Cardiology
Endocrinology
Rheumatology
Nephrology
Heme/Onc
100
A 48-year-old man is evaluated for recurrent pericarditis. Six months ago, he had acute pericarditis treated with ibuprofen and colchicine. His symptoms resolved completely within 3 weeks of initiation of therapy. Evaluations for an infectious cause and connective tissue disease were negative. The patient's symptoms recurred after ibuprofen was tapered over 1 month with continuation of colchicine. Ibuprofen was re-initiated at a high dose with resolution of symptoms and tapered over a 2-month period. His current symptoms began 24 hours ago. Currently, his only medication is colchicine.
On physical examination, temperature is 38.0 °C (100.4 °F); other vital signs are normal. Pulsus paradoxus of 10 mm Hg is present. There is no jugular venous distention. The lungs are clear to auscultation. A friction rub is heard at the left sternal border and apex.
ECG shows normal sinus rhythm with widespread ST-segment elevation of 0.5 to 1.0 mm. Echocardiogram shows a small circumferential pericardial effusion (diastolic echo-free space, 3 mm) without evidence of tamponade.
Which of the following is the most appropriate treatment?
A. Anakinra
B. Colchicine and IVIG
C. Ibuprofen
D. Ibuprofen, colchicine, and Prednisone
Ibuprofen, colchicine, and Prednisone
100
A 28-year-old woman is evaluated for a 6-month history of amenorrhea. Medical history is significant for schizophrenia. Her only medication is risperidone.
On physical examination, vital signs are normal. BMI is 28. No breast discharge is evident.
MRI reveals a normal pituitary gland.
Consultation with the patient's psychiatrist confirms that risperidone cannot be discontinued.
Estrodial is 10 pg/ml
FSH is 1 mU/ml
Prolactin 150 mg/ml
TSH 2.2
free thyroxine is 1.2
Which of the following is the most appropriate management?
A. Begin cabergoline
B. Begin estrogen-progesterone replacement therapy
C. Repeat pituitary MRI in 6 months
D. Repeat prolactin measurement in 6 months.
Begin estrogen-progesterone replacement therapy
untreated hyperprolactinemia can lead to hypogonadism and bone loss. estrogen-progesterone replacement is necessary to prevent this.
100
A 23-year-old man is evaluated for fever, abdominal pain, rash, and arthritis of the right knee of 3 days' duration that resolved 1 week ago. He has had more than 20 similar episodes, the last three occurring in the past year. The first episode occurred at age 5 years and presented as abdominal pain; the patient underwent appendectomy but no appendicitis was found. His paternal grandfather and maternal grandmother had a similar syndrome.
Physical examination findings, including vital signs, are normal.
Laboratory evaluation shows an erythrocyte sedimentation rate of 23 mm/h, a normal serum creatinine level, and 1+ protein on urinalysis.
Which of the following is the most appropriate treatment?
A. Canakinumab
B. Colchicine
C. Indomethacin
D. Prednisone
Colchicine
FMF- fever, abd pain, rash, arthritis for only several days. 1st line tx is Colchicine.
100
A 63-year-old man is evaluated during a follow-up visit for gastroesophageal reflux disease and heartburn. His symptoms are worse after large meals and when lying down and have significantly decreased the quality of his life and disrupted his sleep. He also has stage G4 chronic kidney disease, obesity, and hypertension. Medications are atenolol, lisinopril, and nifedipine.
On physical examination, vital signs are normal. BMI is 38. The remainder of the examination is normal.
Laboratory studies show an estimated glomerular filtration rate of 29 mL/min/1.73 m2.
Weight loss and other lifestyle management modifications for gastroesophageal reflux disease are discussed.
Which of the following is the most appropriate additional therapy?
A. Famotidine
B. Omeprazole
C. Oral Ca Carbonate and Mag Hydroxide
D. Sucralfate
Famotidine
PPI may contribute to progression of CKD so avoid.
100
An 8 yo kid with HbSS disease has a plain film of left femur for leg pain. The film shows sclerosis resulting in a "bone within bone appearance." Which of the following is most likely part of the child's PMHx?
