CVS
A 64-year-old man is evaluated in the emergency department for acute right lower leg pain that began 2 days ago. The pain is now severe at rest, and he reports coolness of the right foot. He has a 3-year history of intermittent claudication. He underwent right femoral-popliteal bypass graft surgery for life-limiting claudication 1 year ago. Medical history is otherwise significant for hypertension, hyperlipidemia, and type 2 diabetes mellitus. He quit smoking 4 years ago. Medications are low-dose aspirin, ramipril, hydrochlorothiazide, rosuvastatin, and metformin.
On physical examination, vital signs are normal. The right foot is cool and pale, sensation is intact, and muscle strength is normal. The pedal pulses are not palpable in the right leg. Arterial Doppler ultrasound signals are not detectable over the right dorsalis pedis and right posterior tibial arteries.
Intravenous anticoagulation with heparin is initiated.
Which of the following is the most appropriate management?
A-Arterial duplex ultrasonography
B-CT angiography
C-Emergent right leg amputation
D-Intravenous recombinant tissue plasminogen activator
E-Urgent invasive angiography
E-Urgent invasive angiography
Key Point
In patients with acute limb ischemia, invasive angiography should be performed immediately to define the anatomic level of occlusion and plan for revascularization.
A 68-year-old man is being evaluated for measures to decrease his risk of acquiring a surgical site infection; he is scheduled for coronary artery bypass graft surgery in 5 weeks for limiting chronic angina despite maximal medical therapy. Medical history includes chronic stable angina, hyperlipidemia, hypertension, and diabetes. Medications are low-dose aspirin, propranolol, isosorbide dinitrate, ranolazine, chlorthalidone, lisinopril, and atorvastatin.
On physical examination, blood pressure is 126/72 mm Hg; all other vital signs are normal. On cardiac examination, an S4 is present. The remainder of the examination is noncontributory.
Which is the most appropriate measure to prevent surgical site infection?
A-Evaluate for Staphylococcus aureus nasal carriage
B-Provide postoperative vancomycin prophylaxis for 7 days
C-Provide preoperative vancomycin prophylaxis
D-Shave patient's chest hair on the morning of surgery
A-Evaluate for Staphylococcus aureus nasal carriage
Patients undergoing cardiothoracic or orthopedic surgery should be screened for nasal carriage of Staphylococcus aureus and, if positive, should have preoperative decolonization.
A 60-year-old woman is evaluated for persistent constipation symptoms of 2 years' duration. She has reflex sympathetic dystrophy syndrome involving the right arm and neck that began 3 years earlier and requires chronic opioid analgesic therapy. She reports passing two hard bowel movements per week. Trials of several fiber supplements caused severe bloating and abdominal distention without relieving symptoms. A trial of polyethylene glycol (PEG) has not been effective; the patient reports that her stool is soft, but she still has no more than two bowel movements per week. Adding bisacodyl caused severe abdominal cramping, prompting its discontinuation. Colonoscopy at the onset of constipation was unremarkable. In addition to PEG, her medications are gabapentin, hydrocodone, fentanyl patch, and a calcium supplement with vitamin D.
On physical examination, vital signs and other findings are normal.
Which of the following is the most appropriate treatment for her constipation?
A-Add docusate sodium
B-Add lactulose
C-Increase PEG dosage
D-Switch to naloxegol
D-Switch to naloxegol
Oral naloxegol is a peripherally acting μ-opioid receptor antagonist that is FDA-approved for the treatment of opioid-induced constipation in adults with chronic noncancer pain.
A 37-year-old man is evaluated for a 1-month history of worsening cough and wheezing requiring use of rescue therapy several times per week, as well as increasing nasal congestion and rhinorrhea. He has a history of moderate persistent asthma and rhinitis since his early twenties. One month ago the patient underwent repair of a traumatic anterior cruciate ligament tear and has some residual daily knee pain. His medical history is notable for sinusitis. He has no symptoms of gastroesophageal reflux disease. Medications are albuterol, budesonide/formoterol, and ibuprofen.
On physical examination, vital signs are normal. Oxygen saturation is 97% breathing ambient air. Examination demonstrates conjunctival injection and nasal polyps in both nostrils. Chest examination reveals wheezing on expiration. The remainder of the examination is noncontributory.
