmic agent is still required, an alternative agent should be used.
400
A 74-year-old man reports a 6-month history of right calf pain that occurs after 30 meters of walking and resolves promptly with rest. His medical history includes insulin-requiring type 2 diabetes, hyperlipidemia, and a previous stroke.
On examination, he has diminished pedal pulses on the right, with palpable femoral and popliteal pulses. The left pedal, femoral, and popliteal pulses are normal. No bruits are present. Neurologic examination of the lower extremities is normal except for symmetrically diminished ankle reflexes, light touch sensation, and pinprick sensation in the feet.
The resting ankle–brachial index is 1.10 on the left and 0.95 on the right (reference range, 1.01–1.40).
Which one of the following next tests is most appropriate for this patient?
A. Angiography of the symptomatic leg
B. CT scan of the abdomen with runoff
C. duplex ultrasound imaging
D. MRI of the lumbar spine
E. ankle-brachial index after exercise
Answer E
The initial test in a patient with suspected peripheral arterial disease (PAD) is the ankle–brachial index (ABI), which is interpreted as follows:
• Normal: 1.01–1.40
• Borderline: 0.91–1.00
• Abnormal: ≤0.90
Although the ABI is reasonably sensitive, a normal value is insufficient to exclude the diagnosis of PAD when symptoms strongly suggest arterial claudication. Exercise improves the sensitivity of ABI in detecting PAD; thus, ABI after exercise is the most appropriate next test in a patient with intermittent claudication and a normal or borderline resting ABI.
Toe–brachial index is used for patients with an ABI >1.40 due to noncompressible vessels.
Key learning point: The most appropriate next test in a patient with symptoms of claudication and a borderline-low resting ankle–brachial index is an exercise ankle–brachial index.
A. Invasive angiography is appropriate after noninvasive testing has suggested the presence of PAD and revascularization is being considered.
B. CT angiography would be useful for localization of lesions in planning for intervention. Given that the resting ABI is borderline, the next best test would be for confirmation of ischemia with exercise.
C. Duplex ultrasound imaging is useful for patients with an abnormal ABI to better localize and characterize the extent of disease or to follow patients who have previously had peripheral arterial revascularization.
D. MRI of the lumbar spine might be considered in a patient with typical features of pseudoclaudication attributable to spinal stenosis. Such patients may have asymmetric neurologic findings in the lower extremities, and pain in the back or leg provoked by ambulation and by certain changes in position. This patient's symmetric neurologic findings in the feet likely reflect diabetic neuropathy.
400
A 68-year-old woman is planning a 3-week trip to Mozambique and seeks travel advice. In addition to updating vaccinations, you discuss malaria prophylaxis and decide on doxycycline. She will take her first dose of doxycycline 2 days before arriving in Mozambique.
For how long should this patient continue taking doxycycline after leaving Mozambique?
A. Take alternate-day dosing for 5 doses
B. Continue for another one week after return
C. Discontinue immediately upon return
D. Continue for another 4 weeks after return
E. Stop 2 days before the trip ends
Answer D
Most medications used for malaria prophylaxis (e.g., chloroquine, mefloquine, and doxycycline) do not prevent initial malaria infection but, rather, prevent illness by eradicating circulating parasites or schizonts that have been released into the bloodstream after maturing in the liver.
Prophylaxis with doxycycline (or chloroquine or mefloquine) should continue for 4 weeks after the last exposure to malaria to eradicate any parasites that were maturing in the liver and might still be released into the bloodstream.
Another frequently used malaria prophylactic, atovaquone–proguanil, acts on both blood-borne schizonts and hepatic schizonts (i.e., parasites developing in the liver). As a result, atovaquone–proguanil can be discontinued one week after departure from a malaria-endemic region. However, this does not apply to doxycycline, which should be continued for 4 weeks after the last exposure.
Key learning point: If a patient is taking doxycycline for malaria prophylaxis, they should continue it for four weeks after returning from the malaria-endemic zone.
