Plumbing and Electricity
A 36-year-old woman is evaluated in the emergency department for progressive dyspnea. She gave birth 3 weeks ago. The pregnancy and delivery were uncomplicated. She has no history of cardiovascular disease.
On physical examination, temperature is normal, blood pressure is 100/72 mm Hg in both arms, pulse rate is 102/min and regular, and respiration rate is 26/min. The estimated central venous pressure is elevated. Cardiac palpation reveals a diffuse apical impulse. The S1 and S2 are soft. An S3 and S4 are present. A grade 2/6 holosystolic murmur is heard at the apex. Crackles are auscultated bilaterally.
An electrocardiogram demonstrates sinus tachycardia without ST-T–wave changes. Transthoracic echocardiogram reveals ventricular dilatation with global reduction in contractility; the left ventricular ejection fraction is 30%.
Which of the following is the most likely diagnosis?
A Acute aortic dissection
B Acute pulmonary embolism
C Peripartum cardiomyopathy
D Takotsubo cardiomyopathy
C
Peripartum cardiomyopathy is left ventricular systolic dysfunction with onset toward the end of pregnancy or in the months following delivery.
A 29-year-old woman is seen in follow-up for evaluation of abnormal thyroid laboratory results. She is currently 26 weeks pregnant. She was originally evaluated 1 week ago for concerns about lack of weight gain during pregnancy, palpitations, anxiety, and insomnia. There is no family history of thyroid or autoimmune disease. Medical history is unremarkable, and her only medication is a prenatal vitamin.
On physical examination, other than a pulse rate of 98/min, vital signs are normal. The patient is a thin, gravid woman with a mild tremor of the outstretched hands, lid lag, and small goiter. There is no exophthalmus.
Laboratory studies obtained last week show a thyroid-stimulating hormone level of 6.5 µU/mL (6.5 mU/mL) and a free thyroxine (T4) level of 2.6 ng/dL (33.5 pmol/L).
Which of the following is the most likely diagnosis?
A Gestational thyrotoxicosis
B Graves disease
C Hypothyroidism
D Thyroid-stimulating hormone-secreting adenoma
D
Signs and symptoms of a thyroid-stimulating hormone-secreting adenoma are those seen in hyperthyroidism, although laboratory evaluation reveals an elevated free thyroxine (T4) level with an inappropriately normal or elevated thyroid-stimulating hormone level.
A 52-year-old man is evaluated for a 9-month history of progressively worsening gait, ataxia, and paresthesia in the legs. He is a dentist who was recently barred from practice because of chronic illicit drug use, specifically amphetamines and nitrous oxide.
On physical examination, vital signs are normal. Decreased vibration and position sense is noted in both feet. Reflexes are 3+ in both legs. Muscle strength is 4/5 in both hips.
A complete blood count is normal, as is a routine chemistry panel.
A T2-weighted MRI of the thoracic spinal cord shows hyperintensity in the posterior columns and throughout the cord. There is no associated contrast enhancement.
Measurement of which of the following serum levels is the most appropriate next diagnostic test?
A 25-Hydroxyvitamin D
B Thiamine
C Vitamin A
D Vitamin B6
E Vitamin B12
E
Subacute combined degeneration is a myelopathy manifesting as dysfunction of the corticospinal tracts and dorsal columns that is caused by vitamin B12 and copper deficiencies.
A 36-year-old man is evaluated in the emergency department after passing three bowel movements of red to maroon–colored blood. He recently injured his knee playing soccer and has been taking ibuprofen three times a day for a week. He has no other relevant medical history and does not smoke or drink alcohol.
On physical examination, he is lightheaded but alert. His blood pressure is 80/60 mm Hg, pulse rate is 126/min, respiratory rate is 12/min, and oxygen saturation is 98% breathing ambient air. Cardiac examination shows tachycardia. Rectal examination shows maroon-colored stool. All other findings are unremarkable.
The patient's vital signs improve after he is given intravenous hydration.
Laboratory studies show a hemoglobin level of 9 g/dL (90 g/L) upon presentation. Six hours later, the hemoglobin level is 7.4 g/dL (74 g/L).
Which of the following is the most appropriate test to perform next?
A Angiography
B Capsule endoscopy
C Colonoscopy
D Upper endoscopy
D
Hematochezia associated with hemodynamic instability in a young patient is likely due to an upper gastrointestinal source.