Laboratory studies reveal IgE is 265 U/mL (265 kU/L). Complete blood count reveals a leukocyte count of 4000/µL (4 × 109/L) with 10% eosinophils.
Office spirometry demonstrates moderate airflow obstruction.
Which of the following is the most appropriate initial management?
A-24-Hour esophageal pH monitoring
B-Add montelukast
C-Discontinue ibuprofen, begin prednisone
D-Nasal polypectomy
C-Discontinue ibuprofen, begin prednisone
Treatment of aspirin-exacerbated respiratory disease consists of symptom treatment with glucocorticoids and removal of the exposure; treatment can also include a leukotriene receptor antagonist.
A 39-year-old woman is evaluated for new-onset nonproductive cough and dyspnea on exertion. She is pregnant at 32 weeks gestation. Medical history is unremarkable. Her only medication is a prenatal vitamin.
On physical examination, temperature is 37.0 °C (98.6 °F), blood pressure is 105/62 mm Hg, pulse rate is 100/min, and respiration rate is 22/min. Oxygen saturation is 86% breathing ambient air. Cardiopulmonary examination is normal. She has a gravid uterus and 1+ edema of the lower extremities without calf tenderness.
Laboratory studies:
Hemoglobin -12.1 g/dL (121 g/L)
Leukocyte count -4800/µL (4.8 × 109/L)
Platelet count -189,000/µL (189 × 109/L)
Urinalysis-Normal
Doppler ultrasonography of both legs is negative for deep venous thrombosis.
Which of the following is the most appropriate diagnostic test to perform next?
A-CT angiography
B-D-dimer assay
C-Magnetic resonance pulmonary angiography
D-Pulmonary function testing
E-Ventilation-perfusion lung scan
E-Ventilation-perfusion lung scan
In the presence of normal Doppler studies of the lower extremities, ventilation-perfusion lung scanning is the initial lung imaging study to evaluate for pulmonary embolism in pregnant patients; D-dimer testing has no diagnostic role.
A 65-year-old woman is evaluated during a routine examination. She was diagnosed with a cardiac murmur in early adulthood. She is active, healthy, and without symptoms. She takes no medications.
On physical examination, vital signs are normal. A grade 3/6 holosystolic murmur preceded by multiple clicks is present at the apex. Physical findings are otherwise unremarkable.
An echocardiogram demonstrates a left ventricular ejection fraction of 50%. The left ventricle is moderately dilated with an end-systolic dimension of 42 mm. Myxomatous degeneration of the mitral valve is present with severe regurgitation due to posterior leaflet prolapse.
Which of the following is the most appropriate next step in management?
A-Serial clinical and echocardiographic evaluations
B-Surgical mitral valve repair
C-Surgical mitral valve replacement
D-Transcatheter mitral valve repair
B-Surgical mitral valve repair
Mitral valve repair is strongly recommended for chronic severe primary mitral regurgitation in symptomatic patients with left ventricular ejection fraction greater than 30%, asymptomatic patients with left ventricular dysfunction, and patients undergoing another cardiac surgical procedure.
A 25-year-old woman is evaluated for chronic intermittent nonbloody diarrhea with associated abdominal cramping, burping, and bloating. Symptoms began several months ago. She has a history of selective IgA deficiency with recurrent sinopulmonary infections. She has not taken antibiotics in the past 6 months.
On physical examination, temperature is 37.3 °C (99.1 °F); the vital signs are otherwise normal. On abdominal examination, bowel sounds are present with minimal diffuse tenderness to palpation.
Stool testing for occult blood is negative.
Which of the following is the most likely cause of this patient's diarrheal illness?
A-Clostridium difficile
B-Enterohemorrhagic Escherichia coli
C-Giardia lamblia
D-Listeria monocytogenes
E-Nontyphoidal Salmonella
C-Giardia lamblia
Patients with selective IgA deficiency are susceptible to Giardia lamblia infection, manifesting as abdominal cramping, bloating, and chronic diarrhea.