400
A 59-year-old woman presents to clinic to establish care after moving to town several months ago. She has a history of stage 4 chronic kidney disease, hypertension, coronary artery disease, and obstructive sleep apnea. Her family history is significant for osteoporosis in her mother and sister. Her current medications include lisinopril 40 mg daily, metoprolol 25 mg twice daily, sodium bicarbonate 650 mg twice daily, aspirin 81 mg daily, and cholecalciferol 1000 IU daily. She also takes acetaminophen 1000 mg twice daily as needed for intermittent lower back pain, which she rates as 2 out of 10 in intensity. She generally feels well, reports good adherence to her medications, and follows a diet that is low in sodium, potassium, and phosphorus.
She has a blood pressure of 132/82 mm Hg, a heart rate of 65 beats per minute, a respiratory rate of 20 breaths per minute, and a weight of 89 kg. Examination of the heart, lungs, and abdomen is within normal limits, and there is no peripheral edema. She has mild tenderness to palpation of the paraspinal muscles in the lumbar region.
Laboratory testing yields the following results:
Sodium (mEq/liter)138 (136–145)
Potassium (mEq/liter)4.8 (3.5–5.0)
Chloride (mEq/liter)102 (98–106)
Carbon dioxide (mEq/liter)22 (21–30)
Blood urea nitrogen (mg/dL)43 (10–20)
Creatinine (mg/dL)2.5 (0.6–1.1)
Albumin (g/dL)3.8 (3.5–5.5)
Calcium (mg/dL)8.8 (9.0–10.5)
Phosphorus (mg/dL)5.7 (3.0–4.5)
Parathyroid hormone (pg/mL)320 (10–60)
25-hydroxyvitamin D (ng/mL)33 (30–80)
Which one of the following next steps is most appropriate in managing this patient’s elevated parathyroid hormone level?
A. Increase the dose of cholecalciferol to 50,000 IU weekly
B. Start sevelamer carbonate three times daily with meals
C. Start alendronate once weekly
Answer B
This patient with stage 4 chronic kidney disease has developed secondary hyperparathyroidism and hyperphosphatemia despite following a low-phosphorus diet. The first step in managing the hyperparathyroidism is to control the hyperphosphatemia with a phosphate binder.
There are two classes of phosphate binders: calcium-containing binders, such as calcium carbonate, and non–calcium-containing binders, such as sevelamer carbonate. Phosphate binders must be taken with meals to bind the phosphorus in foods and limit absorption; they are not effective when taken at bedtime. Non–calcium-containing binders have been endorsed by most experts because calcium may play a role in the development of cardiovascular disease in patients with chronic kidney disease, and non–calcium-based binders have been associated with lower mortality than calcium-based binders. Nevertheless, this recommendation is based on only moderate-quality evidence and therefore calcium-containing binders are still widely used. Non–calcium-based binders tend to be more expensive, which can be a burden for patients.
The elevated parathyroid hormone (PTH) level in this patient is partly driven by hyperphosphatemia, and the PTH level will likely decrease once the hyperphosphatemia is controlled.
Key learning point: In patients with advanced chronic kidney disease, the first step in managing secondary hyperparathyroidism is to improve control of hyperphosphatemia.
A. Increasing the patient’s cholecalciferol dose will not significantly reduce the PTH level because her total 25-hydroxyvitamin D level is already >30 ng/dL.
C. Alendronate and other bisphosphonates are not indicated in the treatment of secondary hyperparathyroidism. Furthermore, their use is contraindicated when the estimated glomerular filtration rate is <30 mL/min/1.73 m2 (or <35 mL/min/1.73 m2 for zoledronic acid).
D. This patient with stage 4 chronic kidney disease has developed secondary hyperparathyroidism and hyperphosphatemia despite following a low-phosphorus diet. The first step in managing the hyperparathyroidism is to control the hyperphosphatemia with a phosphate binder.
