CVS
A 63-year-old man is evaluated in the emergency department for progressive dyspnea. The patient reports increasing difficulty breathing while lying flat. He has a history of atrial fibrillation and underwent catheter ablation 1 week ago. Medical history is otherwise significant for hypertension. He has no history of heart failure or left ventricular dysfunction. Medications are warfarin, dronedarone, and lisinopril.
On physical examination, temperature is normal, blood pressure is 88/72 mm Hg, pulse rate is 112/min, and respiration rate is 16/min. Pulsus paradoxus of 12 mm Hg is present. Oxygen saturation breathing ambient air is 96%. Cardiac examination reveals elevated estimated central venous pressure. Heart sounds are difficult to auscultate. Lung examination reveals no crackles.
An electrocardiogram demonstrates sinus tachycardia.
Which of the following is most likely responsible for the patient's symptoms?
A. Atrioesophageal fistula
B. Cardiac tamponade
C. Pulmonary vein stenosis
D. Retroperitoneal bleeding
B. Cardiac tamponade
Key Point
Cardiac tamponade occurs in approximately 1% of patients who undergo catheter ablation procedures for atrial fibrillation; it is the most common serious complication and is likely to result in death if not recognized and treated urgently.
A 25-year-old woman is evaluated in the hospital for right-upper-quadrant abdominal pain, jaundice, and nausea of 10 days' duration. She is in her 35th week of pregnancy. Her only medication is a prenatal vitamin.
On physical examination, the patient is drowsy. Temperature is normal. Blood pressure is 95/60 mm Hg, pulse rate is 108/min, and respiration rate is 22/min. Jaundice is apparent. Abdominal examination shows tenderness to palpation in the right upper quadrant. The uterus is of appropriate size for gestation.
Laboratory studies:
Hematocrit 34%
Leukocyte count 6000/μL (6 × 109/L)
Platelet count 155,000/μL (155 × 109/L)
INR 2.2
Alanine aminotransferase 115 U/L
Aspartate aminotransferase 130 U/L
Total bilirubin 6.2 mg/dL (106.0 µmol/L)
Glucose 55 mg/dL (3.1 µmol/L)
On abdominal ultrasonography, the liver is hyperechoic. Hepatic vasculature is patent, and there is no bile-duct dilation.
She is transferred to an ICU setting, and intravenous fluids with glucose are administered.
Which of the following is the most appropriate next step in management?
A. ERCP
B. Immediate delivery of the fetus
C. Lactulose
D. Ursodeoxycholic acid
B. Immediate delivery of the fetus
The fetus should be delivered immediately upon recognition of acute fatty liver of pregnancy.
A 72-year-old man is evaluated for near-syncope and a recent fall. History is significant for hypertension, hyperlipidemia, and coronary artery disease. Medications are hydrochlorothiazide, amlodipine, carvedilol, pravastatin, and aspirin. The hydrochlorothiazide dose was increased from 25 mg to 50 mg 1 month ago.
On physical examination, blood pressure is 164/88 mm Hg sitting and 140/76 mm Hg standing after 3 minutes, and pulse rate is 64/min sitting and 66/min standing; other vital signs are normal. Ecchymosis is noted over the left elbow. The remainder of the examination, including the neurologic examination, is unremarkable.
Laboratory studies:
Creatinine: 1.4 mg/dL (123.8 µmol/L); 1 month ago: 1.0 mg/dL (88.4 µmol/L)
Bicarbonate: 30 mEq/L (30 mmol/L); 1 month ago: 26 mEq/L (26 mmol/L)
Potassium: 3.0 mEq/L (3.0 mmol/L); 1 month ago: 3.8 mEq/L (3.8 mmol/L)
Sodium: 132 mEq/L (132 mmol/L); 1 month ago: 136 mEq/L (136 mmol/L)
A 12-lead electrocardiogram shows no changes from previous tracings.
Which of the following is the most appropriate management?
A. Decrease hydrochlorothiazide dose and obtain ambulatory blood pressure monitoring
B. Order telemetry and cardiac enzyme testing
C. Schedule bilateral carotid USG
D. Schedule head CT
A. Decrease hydrochlorothiazide dose and obtain ambulatory blood pressure monitoring
Key Point
Ambulatory blood pressure monitoring provides valuable information supplementary to office blood pressure measurements in the evaluation of antihypertensive treatment.
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
Key Point
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 66-year-old man is evaluated in the hospital following ST-elevation myocardial infarction treated with primary percutaneous coronary intervention of the left anterior descending artery 4 days ago. His initial presentation was complicated by the presence of heart failure and pulmonary edema. He is asymptomatic and ambulating, and he is nearly ready for discharge. Medical history is significant for hyperlipidemia, type 2 diabetes mellitus, and hypertension. Medications are aspirin, prasugrel, lisinopril, carvedilol, atorvastatin, and basal and prandial insulin.