A 58-year-old man is counseled before undergoing colonoscopy and polypectomy in 10 days' time. A routine screening CT colonography showed two polyps in the descending colon, 10 mm and 8 mm in size. Two years earlier, he had an inferior wall myocardial infarction. His medications are low-dose aspirin, atorvastatin, metoprolol, and enalapril.
Which of the following is the most appropriate management of his aspirin therapy?
A-Continue aspirin use until the day of the polypectomy; resume in 48 hours
B-Discontinue aspirin use 7 days before the polypectomy; resume immediately after
C-Discontinue aspirin use 7 days before the polypectomy; resume in 48 hours
D-Do not discontinue aspirin
D-Do not discontinue aspirin
Aspirin for secondary prophylaxis in patients with established cardiovascular disease should be continued after colonoscopy with polypectomy.
A 72-year-old man is evaluated during a follow-up visit. He was evaluated in the emergency department 2 weeks ago for the sudden onset of chest pain. A CT scan was negative for pulmonary embolism but demonstrated an 8-mm ground-glass nodule in the right upper lobe. He has had no recurrence of chest pain. His history is significant for hypertension treated with lisinopril.
Upon physical examination, vital signs are normal. The remainder of the physical examination is normal. The patient undergoes follow-up CT scans of his lung at 12 months and also at 2 years. The nodule is unchanged.
Which of the following is the most appropriate management of the lung nodule?
A-Chest CT scans every 2 years for 5 years
B-PET/CT scan
C-Tissue sampling
D-No further follow-up is needed
A-Chest CT scans every 2 years for 5 years
Subsolid lung nodules 6-8 mm in size should be initially followed up at 6-12 months and then every 2 years for 5 years because of the slow rate of growth if such masses are malignant.
Evaluation with a PET/CT scan would be recommended for a solid nodule that is greater than 8 mm in size. This test most commonly uses fluorodeoxyglucose (FDG) as a metabolic marker to identify rapidly dividing cells such as tumor cells and, to a lesser degree, any inflammatory lesion. A nodule that demonstrates no FDG uptake is unlikely to be malignant.
A 53-year-old man is evaluated for tea-colored urine. He reports no other symptoms. He was hospitalized 2 weeks ago with melena. Upper gastrointestinal endoscopy and colonoscopy at the time did not show a bleeding source, but he stabilized after the transfusion of one unit of blood. He was discharged 10 days ago and has returned to work. Medical history is otherwise significant for trauma sustained in a motor vehicle accident 5 years ago, requiring multiple surgeries. He takes no medications.
On physical examination, temperature is 37.8 °C (100.1 °F), and other vital signs are normal, with no postural blood pressure or pulse changes. Scleral icterus is noted. The stool guaiac test result is negative. The remainder of the examination is unremarkable.
Laboratory studies:
Hemoglobin 6.9 g/dL (69 g/L)
Hb 10 days ago -8 g/dL (80 g/L)
Bilirubin Total -5 mg/dL (34.2 µmol/L)
Indirect -1.1 mg/dL (18.8 µmol/L)
Direct -0.7 mg/dL (12 µmol/L)
Urinalysis-4+ blood, 2-3 erythrocytes/hpf, 1 leukocyte/hpf
Which of the following is the most appropriate next step in the management of this patient?
A-Direct antiglobulin (Coombs) test
B-Flow cytometry
C-Repeat upper and lower endoscopy
D-Transfusion of one unit of blood
A-Direct antiglobulin (Coombs) test
A positive direct antiglobulin (Coombs) test will confirm a delayed hemolytic transfusion reaction, a diagnosis that should be considered in a patient with low-grade fever and features of hemolytic anemia after a recent transfusion.
A 69-year-old man is evaluated during a routine examination. He is asymptomatic. Medical history is significant for hypertension. He has a 50-pack-year smoking history but quit smoking 7 years ago. Medications are aspirin, lisinopril, and amlodipine.
On physical examination, vital signs are normal. A bruit is heard over the abdomen, and a pulsatile mass is present in the epigastrium. The remainder of the examination is unremarkable.
A Duplex ultrasound of the abdomen shows an abdominal aortic aneurysm with transverse diameter of 6.2 cm.
Which of the following is the most appropriate next step in management?
