Cardiology
A 42-year-old man is evaluated in the emergency department for sudden-onset right-sided weakness. His symptoms resolved fully over the past hour. He has no known medical problems and takes no medications.
On physical examination, vital signs are normal. His heart rhythm is regular. Neurologic examination is normal. No carotid bruits or heart murmurs are noted.
Laboratory study results are normal.
Magnetic resonance angiogram of the brain demonstrates a small left-sided ischemic stroke but no other lesions. ECG, carotid ultrasound, telemetry, and lower extremity ultrasound are normal. A transesophageal echocardiogram demonstrates a patent foramen ovale (PFO) with right-to-left shunt noted with cough and Valsalva release. No other abnormalities are identified.
Which of the following is the most appropriate management?
A. Aspirin
B. PFO device closure
C. Warfarin
D. Observation
B. PFO device closure
A 66-year-old man is evaluated for management of type 2 diabetes mellitus, diagnosed 6 years ago. For the past 4 months, he has had fatigue and unsteadiness while walking. Medications are metformin and glipizide, which he has been taking since his diagnosis.
On physical examination, vital signs are normal. BMI is 28. He has decreased vibratory sense in the great toes and loss of patellar and Achilles reflexes. The remainder of the examination is normal.
Laboratory studies:
Hemoglobin A1c 7.4%
Mean corpuscular volume 115 fL
Hematocrit 35%
Creatinine 1.3 mg/dL (115 μmol/L)
Which of the following is the most appropriate diagnostic test?
A. Electromyelography and nerve conduction studies
B. MRI of the spine
C. Serum vitamin B6 measurement
D. Serum vitamin B12 measurement
D. Serum vitamin B12 measurement
A 33-year-old woman is evaluated in the emergency department after a friend found her unresponsive and called emergency medical services. She is now alert and reports that she had used heroin hours earlier, as well as oxycodone and clonazepam just before this episode. She was treated in another local emergency department 2 months ago for a similar accidental polysubstance overdose.
Which of the following is the most appropriate measure for preventing an overdose-related death in this patient?
A. Intranasal naloxone
B. Oral clonidine
C. Naltrexone
D. Transdermal buprenorphine
A. Intranasal naloxone
A 52-year-old woman is evaluated during a follow-up visit for hypertension management. She has a 10-year history of type 2 diabetes mellitus. Diabetic retinopathy was diagnosed 1 year ago. She also has obesity and hyperlipidemia. Medications are hydrochlorothiazide, metformin, empagliflozin, and atorvastatin.
On physical examination, blood pressure is 138/86 mm Hg; other vital signs are normal. BMI is 32. The remainder of the examination is unremarkable.
Laboratory studies:
Creatinine 0.9 mg/dL (79.6 µmol/L)
Electrolytes Normal
Urine albumin-creatinine ratio 550 mg/g
Estimated glomerular filtration rate >60 mL/min/1.73 m2
Which of the following is the most appropriate treatment?
A. Amlodipine
B. Atenolol
C. Doxazosin
D. Losartan
D. Losartan
A 62-year-old man is evaluated for adjuvant therapy after surgical removal of an adenocarcinoma of the colon. Postsurgical pathology revealed a tumor penetrating the full thickness of the colonic wall, and cancer is found in three of 17 lymph nodes. Presurgical imaging revealed no evidence of distant metastatic disease.
Which of the following is the most appropriate adjuvant treatment?
A. Bevacizumab
B. Capecitabine
C. Oxaliplatin, fluorouracil, and leucovorin (FOLFOX)
D. Radiation therapy
E. No additional therapy
C. Oxaliplatin, fluorouracil, and leucovorin (FOLFOX)
A 78-year-old woman is evaluated for a 3-month history of heart failure with reduced ejection fraction (ejection fraction, 20%). She has stable dyspnea when walking up stairs but has no other symptoms. Her medical history is otherwise unremarkable. Medications are valsartan-sacubitril, carvedilol, furosemide, empagliflozin, and spironolactone. Carvedilol is at half-maximum dosage; all other medications are at maximum recommended dosages.