On physical examination, vital signs are normal. Oxygen saturation is 99% breathing ambient air. The remainder of the examination is unremarkable.
Laboratory studies are significant for a serum creatinine level of 1.0 mg/dL (88.4 µmol/L) and a serum potassium level of 3.7 mEq/L (3.7 mmol/L).
An echocardiogram shows a left ventricular ejection fraction of 35%.
Which of the following is the most appropriate treatment?
A. Eplerenone
B. Isosorbide mononitrate
C. Valsartan
D. Warfarin
A. Eplerenone
Key Point
In patients with ST-elevation myocardial infarction, left ventricular ejection fraction of 40% or less, and either heart failure symptoms or diabetes mellitus, an aldosterone antagonist is recommended in addition to ACE inhibitor and β-blocker therapy.
A 72-year-old woman is evaluated in the hospital for new-onset abdominal pain in the right upper quadrant and fever that developed abruptly on hospital day 5. She was hospitalized 5 days earlier for altered mental status. In the emergency department, she was found to be confused, hypotensive, and tachycardic. She was transferred to the ICU, where she was diagnosed and treated for urosepsis. Within 24 hours, she was hemodynamically stable and the sepsis syndrome resolved. She also has type 2 diabetes mellitus, hypertension, and hyperlipidemia. Her medications are insulin glargine, insulin aspart, lisinopril, atorvastatin, and piperacillin-tazobactam.
On physical examination, the patient is alert. Temperature is 38.2 °C (100.8 °F), blood pressure is 90/62 mm Hg, pulse rate is 110/min, and respiration rate is 20/min. Abdominal examination is notable for tenderness to palpation of the right upper quadrant. A soft palpable mass is felt in this area.
Laboratory studies show a leukocyte count of 20,000/µL (20 × 109/L) and a serum total bilirubin level of 5 g/dL (85.5 µmol/L).
Ultrasonography shows a distended gallbladder with wall thickening and pericholecystic fluid. No gallstones are seen and bile ducts are normal.
Which of the following is the most appropriate next step in management?
A. Cholecystostomy tube placement
B. ERCP
C. Hepatobiliary iminodiacetic acid scan
D. MR cholangiopancreatography
A. Cholecystostomy tube placement
Key Point
Acalculous cholecystitis can present with biliary colic symptoms in the alert patient or with unexplained leukocytosis, sepsis, and jaundice in the critically ill patient.
A 56-year-old man is seen during a routine evaluation for stage G4 chronic kidney disease (CKD). History is also significant for hypertension. Medications are losartan, labetalol, furosemide, and amlodipine. He has no symptoms and remains physically active.
On physical examination, blood pressure is 129/76 mm Hg, and pulse rate is 68/min; other vital signs are normal. The physical examination is otherwise unremarkable.
Laboratory studies:
Hemoglobin 11 g/dL (110 g/L)
Bicarbonate 19 mEq/L (19 mmol/L)
Creatinine 3.1 mg/dL (274 µmol/L)
Phosphorus 5.7 mg/dL (1.8 mmol/L)
Potassium 5.1 mEq/L (5.1 mmol/L)
The addition of which of the following will most likely slow progression of this patient's CKD?
A. ACE inhibitor
B. Erythropoiesis-stimulating agent
C. Phosphate binder
D. Sodium bicarbonate
D. Sodium bicarbonate
Key Point
The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend treatment of metabolic acidosis with alkali therapy in patients with chronic kidney disease when the serum bicarbonate is chronically <22 mEq/L (22 mmol/L).
A 52-year-old woman undergoes perioperative evaluation. She has osteoarthritis of the right hip since sustaining injuries in a motor vehicle accident 15 years ago and is scheduled for elective hip arthroplasty in the next few months. Medical history is otherwise notable for type 2 diabetes mellitus. She is up to date on routine health care. Her last menstrual period was 5 weeks ago. Medications are ibuprofen and metformin.
On physical examination, vital signs are normal. She has painful and limited range of motion in the right hip.
Laboratory studies:
Hemoglobin 10 g/dL (100 g/L)
Mean corpuscular volume 81 fL
Platelet count 223,000/µL (223 × 109/L)
Creatinine 1 mg/dL (88.4 µmol/L)
Hemoglobin A1c 7.5%
Which of the following is the most appropriate test to perform next?