A-CT angiography of the abdominal aorta and iliac vessels
B-Endovascular repair
C-Open surgical repair
D-Switch amlodipine to metoprolol
A-CT angiography of the abdominal aorta and iliac vessels
In patients with an indication for abdominal aortic aneurysm repair, the choice between open surgical repair and endovascular aneurysm repair is driven in part by the location of the aneurysm and involvement of the renal and mesenteric arteries
A 39-year-old man is hospitalized for tongue pain, abdominal pain, increased weakness, and a 2-week history of malaise and fever. He reports being in good health previously. He lives in the Ohio River Valley; approximately 1 month ago, he moved his antique business from a barn to an old store in the area, after which he developed “flu-like” symptoms lasting 2 to 3 days. He says that the barn was dusty and had pigeons and bats in the rafters. He also has rheumatoid arthritis. Medications are methotrexate and prednisone.
On physical examination, the patient is lethargic. Temperature is 39.7 °C (103.5 °F), blood pressure is 90/50 mm Hg, pulse rate is 128/min, and respiration rate is 24/min. A shallow ulceration is visible on the right buccal mucosa and left lateral tongue. His neck is supple. Lungs are clear to percussion and auscultation. There is moderate hepatosplenomegaly.
Results of laboratory studies show a hemoglobin level of 9 g/dL (90 g/L), a leukocyte count of 10,500/µL (10.5 × 109/L), and a platelet count of 90,000/µL (90 × 109/L).
Posteroanterior and lateral chest radiographs are unremarkable.
Which of the following is the most appropriate treatment?
A-Ceftriaxone and azithromycin
B-Colchicine
C-Itraconazole
D-Liposomal amphotericin B
D-Liposomal amphotericin B
Liposomal amphotericin B is the treatment of choice for disseminated histoplasmosis.
Itraconazole is an azole triazole used to treat many endemic fungal infections, including histoplasmosis. However, it is not as effective as liposomal amphotericin B in disseminated infection. It may be used for subacute or chronic histoplasmosis, such as pulmonary histoplasmosis.
A 65-year-old man is evaluated after a screening ultrasound for abdominal aortic aneurysm showed incidental gallbladder findings. He reports no symptoms. He continues to smoke cigarettes, 1 pack per day. He has no other medical problems and takes no medications.
On physical examination, vital signs are normal, as is the remainder of the examination.
The results of all laboratory studies, including a complete blood count and alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, and total bilirubin levels, are within normal limits.
The abdominal ultrasound shows numerous layering gallstones and an immobile 8-mm gallbladder polyp.
Which of the following is the most appropriate next step in management?
A-Cholecystectomy
B-MR cholangiopancreatography
C-Repeat ultrasonography in 6 months
D-Ursodeoxycholic acid
A-Cholecystectomy
The finding of a gallbladder polyp larger than 1 cm in size, or a polyp of any size associated with gallstones, is an indication for cholecystectomy even if the patient is asymptomatic.
In a patient with an 8-mm gallbladder polyp in the absence of gallstones or primary sclerosing cholangitis, repeat ultrasonography in 6 months would be indicated. However, follow-up ultrasonography is not appropriate for this patient with a gallbladder polyp and gallstones, which increase the risk for gallbladder cancer.
A 55-year-old man with COPD is evaluated in the emergency department for worsening dyspnea. He was doing well until 3 days ago when he developed fever, myalgia, increased cough productive of yellow sputum, and progressive dyspnea. He has no headaches, hypersomnolence, tremors, or extremity edema. Pulmonary function tests obtained 4 months ago demonstrated severe obstruction with air trapping. Current medications are albuterol and umeclidinium/vilanterol.
On physical examination, temperature is 38.2 °C (100.9 °F), blood pressure is 142/82 mm Hg, pulse rate is 94/min, and respiration rate is 18/min. Oxygen saturation is 90% breathing ambient air. He has end-expiratory wheezing throughout. There is no jugular venous distention or extracardiac sounds.
A complete blood count and comprehensive metabolic profile are normal.
Other than tachycardia, an electrocardiogram is normal. Chest radiograph shows the lungs to be clear.
Therapy for a COPD exacerbation is initiated.
Which of the following is the most appropriate next diagnostic test?