There are two classes of phosphate binders: calcium-containing binders, such as calcium carbonate, and non–calcium-containing binders, such as sevelamer carbonate. Phosphate binders must be taken with meals to bind the phosphorus in foods and limit absorption; they are not effective when taken at bedtime. Non–calcium-containing binders have been endorsed by most experts because calcium may play a role in the development of cardiovascular disease in patients with chronic kidney disease, and non–calcium-based binders have been associated with lower mortality than calcium-based binders. Nevertheless, this recommendation is based on only moderate-quality evidence and therefore calcium-containing binders are still widely used. Non–calcium-based binders tend to be more expensive, which can be a burden for patients.
The elevated parathyroid hormone (PTH) level in this patient is partly driven by hyperphosphatemia, and the PTH level will likely decrease once the hyperphosphatemia is controlled.
E. Intake of active vitamin D in the form of calcitriol will suppress PTH levels by increasing calcium absorption from the gut, thus increasing serum calcium levels. Although calcitriol is useful in patients with low or low–normal serum calcium levels, it should not be started in this patient before the phosphorus level is controlled because calcitriol also increases phosphorus absorption in the gut and is therefore likely to result in worsening hyperphosphatemia.
400
An 82-year-old woman who was treated for acute diverticulitis one week ago develops acute-onset severe abdominal pain, abdominal distention, and nonbloody emesis. She denies hematochezia or diarrhea. She has a history of coronary artery disease, congestive heart failure, and giant-cell arteritis. Her current medications are aspirin, lisinopril, digoxin, prednisone, and simvastatin.
On examination, the patient is in moderate distress and confused, with a temperature of 38.8°C, a heart rate of 125 beats per minute, and a blood pressure of 100/66 mm Hg. She has a regular rhythm with no murmur, her lungs are clear to auscultation, and abdominal examination reveals diffuse, minimal tenderness to palpation.
A plain-film abdominal radiograph shows no evidence of obstruction or free air. Initial blood cultures are negative.
This patient’s presentation is most consistent with which one of the following diagnoses?
A. chronic mesenteric ischemia
B. superior mesenteric artery embolus
C. mesenteric venous thrombosis
D. celiac artery compression syndrome
E. chronic ischemic colitis
Answer C
Several conditions can cause primary mesenteric ischemia, including superior mesenteric artery embolus, mesenteric venous thrombosis, ischemic colitis, and chronic mesenteric ischemia, all of which have different clinical presentations. This patient likely has mesenteric venous thrombosis related to the antecedent diverticulitis.
Mesenteric venous thrombosis is most commonly seen after intra-abdominal inflammatory processes such as diverticulitis or appendicitis; the inflammation can extend to the venous walls and lead to thrombosis, particularly in patients who are otherwise at risk for venous thrombosis (e.g., because of malignancy, estrogen treatment, or other hypercoagulable states). Patients typically present with acute or subacute onset of dull abdominal pain that is out of proportion to the physical examination — and sometimes have abdominal distention and occult blood present in the feces. More chronic presentations may also be seen.
Key learning point: In a patient whose history and physical examination are suggestive of primary mesenteric ischemia, a recent history of intra-abdominal infection should suggest a diagnosis of mesenteric venous thrombosis.
A. Chronic mesenteric ischemia is typically caused by stable atherosclerosis of the mesenteric arteries, often in patients with risk factors or with other known sites of atherosclerosis; patients usually present with gradual onset of chronic postprandial pain. An acute presentation with fever and severe pain unrelated to meals would be unlikely.
B. Superior mesenteric artery occlusion is usually acute and can be embolic (most often in patients with atrial fibrillation or other sources of embolism) or thrombotic (most often in patients with risk factors for atherosclerotic cardiovascular disease or atherosclerosis in other arteries, although it can also be seen with vasculitis). Patients present with acute onset of abdominal pain that is out of proportion to the physical examination and may have evidence of poor perfusion on laboratory tests (e.g., metabolic acidosis, elevated lactate levels).
D. Celiac artery compression syndrome typically occurs in young women and manifests with chronic abdominal pain and recent unintended weight loss.