On physical examination, blood pressure is 118/74 mm Hg and pulse rate is 88/min. BMI is 27, unchanged from her last visit. Central venous pressure and the remainder of the examination are normal.
Which of the following is the most appropriate treatment?
A. Add ivabradine
B. Decrease valsartan-sacubitril
C. Increase carvedilol
D. Increase furosemide
C. Increase carvedilol
A 73-year-old woman is evaluated in the emergency department after 2 days of weakness, headache, and nausea. She underwent uncomplicated transsphenoidal resection of a pituitary macroadenoma 6 days ago and was discharged from the hospital 3 days ago.
On physical examination, vital signs are normal. No orthostasis and no neurologic or visual deficits are present. Her mucous membranes are moist.
Laboratory studies show a serum sodium level of 128 mEq/L (128 mmol/L), thyroid-stimulating hormone level of 0.9 μU/mL (0.9 mU/L), and free thyroxine level of 1.1 ng/dL (14.2 pmol/L). Before discharge, her 8 AM serum cortisol level was 15 μg/dL (414 nmol/L), and a random serum cortisol level taken at 3 PM was 10 μg/dL (276 nmol/L).
Which of the following is the most likely diagnosis?
A. Adrenal insufficiency
B. Dehydration
C. Secondary hypothyroidism
D. Syndrome of inappropriate antidiuretic hormone secretion
D. Syndrome of inappropriate antidiuretic hormone secretion
A 74-year-old man undergoes follow-up evaluation 4 weeks after an urgent care visit for benign paroxysmal positional vertigo. He is concerned about an upcoming trip and the possibility of falling. He has had no recent falls but did have a near fall. Medical history is significant for atrial fibrillation. Current medications are metoprolol, apixaban, and meclizine.
On physical examination, blood pressure and pulse rate are normal and without orthostatic changes. Cardiac examination reveals an irregular rhythm. Screening neurologic examination is normal.
The Timed Up and Go Test result is prolonged (16 seconds).
The patient undergoes canalith repositioning with the Epley maneuver.
Which of the following is the most appropriate additional management to reduce this patient's risk for falls?
A. Discontinue meclizine
B. Discontinue metoprolol
C. Prescribe a four-prong cane
D. Prescribe vitamin D
A. Discontinue meclizine
A 62-year-old woman comes to the office for kidney transplantation evaluation. She has end-stage kidney disease. A peritoneal dialysis catheter was placed 2 weeks ago. She also has hypertension. Medications are amlodipine, benazepril, furosemide, metoprolol, and sodium bicarbonate.
On physical examination, vital signs are normal. A peritoneal dialysis catheter is present. The remainder of the examination is normal.
Laboratory studies:
Hepatitis B core antibody Positive
Hepatitis B surface antibody Positive
Hepatitis B surface antigen Negative
Hepatitis C antibody Positive
Hepatitis C viral load 2.8 million IU/mL
Which of the following is the most appropriate management?
A. Avoid antiviral treatment and transplantation
B. Begin entecavir
C. Begin pegylated interferon and ribavirin
D. Discuss hepatitis C virus treatment and timing
D. Discuss hepatitis C virus treatment and timing
A 65-year-old man is evaluated for a single episode of painless gross hematuria that occurred 1 month ago. Medical history is notable only for atrial fibrillation managed with metoprolol and rivaroxaban.
On physical examination, vital signs are normal. Cardiac examination reveals an irregularly irregular rhythm.
Urinalysis is normal.
Ultrasound of the kidneys and bladder is normal.
Which of the following is the most appropriate management?
A. Cystoscopy
B. Repeat urinalysis in 1 week
C. Substitute warfarin for rivaroxaban
D. Urine cytology
E. Reassurance and no additional intervention
A. Cystoscopy
A 55-year-old woman is evaluated for a 6-month history of progressive fatigue and dyspnea while walking on level ground.
On physical examination, blood pressure is normal and pulse rate is 80/min. Cardiac examination reveals an opening snap and a diastolic rumble heard best at the cardiac apex. Estimated central venous pressure is normal.
