A 58-year-old man presents to the emergency department with severe chest pain and uneasiness. He says that symptoms onset acutely half an hour ago while he was watching television. He describes the pain as being 8/10 in intensity, sharp in character, localized to the center of the chest and retrosternal, and radiating to the back and shoulders. The patient denies any associated change in the pain with breathing or body position. He says he has associated nausea but denies any vomiting. He denies any recent history of fever, chills, or chronic cough. His past medical history is significant for hypertension, hyperlipidemia, and diabetes mellitus for which he takes lisinopril, hydrochlorothiazide, simvastatin, and metformin. He reports a 30-pack-year smoking history and has 1–2 alcoholic drinks during the weekend. Family history is significant for hypertension, hyperlipidemia, and an ST elevation myocardial infarction in his father and paternal uncle. His blood pressure is 220/110 mm Hg in the right arm and 180/100 mm Hg in the left arm. On physical examination, the patient is diaphoretic. Cardiac exam reveals a grade 2/6 diastolic decrescendo murmur loudest over the left sternal border. Remainder of the physical examination is normal. The chest radiograph shows a widened mediastinum. The electrocardiogram (ECG) reveals non-specific ST segment and T wave changes. Intravenous morphine and beta-blockers are started. Which of the following is the most likely diagnosis in this patient?
Q1032
A 21-year-old man comes to the physician's office due to a 3-week history of fatigue and a rash, along with the recent development of joint pain that has moved from his knee to his elbows. The patient reports going camping last month but denies having been bitten by a tick. His past medical history is significant for asthma treated with an albuterol inhaler. His pulse is 54/min and blood pressure is 110/72. Physical examination reveals multiple circular red rings with central clearings on the right arm and chest. There is a normal range of motion in all joints and 5/5 strength bilaterally in the upper and lower extremities. Without proper treatment, the patient is at highest risk for which of the following complications?
Q1033
A 28-year-old man presents to his primary care provider because of shortness of breath, cough, and wheezing. He reports that in high school, he occasionally had shortness of breath and would wheeze after running. His symptoms have progressively worsened over the past 6 months and are now occurring daily. He also finds himself being woken up from sleep by his wheeze approximately 3 times a week. His medical history is unremarkable. He denies tobacco use or excessive alcohol consumption. His temperature is 37.1°C (98.8°F), blood pressure is 121/82 mm Hg, and heart rate is 82/min. Physical examination is remarkable for expiratory wheezing bilaterally. Spirometry shows an FEV1 of 73% of predicted, which improves by 19% with albuterol. In addition to a short-acting beta-agonist as needed, which of the following is the most appropriate therapy for this patient?
Q1034
A 37-year-old man is presented to the emergency department by paramedics after being involved in a serious 3-car collision on an interstate highway while he was driving his motorcycle. On physical examination, he is responsive only to painful stimuli and his pupils are not reactive to light. His upper extremities are involuntarily flexed with hands clenched into fists. The vital signs include temperature 36.1°C (97.0°F), blood pressure 80/60 mm Hg, and pulse 102/min. A non-contrast computed tomography (CT) scan of the head shows a massive intracerebral hemorrhage with a midline shift. Arterial blood gas (ABG) analysis shows partial pressure of carbon dioxide in arterial blood (PaCO2) of 68 mm Hg, and the patient is put on mechanical ventilation. His condition continues to decline while in the emergency department and it is suspected that this patient is brain dead. Which of the following results can be used to confirm brain death and legally remove this patient from the ventilator?
Q1035
A 65-year-old man comes to the physician because of a 10-month history of crampy left lower extremity pain that is exacerbated by walking and relieved by rest. The pain is especially severe when he walks on an incline. He has a 20-year history of type 2 diabetes mellitus, for which he takes metformin. He has smoked 1 pack of cigarettes daily for 40 years. His blood pressure is 140/92 mm Hg. Physical examination shows dry and hairless skin over the left foot. Which of the following is the most likely underlying cause of this patient's symptoms?