A 78-year-old woman is evaluated in the hospital for progressive dyspnea requiring increased oxygen. She was diagnosed with idiopathic pulmonary fibrosis 5 years ago. She was evaluated in the clinic 2 months ago; at that time she required 5 L/min of supplemental oxygen at rest and daily activities were limited to dressing and eating, both of which caused severe dyspnea. Currently, despite broad spectrum antibiotics and intravenous methylprednisolone, 1 g daily for 5 days, she is in severe respiratory distress requiring high-flow oxygen at 80%. She is alert and breathless, and understands her condition and treatment options.
On physical examination, blood pressure is 150/85 mm Hg, pulse rate is 110/min, and respiration rate is 36/min. Oxygen saturation is 88% on 80% high-flow oxygen. BMI is 24. Pulmonary examination reveals diffuse inspiratory crackles. She has clinical findings of pulmonary hypertension on cardiac examination, unchanged from 2 months ago. She has no edema or jugular venous distention.
Chest radiograph is unchanged.
Which of the following is the most appropriate management?
A Increase methylprednisolone
B Initiate albuterol
C Mechanical ventilation
D Palliative care
D
For individuals with idiopathic pulmonary fibrosis who develop severe respiratory distress that has no underlying reversible cause, supportive mechanical ventilation is of little long-term benefit; in these circumstances, the focus should be on palliation of the patient's underlying dyspnea.
A 48-year-old man is evaluated for a 6-month history of intermittent palpitations with accompanying lightheadedness and near-syncope. The episodes last approximately 5 minutes and occur once or twice per week. He cannot identify any precipitating triggers for his symptoms. Medical history is notable for hypertension. His only medication is chlorthalidone.
On physical examination, vital signs and the remainder of the examination are normal.
An electrocardiogram shows normal sinus rhythm with no evidence of preexcitation.
Which of the following is the most appropriate diagnostic testing option?
A Electrophysiology study
B External event recorder
C 24-Hour ambulatory electrocardiographic monitor
D Implantable loop recorder
B
In patients with infrequent episodes of palpitations, presyncope, or syncope, an event recorder may be used to correlate symptoms with an arrhythmia.
A 31-year-old woman is evaluated for amenorrhea. She stopped taking her oral contraceptive pill (OCP) 6 months ago with the goal of becoming pregnant. She has not had a menstrual cycle since stopping her OCP. Her cycles were regular prior to starting an OCP 6 years ago and while on the OCP. She notes a small amount of breast discharge with nipple stimulation; this has been a noted issue for approximately 3 months. Medical history is otherwise unremarkable. Her only medication is a folic acid supplement.
On physical examination, vital signs are normal. There is an elicitable milky discharge from the nipples bilaterally. Thyroid and skin examinations are normal. Visual field testing is normal.
Laboratory studies show a prolactin level of 75 ng/mL (75 µg/L). Serum pregnancy test is negative, and thyroid-stimulating hormone level, kidney function tests, and liver chemistry tests are normal.
MRI of the brain with and without contrast with fine cuts through pituitary reveals a 7-mm pituitary microadenoma.
Which of the following is the most appropriate management?
A Clomiphene citrate therapy
B Dopamine agonist therapy
C Pituitary surgery
D Resume oral contraceptive pill
B
Symptomatic prolactinomas are treated with dopamine agonists.
A 19-year-old woman is evaluated in the emergency department for a 6-month history of headaches that initially were intermittent but have been occurring daily for the past 6 weeks. She describes the pain as bilateral, frontotemporal, and a steady pressure. Neck stiffness has been present for 8 weeks. Vision intermittently darkens for seconds. For the past 3 nights, she has noted pulsatile tinnitus. The patient has inflammatory acne treated with minocycline and topical benzoyl peroxide gel.
On physical examination, vital signs are normal; BMI is 22. Papilledema and left abducens nerve (cranial nerve VI) palsy are noted, but all other findings are normal.
Results of brain MRI and magnetic resonance venography are normal.
Which of the following is the most appropriate management?
A Amitriptyline
B Indomethacin
C Lumbar puncture
D Magnetic resonance angiography
E Temporal artery biopsy
C
In a patient with suspected idiopathic intracranial hypertension, lumbar puncture is required to confirm the diagnosis.
