Abridged Version
A 75-year-old man is evaluated for dyspnea and an episode of exertional syncope. He is diagnosed on clinical examination with aortic stenosis.
An ECG shows normal sinus rhythm and left ventricular hypertrophy with repolarization abnormalities. The echocardiogram reveals a severely thickened, minimally mobile tricuspid aortic valve compatible with severe aortic stenosis. However, hemodynamic data from echocardiography show a mean aortic gradient and aortic valve area consistent with moderate aortic stenosis. Left ventricular ejection fraction is greater than 55%, and stroke volume index is normal.
Which of the following is the most appropriate next step?
A. Cardiac Catheterization
B. CT of the aortic valve
C. Exercise Stress Testing
D. Surgical Aortic Valve Replacement
E. Transcatheter aortic valve implantation
A. Cardiac Catheterization
This patient's symptoms of dyspnea and syncope are consistent with symptomatic, potentially severe aortic stenosis. When caused by aortic stenosis, syncope is usually a late finding and raises concern for sudden cardiac death if aortic stenosis is not adequately treated. Severe aortic stenosis is typically defined by a small valve area (≤1.0 cm2), high peak velocity (≥4 m/s), and/or high mean gradient (≥40 mm Hg). However, although the two-dimensional morphologic description of this patient's aortic valve is consistent with severe aortic stenosis (severely thickened, minimally mobile tricuspid aortic valve), the mean valve gradient and aortic valve area are consistent with moderate aortic stenosis. Because technical considerations may result in either over- or underestimation of aortic valve gradient and aortic valve area by echocardiography, further hemodynamic testing with cardiac catheterization should be pursued in cases of discrepant clinical and echocardiographic findings.
A 21-year-old man is evaluated for a 4-month history of diarrhea. Bowel movements are liquid and nonbloody and sometimes are preceded by lower abdominal cramps. He has near-daily bloating. Symptoms do not awaken him at night but improve with fasting. He reports no recent travel, antibiotic use, or weight loss.
On physical examination, vital signs are normal. Abdominal examination is normal.
Laboratory evaluation shows a hematocrit of 41% and negative fecal calprotectin level.
Which of the following is the most appropriate management?
A. Colonoscopy
B. Fructose Breath Test
C. Stool Culture
D. Trial of Lactose Free Diet
D. Trial of Lactose Free Diet
The most appropriate management is a trial of a lactose-free diet (Option D). The patient describes diarrhea lasting longer than 4 weeks, thereby meeting the criteria for chronic diarrhea. The lack of nocturnal symptoms and improvement of symptoms with fasting suggest osmotic diarrhea. Osmotic diarrhea results from a nonabsorbed, osmotically active substance in the intestinal lumen, leading to luminal fluid accumulation due to an osmotic gradient. This gradient is present after ingestion of an osmotically active substance and is absent during fasting (including during sleep). A common cause of osmotic diarrhea is lactase deficiency that results in lactose malabsorption, which typically presents in young adulthood. In this condition, brush-border lactase is lost and ingested lactose is no longer broken down to its constituent monosaccharides. The persistent presence of this unabsorbed disaccharide creates an osmotic gradient. Although a lactose breath test is available to test for lactase deficiency, the diagnosis can typically be based on improvement after exclusion of dietary lactose or administration of lactase enzymes with meals.
A 54-year-old woman is evaluated in the emergency department for coffee-ground emesis. Medical history is significant for schizoaffective disorder. She lives in a group home and is accompanied to the hospital by her group home manager. She identifies as an active Jehovah's Witness. Medications are risperidone and escitalopram.
On physical examination, blood pressure is 90/60 mm Hg and pulse rate is 110/min. The remainder of the physical examination is unremarkable.
Laboratory studies reveal a hemoglobin level of 6.0 g/dL (60 g/L).
Transfusion is planned; however, the patient refuses, stating that the procedure is against her religious beliefs as a Jehovah's Witness, and expresses a desire to return home.
Which of the following is the most appropriate management?