Q1036
A 51-year-old woman with a history of palpitations is being evaluated by a surgeon for epigastric pain. It is discovered that she has an epigastric hernia that needs repair. During her preoperative evaluation, she is ordered to receive lab testing, an electrocardiogram (ECG), and a chest X-ray. These screening studies are unremarkable except for her chest X-ray, which shows a 2 cm isolated pulmonary nodule in the middle lobe of the right lung. The nodule has poorly defined margins, and it shows a dense, irregular pattern of calcification. The patient is immediately referred to a pulmonologist for evaluation of the lesion. The patient denies any recent illnesses and states that she has not traveled outside of the country since she was a child. She has had no sick contacts or respiratory symptoms, and she does not currently take any medications. She does, however, admit to a 20-pack-year history of smoking. Which of the following is the most appropriate next step in evaluating this patient’s diagnosis with regard to the pulmonary nodule?
Q1037
A 68-year-old woman is brought to the emergency department after being found unresponsive in her bedroom in a nursing home facility. Her past medical history is relevant for hypertension, diagnosed 5 years ago, for which she has been prescribed a calcium channel blocker and a thiazide diuretic. Upon admission, she is found with a blood pressure of 200/116 mm Hg, a heart rate of 70/min, a respiratory rate of 15 /min, and a temperature of 36.5°C (97.7°F). Her cardiopulmonary auscultation is unremarkable, except for the identification of a 4th heart sound. Neurological examination reveals the patient is stuporous, with eye-opening response reacting only to pain, no verbal response, and flexion withdrawal to pain. Both pupils are symmetric, with the sluggish pupillary response to light. A noncontrast CT of the head is performed and is shown in the image. Which of the following is the most likely etiology of this patient’s condition?
Q1038
A 51-year-old woman comes to the physician because of a 3-day history of worsening shortness of breath, nonproductive cough, and sharp substernal chest pain. The chest pain worsens on inspiration and on lying down. The patient was diagnosed with breast cancer 2 months ago and was treated with mastectomy followed by adjuvant radiation therapy. She has hypertension and hyperlipidemia. Current medications include tamoxifen, valsartan, and pitavastatin. She has smoked a pack of cigarettes daily for 15 years but quit after being diagnosed with breast cancer. Her pulse is 95/min, respirations are 20/min, and blood pressure is 110/60 mm Hg. Cardiac examination shows a scratching sound best heard at the left lower sternal border. An ECG shows sinus tachycardia and ST segment elevations in leads I, II, avF, and V1–6. Which of the following is the most likely underlying cause of this patient's symptoms?
Q1039
A 35-year-old African-American female presents to the emergency room complaining of chest pain. She also complains of recent onset arthritis and increased photosensitivity. Physical examination reveals bilateral facial rash. Which of the following is most likely to be observed in this patient?
Q1040
A 67-year-old man with a 55-pack-year smoking history, diabetes type II, and hyperlipidemia presents to his primary care clinic for an annual exam. He has no complaints. He reports that his blood glucose has been under tight control and that he has not smoked a cigarette for the past 5 months. His temperature is 97.5°F (36.4°C), blood pressure is 182/112 mmHg, pulse is 85/min, respirations are 15/min, and oxygen saturation is 95% on room air. Physical examination is notable for bruits bilaterally just lateral of midline near his umbilicus. The patient is started on anti-hypertensive medications including a beta-blocker, a thiazide diuretic, and a calcium channel blocker. He returns 1 month later with no change in his blood pressure. Which of the following is the best next step in management?
Cardiology US Medical PG Practice Questions and MCQs
Question 1031: A 58-year-old man presents to the emergency department with severe chest pain and uneasiness. He says that symptoms onset acutely half an hour ago while he was watching television. He describes the pain as being 8/10 in intensity, sharp in character, localized to the center of the chest and retrosternal, and radiating to the back and shoulders. The patient denies any associated change in the pain with breathing or body position. He says he has associated nausea but denies any vomiting. He denies any recent history of fever, chills, or chronic cough. His past medical history is significant for hypertension, hyperlipidemia, and diabetes mellitus for which he takes lisinopril, hydrochlorothiazide, simvastatin, and metformin. He reports a 30-pack-year smoking history and has 1–2 alcoholic drinks during the weekend. Family history is significant for hypertension, hyperlipidemia, and an ST elevation myocardial infarction in his father and paternal uncle. His blood pressure is 220/110 mm Hg in the right arm and 180/100 mm Hg in the left arm. On physical examination, the patient is diaphoretic. Cardiac exam reveals a grade 2/6 diastolic decrescendo murmur loudest over the left sternal border. Remainder of the physical examination is normal. The chest radiograph shows a widened mediastinum. The electrocardiogram (ECG) reveals non-specific ST segment and T wave changes. Intravenous morphine and beta-blockers are started. Which of the following is the most likely diagnosis in this patient?
