Cards
A 57-year-old man is evaluated for a 6-month history of stable chest pain. He experiences chest pressure that occurs after walking 1 mile and resolves promptly with rest. He has no symptoms at rest. His history includes aspirin allergy manifesting as hives and difficulty breathing after taking 325 mg of aspirin as a teenager. He is a never smoker. He has hyperlipidemia. His only medication is atorvastatin.
On physical examination, vital signs are normal. BMI is 30. The remainder of the examination is normal.
Resting ECG is normal, and an exercise ECG is scheduled. The patient receives counseling on lifestyle interventions to reduce his risk for disease progression. Antianginal medications will be initiated.
Which of the following is the most appropriate cardioprotective treatment?
A) Clopidogrel
B) Low-dose Aspirin
C) Prasugrel
D) Ticagrelor
A) Clopidogrel
MKSAP Cards 1 Question 12
52-year-old man is evaluated during a follow-up visit for membranous nephropathy diagnosed by kidney biopsy 1 month ago. His medical history is otherwise unremarkable. Medications are lisinopril, furosemide, and atorvastatin.
On physical examination, vital signs are normal. There is symmetric 2+ pitting edema of the lower extremities. The remainder of the examination is unremarkable.
Laboratory studies:
Albumin 2.1 g/dL (21 g/L)
Total cholesterol 359 mg/dL (9.3 mmol/L)
Creatinine 0.8 mg/dL (70.7 µmol/L)
Urine protein-creatinine ratio 5500 mg/g
Which of the following is the most likely complication to develop in this patient during the next 12 months?
A) Diabetes Mellitus
B) End-stage Kidney Disease
C) Pulmonary hemorrhage
D) Venous thromboembolism
D) Venous thromboembolism
MKSAP Nephro Question 7
49-year-old man is hospitalized for a 1-day history of melenic stools. He is taking ibuprofen daily to prevent migraine headaches.
On physical examination, vital signs and physical examination findings are normal.
Laboratory studies reveal a hemoglobin level of 11.2 g/dL (112 g/dL).
Upper endoscopy shows a 1.5-cm, clean-based, superficial duodenal ulcer. Findings from gastric biopsy specimens for assessment of Helicobacter pylori infection are pending.
Ibuprofen is stopped.
Which of the following is the most appropriate management?
A) Intravenous proton pump inhibitor (PPI) and hospital observation for 72 hours
B) Once-daily oral PPI, feeding, and hospital discharge
C) Once-daily oral PPI, no feeding, and hospital observation for 72 hours
D) Upper endoscopy repeated in 24 hours
B) Once-daily oral PPI, feeding, and hospital discharge
MKSAP GI Question 6
43-year-old man is hospitalized for shortness of breath, tingling in the extremities, and weakness. Three weeks ago, he had watery diarrhea that lasted 5 days. He reports no travel and no sexual contact in the past year. He takes no medications.
On physical examination, temperature is 37.2 °C (98.9 °F), blood pressure is 140/90 mm Hg, pulse rate is 101/min, and respiration rate is 22/min. Oxygen saturation is 93% breathing ambient air. Neurologic examination reveals no movement in the lower extremities and only 3/5 upper extremity strength bilaterally. Diminished or absent deep tendon reflexes are present throughout. Sensory examination is intact. Lung sounds are diminished, with poor inspiratory effort.
Which of the following is the most likely cause of this patient's neurologic syndrome?
A) Botulism
B) Campylobacter infection
C) West Nile Virus infection
D) Zika virus
B) Campylobacter infection
MKSAP ID Question 3
23-year-old man is evaluated for cough, rhinorrhea, and wheezing of 3 weeks' duration. He has no fevers, chills, or chest pain and no history of asthma or allergies. He is a pastry chef and notes that his symptoms improve on nonworking weekends.
On physical examination, vital signs are normal. Oxygen saturation is 94% with the patient breathing ambient air. Expiratory wheezing is noted.
Laboratory studies show a normal Aspergillus-specific IgE level.