A. Ask the home manager for permission to transfuse
B. Assess the patient's decision making capacity
C. Discharge the patient
D. Transfuse
E. Urgently petition the court for evaluation of competence
B. Assess the patient's decision making capacity
The most appropriate next step in management is to assess the patient's capacity to refuse blood products (Option B). Patients are presumed to be legally competent to make medical decisions for themselves unless determined to be incompetent by the court. However, in routine clinical care, physicians must frequently determine a patient's decision-making capacity, including the patient's ability to understand relevant information; consider treatment options; appreciate the potential medical consequences of their decision; and communicate a choice, preferably a choice that is stable over time. Unlike competence, which is a global determination, decision-making capacity needs to be evaluated for each decision to be made. In this instance, the patient's capacity to refuse blood products needs to be evaluated before any transfusion. Her mental health disorder does not automatically invalidate her capacity, and her refusal of blood products, if consistent with previously expressed religious beliefs, makes her decision more valid.
A 28-year-old woman is seen during a routine visit. She is in the third trimester of a normal pregnancy. She is up to date on all of her immunizations and received the tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine during her first pregnancy 24 months ago and the inactivated influenza vaccine just before the start of the current pregnancy for the current influenza season. She has no medical problems. She takes a multivitamin and folic acid but no other medications or supplements.
Which of the following is the most appropriate vaccination?
A. HPV
B. Influenza
C. Tdap
D. No vaccination is needed
C. Tdap
The most appropriate vaccination is tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) (Option C). Primary vaccination against tetanus, diphtheria, and acellular pertussis consists of a five-dose vaccine series administered during childhood. Persons aged 11 to 18 years who have completed the primary series should receive one dose of the Tdap vaccine. Adults aged 19 years or older who did not receive the Tdap vaccine at age 11 years or older should receive one dose of the Tdap vaccine. All adults should receive a tetanus and diphtheria toxoids (Td) or Tdap booster every 10 years. Pregnant women should receive at least one dose of the Tdap vaccine between 27 weeks' and 36 weeks' gestation with every pregnancy. Pregnant women who had not previously been fully vaccinated against tetanus and diphtheria should also receive a Td series.
A 65-year-old man is diagnosed with multiple segmental pulmonary emboli in the right lung. He has no other medical problems, and he takes no medications.
On physical examination, blood pressure is 132/76 mm Hg, pulse rate is 100/min, and respiration rate is 18/min. Oxygen saturation is 98% at rest breathing ambient air.
The patient is alert and quickly comprehends the diagnostic implications and required therapy. He does not require pain medication. The patient is engaged in a shared decision-making process regarding treatment.
Which of the following is the most appropriate recommendation?
A. Discharge Home and Treat with Dabigatran
B. Discharge Home and Treat with Rivaroxaban
C. Hospitalize and Treat with Thrombolytic therapy
D. Hospitalize and treat with unfractionated heparin and warfarin
B. Discharge home and treat with rivaroxaban
The most appropriate recommendation is to discharge the patient home on a direct oral anticoagulant (DOAC) such as rivaroxaban (Option B). For patients with pulmonary embolism (PE) with a low risk for complications, the American Society of Hematology guideline suggests offering home treatment over hospital treatment. Clinical prediction scores have a moderate ability to predict patient outcomes and do not replace clinical judgment. However, they may help to select patients at low risk for complications. The Pulmonary Embolism Severity Index (PESI) and simplified PESI have been most widely validated. This recommendation does not apply to patients who have other conditions that would require hospitalization, have limited or no support at home, and cannot afford medications or have a history of poor adherence. The simplified PESI assigns 1 point for each of the following: age older than 80 years, history of cardiopulmonary disease, history of cancer, pulse rate 110/min or greater, systolic blood pressure less than 100 mm Hg, and oxygen saturation less than 90%. If none of these criteria are met, the patient is considered low risk, with a 30-day mortality of 1.1%; these patients can be considered for home anticoagulation treatment with either rivaroxaban or apixaban. This patient meets none of the risk criteria, and treatment at home is reasonable.