A. Pulmonary embolism
B. Acute myocardial infarction
C. Myocarditis
D. Aortic regurgitation
E. Aortic dissection (Correct Answer)
Explanation: ***Aortic dissection***
- The patient's **sudden onset, sharp tearing chest pain radiating to the back** is the classic presentation of aortic dissection.
- The **blood pressure differential between arms** (220/110 mm Hg right vs 180/100 mm Hg left) is a highly specific finding indicating involvement of the brachiocephalic or subclavian arteries.
- The **diastolic decrescendo murmur** represents acute aortic regurgitation secondary to the dissection involving the aortic root.
- The **widened mediastinum on chest X-ray** is a key radiographic finding strongly suggestive of aortic dissection.
- Major risk factors present: **uncontrolled hypertension, smoking history, age, and atherosclerotic disease** (hyperlipidemia, diabetes).
*Pulmonary embolism*
- While PE can cause acute chest pain and dyspnea, the pain is typically **pleuritic in nature** (worsens with breathing or coughing).
- PE does not cause **blood pressure differentials between arms** or a **widened mediastinum**.
- The sharp, tearing quality radiating to the back is not characteristic of PE.
*Acute myocardial infarction*
- MI typically presents with **pressure-like or crushing chest pain**, often radiating to the left arm, jaw, or epigastrium rather than the back.
- While the patient has significant MI risk factors, the **unequal blood pressures between arms** and **diastolic murmur** are not explained by isolated MI.
- The **widened mediastinum** is not a feature of uncomplicated MI.
*Myocarditis*
- Myocarditis typically presents with **chest pain following a viral prodrome** (fever, URI symptoms), which this patient denies.
- It does not cause **blood pressure differentials**, **widened mediastinum**, or the acute tearing pain radiating to the back.
- Myocarditis pain is usually more constant and pressure-like, not sharp and tearing.
*Aortic regurgitation*
- While the **diastolic decrescendo murmur** indicates aortic regurgitation, this is a **finding rather than the primary diagnosis**.
- In this acute presentation, the AR is **secondary to aortic dissection** involving the aortic root.
- Chronic AR is typically asymptomatic until heart failure develops; acute severe AR (as in dissection) causes acute decompensation.
- The constellation of findings (acute pain, BP differential, widened mediastinum) indicates **aortic dissection as the primary catastrophic event** causing secondary AR.
Question 1032: A 21-year-old man comes to the physician's office due to a 3-week history of fatigue and a rash, along with the recent development of joint pain that has moved from his knee to his elbows. The patient reports going camping last month but denies having been bitten by a tick. His past medical history is significant for asthma treated with an albuterol inhaler. His pulse is 54/min and blood pressure is 110/72. Physical examination reveals multiple circular red rings with central clearings on the right arm and chest. There is a normal range of motion in all joints and 5/5 strength bilaterally in the upper and lower extremities. Without proper treatment, the patient is at highest risk for which of the following complications?
A. Liver capsule inflammation
B. Bone marrow failure
C. Heart valve stenosis
D. Glomerular damage
E. Cranial nerve palsy (Correct Answer)
Explanation: ***Cranial nerve palsy***
- This patient presents with classic **Lyme disease** (caused by *Borrelia burgdorferi*), including camping exposure, fatigue, migratory arthralgia, and **erythema migrans** (multiple circular red rings with central clearings on the arm and chest).
- The **bradycardia (pulse 54/min)** suggests early **Lyme carditis** with possible first-degree AV block, which typically resolves with treatment and rarely progresses to complete heart block in treated cases.
- Without proper antibiotic treatment, **cranial neuropathy** is one of the most common neurological complications in early disseminated Lyme disease, with **facial nerve palsy (Bell's palsy)** being the most frequent, occurring in up to 10% of untreated patients.
- Other neurological complications include meningitis, radiculoneuropathy, and peripheral neuropathy, making neurologic involvement a significant risk in untreated disease.
*Liver capsule inflammation*
- **Perihepatitis (Fitz-Hugh-Curtis syndrome)** is associated with **pelvic inflammatory disease (PID)** caused by *Chlamydia trachomatis* or *Neisseria gonorrhoeae*, not Lyme disease.
- This presents with right upper quadrant pain and "violin string" adhesions between the liver capsule and peritoneum.
*Bone marrow failure*
- **Bone marrow failure** (aplastic anemia) can be caused by parvovirus B19, certain medications, radiation, or idiopathic causes, but is **not a recognized complication of Lyme disease**.