Spirometry reveals moderate airflow obstruction that improves after inhaled albuterol.
Chest radiograph is normal.
Which of the following is the most likely diagnosis?
A) Acute bronchitis
B) Acute hypersensitivity pneumonitis
C) Allergic bronchopulmonary aspergillosis
D) Occupational asthma
D) Occupational asthma
MKSAP PCC Question 8
27-year-old woman is hospitalized for a 1-day history of orthopnea and paroxysmal nocturnal dyspnea. She delivered a healthy baby boy 6 days ago. She is breastfeeding.
On physical examination, blood pressure is 134/78 mm Hg, pulse rate is 98/min, respiration rate is 26/min, and oxygen saturation is 94% with the patient breathing ambient air. There is jugular venous distention and an S3. Crackles are heard about halfway up the lungs. There is lower extremity edema to the knees.
Laboratory studies show an elevated B-type natriuretic peptide level, a normal high-sensitivity troponin level (<99th percentile upper reference limit), and a serum creatinine level of 1.2 mg/dL (106.1 μmol/L).
Chest radiograph shows pulmonary edema. Echocardiogram shows an ejection fraction of 20% and diffuse hypokinesis.
Intravenous furosemide and bilevel positive airway pressure are initiated.
Which of the following is the most appropriate additional treatment?
A) Bisoprolol
B) Diltiazem
C) Enalapril
D) Ivabradine
C) Enalapril
MKSAP Cards Question 70
45-year-old woman is evaluated in the emergency department for a 3-day history of lower extremity weakness. Medical history is significant for hypertension, type 2 diabetes mellitus, and gastroesophageal reflux disease. Medications are lisinopril, metformin, canagliflozin, and pantoprazole.
On physical examination, vital signs are normal. Knee and ankle reflexes are decreased. Muscle strength is 4/5 in the lower extremities. The remainder of the examination is unremarkable.
Laboratory studies:
Creatinine 1.1 mg/dL (97.2 µmol/L)
Electrolytes :
Sodium 138 mEq/L (138 mmol/L)
Potassium 3.0 mEq/L (3.0 mmol/L)
Chloride 104 mEq/L (104 mmol/L)
Bicarbonate 23 mEq/L (23 mmol/L)
Magnesium 1.1 mg/dL (0.45 mmol/L)
Which of the follow is the most likely cause of this patient's hypokalemia?
A) Canagliflozin
B) Lisinopril
C) Pantoprazole
D)Surreptitious diuretic use
C) Pantoprazole
MKSAP Nephro Question 12
75-year-old man is evaluated for choking that started 3 months ago and has progressively worsened. He has trouble initiating the swallowing of pills and coughs when drinking liquids. He can eat soft foods without choking. He reports no heartburn, regurgitation, or chest pain. Parkinson disease was diagnosed 3 months ago. His only medication is carbidopa-levodopa.
On physical examination, vital signs are normal. A right, resting hand tremor, bradykinesia, rigidity, slow speech, and evidence of balance impairment are noted. The remainder of the examination is normal.
Which of the following is the most likely diagnosis?
A) Achalasia
B) Incarcerated paraesophageal hernia
C) Oropharyngeal dysphagia
D) Peptic stricture
C) Oropharyngeal dysphagia
MKSAP GI 3 Question 7
29-year-old woman is evaluated for cough and fever of 2 days' duration. She has a history of cystic acne, which is treated with a topical retinoid cream and daily minocycline.
On physical examination, temperature is 38.3 °C (100.9 °F), blood pressure is 110/70 mm Hg, pulse rate is 90/min, and respiration rate is 20/min. Oxygen saturation is 93% breathing ambient air. Decreased breath sounds are heard at the right lung base.
COVID-19 testing is negative.
A chest radiograph shows a right lower lobe infiltrate.
Which of the following is the most appropriate treatment?