A. Repeated Vaso occlusive painful crisis
B. Avascular necrosis
C. Recurrent fractures
D. Septic arthritis
E. Chronic transfusion therapy for stroke
Repeated vasoocclusive painful crisis
200
A 69-year-old woman is evaluated during a follow-up visit 7 months after coronary stent placement for non–ST-elevation myocardial infarction. History is also notable for paroxysmal atrial fibrillation, hypertension, and gastrointestinal bleeding due to diverticulosis 5 years ago. Medications are aspirin, clopidogrel, rivaroxaban, metoprolol, lisinopril, and rosuvastatin.
On physical examination, vital signs are normal. The patient weighs 80 kg (176.4 lb). Bruising is present on the arms and legs. The remainder of the examination is unremarkable.
Serum creatinine level is 1.0 mg/dL (88.4 μmol/L).
Which of the following is the most appropriate management?
A. D/c ASA
B. D/c Rivaroxaban
C. Switch to Rivaroxaban to reduce dose Apixaban
D. Switch Rivaroxaban to Warfarin
D/c ASA
200
A 62-year-old woman is evaluated after a fall, sustaining a right humerus fracture. Medical history is significant for gastric bypass surgery 10 years earlier. She takes a multivitamin and vitamin B12. She discontinued calcium and vitamin D assuming that the multivitamin was sufficient for her needs.
On physical examination, vital signs are normal. BMI is 29.
Laboratory studies:
Alkaline phosphatase 92 U/L
Calcium 9.0 mg/dL (2.3 mmol/L)
Creatinine 1.1 mg/dL (97.2 μmol/L)
Parathyroid hormone 92 pg/mL (92 ng/L)
25-Hydroxyvitamin D 31 ng/mL (77.4 nmol/L)
Dual-energy x-ray absorptiometry shows a left femur neck T-score of -2 and lumbar spine T-score of -2.2.
Which of the following is the appropriate next step in the patient's evaluation?
A. Measure 24hour urine/calcium excretion
B. Measure serum 1,25 dihydroxy vitamin D
C. Order parathyroid sestamibi scan
D. Order technetium bone scan
Measure 24-hour urine calcium excretion
If suspect malnutrition or malabsorption of Vit D, need to confirm by low serum 25 hydroxyvitamin D level or low 24-hour urine calcium excretion.
200
A 15 yo girl presents for c/o b/l knee pain and swelling that started one day ago. No trauma. she feels warm. No n/v/d but c/o some dysuria. was treated 2 weeks ago for Chlamydia. Exam shows temp of 38.3, red conjunctiva and b/l knee pain with swelling with decreased ROM. rest of the exam is normal. Urine dip is 2 + leukocytes. Which of the following is the most likely diagnosis?
A. Enthesitis related arthritis
B. Reactive arthritis
C. Juvenile psoriatic arthritis
D. Dermatomyositis
E. Juvenile idiopathic arthritis
Reactive arthritis= triad= urethritis, conjunctivitis and arthritis.
200
A 69-year-old woman is evaluated for a 2-month history of worsening fatigue, weight loss, and anorexia. She has no other medical problems and takes no medications.
On physical examination, the patient is afebrile. Blood pressure is 160/95 mm Hg, pulse rate is 88/min, respiration rate is 16/min, and oxygen saturation is 100% breathing ambient air. The remainder of the examination is unremarkable.
Laboratory studies:
Hematocrit 25.5%
Albumin 3.7 g/dL (37 g/L)
Calcium 10.9 mg/dL (2.7 mmol/L)
Creatinine 4.2 mg/dL (371.3 µmol/L)
Free κ light chains-Elevated
Free λ light chains-Elevated
κ/λ Free light chain ratio-4.1 (normal, 0.26-1.65)
Urinalysis- No blood; 1+ protein
Urine protein-creatinine ratio -2500 mg/g
Urine output-2.3 L/24 h
Kidney biopsy confirms the presence of myeloma cast nephropathy.
Which of the following is the most appropriate management?
A. Chemo
B. HD
C. Hospice referral
D. Plasmapheresis
Chemo
most appropriate for treatment of myeloma cast nephropathy to reduce concentration of free light chains.
200
A 58-year-old man is evaluated for possible smoldering myeloma. Medical history is unremarkable, and he takes no medications.
On physical examination, vital signs and other examination findings are normal.
Serum protein electrophoresis and immunofixation show an IgA protein spike of 3.5 g/dL (35 g/L). Bone marrow biopsy reveals 50% clonal plasma cells.
Whole-body low-dose CT scan is negative for bone lesions.
Which of the following is the most appropriate imaging test to perform next?