A 72-year-old woman is evaluated for a 3-month history of large-volume, watery, nonbloody diarrhea with mucus, which occurs even when she is fasting. She reports no abdominal pain or flushing but has experienced an unintentional 3-kg (6.6-lb) weight loss. She has never had a colonoscopy.
On physical examination, blood pressure is 100/50 mm Hg and pulse rate is 95/min; other vital signs and examination findings are normal.
Laboratory studies show a serum sodium level of 130 mEq/L (130 mmol/L) and a serum potassium level of 3.3 mEq/L (3.3 mmol/L). Hemoglobin and serum creatinine levels are within normal limits.
Which of the following types of diarrhea is most compatible with the patient's findings?
A Infectious
B Inflammatory
C Osmotic
D Secretory
D
Patients with secretory diarrhea may pass liters of stool daily, causing severe dehydration and electrolyte disturbances, with persistent stooling despite fasting.
A 45-year-old woman with hypovolemic shock is evaluated for rapid resuscitation in the ICU. She has sickle cell disease with recurrent pain and hemolytic crises, and osteoporosis.
On physical examination, temperature is 39 °C (102.3 °F), blood pressure is 70/40 mm Hg, pulse rate is 142/min and weak, and respiration rate is 22/min. Oxygen saturation is 99% breathing ambient air. There is a subcutaneous port in the right anterior chest wall.
Which of the following is the most appropriate type of venous access for this patient?
A Intraosseous port
B Peripheral wide-bore catheter
C Subcutaneous intravenous port
D Triple-lumen central catheter
B
Peripheral wide-bore venous catheters are the preferred method for rapid intravenous administration of large amounts of fluids.
A 77-year-old man is evaluated for a 4-week history of progressive left foot pain that occurs at rest. He also has calf muscle pain that worsens when he ambulates. Medical history is significant for type 2 diabetes mellitus, hypertension, and hyperlipidemia. Medications are low-dose aspirin, metformin, amlodipine, lisinopril, and rosuvastatin.
On physical examination, temperature is 36.8 °C (98.2 °F), blood pressure is 134/74 mm Hg, and pulse rate is 92/min. The left foot is cool. There is a shallow 3.0-cm × 2.5-cm ulceration on the medial aspect of the left first metatarsal. Pedal pulses are diminished on the right and absent on the left. Left foot sensation and muscle strength are intact.
The ankle-brachial index is 0.62 on the right and unobtainable on the left.
Which of the following is the most appropriate next step in management?
A Add vorapaxar
B Invasive angiography of the left leg
C Magnetic resonance angiography
D Primary below-knee amputation
B
In patients with critical limb ischemia, immediate invasive angiography with endovascular revascularization is often the most effective strategy to preserve tissue viability.
A 63-year-old woman was diagnosed with osteoporosis 6 years ago. Initial treatment with an oral bisphosphonate resulted in upper gastrointestinal symptoms, so subcutaneous denosumab twice yearly was prescribed. The patient has now completed 5 years of denosumab therapy. Medical history is otherwise unremarkable. Denosumab was last administered 6 months ago.
Vital signs and the remainder of the physical examination are normal.
Which of the following is the most appropriate management?
A Continue denosumab
B Dual-energy x-ray absorptiometry (DEXA) scan
C Osteoporosis drug holiday
D Switch to zoledronic acid
A
When administered subcutaneously twice yearly, denosumab suppresses bone resorption, increases bone density, and reduces the incidence of osteoporotic fractures in men and women; the effects of denosumab are not sustained when treatment is stopped.
A 78-year-old man is evaluated in the emergency department for a 2-day history of bilateral leg weakness and urinary retention. He has atrial fibrillation and hypertension. Medications are warfarin, lisinopril, and hydrochlorothiazide.
On physical examination, vital signs are normal. Muscle strength is 4/5 in both legs. Decreased sensation in the groin, medial buttocks, and rectal area is noted, as is decreased rectal tone. No spinal sensory level is detected in the abdomen or chest region. Gait is wide based.
Results of laboratory studies show an INR level of 5.3.
Which of the following is the most appropriate management?