A resting echocardiogram shows a left ventricular ejection fraction greater than 55% and a normal-size right ventricle with preserved function. The mitral valve is thickened and appears rheumatic, with restricted opening of the leaflet tips. The mitral gradient and calculated valve area are consistent with moderate mitral stenosis.
Which of the following is the most appropriate management?
A. Exercise echocardiography
B. Cardiac catheterization
C. Cardiac magnetic resonance imaging
D. Percutaneous balloon mitral commissurotomy
E: Transesophageal echocardiography
A. Exercise echocardiography
A 58-year-old woman is evaluated for further management of type 2 diabetes mellitus after hospital discharge. She was hospitalized with a myocardial infarction and subsequent coronary stenting, and her hospital course was complicated by heart failure. Her hemoglobin A1c level was 8.2% while hospitalized. Hyperglycemia was treated with insulin. Her medical history is significant for hypertension, dyslipidemia, obesity, and idiopathic pancreatitis. Medications are metformin, lisinopril, carvedilol, atorvastatin, furosemide, aspirin, and clopidogrel.
On physical examination, vital signs are normal. BMI is 29.
Laboratory studies show an estimated glomerular filtration rate of 52 mL/min/1.73 m2 and blood glucose level of 202 mg/dL (11.2 mmol/L).
Which of the following is the best additional treatment for diabetes mellitus?
A. Empagliflozin
B. Glipizide
C. Liraglutide
D. Pioglitazone
A. Empagliflozin
A 34-year-old woman is evaluated for a 3-month history of dry cough. She does not use tobacco. A chest radiograph obtained 1 month ago was normal. The patient has a history of seasonal rhinitis. Since the onset of the cough, she has used fluticasone nasal spray daily without improvement. She has no other symptoms.
Vital signs and physical examination are normal.
Which of the following is the most appropriate next step in management?
A. Ambulatory pH monitoring
B. Chest CT
C. Omeprazole
D. Spirometry
E. Sputum eosinophil evaluation
D. Spirometry
A 46-year-old man is evaluated for confirmed primary hypertension. The patient is asymptomatic and takes no medications. He is a current smoker with a 20-pack-year history. Family history is significant for hypertension in his mother and father; his father had a stroke at age 55 years.
On physical examination, blood pressure is 154/96 mm Hg in both arms, pulse rate is 74/min, and respiration rate is 18/min. BMI is 30. The remainder of the examination is normal.
Laboratory studies:
Fasting lipid profile: Total cholesterol 220 mg/dL (5.7 mmol/L), LDL cholesterol 160 mg/dL (4.1 mmol/L), HDL cholesterol 48 mg/dL (1.2 mmol/L)
Creatinine 1.0 mg/dL (88.4 µmol/L). Electrolytes Normal. Glucose, fasting 80 mg/dL (4.4 mmol/L)
Urinalysis No protein, erythrocytes, or leukocytes
A 12-lead ECG is normal.
The patient is instructed in lifestyle modifications, including smoking cessation, exercise, and a low sodium diet. Moderate-intensity atorvastatin is initiated.
Which of the following is the most appropriate additional therapy?
A. Amlodipine
B. Amlodipine-valsartan
C. Chlorthalidone
D. Valsartan
B. Amlodipine-valsartan
A 52-year-old woman is evaluated in the office for a left breast lump that developed 3 months ago. She is asymptomatic. Medical history is unremarkable, and she takes no medications.
On physical examination, there is a 1.8-cm firm mass in the upper outer left breast. There is no axillary or supraclavicular adenopathy.
Complete blood count and comprehensive metabolic profile, including alkaline phosphatase level, are normal.
Mammogram and ultrasound confirm a 1.8-cm mass in the left upper outer breast.
Core biopsy of the left breast reveals estrogen receptor–negative, progesterone receptor–negative, and human epidermal growth factor receptor 2–negative invasive ductal carcinoma.
Which of the following is the most appropriate pretreatment imaging for this patient?