A. Bone scan
B. Skeletal survey
C. Whole body MRI
D. No more testing
Whole body MRI
Smoldering multiple myeloma (MM) is characterized by a serum M protein level of 3 g/dL (30 g/L) or greater (or ≥500 mg/24 hr of urinary monoclonal free light chains) or bone marrow plasma clonal cells of 10% to 59% and no evidence of myeloma-related signs or symptoms.
If whole body low dose Ct scan is negative for smoldering Myeloma, then needs a whole-body MRI next
300
A 3 days old neonate presents to the ED in cardiogenic shock. Prostaglandin E1 is useful for the palliation of which of the following?
A. MR
B. Critical coarct
C. Partial anomalous pulmonary venous return
D. VSD
E. AV canal defect
Critical coarct
Remember- it opens ductus arteriosus, which give pulmonary blood flow in cyanotic lesions, which cause obstruction to pulmonary blood flow.
300
A 58-year-old woman is evaluated for a 1-week history of palpitations and dyspnea. She reports having symptoms of mild exertional dyspnea, episodic palpitations, and fatigue 3 weeks earlier, for which she was evaluated in the emergency department with CT angiography for suspected pulmonary embolism. Results were negative. Her symptoms resolved, but then they reappeared 1 week ago. She otherwise has been well and takes no medications.
On physical examination, blood pressure is 150/80 mm Hg, pulse rate is 102/min and irregularly irregular, and oxygen saturation is 95% breathing ambient air. Other than tachycardia with an irregular rhythm, cardiopulmonary examination is normal. She has a large multinodular goiter with multiple nodules approximately 2 cm without one dominant nodule.
Laboratory studies show a thyroid-stimulating hormone level of less than 0.01 μU/mL (0.01 mU/L), free thyroxine level of 2.3 ng/dL (30.0 pmol/L), and total triiodothyronine level of 230 ng/dL (3.5 nmol/L).
ECG shows atrial fibrillation.
Which of the following is the most appropriate initial step in management?
A. Methimazole and propranolol initiation
B. Thyroid nodule fine needle aspiration biopsy
C. Thyroid scintigraphy with radioactive iodine uptake
D. Thyroid U/S
Methimazole and propranolol initiation
Ppl with multinodular goiters can develop thyrotoxicosis after administration of iodinated contrast material. It decreases thyroid hormone production and release within 1-2 weeks.
300
A 14 yo girl with 4 month hx of fatigue, diffuse arthralgia, poor concentration and sleep. She has widespread MSK pain. Exam is unremarkable. Labs normal including CBC, CMP, ESR, CRP mono, UDS, pregnancy, ANA. she missed 2 weeks of school. What is the most likely diagnosis?
A. Growing pains
B. SLE
C. Hypermobility spectrum disorder
D. Juvenile fibromyalgia
E. JIA
Juvenile fibromyalgia
300
During routine 5 yo well visit, a boy is discovered to have haering loss and microscopic hematuria. He has 2 OM in the past. his brother and mom's grandfather have hx of hearing loss. His brother also has microscopic hematuria and grandfather has ESKD. Whic of the following complications is most likely to occur in thie patient?
A. Recurrent UTI
B. Severe postural hypotension with urinary sodium loss
C. Recurrent episodes of gross hematuria
D. Recurrent fx due to progressive osteoporosis
E. Macular degeneration
What syndrome do you worry about?
Fam Hx of kidney dz with hearing loss and hematuria= Alport
Answer: Recurrent episodes of gross hematuria
300
A 51-year-old woman is evaluated before hospital discharge. She was diagnosed with high-risk acute myeloid leukemia and completed induction chemotherapy. Her leukemia is believed to be secondary to breast cancer therapy, which included surgery and chemotherapy following diagnosis 2 years ago.
On physical examination, vital signs and other findings are normal. A peripherally inserted central catheter is located in the left upper extremity.
Complete blood count and bone marrow aspirate and biopsy indicate complete remission.
Which of the following is the most appropriate management?
A. Allogeneic hematopoietic stem cell transplantation
B. Consolidation chemotherapy
C. Intrathecal chemotherapy plus whole brain irradiation
D. Maintenance chemotherapy
E. No additional treatment
Allogeneic hematopoietic stem cell transplantation
400
A 68-year-old man is evaluated in the hospital for a 1-month history of nonproductive cough, dyspnea, and constant chest pressure. He is a never-smoker.