A. Hemoglobin electrophoresis
B. Iron studies
C. Vitamin B12 level
D. No further evaluation
B. Iron studies
Key Point
Patients scheduled for elective surgery who have anemia should be evaluated for iron deficiency; preoperative management of iron deficiency anemia includes oral iron replacement and evaluation to determine the source of blood loss.
An 88-year-old man is evaluated for chest tightness and dyspnea. His symptoms began 8 months ago and now occur with ambulation. Medical history is significant for type 2 diabetes mellitus, hypertension, chronic kidney disease, and a transient ischemic attack that occurred 4 years ago. Current medications are metformin, atorvastatin, lisinopril, and low-dose aspirin.
On physical examination, temperature is normal, blood pressure is 145/82 mm Hg, pulse rate is 64/min, and respiration rate is normal. The lungs are clear. A grade 3/6 late-peaking systolic murmur is auscultated at the cardiac base with radiation to the carotid arteries. There is no S3.
Echocardiogram demonstrates severe aortic stenosis with a mean gradient of 62 mm Hg and an aortic valve area of 0.65 cm2.
Cardiac surgery assessment estimates the surgical risk to be high (estimated risk for mortality, 10%; estimated risk for major morbidity plus mortality, 38%).
Which of the following is the most appropriate treatment?
A. Balloon aortic valvuloplasty
B. Medical therapy
C. Surgical aortic valve replacement
D. Transcatheter aortic valve replacement
D. Transcatheter aortic valve replacement
Transcatheter aortic valve replacement has been found to be comparable to surgical intervention and is indicated for symptomatic patients with aortic stenosis and intermediate or high surgical risk, as assessed by a multidisciplinary heart team.
A 52-year-old man is evaluated for dysphagia of 3 months' duration. He reports regurgitating undigested food soon after eating solid food, occasional coughing and choking after swallowing, and chronic halitosis. He reports no weight loss or chest pain. He drinks two beers weekly and does not smoke.
On physical examination, vital signs are normal; BMI is 25. The remainder of the examination, including abdominal examination, is unremarkable.
Which of the following is the most appropriate diagnostic test to perform next?
A. Barium esophagography
B. Esophageal manometry
C. 24-Hour esophageal pH monitoring
D. Upper endoscopy
A. Barium esophagography
Key Point
Patients with dysphagia associated with regurgitation of undigested food should be evaluated with a barium esophagram for the presence of a Zenker diverticulum.
A 67-year-old man is seen for an increase in serum creatinine level and an abnormal urinalysis found during the evaluation of monoclonal gammopathy of undetermined significance. His evaluation revealed an M-protein spike of 1.5 g/dL, <10% clonal plasma cells on bone marrow biopsy, and no evidence of anemia, hypercalcemia, or lytic bone lesions on skeletal survey. Immunofixation revealed IgG as the monoclonal type. He has no constitutional symptoms, no other medical problems, and takes no medications.
On physical examination, vital signs are normal. Trace lower extremity edema is noted. The remainder of the examination is unremarkable.
Laboratory studies:
Albumin 3.6 g/dL (36 g/L)
Creatinine 1.6 mg/dL (141.4 µmol/L)
Urinalysis pH 5.5; 2+ blood; 3+ protein; 5-8 erythrocytes/hpf
Urine albumin-creatinine ratio 400 mg/g
Which of the following is the most appropriate next diagnostic test?
A. ANCA testing
B. β2-Microglobulin levels
C. Kidney biopsy
D. Serum free light chains
C. Kidney biopsy
Key Point
Monoclonal gammopathy of renal significance is diagnosed in patients who would otherwise meet the criteria for monoclonal gammopathy of undetermined significance but have an abnormal urinalysis and kidney insufficiency; kidney biopsy confirms the diagnosis.
A 50-year-old woman undergoes follow-up evaluation for a right iliofemoral deep venous thrombosis diagnosed 6 weeks ago by Doppler ultrasonography. She reports no new symptoms and notes her right leg edema is improving. She has no history of travel, surgery, or immobility. She indicates feeling well before her diagnosis, with no shortness of breath. She had a normal screening colonoscopy 3 months ago and a normal mammogram and Pap smear 6 months ago. Medical history is otherwise unremarkable. Her only medication is rivaroxaban.
On physical examination, vital signs are normal. She has mild edema of the right lower extremity. The examination is otherwise unremarkable.
Which of the following is the most appropriate diagnostic test to perform next?
A. Abdominal and pelvic CT
B. Chest CT
C. Repeat lower extremity Doppler ultrasonography
D. No additional testing
D. No additional testing
Key Point
In approximately 10% of patients in whom an unprovoked venous thromboembolism is diagnosed, cancer will be found within 1 year, so an age-appropriate screening test should be performed.