A Administration of intravenous glucocorticoids
B CT myelogram
C MRI of the lumbosacral spine
D Radiograph of the lumbosacral spine
C
In a patient with suspected compression of the lower spinal cord, emergent MRI of the lumbosacral spine is the most appropriate test both to localize the injury and to determine its cause.
A 55-year-old man is evaluated at a follow-up appointment 4 days after being diagnosed with acute sigmoid diverticulitis. He is on day 4 of oral antibiotics and reports that his pain is almost gone. He has no other symptoms and has never had a colonoscopy. He takes no other medication.
His vital signs are normal. Abdominal examination is positive for minimal tenderness on deep palpation in the left lower quadrant without rebound or guarding.
The CT scan of the abdomen from the emergency department shows mild sigmoid diverticulitis with no abscess.
When should this patient undergo colonoscopy?
A Now
B In 1 to 2 months
C In 6 months
D In 12 months
D
Patients with uncomplicated diverticulitis should undergo colonoscopy 1 to 2 months after the episode of acute diverticulitis, when colonic inflammation has resolved
A 65-year-old woman is admitted to the ICU with sepsis. She has become increasingly hypotensive despite intravenous fluid resuscitation of 30 mL/kg and the administration of increasing doses of norepinephrine and a standard dose of vasopressin. She has an arterial catheter in place. Appropriate antibiotics have been administered.
On physical examination, temperature is 37.7 °C (100 °F), blood pressure is 88/45 mm Hg, pulse rate is 116/min. Oxygen saturation is 98% on 2 L/min of oxygen through nasal cannula. She is alert and oriented. Her skin is cool. The remainder of the examination is normal.
Telemetry shows premature ventricular complexes.
Which of the following is the most appropriate treatment?
A Change norepinephrine to dopamine
B Hydrocortisone
C Increase the vasopressin infusion rate
D Intravenous immune globulin
B
Glucocorticoids are indicated in patients with sepsis who have not achieved hemodynamic stability from intravenous fluid administration and vasopressor therapies.
A 73-year-old man is evaluated during a routine examination. He is physically active and participates regularly in charitable running events. He has no cardiac symptoms, and his medical history is unremarkable.
On physical examination, vital signs are normal. The lungs are clear. Jugular venous pulse is normal. Carotid upstrokes are normal. The apical impulse is palpable and not displaced or sustained. There is a grade 3/6 diastolic decrescendo murmur best heard at the left lower sternal border. The remainder of the examination is normal.
A transthoracic echocardiogram shows severe aortic regurgitation. The left ventricular ejection fraction is 65%. The left ventricle is minimally dilated with an end-systolic dimension of 40 mm.
Which of the following is the most appropriate next step in management?
A Carvedilol
B Lisinopril
C Surgical aortic valve replacement
D Clinical and echocardiographic follow-up in 6 to 12 months
D
For patients with severe aortic regurgitation, indications for surgery are the presence of attributable symptoms, left ventricular ejection fraction less than 50%, or significant left ventricular dilatation; in the absence of these findings, surveillance echocardiography every 6 to 12 months is recommended.
A 55-year-old man with type 1 diabetes mellitus was admitted to the hospital for management of a non-ST-elevation myocardial infarction. He is clinically stable and eating well. He will begin fasting at midnight in preparation for a cardiac catheterization tomorrow. His current fasting blood glucose values range from 70 to 80 mg/dL (3.9-4.4 mmol/L), and his premeal blood glucose values range from 140 to 160 mg/dL (7.8-8.9 mmol/L) on his home doses of basal insulin glargine and prandial insulin aspart. His last hemoglobin A1c value was 7.2%.
In addition to holding prandial insulin, which of the following is the most appropriate management for this patient's diabetes?
A Continue basal insulin dose
B Continue basal insulin dose and add correction insulin regimen
C Decrease basal insulin dose and add correction insulin regimen
D Hold basal insulin and add sliding-scale insulin regimen
C
In fasting hospitalized patients with type 1 diabetes mellitus, the basal insulin dose should be decreased, the prandial insulin held to avoid hypoglycemia, and a correction insulin regimen should be added to help manage hyperglycemia.
A 51-year-old woman is evaluated for increasingly poor ambulation ever since having a relapse of multiple sclerosis (MS) 20 months ago. She was diagnosed with MS 4 years ago and has been taking natalizumab, baclofen, and a vitamin D supplement since that time.