A-Arterial blood gas analysis
B-B-type natriuretic peptide measurement
C-CT pulmonary angiography
D-Echocardiogram
A-Arterial blood gas analysis
Arterial blood gas analysis is recommended for patients with a severe exacerbation of COPD to assess for hypercapnia and hypoxemia.
According to best practice advice from the Clinical Guidelines Committee of the American College of Physicians, patients who have a low pretest probability for pulmonary embolism (PE) using a validated clinical prediction rule (such as the Wells criteria for prediction of PE) and who meet all Pulmonary Embolism Rule-Out Criteria do not need further testing to rule out PE. Using the Wells criteria, this patient is a low risk for PE (0 points) and scores 2 points on the Pulmonary Embolism Rule-Out Criteria (fails to meet 2 criteria: age younger than 50 years and oxygen saturation greater than 94%). Additional evaluation for PE in this patient might include a D-dimer measurement as an initial test, but not an imaging study.
A 34-year-old woman is evaluated for a rash on her lower extremities that appeared 3 days ago. She also reports easy bruising for the past week and bleeding when she brushes her teeth. Her medical history is otherwise unremarkable, and she takes no medications.
On physical examination, vital signs are normal. Petechiae are noted on the lower extremities, and ecchymoses are present on her right thigh and on her abdomen. No hepatomegaly, splenomegaly, or lymphadenopathy is noted.
Laboratory studies:
Hemoglobin 12.8 g/dL (128 g/L)
Leukocyte count 6600/µL (6.6 × 109/L) with a normal differential
Mean corpuscular volume -82 fL
Platelet count -28,000/µL (28 × 109/L)
Hepatitis C antibody-Negative
Large and giant platelets are seen on the peripheral blood smear, but no schistocytes or platelet clumping is noted.
Which of the following laboratory tests should be performed?
A-Antiplatelet antibodies
B-HIV testing
C-Lupus anticoagulant
D-Vitamin B12 level
B-HIV testing
Immune thrombocytopenic purpura can be idiopathic, triggered by medications, or associated with other disorders, such as systemic lupus erythematosus, chronic lymphocytic leukemia, lymphoma, HIV, hepatitis C, or Helicobacter pylori infection.
ITP may be associated with other autoimmune diseases, such as Hashimoto thyroiditis, or with SLE. This patient lacks any history of venous thromboembolism or fetal loss that would suggest an underlying anticardiolipin antibody syndrome and has no other clinical features to suggest SLE; testing for the lupus anticoagulant is unnecessary.
A 75-year-old woman is hospitalized for a 3-week history of progressive exertional dyspnea, increasing peripheral edema, and mental status changes. For the past 4 nights, she has been sleeping in a recliner instead of her bed. She reports no chest pain. She has a 6-year history of ischemic cardiomyopathy, for which she takes low-dose aspirin, furosemide, carvedilol, lisinopril, digoxin, spironolactone, and as-needed metolazone.
On physical examination, the patient is afebrile, blood pressure is 84/52 mm Hg, pulse rate is 118/min, and respiration rate is 28/min. Oxygen saturation is 95% breathing ambient air. She is confused. Jugular venous distention is present. Cardiac examination reveals an S3. There is ascites on abdominal examination. The extremities are cool, and there is lower extremity edema to the knees.
Laboratory studies:
Alanine aminotransferase -172 U/L
Aspartate aminotransferase -163 U/L
Creatinine -2.9 mg/dL (baseline, 1.2 mg/dL)
Potassium -4.7 mEq/L
Sodium -132 mEq/L (baseline, 140 mEq/L)
Digoxin-0.3 ng/mL (normal range, 0.5-2.0 ng/mL)
An electrocardiogram shows no acute changes. An echocardiogram shows a left ventricular ejection fraction of 20%.
Which of the following is the most appropriate initial treatment?
A-Increase carvedilol
B-Increase digoxin
C-Increase lisinopril
D-Start dobutamine
D-Start dobutamine
In patients with cardiogenic shock, inotropes such as dobutamine or milrinone may be considered to improve cardiac function
A 25-year-old woman is hospitalized with a 4-day history of fever and cough productive of brown sputum. She is at 14 weeks' gestation with her first pregnancy. Medical history is significant for mild persistent asthma. Medications are an albuterol inhaler, beclomethasone inhaler, and a prenatal vitamin.