On physical examination, blood pressure is 106/62 mm Hg with 18 mm Hg pulsus paradoxus, and pulse rate is 100/min. Central venous pressure is elevated, and heart sounds are distant.
A focused echocardiogram shows a 2-cm circumferential pericardial effusion with evidence of tamponade. Pericardiocentesis yields 650 mL of sanguinous fluid with marked improvement in symptoms.
A transthoracic echocardiogram (apical four-chamber view) after pericardiocentesis is shown (RA = right atrium, RV = right ventricle, LV = left ventricle, EFF = pericardial effusion). A chest CT scan with contrast after pericardiocentesis reveals a 4-mm right middle lobe nodule and a small pericardial effusion with drain in place. A 3 × 3–cm right atrial mass is present, contiguous with the lateral wall of the right atrium.
Which of the following is the most likely diagnosis?
A. Atrial myxoma
B. Bronchogenic carcinoma with cardiac mets
C. Cardiac angiosarcoma
D. Papillary fibroelastoma
Cardiac angiosarcoma
rare. seen in right atrium and associated with sanguinous pericardial effusion
400
You are called to the nursery to see a 2 day old male with recurrent hypoglycemia. His exam is normal except for a stretched penile length of 0.8 cm. Testicles are palpated. Which of the following is most likely?
A. Hypopituitarism
B. Prolactin deficiency
C. XX karyotype
D. Hypothyroidism
E. Androgen insensitivity syndrome
Hypopituitarism
can see low sugar, high direct bili and microphallus
400
A 73-year-old woman is hospitalized for progressive dyspnea. Six months ago, she developed chronic sinusitis and nose bleeds. Four months ago, a persistent dry chronic cough developed, followed by myalgia and distal paresthesia. She has lost 13.6 kg (30 lb).
On physical examination, temperature is 38.2 °C (100.8 °F), blood pressure is 148/96 mm Hg, pulse rate is 104/min, respiration rate is 24/min, and oxygen saturation is 94% with the patient breathing ambient air. Dry crackles are heard at the lung bases. There is loss of sensation to light touch in the left foot. Numerous small palpable red-purple lesions are present on the lower legs.
Laboratory studies:
Erythrocyte sedimentation rate 120 mm/h
Creatinine -1.7 mg/dL (150.3 μmol/L)
ANCA-Positive
Antiproteinase-3 antibodies- 70 antibody index (normal <1 antibody index)
Urinalysis 3+ blood; 2+ protein; 20-30 dysmorphic erythrocytes/hpf; 5-10 leukocytes/hpf
Chest radiograph shows peripheral pulmonary parenchymal opacities. Chest CT scan shows multiple opacities and nodules throughout both lungs.
Kidney biopsy results are pending.
High-dose glucocorticoids are started.
Which of the following will most likely be the appropriate additional treatment?
A. Azathioprine
B. Methotrexate
C. Mycophenolate mofetil
D. Rituximab
Rituximab
for new ANCA vasculitis (Granulomatosis with polyangiitis) - need steroids + rituximab or cyclophosphamide for induction of remission for severe organ threatening or life-threatening granulomatosis with polyangiitis.
400
A 67-year-old man is evaluated during a follow-up visit 4 weeks after being diagnosed with the nephrotic syndrome. He has a 7-year history of well-controlled type 2 diabetes mellitus with no retinopathy, neuropathy, or clinically evident vascular disease. He has no other medical problems, and his only medication is metformin.
On physical examination, blood pressure is 110/60 mm Hg; other vital signs are normal. No rash is noted. There is 2-mm pitting edema in the lower extremities to the knees bilaterally.
Laboratory studies:
Albumin
2.1 g/dL (21 g/L)
Total cholesterol
330 mg/dL (8.5 mmol/L)
Creatinine
1.4 mg/dL (123.8 µmol/L) (4 months ago, 1.0 mg/dL [88.4 µmol/L])
Hemoglobin A1c
6.9%
Serum protein electrophoresis
Negative
24-Hour urine protein excretion
12,000 mg/24 h
Kidney biopsy shows expansion of the mesangial areas by deposits of homogenous, pale eosinophilic material that are positive with Congo red staining and demonstrate apple-green birefringence when viewed under polarized light.
Which of the following is the most likely diagnosis?
A. DM kidney disease
B. IgA nephropathy
C. Membranous nephropathy
D. Renal AL amyloidosis
Renal AL amyloidosis
Gold standard for amyloidosis is the characteristic apple green birefringence with Congo red stain under polarized light.