On physical examination, vital signs are normal. Muscle strength is 4/5 in the left hip flexor, knee flexor, and ankle dorsiflexor. Gait is slow and deliberate with the assistance of a cane; left leg swing is noted. All other physical examination findings are unremarkable.
Which of the following medications is the most appropriate treatment?
A Dalfampridine
B Dextromethorphan-quinidine
C Gabapentin
D Memantine
E Modafinil
A
In patients with multiple sclerosis and impaired mobility, dalfampridine is the most appropriate medication.
A 65-year-old woman is reevaluated following an initial evaluation for anemia. Other than a gradually increasing sense of fatigue, she has no symptoms. Her only other medical problem is autoimmune thyroid disease, which is being treated with levothyroxine. Her last screening colonoscopy, done 4 years earlier, was normal.
Physical examination reveals normal vital signs. There is evidence of conjunctival rim pallor. The remainder of the examination, including thyroid and neurologic examinations, is normal.
At the time of her initial evaluation, laboratory studies showed a hemoglobin level of 10 g/dL (100 g/L) and mean corpuscular volume of 104 fL. Serum cobalamin and ferritin levels were low. An antiparietal cell antibody test was positive. Stool testing revealed no evidence of blood.
Which of the following is the most appropriate test to perform next?
A Capsule endoscopy
B Glucose hydrogen breath test
C Serum gastrin measurement
D Upper endoscopy
D
Patients with newly diagnosed pernicious anemia should be evaluated for gastric adenocarcinoma and gastric carcinoid with upper endoscopy and gastric biopsy.
A 60-year-old woman is evaluated in the hospital for respiratory failure. She was hospitalized 3 weeks ago after a house fire. She suffered significant third-degree burns covering 40% of her body and mucosal burns to her nose. She was intubated, but was successfully liberated from the ventilator last week. A surveillance bronchoscopy performed before extubation was unremarkable. Last night she became progressively dyspneic and hypoxic, eventually requiring reintubation. Current medications are topical antibiotics and subcutaneous heparin.
On physical examination, temperature is 37.9 °C (100.2 °F), blood pressure is 104/60 mm Hg, pulse rate is 95/min, and respiration rate is 26/min. Oxygen saturation is 91% breathing from a ventilator (FIO2 of 0.6). Copious yellow sputum is present in the endotracheal tube when suctioned.
Laboratory studies reveal a leukocyte count of 16,000/µL (16 × 109/L), increased from 12,000/µL (12 × 109/L) yesterday.
A chest radiograph shows a focal consolidation in the lower left lobe.
Which of the following is the most appropriate treatment?
A Administer hydroxocobalamin
B Administer intravenous antibiotics
C Bronchoscopic airway stenting
D Insert a thoracostomy tube
B
Secondary respiratory infections are common in patients with inhalational injuries, especially from Staphylococcus and Pseudomonas species, and are a major cause of morbidity and mortality.
A 78-year-old man is evaluated for exertional dyspnea. He was previously asymptomatic, but 4 months ago he began having shortness of breath during moderate levels of activity. The dyspnea dissipates with rest. He is otherwise healthy and takes no medications.
On physical examination, temperature is normal, supine blood pressure is 132/80 mm Hg, pulse rate is 80/min, and respiration rate is 22/min. The lungs are clear to auscultation. The carotid upstroke is delayed. There is a grade 3/6 late-peaking systolic murmur best heard at the base of the heart with radiation to both carotid arteries. S1 is normal; the aortic component of S2 is diminished. The remainder of the examination is unremarkable.
An echocardiogram demonstrates a left ventricular ejection fraction of 65%. There is moderate aortic stenosis, with a mean gradient of 28 mm Hg and an aortic valve area of 1.5 cm2.
Which of the following is the most appropriate next step in management?
A Cardiac catheterization
B Surgical aortic valve replacement
C Transcatheter aortic valve replacement
D Continued clinical observation
A
In patients with symptoms of aortic stenosis and discrepancies between the physical examination and echocardiographic findings, the severity of stenosis should be established with cardiac catheterization before aortic valve replacement is performed.