A. Chest radiograph and bone scan
B. CT of the chest, abdomen, and pelvis
C. CT of the chest, abdomen, and pelvis and MRI of the brain
D. No imaging
D. No imaging
A 75-year-old man is evaluated in the emergency department for a 2-day history of left leg pain. The pain started abruptly and has been constant. He has diabetes mellitus, hypertension, peripheral artery disease, and hyperlipidemia. Medications are metformin, chlorthalidone, atorvastatin, cilostazol, and low-dose aspirin.
On physical examination, pulse rate is 108/min and irregular; other vital signs are normal. Cardiac examination reveals an irregularly irregular rhythm. The left lower extremity is cold and mottled. The left popliteal and ankle pulses are absent. Passive range of motion is normal in the left leg, but the patient has significant pain and is unable to actively flex the left knee fully. Left leg sensation is intact. The remainder of the physical examination is unremarkable.
ECG shows atrial fibrillation.
Which of the following is the most appropriate next step in management?
A. Angiography
B. Apixaban
C. Intravenous tenecteplase
D. Unfractionated heparin
E. Venous duplex ultrasonography
D. Unfractionated heparin
A 74-year-old woman is evaluated during a follow-up visit for osteoporosis. She sustained fractures in thoracic vertebra 11 and lumbar vertebra 1 without a fall 2 years earlier. Dual-energy x-ray absorptiometry scan at the time of injury showed left femur neck T-score of -2.9. Teriparatide was initiated.
Which of the following is the most appropriate management?
A. Discontinue teriparatide
B. Discontinue teriparatide, start alendronate
C. Discontinue teriparatide, start romosozumab
D. Discontinue teriparatide, start abaloparatide
B. Discontinue teriparatide, start alendronate
A 58-year-old woman is evaluated for follow-up of chronic insomnia. She has participated in cognitive behavioral therapy for insomnia; however, she continues to have difficulties maintaining sleep. After a discussion of risks and benefits and shared decision making, the patient has opted for a limited course of pharmacologic therapy for her insomnia. She has no other medical problems and takes no medications.
Which of the following is the most appropriate treatment?
A. Diphenhydramine
B. Doxepin
C. Trazodone
D. No pharmacologic treatment
B. Doxepin
An 87-year-old man is evaluated in the emergency department for a 36-hour history of lower abdominal discomfort, urinary frequency, and nocturia. He has no other symptoms. Medical history is significant for type 2 diabetes mellitus, hypertension, and IgG4-related autoimmune pancreatitis. Medications are metformin, hydrochlorothiazide, and rituximab. He began taking over-the-counter chlorpheniramine last week for symptoms related to seasonal allergies.
On physical examination, he is afebrile. Blood pressure is 158/64 mm Hg, and pulse rate is 78/min. There is tenderness to palpation of the lower abdomen. The prostate is diffusely enlarged.
Laboratory studies show a blood urea nitrogen level of 50 mg/dL (17.9 mmol/L) and a serum creatinine level of 2.4 mg/dL (212.2 µmol/L). Urinalysis shows a specific gravity of 1.012, 1+ blood, 1+ protein, 1+ leukocytes, 3 nondysmorphic erythrocytes/hpf, 1-3 leukocytes/hpf, and no casts.
Which of the following is the most appropriate initial step in management?
A. Bladder Ultrasonography
B. Kidney Ultrasonography
C. MRI of the abdomen and pelvis
D. Noncontrast CT of the abdomen and pelvis
A. Bladder Ultrasonography
A 52-year-old man is seen following an axillary lymph node biopsy confirming a diagnosis of large B-cell lymphoma.
Complete blood count, liver chemistry tests, and electrolyte, blood urea nitrogen, and creatinine levels are normal.
PET/CT shows uptake in left axillary, mediastinal, hilar, and retroperitoneal nodes, as well as multiple foci in the ileum, ribs, and vertebral bodies.
Which of the following is the most appropriate staging test to perform next?