400
A 4 mo old male who is hospitalized for severe bacteremia and sepsis x 2 with 1 picu admit for PNA. Several CBC show WBC of 2.4-3k cells and ANC of < 200. A recent bone marrow shows promyelocytic arrest. Which of the following best describes possible pathophysiology behind the condition?
A. Infiltration of marrow by leukemic blasts
B. Autoantibodies to granulocytes
C. Severe congenital neutropenia
D. GBS infection
E. Vit B12 deficiency
Severe congenital neutropenia
Kostman syndrome
see deficit of myeloid cell maturation and promyelocytic arrest. pt need treated with granulocyte colony stimulating factor.
500
a 20 day old male born at 25 weeks is severely ill and undergoing treatment for RDS. He has prominent apical pulse, bounding brachial and femoral pulses and continuous murmur at 2nd left ICS. O2 sats are equal in arms and legs. SBP in arms and legs are also equal with a widened pulse pressure. The cause of his cardiac findings is best treated with which meds?
A. Dig
B. Ibuprofen
C. Dexamethasone
D. Inhaled NO
E. PGE1
Ibuprofen
This is an open PDA when pulmonary vascular resistance is falling. Continuous L to R shunt aka machine like. hyperdynamic precordium with increased left volume load and wide pulse pressure
500
You are taking care of a 12 yo with T1DM. She was recently diagnosis with primary adrenal insufficiency. You suspect autoimmune polyglandular syndrome Type 2. For which of the following is she most at risk with this syndrome?
A. Hypothyroidism
B. Chronic mucocutaneous candidiasis
C. Chronic active hepatitis
D. Nial disease
E. Hypoparathyroidism
APS type 2 = Hypothyroidism, T1DM and primary adrenal insufficiency
500
A 60-year-old man is evaluated for a 1-year history of lower extremity edema. He has a 30-year history of poorly controlled ankylosing spondylitis. He also has intermittent uveitis. His only medication is naproxen; he has been reluctant to initiate biologic agents.
On physical examination, blood pressure is 158/90 mm Hg. Other vital signs are normal. He has kyphosis with immobility of the cervical, thoracic, and lumbar spine. There is decreased range of motion of the shoulders and hips with 30-degree flexion contractures at both hips. There is 2+ bilateral swelling of the lower extremities.
Laboratory studies:
Albumin 2.5 g/dL (25 g/L)
C-reactive protein 6.3 mg/dL (63 mg/L)
Creatinine 1.8 mg/dL (159.1 μmol/L)
Urinalysis3+ protein; no erythrocytes, leukocytes, casts, or eosinophils
Protein-creatinine ratio 5200 mg/g
Which of the following is the most likely diagnosis?
A, Analgesic nephropathy
B. IgA nephropathy
C. Interstitial nephritis
D. Renal amyloidosis
Renal amyloidosis
long standing poorly controlled AS can develop renal AA amyloidosis
AA amyloidosis of kidneys shows proteinuria and then develops insufficiency
500
A 5 yo boy presents with a 4 day history of severe diarrhea. he is drinking plenty of water but acting tired. no fever and otherwise well. Which of the following is most consistent with this kid's condition?
A. Met acidosis with NAG and neg urine AG- d/t gi bicarb loss
B. Met Acidosis with HAG and neg UAG - d/t gi bicarb loss
C. Met acidosis with NAG and pos UAG- d/t gi bicarb loss
D. Met acidosis with HAG and Pos UAG- d/e gi bicarb loss
E. Met acidosis with HAG and urine pH < 5 d/t RTA
Met acidosis with NAG and neg urine AG- d/t gi bicarb loss (NAGMA)
NAGMA ddx: gi loss, prox type 2 RTA or chloride intoxication. need uAG = (Na + K - Cl)
Neg Urine UAG = Ne"Gut"ive AG= adequate ammonium excretion and normal kidney handling.
500
A 2 month old child comes for well visit. Review of NBS shows HbFAS on Hb electrophoresis. Which form of cancer is associated with this diagnosis?
A. Renal medullary carcinoma
B. Medulloblastoma
C. AML
D. Melanoma
E. Hepatoblastoma
Renal medullary carcinoma
HbAS = sickle trait - this is the only form of cancer associated with sickle trait but no need for universal screening.
needs prompt eval if develops hematuria.