A 38-year-old woman is seen in follow-up to discuss the findings of an abdominal and pelvic CT scan done to evaluate renal colic, which has since resolved. The abdominal CT scan showed two small nonobstructing renal calculi in the right kidney and a 1.6-cm left adrenal mass with a density of 21 Hounsfield units (indeterminate for adrenal adenoma). Other than nephrolithiasis, the remainder of the medical history is unremarkable, and she takes no medications.
On physical examination, vital signs and the remainder of the examination are unremarkable.
Laboratory studies show normal serum electrolytes.
Which of the following is the most appropriate test to perform next?
A 24-Hour urine free cortisol measurement
B 24-Hour urine total metanephrine measurement
C Plasma aldosterone-plasma renin ratio (ARR) measurement
D Serum dehydroepiandrosterone sulfate (DHEAS) measurement
B
Biochemical testing for pheochromocytoma should be undertaken in all patients with an adrenal mass that is clearly not an adenoma, even in the absence of typical symptoms or hypertension.
A 47-year-old man is evaluated for recent weakness and loss of balance during ambulation, multiple episodes of orthostatic syncope, and a 2-year history of burning paresthesia in the lower extremities. He also reports dry mouth and dry eyes. The patient has glaucoma, erectile dysfunction, constipation, and carpal tunnel syndrome. His father had sensory neuropathy, and his father and paternal uncle died of restrictive cardiomyopathy. Medications are gabapentin, sildenafil, and docusate sodium.
On physical examination, blood pressure is 130/70 mm Hg sitting and 110/64 standing, and pulse rate is 110/min. Weakness in the distribution of the bilateral median nerves and in the proximal lower extremities is noted. Loss of sensation to pinprick is present in both hands and below the knees. Deep tendon reflexes are reduced in the lower extremities.
Electromyography, including nerve conduction studies and needle electrode examination, reveals diffuse axonal sensorimotor polyneuropathy.
Which of the following is the most likely diagnosis?
A Amyotrophic lateral sclerosis
B Cervical myelopathy
C Chronic inflammatory demyelinating polyradiculoneuropathy
D Familial amyloidosis
E West Nile virus infection
D
Familial amyloidosis is characterized by predominantly sensory and motor peripheral neuropathy and/or autonomic neuropathy; it is diagnosed by detecting a mutation of the transthyretin gene.
A 60-year-old man is evaluated for epigastric pain that occurs intermittently after eating. He was hospitalized twice in the preceding year for idiopathic recurrent acute pancreatitis. He is a former smoker and reports no alcohol use.
On physical examination, vital signs are normal, as is the remainder of the examination.
Contrast-enhanced CT of the abdomen shows a diffusely dilated main pancreatic duct with normal intrahepatic and extrahepatic bile ducts and a normal gallbladder. No tumor is seen in the pancreas or liver, and there is no peripancreatic inflammation or necrosis. Endoscopic ultrasonography confirms no evidence of a tumor or gallstone, but the main pancreatic duct appears dilated throughout the pancreas. Mucin is seen exuding from the ampulla of Vater during the endoscopy.
Which of the following is the most appropriate next step in management?
A Endoscopic ultrasonography in 1 year
B MRI of the abdomen in 1 year
C Oral prednisone
D Pancreatic resection
D
Surgical resection is the best management option for high-risk cystic lesions of the pancreas, such as intraductal papillary mucinous neoplasms that involve the main duct.
A 72-year-old woman is evaluated in the hospital for a pneumothorax. The patient has severe, oxygen-dependent COPD complicated by several exacerbations. She was hospitalized 72 hours ago with abrupt onset of chest pain and dyspnea. Chest radiography confirmed the presence of a large left-sided pneumothorax and a thoracostomy tube was placed. She had 90% expansion of the lung following thoracostomy.
On physical examination, the patient is frail appearing but comfortable. Vital signs are normal. Oxygen saturation is 96% breathing 3 L/min of oxygen through nasal cannula. Pulmonary examination reveals diminished but present breath sounds bilaterally. A left thoracostomy tube is in place.
Chest radiograph demonstrates resolution of pneumothorax with a thoracostomy tube in place.
Which of the following is the most appropriate management?
A Clamp thoracostomy tube
B Place thoracostomy tube to high suction
C Pleurodesis
D Remove thoracostomy tube
C
Recurrence prevention with pleurodesis is recommended after the first occurrence of secondary spontaneous pneumothorax.