E. Patients with chronic ischemic colitis usually present with recurrent abdominal pain, diarrhea, and hematochezia; in rare cases, they may present with bacteremia, sepsis, or colonic strictures.
400
A 43-year-old woman with a 2-year history of asthma presents with chronic nasal congestion that began after an uncomplicated upper respiratory infection 3 months ago in which she tested negative for SARS-CoV-2. Since then, she has noted a loss of her senses of smell and taste, as well as an increase in asthma symptoms.
She works as a hair stylist and notes that exposure to hair spray in the salon worsens her nasal congestion. She does not smoke cigarettes.
On examination, she has severe nasal congestion but no purulent drainage. In her right naris, she appears to have a small nasal polyp.
Which one of the following next steps is most appropriate in evaluating this patient?
A. Waters’ radiographic views of the sinuses
B. Immunoglobulin levels
C. CT of the sinuses
Answer C
The often-subtle clinical manifestations of chronic sinusitis include nasal congestion and loss of the sense of smell (and resulting reduction in the sense of taste). Compared with acute sinusitis, chronic sinusitis is more gradual in onset and is not associated with fever. Because the physical examination in chronic sinusitis may be normal and fail to reveal the extent of disease, CT of the sinuses is indicated in patients with this clinical presentation. This imaging will help rule out alternate diagnoses such as malignancy, determine the presence and extent of chronic rhinosinusitis, and show any nasal polyps. CT is especially important to establish a diagnosis for patients who have received multiple courses of antibiotics for presumed, but not documented, chronic sinusitis.
Key learning point: The most effective test to further evaluate for chronic sinusitis is CT of the sinuses.
A. Radiographic examination of the sinuses, including a Waters’ view, does not provide sufficient detail to reveal the extent of disease or to identify the specific sinus components affected.
B. Immunoglobulin levels are appropriate to exclude common variable immunodeficiency in patients with recurrent sinopulmonary infections, especially if those infections develop without a preceding viral infection.
D. Biopsy of the nasal polyp is rarely indicated and thus should not be considered in the initial evaluation.
E. In the absence of signs and symptoms consistent with allergic rhinitis, allergy testing would not be the best next step in the evaluation. Asking this patient about sensitivity to aspirin and nonsteroidal antiinflammatory drugs (NSAIDs) is important because if these medications trigger her asthma, she likely has aspirin-exacerbated respiratory disease (AERD). Although NSAIDs should be avoided in these patients, aspirin desensitization should be considered because it has been shown to improve asthma and nasal polyposis in patients with AERD.
500
A 31-year-old woman reports progressive shortness of breath for the past 6 months. She moved from West Africa to the United States 2 years ago. Her only medication is an oral contraceptive pill.
On presentation, she is afebrile, with a heart rate of 110 beats per minute, a blood pressure of 120/70 mm Hg, and a respiratory rate of 20 breaths per minute. Her jugular venous pressure is 10 cm above the sternal border while she is reclining at a 45-degree angle, and it increases with inspiration. Breath sounds are normal bilaterally, and a loud heart sound is audible immediately after S2 . She has a distended abdomen with a fluid wave and bilateral pedal edema.
A chest radiograph is obtained (figure).
Which one of the following diagnoses is most likely in this case?
A. Rheumatic mitral stenosis
Answer C
Constrictive pericarditis is the result of a chronic inflammatory process that leads to pericardial thickening and subsequent constriction of the cardiac chambers, with impaired diastolic filling and venous congestion.
Although not common in industrialized countries, tuberculosis is the leading cause of constrictive pericarditis worldwide. When tuberculosis infection spreads to the pericardium, it initially causes a suppurative exudate that eventually leads to pericardial thickening and calcification. Affected patients often present with symptoms and signs of peripheral venous congestion, including elevated jugular venous pressure, ascites, pedal edema, and shortness of breath. A pericardial knock may be audible immediately after S2 ; it is caused by abrupt cessation of diastolic filling of the ventricles. A chest radiograph may reveal pericardial calcification, although CT and MRI are more sensitive than radiography for detecting pericardial thickening and calcification.