On physical examination, temperature is 38.2 °C (100.8 °F), blood pressure is normal, pulse rate is 122/min, and respiration rate is 24/min. Oxygen saturation is 94% breathing ambient air. Crackles are heard at the left lung base on pulmonary auscultation.
Chest radiograph shows a left lower lobe infiltrate.
Which of the following is the most likely cause of pneumonia in this patient?
A-Escherichia coli
B-Klebsiella pneumonia
C-Listeria monocytogenes
D-Staphylococcus aureus
E-Streptococcus pneumoniae
E-Streptococcus pneumoniae
The microbiology of community-acquired pneumonia in pregnancy is similar to that seen in the general population; among patients requiring hospitalization, the most common pathogens are Streptococcus pneumoniae, Haemophilus influenzae, and atypical organisms, including Legionella species, Chlamydia pneumoniae, and Mycoplasma pneumoniae.
A 55-year-old man is evaluated after emergent treatment for an episode of hematemesis. Emergency endoscopy was performed in the emergency department, and the bleeding was successfully treated with band ligation. The endoscopy revealed esophageal varices, one of which had stigmata of recent hemorrhage. Treatment with octreotide and a proton pump inhibitor was initiated. The patient has a history of cirrhosis due to hepatitis C viral infection. He has no other medical problems and takes no medication.
On physical examination, vital signs and other findings are normal.
Laboratory studies show a hemoglobin level of 8.9 g/dL, leukocyte count of 3600/µL (3.6 × 109/L), and platelet count of 80,000/µL (80 × 109/L).
Which of the following is the most appropriate next treatment?
A-Blood transfusion
B-Ciprofloxacin
C-Platelet transfusion
D-Transjugular intrahepatic portosystemic shunt placement
B-Ciprofloxacin
The mainstay of therapy for variceal hemorrhage is endoscopic therapy, and adjunctive therapies such as antibiotic therapy improve outcomes.
Antibiotic therapy after variceal bleeding reduces rates of infection and rebleeding as well as mortality after variceal bleeding. There is also benefit to administering antibiotics for patients with cirrhosis who present with nonvariceal upper gastrointestinal bleeding.
A 71-year-old man is evaluated during a follow-up visit for sleep-related breathing pauses observed by the hospital staff when he was admitted for implantation of a cardioverter-defibrillator for ischemic cardiomyopathy (left ventricular ejection fraction of 30%). He has recently experienced dyspnea, a few episodes of which have awakened him from sleep. He has no insomnia or daytime sleepiness. He has dyslipidemia, stable coronary artery disease, and hypertension. Current medications are aspirin, atorvastatin, valsartan, metoprolol, and nitroglycerin as needed.
On physical examination, vital signs are normal. Oxygen saturation is 93% breathing ambient air. BMI is 23. Lung examination reveals bibasilar crackles, faint end-expiratory wheezing, neck vein distention, and 1+ ankle edema.
Polysomnography demonstrates central sleep apnea with a Cheyne-Stokes breathing pattern.
Which of the following is the most appropriate treatment of the patient's central sleep apnea?
A-Adaptive servo-ventilation
B-Auto-adjusting positive airway pressure
C-Furosemide
D-Supplemental oxygen
C-Furosemide
Initial treatment of central sleep apnea should target modifiable risk factors; medical optimization of heart failure has been shown to improve central sleep apnea and Cheyne-Stokes breathing and should precede other therapies for sleep apnea.
A 74-year-old man is evaluated in follow-up for myelodysplastic syndrome diagnosed 3 months ago. Cytogenetic studies and fluorescence in-situ hybridization showed deletion of 5q. It was determined he has low-risk MDS by the Revised International Prognostic Scoring System. He requires erythrocyte transfusions every 2 weeks to prevent symptomatic anemia. He takes no medications.
On physical examination, pulse rate is 120/min, and respiration rate is 24/min; other vital signs are normal. Skin pallor is noted. Cardiac examination reveals tachycardia.
Laboratory studies show a hemoglobin level of 6.5 g/dL (65 g/L), leukocyte count of 2500/µL (2.5 × 109/L), and platelet count of 220,000/µL (220 × 109/L).