A. Bone marrow biopsy
B. Brain MRI
C. CT-guided biopsy of retroperitoneal lymph node
D. Serum lactate dehydrogenase measurement
D. Serum lactate dehydrogenase measurement
A 28-year-old woman is evaluated in the emergency department for substernal chest tightness that started several hours ago. She is 2 weeks postpartum after an uncomplicated pregnancy and delivery. She has no history of cardiopulmonary disease and has no risk factors for atherosclerotic cardiovascular disease.
On physical examination, blood pressure is 122/72 mm Hg in both arms, pulse rate is 90/min and regular, and respiration rate is 24/min. The estimated central venous pressure and apical impulse are normal. An S4 is present. The rest of the examination is unremarkable.
Laboratory studies are significant for an elevated high-sensitivity cardiac troponin level (>99th percentile upper reference limit).
An ECG shows ST-segment elevation in the anterior precordial leads. An echocardiogram shows anterior wall hypokinesis. Estimated ejection fraction is 40%.
Which of the following is the most likely diagnosis?
A. Atherosclerotic plaque rupture
B. Peripartum cardiomyopathy
C. Spontaneous coronary artery dissection
D. Stress-induced (takotsubo) cardiomyopathy
C. Spontaneous coronary artery dissection
A 45-year-old woman is evaluated for management of obesity and type 2 diabetes mellitus diagnosed 1 year ago. During the past 6 months, she has implemented lifestyle modifications, including a low-calorie diet, weight-loss group meetings, and exercise. She has achieved a 5.0-kg (11.0-lb) weight loss. Medical history is significant for recurrent urinary tract infections. Her only medication is metformin, 850 mg twice daily.
Vital signs and physical examination findings are unremarkable. BMI is 35.
Laboratory studies show a hemoglobin A1c level of 7.6%.
Which of the following medication changes would most benefit this patient?
A. Add dapagliflozin
B. Add glimepiride
C. Add liraglutide
D. Increase metformin dosage
C. Add liraglutide
A 70-year-old man is evaluated for a 1-year history of fatigue and sleeping difficulties that he finds distressing. He reports going to bed at 10 PM and watching television for 20 minutes before attempting sleep. However, it takes up to 2 hours to fall asleep. He wakes once a night to urinate and takes about an hour to fall back asleep. He takes a 2-hour nap every afternoon.
Vital signs and physical examination are normal.
The patient has no access to cognitive behavioral therapy in his community.
Which of the following is the most appropriate treatment?
A. Avoid daytime naps
B. Avoid watching television in bed
C. Brief behavioral therapy for insomnia
D. Melatonin
E. Sleep restriction therapy
C. Brief behavioral therapy for insomnia
A 38-year-old woman seeks treatment for polyuria and nocturia that began 6 weeks ago after starting lithium for bipolar disorder. Medical history is otherwise unremarkable. Her only other medication is olanzapine.
Physical examination findings, including vital signs, are normal.
Laboratory studies show a serum sodium level of 145 mEq/L (145 mmol/L) and a urine osmolality of 200 mOsm/kg H2O.
Which of the following is the most appropriate management?
A. Add amiloride
B. Add furosemide
C. Decrease water intake
D. Increase protein intake
A. Add amiloride
A 68-year-old man is evaluated for early satiety and right upper quadrant discomfort. He is otherwise well. He reports that he is still working full time and walks about a half mile to and from work each day.
On physical examination, vital signs are normal. Examination is notable for hepatomegaly.
Complete blood count is normal. On serum chemistry testing, alkaline phosphatase and aminotransferase levels are elevated; bilirubin and creatinine levels are normal.
CT scan of the chest, abdomen, and pelvis shows hepatomegaly with multiple metastatic lesions and abdominal carcinomatosis with a small amount of ascites. No other abnormalities are noted. Liver biopsy reveals adenocarcinoma.
The patient is diagnosed with metastatic cancer from an unknown primary.
Which of the following is the most appropriate management?
A. Measure serum CA-19-9, CA-15-3, and CA-125 antigens
B. Obtain a gene expression array
C. PET
D. Upper endoscopy, wireless capsule endoscopy, and colonoscopy
E. No additional testing; initiate combination chemotherapy
E. No additional testing; initiate combination chemotherapy