Key learning point: Elevated jugular venous pressure with Kussmaul sign (increase in jugular venous pressure with inspiration), ascites, lower-extremity edema, and a pericardial knock are classic findings in a patient with constrictive pericarditis.
A. Rheumatic mitral stenosis is associated with a low-pitched, rumbling diastolic murmur and symptoms of pulmonary venous congestion (i.e., pulmonary edema).
B. Viral myocarditis is usually associated with acute-onset heart failure symptoms. A viral prodrome would suggest a diagnosis of viral myocarditis.
D. Although arrhythmogenic right ventricular dysplasia (i.e., replacement of the ventricular myocardium with fibrofatty tissue) may yield signs and symptoms of right ventricular failure, it is frequently associated with ventricular arrhythmias and sudden death in children and young adults.
E. Endomyocardial fibrosis, a disease predominantly seen in West Africans, may lead to a restrictive cardiomyopathy. Although symptoms and signs of peripheral venous congestion are seen with both restrictive cardiomyopathy and constrictive pericarditis, calcification of the pericardium is seen only with the latter.
500
A 49-year-old man with no significant medical history presents to the hospital with a one-day history of fever, severe headache, myalgias, and loose stools that began 10 days after he returned from Mumbai, India.
On examination, his temperature is 38.9°C, his heart rate is 117 beats per minute, his blood pressure is 102/64 mm Hg, his respiratory rate is 24 breaths per minute, and his oxygen saturation is 96% while he is breathing ambient air.
He is up to date with Covid-19 vaccinations, and testing for SARS-CoV-2 is negative. Laboratory findings are as follows:
Leukocyte count (per mm3): 4200 (4500–11,000)
Hemoglobin (g/dL): 11.4 (13.5–17.5)
Platelet count (per mm3): 110,000 (150,000–350,000)
Aspartate aminotransferase (U/liter): 77 (0–35)
Alanine aminotransferase (U/liter)85: (0–35)
Lactate dehydrogenase (U/liter): 285 (100–190)
Indirect bilirubin (mg/dL): 0.4 (0.1–0.3)
His creatinine level is normal. His cerebrospinal fluid analysis is within normal limits. One set of thick and thin smears is obtained and is found to be negative for malaria. Blood cultures are pending. His chest radiograph shows a mild diffuse interstitial pattern.
He is admitted to the hospital and started on empiric ceftriaxone and azithromycin for presumed pneumonia. Twelve hours after admission, he reports worsening shortness of breath, headaches, and malaise.
Which one of the following next steps is most appropriate in this patient's care?
A. Order serological testing for dengue fever
B. Repeat thick and thin smears for malaria
Answer B
Any patient with recent travel to a malaria-endemic country who presents with fever should be evaluated immediately for malaria, which is a life-threatening infection. Thin smears of peripheral blood are 100% specific, but not 100% sensitive, for the diagnosis of malaria; therefore, repeat testing should be performed every 12 to 24 hours until at least three smears have been evaluated.
Symptoms of malaria can be nonspecific and include headache, myalgias, and gastrointestinal symptoms in addition to the fever. An abnormal chest radiograph and shortness of breath can indicate the development of pulmonary edema. Mild anemia, thrombocytopenia, and elevation in aminotransferase levels are consistent with malaria. Laboratory evidence for hemolysis, such as elevated lactate dehydrogenase or indirect bilirubin levels, may be seen.
Key learning point: The most appropriate test for diagnosing malaria in a patient who presents with fever after travel to an endemic area is to repeat thick and thin blood smears every 12 to 24 hours until at least three smears have been evaluated.
A. Although this patient's symptoms are consistent with dengue fever, testing for malaria is more important than testing for dengue because the treatment for malaria is so specific; the treatment for dengue is supportive care.
C. Early yellow fever can manifest similarly to malaria but is not endemic to India.
D/E. Broader antibiotics are not indicated in this patient because the azithromycin already offers sufficient coverage for bacterial enteric pathogens.