- Lyme disease primarily affects the skin, joints, heart (conduction system), and nervous system, not hematopoietic function.
*Heart valve stenosis*
- **Lyme carditis** affects the **cardiac conduction system**, causing **AV blocks** (first, second, or third degree) and myocarditis, as suggested by this patient's bradycardia.
- Lyme does **not cause valvular stenosis or regurgitation**. Valvular disease is associated with rheumatic fever (post-streptococcal), endocarditis, or degenerative changes.
- The cardiac manifestations of Lyme typically resolve with appropriate antibiotic therapy and rarely cause permanent structural damage.
*Glomerular damage*
- **Glomerulonephritis** is not a typical complication of Lyme disease in humans (though "Lyme nephritis" occurs in dogs).
- Renal involvement in human Lyme disease is extremely rare and not a significant clinical concern compared to neurological, cardiac, or rheumatological manifestations.
Question 1033: A 28-year-old man presents to his primary care provider because of shortness of breath, cough, and wheezing. He reports that in high school, he occasionally had shortness of breath and would wheeze after running. His symptoms have progressively worsened over the past 6 months and are now occurring daily. He also finds himself being woken up from sleep by his wheeze approximately 3 times a week. His medical history is unremarkable. He denies tobacco use or excessive alcohol consumption. His temperature is 37.1°C (98.8°F), blood pressure is 121/82 mm Hg, and heart rate is 82/min. Physical examination is remarkable for expiratory wheezing bilaterally. Spirometry shows an FEV1 of 73% of predicted, which improves by 19% with albuterol. In addition to a short-acting beta-agonist as needed, which of the following is the most appropriate therapy for this patient?
A. A high-dose inhaled corticosteroid and a long-acting beta-agonist
B. A long-acting beta-agonist alone
C. A low-dose inhaled corticosteroid alone
D. A medium-dose inhaled corticosteroid and a long-acting beta-agonist
E. A low-dose inhaled corticosteroid and a long-acting beta-agonist (Correct Answer)
Explanation: ***A low-dose inhaled corticosteroid and a long-acting beta-agonist***
- This patient presents with **persistent asthma symptoms** (daily symptoms, nighttime awakenings 3x/week, and a significant bronchodilator response) that are not controlled by a short-acting beta-agonist alone. This indicates **moderate persistent asthma**.
- According to GINA guidelines, the appropriate step-up therapy for moderate persistent asthma is a **low-dose inhaled corticosteroid (ICS) combined with a long-acting beta-agonist (LABA)**.
*A high-dose inhaled corticosteroid and a long-acting beta-agonist*
- **High-dose ICS/LABA** is reserved for **severe uncontrolled asthma**, typically as Step 4 or 5 therapy, when symptoms persist despite lower-dose combinations or higher-step single agents.
- The patient's current symptoms, while persistent, do not warrant immediate initiation of high-dose therapy as initial step-up from mild persistent.
*A long-acting beta-agonist alone*
- **LABAs should never be used as monotherapy** in asthma due to the risk of severe asthma exacerbations and asthma-related death.
- They must always be combined with an **inhaled corticosteroid** to control underlying airway inflammation.
*A low-dose inhaled corticosteroid alone*
- While a **low-dose ICS alone** is appropriate for **mild persistent asthma** (Step 2), this patient's symptoms (daily symptoms, nighttime awakenings 3x/week) are more severe than mild persistent.
- His severity warrants combination therapy (ICS/LABA) to achieve better symptom control.
*A medium-dose inhaled corticosteroid and a long-acting beta-agonist*
- A **medium-dose ICS/LABA** is typically considered for patients whose asthma remains **uncontrolled on low-dose ICS/LABA**, representing Step 4 therapy.
- Given that this is the initial step-up from SABA-only use, medium-dose is generally too aggressive and should be reserved for subsequent steps if the low-dose combination proves insufficient.
Question 1034: A 37-year-old man is presented to the emergency department by paramedics after being involved in a serious 3-car collision on an interstate highway while he was driving his motorcycle. On physical examination, he is responsive only to painful stimuli and his pupils are not reactive to light. His upper extremities are involuntarily flexed with hands clenched into fists. The vital signs include temperature 36.1°C (97.0°F), blood pressure 80/60 mm Hg, and pulse 102/min. A non-contrast computed tomography (CT) scan of the head shows a massive intracerebral hemorrhage with a midline shift. Arterial blood gas (ABG) analysis shows partial pressure of carbon dioxide in arterial blood (PaCO2) of 68 mm Hg, and the patient is put on mechanical ventilation. His condition continues to decline while in the emergency department and it is suspected that this patient is brain dead. Which of the following results can be used to confirm brain death and legally remove this patient from the ventilator?