Which of the following is the most appropriate treatment?
A-Allogeneic hematopoietic stem cell transplantation
B-Antithymocyte globulin and cyclosporine
C-Imatinib
D-Lenalidomide
D-Lenalidomide
In patients with myelodysplastic syndrome requiring frequent transfusions, supplemental treatments to help decrease transfusion requirements, such as lenalidomide, should be used to improve quality of life and decrease transfusion-associated iron overload and alloimmunization.
Other second-line treatments for low-risk MDS with −5q include recombinant erythropoietin and the hypomethylating agents azacitidine and decitabine. Hypomethylating agents can reduce transfusion requirements and delay transformation to AML. However, both also worsen blood counts initially and may take up to 6 months to show an effect. Finally, this patient is not at high risk for AML transformation.
A 37-year-old man is evaluated in the emergency department for right-sided weakness. Medical history is significant for heart failure with placement of a left ventricular assist device 2 years ago. Family history is significant for familial cardiomyopathy. Medications are warfarin, aspirin, lisinopril, carvedilol, and furosemide.
On physical examination, temperature is normal, mean arterial pressure measured by Doppler ultrasonography is 106 mm Hg, pulse rate is 98/min, and respiration rate is 16/min. Oxygen saturation is 94% breathing ambient air. There is no jugular venous distention. Neurologic examination demonstrates global aphasia, right arm paralysis, antigravity movement in the right leg, left gaze preference, and decreased blink response to threat from the right side.
CT of the head shows sulcal effacement and loss of gray-white differentiation in the territory of the left middle cerebral artery.
Which of the following is the most likely cause of this patient's stroke?
A-Carotid artery stenosis
B-Cryptogenic stroke
C-Lacunar infarction
D-Left ventricular assist device–related thrombosis
D-Left ventricular assist device–related thrombosis
The incidence of hemorrhagic and embolic strokes approaches 20% at 1 year after insertion of a left ventricular assist device.
A 48-year-old man is evaluated in the emergency department for skin trauma sustained in a freshwater lake 2 days ago, with abrasions and tiny lacerations over the right forearm; he developed a fever and pain at the site of trauma 1 day ago. Medical history is remarkable for cirrhosis secondary to alcohol use. He takes no medications.
On physical examination, temperature is 39.1 °C (102.4 °F), blood pressure is 100/70 mm Hg, pulse rate is 120/min, and respiration rate is 25/min. The right forearm is tender and warm, with several hemorrhagic bullae noted. The remainder of the examination is unremarkable.
A plain radiograph of the right forearm shows no evidence of gas or a foreign body. Surgical exploration and debridement is performed, confirming a diagnosis of necrotizing fasciitis. Gram stain of intraoperative tissue specimens reveals gram-negative bacilli. Empiric antibiotic treatment with vancomycin plus piperacillin-tazobactam is initiated. Twenty-four hours later, the tissue culture grows Aeromonas hydrophila.
Which of the following is the most appropriate treatment?
A-Ciprofloxacin plus doxycycline
B-Linezolid plus metronidazole
C-Nafcillin plus rifampin
D-Vancomycin plus clindamycin
A-Ciprofloxacin plus doxycycline
Lacerations and puncture wounds sustained in fresh and brackish water environments can result in necrotizing infection with Aeromonas hydrophila; this infection should be treated with surgery, supportive care, and antibiotics with gram-negative coverage, such as doxycycline plus ciprofloxacin.
A 73-year-old man is evaluated in the hospital for lightheadedness. He also reports nonbloody, watery diarrhea of 4 months' duration and an unintentional 4.5-kg (9.9-lb) weight loss over the same time period. He has hypertension and hyperlipidemia. His medications are olmesartan and atorvastatin.
On physical examination, blood pressure is 100/50 mm Hg and pulse rate is 108/min; other vital signs are normal. Physical examination findings are unremarkable.
Results of laboratory studies, including serum creatinine, total IgA, and tissue transglutaminase IgA, are within normal limits.
The patient responds to fluid resuscitation with normalization of his pulse and blood pressure. Colonoscopy is grossly normal, and biopsy samples show no evidence of microscopic colitis. Upper endoscopy with duodenal biopsies shows villous flattening and increased intraepithelial lymphocytes.