A 64-year-old woman is evaluated in the emergency department 4 hours after the abrupt onset of sharp, tearing chest and back pain. Medical history is significant for hyperlipidemia. Her only medication is atorvastatin.
On physical examination, temperature is 36.8 °C (98.2 °F), blood pressure is 173/99 mm Hg, and pulse rate is 90/min. Blood pressure measurements in both arms are equal. The remainder of the physical examination is unremarkable.
CT angiography shows a descending thoracic aortic aneurysm with a maximal diameter of 6.8 cm and aortic dissection originating just distal to the left subclavian artery and extending to just below the diaphragm; there is no involvement of the renal arteries.
Which of the following is the most appropriate initial management?
A. Immediate endovascular stenting
B. Immediate open surgical repair
C. Medical therapy
D. Repeat CT angiography in 12 hours
C. Medical therapy
Key Point
Patients with uncomplicated type B aortic dissection may be initially treated with medical therapy, including β-blockers, sodium nitroprusside, and opioids.
A 75-year-old man is evaluated for progressive dysphagia of 8 months' duration for both solid food and water, and the necessity to induce vomiting several times each month to relieve his symptoms. He also has experienced chest pain and heartburn symptoms. He has lost approximately 6 kg (13 lb) of weight over the preceding 3 months and a total of 9 kg (20 lb) since his symptoms began. He has a long history of cigarette and alcohol use. His medical history and review of systems is otherwise negative. He has no travel history outside the northeastern United States. He takes no medication.
On physical examination, vital signs are normal; BMI is 23. He appears thin and tired. The remainder of the physical examination is unremarkable.
Upper endoscopic findings reveal retained saliva, liquid, and food in the esophagus without mechanical obstruction. Manometry demonstrates incomplete lower esophageal relaxation and aperistalsis.
Which of the following is the most likely diagnosis?
A. Achalasia
B. Chagas disease
C. Eosinophilic esophagitis
D. Pseudoachalasia
D. Pseudoachalasia
Pseudoachalasia is caused by a tumor at the gastroesophageal junction infiltrating the myenteric plexus causing esophageal motor abnormalities; symptoms, barium-imaging and manometric findings, and endoscopic appearance are similar to achalasia.
A 48-year-old woman is evaluated in the emergency department for a 1-day history of hearing voices. History is significant for bipolar disorder. Medications are lithium carbonate and quetiapine.
On physical examination, the patient is disheveled and looks chronically ill. She is alert and oriented but appears anxious. Blood pressure is 138/78 mm Hg, and pulse rate is 80/min without orthostatic changes. There is no edema. The remainder of the examination is normal.
Laboratory studies:
Blood urea nitrogen 6 mg/dL (2.1 mmol/L)
Creatinine 0.9 mg/dL (79.6 µmol/L)
Sodium 126 mEq/L (126 mmol/L)
Potassium 3.5 mEq/L (3.5 mmol/L)
Chloride 94 mEq/L (94 mmol/L)
Bicarbonate 26 mEq/L (26 mmol/L)
Glucose 156 mg/dL (8.7 mmol/L)
Urine sodium12 mEq/L (12 mmol/L)
Urine osmolality 96 mOsm/kg H2O
Which of the following is the most likely cause of this patient's hyponatremia?
A. Hyperglycemia
B. Nephrogenic diabetes insipidus
C. Polydipsia
D. Syndrome of inappropriate antidiuretic hormone secretion
E. Volume depletion
C. Polydipsia
Key Point
Isovolemic hypotonic hyponatremia associated with urine osmolality <100 mOsm/kg H2O indicates excessive water intake, as seen with psychogenic polydipsia or poor solute intake.
A 52-year-old man is evaluated in the emergency department for decreased exercise tolerance and yellowing of the eyes for the past 3 days. He was diagnosed with leprosy 6 days ago and began antibacterial therapy 4 days ago. His complete blood count at that time was normal. He is a Haitian immigrant. Medications are dapsone, rifampicin, and clofazimine.
On physical examination, temperature is 36.7 °C (98.0 °F), blood pressure is 125/75 mm Hg, pulse rate is 100/min, and respiration rate is 18/min. He has icteric sclerae. Cardiac examination reveals a grade 2/6 systolic flow murmur. Multiple raised erythematous papules with decreased sensation are noted on the back and hands. No organomegaly is observed.