A. Electrocardiogram
B. Apnea test (Correct Answer)
C. Lumbar puncture and CSF culture
D. Electromyography with nerve conduction studies
E. CT scan
Explanation: ***Correct: Apnea test***
- The **apnea test** is a **mandatory component** of brain death determination according to American Academy of Neurology (AAN) guidelines
- It directly confirms the **irreversible absence of brainstem function** by demonstrating no respiratory drive despite adequate stimulus (PaCO2 ≥60 mm Hg or 20 mm Hg rise from baseline)
- This patient already has a PaCO2 of 68 mm Hg, making the apnea test particularly relevant for confirmation
- Brain death requires both **clinical examination** (absent brainstem reflexes, coma) and a **positive apnea test** to legally declare death and discontinue mechanical ventilation
- The apnea test is performed by disconnecting the ventilator, providing supplemental oxygen, and observing for any respiratory effort while PaCO2 rises to adequate levels
*Incorrect: CT scan*
- While a **CT scan showing massive intracerebral hemorrhage with midline shift** provides anatomical evidence of severe, irreversible structural brain damage, it is **NOT sufficient to confirm brain death**
- CT imaging is used to establish the **etiology** and rule out reversible causes, but does not directly test brainstem function
- Brain death is a **clinical and functional diagnosis**, not purely an anatomical one—imaging alone cannot confirm cessation of all brain function
- A patient can have devastating structural damage on CT but still retain some brainstem reflexes
*Incorrect: Electrocardiogram*
- An **electrocardiogram (ECG)** measures cardiac electrical activity and provides no information about brain or brainstem function
- Cardiac activity commonly persists after brain death due to the heart's intrinsic automaticity
- ECG findings are irrelevant to brain death determination
*Incorrect: Lumbar puncture and CSF culture*
- **Lumbar puncture and CSF culture** are used to diagnose CNS infections (meningitis, encephalitis) or inflammatory conditions
- These tests are **completely irrelevant** for brain death diagnosis, which is based on irreversible cessation of all brain function, not infection
- In this trauma case with known intracerebral hemorrhage, LP would be contraindicated due to increased intracranial pressure and risk of herniation
*Incorrect: Electromyography with nerve conduction studies*
- **EMG and nerve conduction studies** assess peripheral nerve and muscle function, used for diagnosing neuromuscular disorders
- These tests provide no information about brain or brainstem function
- They are not part of brain death determination protocols
Question 1035: A 65-year-old man comes to the physician because of a 10-month history of crampy left lower extremity pain that is exacerbated by walking and relieved by rest. The pain is especially severe when he walks on an incline. He has a 20-year history of type 2 diabetes mellitus, for which he takes metformin. He has smoked 1 pack of cigarettes daily for 40 years. His blood pressure is 140/92 mm Hg. Physical examination shows dry and hairless skin over the left foot. Which of the following is the most likely underlying cause of this patient's symptoms?
A. Osteophytic compression of the lumbar spinal canal
B. Intimal plaque in the posterior tibial artery (Correct Answer)
C. Systemic hyperplastic arteriolosclerosis
D. Thrombosing vasculitis of the popliteal artery
E. Fibrin clot in the left popliteal vein
Explanation: ***Intimal plaque in the posterior tibial artery***
- The patient's symptoms of **crampy left lower extremity pain** exacerbated by walking and relieved by rest (**intermittent claudication**) are classic for **peripheral arterial disease (PAD)**.
- Risk factors like **diabetes mellitus**, **smoking**, and **hypertension** strongly predispose to **atherosclerosis** and **intimal plaque formation** in peripheral arteries, such as the posterior tibial artery, leading to reduced blood flow.
*Osteophytic compression of the lumbar spinal canal*
- While this can cause leg pain (**neurogenic claudication**), the pain typically **improves with leaning forward** and can be exacerbated by standing still, not necessarily relieved by rest of the legs.
- The patient's symptoms would not typically manifest with **dry and hairless skin** over the foot, which is indicative of chronic ischemia.