Which of the following is the most appropriate next step in management?
A-Discontinue atorvastatin
B-Discontinue olmesartan
C-Start a gluten-free diet
D-Start prednisone
B-Discontinue olmesartan
Olmesartan causes medication-induced enteropathy that can mimic refractory celiac disease.
The patient's presentation is most consistent with drug-associated enteropathy related to olmesartan. In 2013, the FDA issued a warning that olmesartan medoxomil can cause intestinal symptoms known as sprue-like enteropathy and approved labeling changes to include this concern. The enteropathy may develop months to years after starting olmesartan.
A 62-year-old woman is evaluated for increasing exertional dyspnea during the past 6 months. She is a former smoker who was diagnosed with severe COPD 3 years ago (FEV1 is 35% of predicted). For the past 18 months, she has used tiotropium and salmeterol; inhaled fluticasone was added 4 months ago, but without any perceived benefit. She takes no other medications.
On physical examination, blood pressure is 130/79 mm Hg, pulse rate is 88/min, and respiration rate is 18/min. Oxygen saturation is 89% breathing ambient air. Lung examination demonstrates diminished breath sounds. A prominent pulmonic sound is heard on cardiac examination.
Arterial blood gas studies breathing ambient air show a pH of 7.41, a PCO2 of 43 mm Hg (5.7 kPa), and a PO2 of 55 mm Hg (7.3 kPa).
Chest radiograph reveals hyperinflation. Echocardiography shows an estimated right ventricular systolic pressure of 58 mm Hg. Polysomnography showed an apnea–hypopnea index of 2 and mean oxygen saturation of 87%.
Which of the following is the most appropriate treatment?
A-Bilevel positive airway pressure
B-Prednisone
C-Sildenafil
D-Supplemental oxygen
D-Supplemental oxygen
Patients with pulmonary hypertension secondary to lung disease and associated hypoxemia should be treated with supplemental oxygen.
The most appropriate treatment is supplemental oxygen. The clinical assessment and echocardiographic findings are consistent with pulmonary hypertension in the setting of advanced COPD (Group 3 pulmonary hypertension [PH]). The mainstay of treatment of Group 3 PH targets the underlying lung disease. This patient is on maximal inhaler therapy for COPD. Hypoxemia during daytime rest and, in the setting of cor pulmonale or secondary polycythemia, hypoxemia during sleep, is an indication for supplemental oxygen, which has proved benefit in pulmonary hemodynamics and survival in this population.
A 50-year-old woman is evaluated for nausea and abdominal discomfort that have been present and increasing for the past 3 to 4 months. She takes no medications.
On physical examination, vital signs are normal. BMI is 24. The abdominal examination reveals no masses, tenderness, or organomegaly.
An esophagogastroscopy identifies a discrete 8-cm mass in the pylorus. The biopsy specimen shows a gastrointestinal stromal tumor (GIST). Immunohistochemical stain for the KIT gene is strongly positive.
Contrast-enhanced CT scans of the chest, abdomen, and pelvis confirm the mass and do not identify any other abnormal findings.
The patient undergoes a distal gastrectomy. Pathologic findings confirm a GIST and further note a high mitotic rate (10 mitoses per 50 high-power fields). Margins of resection and all lymph nodes examined are free of tumor.
Which of the following is the most appropriate management?
A-Intravenous rituximab
B-Oral imatinib
C-Radiation therapy
D-Observation without further therapy
B-Oral imatinib
High-risk gastrointestinal stromal tumors should be treated with surgery and 3 years of adjuvant imatinib.
The most appropriate management for this patient is oral imatinib for 3 years. Gastrointestinal stromal tumors (GISTs) most commonly occur in the stomach, although they can arise anywhere in the digestive tract. Although rare, they are the most common sarcoma of the digestive tract. Location outside of the stomach, larger size, and higher mitotic index are all factors that increase the risk of recurrence after resection and indicate use of adjuvant therapy.
Small gastric GISTs with low mitotic indices may often be managed with surgery alone, but because this patient has a GIST with several factors that increase the risk of recurrence, observation without further therapy is not sufficient.