500
A 47-year-old man who is a former smoker presents with gross hematuria. He has no prior history of hematuria or genitourinary cancer.
On cystoscopy, a solitary velvety erythematous patch of mucosa, 3.2 cm in diameter, is found in the bladder. Resection and fulguration is performed; no intravesical therapy is administered.
Histologic evaluation confirms high-grade papillary urothelial carcinoma of the bladder with invasion of the lamina propria.
No lymphadenopathy, renal parenchymal mass, or filling defects within the renal pelvises or ureters is seen on CT urography.
Which one of the following management options is the most appropriate for this patient?
A. External-beam radiation therapy
B. Radical cystectomy
C. Partial cystectomy
D. Intravesical bacillus Calmette–Guérin
E. Repeat cystoscopy with transurethral resection and fulguration
Answer E
This tumor is considered high risk for recurrence and progression based on the high-grade pathologic changes. In a patient with no previous history of genitourinary cancer who undergoes initial transurethral resection of high-risk non–muscle-invasive high-grade papillary urothelial carcinoma of the bladder, the most appropriate next step in management is to repeat the cystoscopy within 6 weeks of the initial cystoscopy, with resection of any residual or synchronous tumors. This approach provides both diagnostic and therapeutic benefit.
In patients with bladder cancer that invades the lamina propria but not the muscularis layer (staged as T1 disease), disease understaging is common, with up to 30% of patients being upstaged to muscle-invasive disease at repeat resection. From a therapeutic standpoint, 50% to 70% of patients with T1 tumors may have residual disease at the time of repeat cystoscopy. Repeat resection is associated with improved response to subsequent intravesical bacillus Calmette–Guérin (BCG) therapy or mitomycin C therapy.
Key learning point: In a patient with no previous history of genitourinary cancer who undergoes initial transurethral resection of high-risk non–muscle-invasive high-grade papillary urothelial carcinoma of the bladder, the most appropriate next step in management is repeat transurethral resection and fulguration.
A. Radiation therapy does not have a role in treating this type of cancer.
B. Radical cystectomy is considered standard therapy for stage II and stage III bladder cancer (where there is invasion of the muscularis layer). It may also be an option in patients with extensive or refractory stage Ta or stage I cancer. It is not indicated in this case of a first occurrence of stage I bladder cancer.
C. Partial cystectomy is rarely performed for this indication, given that recurrent tumors tend to occur throughout the bladder.
D. Intravesical BCG or chemotherapy instillations are considered standard therapy in most patients with non–muscle-invasive bladder cancer (especially those patients at high risk for progression or with multiple or recurrent tumors) and will help reduce recurrence risk. However, it is not indicated until after repeat cystoscopy has been performed.
500
A 26-year-old man presents to the emergency department with new lower-extremity edema and tongue swelling. He also reports 6 months of nonbloody diarrhea, fatigue, and unintended weight loss of 9 kg. He recently immigrated to the United States from Thailand.
Physical examination reveals glossitis, hyperactive bowel sounds, and 2+ lower extremity edema to his shins.
On initial laboratory testing, his international normalized ratio is 1.3, and other notable results are as follows:
Patient valueReference rangeLeukocyte count (per mm3)75004500–11,000Hemoglobin (g/dL)9.213.5–17.5Mean corpuscular volume (μm3)11080–100Albumin (g/dL)2.93.5–5.5
Stool studies — including culture, ova and parasites, and testing for Giardia antigen — are negative. Tissue transglutaminase immunoglobulin A, total IgA, and IgA endomysial antibody levels are all normal. Folic acid and vitamin B12 levels are low. Esophagogastroduodenoscopy reveals a scalloped and nodular duodenum, with histology showing villous atrophy and intraepithelial lymphocytosis.
In addition to vitamin B12 and folate supplementation, which one of the following is the most appropriate next step in management?