A) Amoxicillin
B) Ceftriaxone and azithromycin
C) Cefuroxime and doxycycline
D) Doxycycline
E) Levofloxacin
A) Amoxicillin
MKSAP ID Question 72
66-year-old man is evaluated for increased confusion and lethargy over the past 2 days, as well as nausea and vomiting. He has also had diffuse bone pain that began 6 weeks ago and has worsened over the past month. His medical history is otherwise unremarkable, and he takes no medications.
On physical examination, temperature is 36.4 °C (97.6 °F), blood pressure is 110/60 mm Hg, pulse rate is 110/min, and respiration rate is 16/min. He is somnolent but can be aroused. Mucous membranes are dry, and he has decreased skin turgor. Cardiopulmonary examination is normal.
Results of laboratory studies show an albumin level of 3.8 g/dL (38 g/L), calcium level of 14.8 mg/dL (3.7 mmol/L), and creatinine level of 2.5 mg/dL (221 µmol/L).
Which of the following is the most appropriate initial management?
A) Denosumab
B) Intravenous isotonic saline and calcitonin
C) Intravenous isotonic saline and furosemide
D) Zoledronic acid
B) Intravenous isotonic saline and calcitonin
MKSAP HemeOnc Question 43
74-year-old man is evaluated in the hospital for a 6-month history of progressive fatigue and exertional dyspnea, along with increasing peripheral edema and abdominal girth over the past 3 months. He also has coronary artery disease, for which he had a coronary artery bypass graft at age 62 years. Medications are metoprolol, low-dose aspirin, and atorvastatin.
On physical examination, vital signs are normal. Jugular venous distention with prominent waveforms is noted. There is no discernable fall in the central venous pressure during inspiration. An early diastolic sound is present. The liver is enlarged and pulsatile. Ascites is present, and peripheral edema extends to the knees bilaterally.
On chest radiograph, sternotomy wires and vascular clips are seen, and small bilateral pleural effusions are present.
Which of the following is the most likely diagnosis?
A) Cardiac tamponade
B) Chronic liver disease
C) Constrictive pericarditis
D) Restrictive cardiomyopathy
C) Constrictive pericarditis
Diagnostic findings are consistent with constrictive pericarditis (Option C), which typically presents with indolent, progressive signs and symptoms of right heart failure, including fatigue and exertional dyspnea. On physical examination, the central venous pressure is elevated in nearly all patients, with prominent x and y descents. The height of the waveform does not fall or may increase during inspiration (Kussmaul sign), reflecting the fixed diastolic volume of the right heart.
Pericardial knock (early diastolic sound) also a clue for Constrictive pericarditis
MKSAP Cards Question 5
69-year-old man is evaluated 7 days after starting nafcillin to treat a culture-proven methicillin-sensitive Staphylococcal aureus sternal wound infection. The infection was diagnosed 10 days after coronary artery bypass surgery. History is significant for diabetes mellitus. Other medications are aspirin, metformin, metoprolol, atorvastatin, and acetaminophen as needed.
On physical examination, vital signs are normal. The sternal wound appears to be healing, with minimal tenderness and redness and decreased drainage. The remainder of the examination is unremarkable.
Laboratory studies:
C3 61 mg/dL (610 mg/L)
C4 13 mg/dL (130 mg/L)
Creatinine 2.0 mg/dL (176.8 µmol/L); before hospital admission: 0.9 mg/dL (79.6 µmol/L)
Urinalysis 3+ blood; 2+ protein; 30-40 erythrocytes/hpf; 2-5 leukocytes/hpf; dysmorphic erythrocytes; rare erythrocyte casts
Kidney biopsy shows a mild proliferative glomerulonephritis with infiltrating neutrophils, granular C3, and IgG and IgM staining on immunofluorescence; hump-shaped subepithelial electron-dense deposits are seen on electron microscopy.
Which of the following is the most appropriate treatment?