Laboratory studies:
Haptoglobin Undetectable
Hemoglobin 5.6 g/dL (56 g/L)
Leukocyte count 5600/µL (5.6 × 109/L)
Platelet count 223,000/µL (223 × 109/L)
Reticulocyte count 12% of erythrocytes
Examination of the peripheral blood smear shows bite cells. The direct antiglobulin (Coombs) test is negative.
Which of the following is the most appropriate immediate management?
A. Administer prednisone
B. Administer rituximab
C. Discontinue dapsone
D. Measure ADAMTS13 activity
E. Measure G6PD levels
C. Discontinue dapsone
Key Point
Testing for glucose-6-phosphate dehydrogenase activity is reliable in men who are not experiencing an acute hemolytic episode but is less useful during acute episodes because reticulocytes produce higher levels of enzyme, resulting in a falsely normal test result.
A 52-year-old woman is evaluated during a follow-up visit. She was discharged from the hospital 3 weeks ago following a small non–ST-elevation myocardial infarction treated with drug-eluting stent placement in the right coronary artery. An echocardiogram obtained during hospitalization showed normal left ventricular function and normal valvular function. Her hospital course was uncomplicated. Since discharge, she has had shortness of breath. Medical history is significant for hyperlipidemia. Medications are aspirin, ticagrelor, lisinopril, metoprolol, and atorvastatin.
On physical examination, vital signs are normal. Oxygen saturation is 99% breathing ambient air. The estimated central venous pressure is normal. Cardiac examination reveals no S3 or murmurs. The lungs are clear to auscultation.
A chest radiograph is normal. An electrocardiogram is unchanged from those obtained in the hospital.
Which of the following is the most likely cause of this patient's dyspnea?
A. Heart failure
B. In-stent restenosis
C. Stent thrombosis
D. Ticagrelor-mediated side effect
D. Ticagrelor-mediated side effect
Key Point
Dyspnea is a well-recognized and often self-limited side effect of ticagrelor therapy.
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
Key Point
Aspirin for secondary prophylaxis in patients with established cardiovascular disease should be continued after colonoscopy with polypectomy.
A 26-year-old man is evaluated during a follow-up visit after presenting to an urgent care clinic for back pain 1 week ago. Laboratory studies at that time were significant for a serum creatinine level of 1.4 mg/dL (123.8 µmol/L); other laboratory studies, including urinalysis, were normal. A urine albumin-creatinine ratio obtained in preparation for this visit is 10 mg/g. He is a personal trainer, and his daily exercise regimen includes weightlifting. He states that his back pain has resolved. He occasionally takes ibuprofen; the last use was 1 week ago. He takes no over-the-counter supplements.
On physical examination today, vital signs are normal. BMI is 29. The patient is muscular, without signs of obesity. There is no muscle tenderness.
Which of the following is the most appropriate management?
A. Avoid all NSAID medications
B. Measure the serum creatine kinase level
C. Measure the serum cystatin C level
D. Schedule a kidney biopsy
C. Measure the serum cystatin C level
Key Point
Increased muscle mass can result in an increase in serum creatinine level in the absence of change in kidney function. Cystatin C may be preferable to creatinine to assess kidney function in individuals with higher muscle mass
A 68-year-old man notes 3 days of melena and the recent onset of epistaxis and easy bruising. He had no bleeding problems until the past week. He has advanced ischemic cardiomyopathy and had a left ventricular assist device (LVAD) placed 3 months ago. He had no bleeding history before LVAD implantation surgery, and his preoperative coagulation studies were normal. Medications are atorvastatin, carvedilol, lisinopril, spironolactone, and warfarin initiated after LVAD placement.
On physical examination, other than a pulse rate of 112/min, vital signs are normal. Oxygen saturation is 94% breathing ambient air. He has crusted blood in the left nares, scattered ecchymoses, and multiple petechiae. The surgical scar on the anterior chest appears well healed. Stool for fecal occult blood is strongly positive. The remainder of the examination is normal.
Laboratory studies:
Activated partial thromboplastin time 40 s
Hemoglobin 8.0 mg/dL (80 g/L)
Platelet count 130,000/µL (130 × 109/L)
Prothrombin time 19 s
INR 2.0
Platelet Function Analyzer-100Prolonged
Aminotransferases Normal
Fibrinogen 350 mg/dL (3.5 g/L)
Which of the following is the most likely cause of this patient's new bleeding symptoms?
A. Acquired von Willebrand disease
B. Coagulopathy of liver disease
C. Dysfibrinogenemia
D. Immune thrombocytopenic purpura
A. Acquired von Willebrand disease
Key Point
High sheer force seen in some patients with prosthetic heart valves, abnormal native valves, and left ventricular assist device placement may cause an acquired von Willebrand disease with clinical bleeding.