Key info
A. Trimethoprim–sulfamethoxazole
B. Praziquantel
C. Metronidazole
E
Rifaximin
Answer D.
Tropical sprue is a syndrome that occurs in tropical climates and is characterized by chronic diarrhea, weight loss, and malabsorption of nutrients due to villous atrophy. Glossitis can occur because of iron deficiency. The cause of tropical sprue is unknown but is thought to be due to a microbial infection. Empiric treatment with oral tetracycline 250 mg four times daily is known to be effective.
Key learning point: The most appropriate treatment for tropical sprue is oral tetracycline for 3 to 6 months.
A. Trimethoprim-sulfamethoxazole is commonly prescribed for Whipple disease, which is not seen on this patient’s biopsy (one would expect periodic acid–Schiff–positive macrophages and positive results on a polymerase-chain-reaction assay for Tropheryma whipplei.)
B. One to two doses of oral praziquantel is used to treat intestinal schistosomiasis, but stool testing in this patient is negative, and one would not expect the duodenal biopsy findings described.
C. Rifaximin and metronidazole are often used for small-intestine bacterial overgrowth; however, this patient does not have risk factors for this condition, and one would expect high serum folate levels with low serum vitamin B12 levels.
E. Rifaximin and metronidazole are often used for small-intestine bacterial overgrowth; however, this patient does not have risk factors for this condition, and one would expect high serum folate levels with low serum vitamin B12 levels.
500
A 72-year-old man presents with a neck mass. He has no known medical problems but has not been seen in a health care setting in more than 30 years. He operates his own rural farm, has smoked two packs of cigarettes a day since the age of 14, and drinks a six-pack of beer once a week.
Physical examination is notable for poor dentition, multiple actinic keratoses, expiratory wheezes at both lung bases, and a 2.5-cm indurated mass in the right side of his neck that is fixed to the underlying tissues. No supraclavicular lymphadenopathy is appreciated. Flexible laryngoscopy is unremarkable.
A chest radiograph is normal. A CT scan of the neck shows a 3-cm necrotic lymph node and several other subcentimeter lymph nodes on the right side but no other obvious abnormalities.
Biopsy of the cervical lymph node shows poorly differentiated squamous-cell carcinoma.
Which one of the following procedures is a critical component of the diagnostic workup?
A. Bronchoscopy and bronchoalveolar lavage
B. Direct laryngoscopy under anesthesia and concurrent tonsillectomy
C. MRI of the brain
Answer B
Squamous-cell carcinomas can originate from the skin, the mucosa of the upper aerodigestive tract (e.g., head, neck, and esophagus), and the cervix. However, squamous-cell carcinoma isolated to a cervical lymph node should be considered head and neck cancer until proven otherwise, especially in the absence of supraclavicular lymphadenopathy.
The diagnostic workup for squamous-cell carcinoma of the head and neck includes direct laryngoscopy examination under anesthesia and concurrent bilateral tonsillectomy. In all but a few cases, this approach will determine the primary site of the cancer. If the primary site cannot be determined, treatment (usually surgery, radiation therapy, or both) is less successful.
Key learning point: The diagnostic workup of squamous-cell carcinoma found in a cervical lymph node includes evaluation for a primary tumor. If one is not located, the next step is evaluation of the entire upper aerodigestive tract, including direct laryngoscopy under anesthesia and concurrent tonsillectomy.
A. Bronchoscopy and bronchoalveolar lavage can be useful in obtaining tissue for diagnosis of a lung mass, but squamous-cell carcinoma of the lung would be an unlikely cause of an enlarged isolated cervical lymph node.
C. MRI of the head and neck could be helpful, but imaging of the brain does not necessarily include the neck.
D. CT of the chest might be part of a staging workup and could, in rare cases, identify a primary lung cancer, but CT of the abdomen and pelvis is not routinely ordered.
E. Upper endoscopy could be indicated to look for a primary esophageal tumor, but gastric biopsies are not warranted because the vast majority of gastric cancers are adenocarcinomas, not squamous-cell carcinomas.