A) Add lisinopril
B) Add prednisone
C) Continue nafcillin
D) Initiate sodium restriction and furosemide
C) Continue nafcillin
MKSAP Nephrology Question 9
56-year-old woman is evaluated for a 3-month history of watery, nonbloody diarrhea that occurs four times daily, usually after meals. Abdominal cramping precedes each bowel movement. She occasionally experiences rectal urgency. She has not lost weight. She also has osteoarthritis of the knees, self-treated with daily ibuprofen for the past 5 years.
On physical examination, vital signs and other findings are normal.
Colonoscopy reveals a normal-appearing colon. Biopsy specimens of normal-appearing ascending and sigmoid colon are notable for a marked increase in intraepithelial lymphocytes.
Which of the following is the most appropriate management?
A) Check fecal calprotectin
B) Discontinue ibuprofen
C) Initiate oral budesonide
D) Initiate oral prednisone
B) Discontinue ibuprofen
MKSAP GI Question 91
66-year-old woman is evaluated for increasing oxygen requirements over the past 18 hours. She developed hypercapnic respiratory failure requiring intubation 7 days ago following a colectomy for colon cancer. Suctioned sputum has become thicker. Medical history is significant for moderately severe COPD and right leg cellulitis, which was treated with cefazolin 1 month ago. Medications are albuterol, tiotropium bromide, and salmeterol-fluticasone inhalers.
On physical examination, temperature is 38.4 °C (101.1 °F); other vital signs are normal. Oxygen saturation is 90% on an FIO2 of 0.6 and positive end-expiratory pressure of 10 cm H2O. Pulmonary examination reveals scattered right-sided rhonchi.
Laboratory studies show a leukocyte count of 17,200/µL (17.2 × 109/L).
Chest radiograph shows right lower lobe and right middle lobe infiltrates.
Which of the following is the most appropriate treatment?
A) Ceftazidime and vancomycin
B) Ceftazidime, ciprofloxacin, and vancomycin
C) Ertapenem
D) Piperacillin-tazobactam and vancomycin
B) Ceftazidime, ciprofloxacin, and vancomycin
Empiric therapy for ventilator-associated pneumonia should include coverage for Staphylococcus aureus, Pseudomonas aeruginosa, and other gram-negative bacilli.
Empiric coverage for antibiotic-resistant organisms is recommended for patients who have risk factors for antibiotic resistance (previous intravenous antibiotics within 90 days; septic shock at the time of VAP diagnosis; acute respiratory distress syndrome preceding VAP; 5 or more hospitalized days before VAP; or undergoing dialysis before VAP onset). This patient has risk factors for methicillin-resistant S. aureus (MRSA) and antibiotic-resistant Pseudomonas, so two antipseudomonal agents from different antibiotic classes (such as a β-lactam and a fluoroquinolone) are indicated.
MKSAP ID Question 4
50-year-old man is evaluated for severe pain and swelling in the left knee of 2 days' duration. He has a long history of psoriasis and polyarticular psoriatic arthritis. He reports no fever, chills, or pain in other joints. Current medications are methotrexate, folic acid, and topical clobetasol propionate.
On physical examination, vital signs are normal. There are psoriatic plaques on the elbows, sacrum, and anterior shins. The left knee is swollen and warm; the patient holds it at 45 degrees of flexion, and he is unwilling to further flex or extend. There is no other joint swelling.
Arthrocentesis of the left knee reveals a synovial fluid leukocyte count of 40,000/μL (40 × 109/L) with 90% neutrophils. Gram stain is negative, and synovial fluid analysis for crystals and bacterial culture are pending.
Which of the following is the most likely diagnosis?
A) Gouty arthritis
B) Infectious arthritis
C) Osteoarthritis
D) Psoriatic arthritis
A) Gouty arthritis
Hyperuricemia and gout are comorbidities associated with psoriasis. It is thought that the rapid turnover of skin cells in patients with psoriasis drives protein metabolism and increases serum urate levels.
With infectious arthritis, fever is common, synovial fluid leukocyte counts range from 50,000 to 100,000/μL (50-100 × 109/L) or higher, and the Gram stain is positive in up to 50% of patients.
MKSAP Rheum Question 3