*Systemic hyperplastic arteriolosclerosis*
- This condition is usually associated with **severe hypertension** and primarily affects **small arterioles**, leading to **organ damage** (e.g., kidney failure, hypertensive retinopathy).
- It would not typically cause isolated, **crampy leg pain** that is specifically exacerbated by walking and relieved by rest, which is a hallmark of large vessel occlusive disease.
*Thrombosing vasculitis of the popliteal artery*
- **Vasculitis** typically involves **inflammation of blood vessel walls** and can cause a variety of symptoms including pain, skin lesions, and systemic signs.
- While it can lead to thrombosis, it's less common than atherosclerosis in a 65-year-old with multiple risk factors, and the presentation of isolated claudication is more characteristic of atherosclerotic disease.
*Fibrin clot in the left popliteal vein*
- A fibrin clot in a vein would cause **deep vein thrombosis (DVT)**, presenting with **swelling**, **redness**, and **tenderness** in the leg, not typically claudication.
- The pain associated with DVT usually **worsens with activity** and does not improve with rest in the same way as arterial claudication.
Question 1036: A 51-year-old woman with a history of palpitations is being evaluated by a surgeon for epigastric pain. It is discovered that she has an epigastric hernia that needs repair. During her preoperative evaluation, she is ordered to receive lab testing, an electrocardiogram (ECG), and a chest X-ray. These screening studies are unremarkable except for her chest X-ray, which shows a 2 cm isolated pulmonary nodule in the middle lobe of the right lung. The nodule has poorly defined margins, and it shows a dense, irregular pattern of calcification. The patient is immediately referred to a pulmonologist for evaluation of the lesion. The patient denies any recent illnesses and states that she has not traveled outside of the country since she was a child. She has had no sick contacts or respiratory symptoms, and she does not currently take any medications. She does, however, admit to a 20-pack-year history of smoking. Which of the following is the most appropriate next step in evaluating this patient’s diagnosis with regard to the pulmonary nodule?
A. Order a positron emission tomography scan of the chest
B. Perform a flexible bronchoscopy with biopsy
C. Obtain a contrast-enhanced CT scan of the chest
D. Try to obtain previous chest radiographs for comparison (Correct Answer)
E. Send sputum for cytology
Explanation: ***Try to obtain previous chest radiographs for comparison***
- Comparing current imaging with **previous chest radiographs** is crucial to assess if the nodule is new or has changed in size, an essential factor in determining its malignant potential.
- A **stable nodule** for over two years is often considered benign, potentially avoiding unnecessary invasive procedures.
*Order a positron emission tomography scan of the chest*
- A **PET scan** is useful for assessing the metabolic activity of a nodule, indicating malignancy, but it is typically ordered after evaluating nodule stability and risk factors, not as a primary first step.
- While it can help differentiate benign from malignant lesions, it's a more advanced imaging technique and might not be immediately necessary if previous imaging exists.
*Perform a flexible bronchoscopy with biopsy*
- **Bronchoscopy with biopsy** is an invasive procedure that carries risks and is generally reserved for nodules with a high suspicion of malignancy after initial non-invasive evaluations.
- Given the patient's presentation, less invasive steps for diagnosis should be exhausted first including evaluation of previous imaging and further characterization with CT.
*Obtain a contrast-enhanced CT scan of the chest*
- A **CT scan** provides much more detailed imaging of the nodule than an X-ray and is often the next step after plain radiographs, but comparing with previous films (if available) should precede it to establish nodule kinetics.
- While a CT scan can characterize the nodule's features more accurately (e.g., size, borders, calcification pattern), the **stability of the nodule over time** is paramount in risk assessment.
*Send sputum for cytology*
- **Sputum cytology** has a very low sensitivity for diagnosing pulmonary nodules, especially for small, isolated lesions that are not centrally located.
- Its utility is primarily in patients with central masses and productive cough, none of which are descriptive of this patient's presentation.
Question 1037: A 68-year-old woman is brought to the emergency department after being found unresponsive in her bedroom in a nursing home facility. Her past medical history is relevant for hypertension, diagnosed 5 years ago, for which she has been prescribed a calcium channel blocker and a thiazide diuretic. Upon admission, she is found with a blood pressure of 200/116 mm Hg, a heart rate of 70/min, a respiratory rate of 15 /min, and a temperature of 36.5°C (97.7°F). Her cardiopulmonary auscultation is unremarkable, except for the identification of a 4th heart sound. Neurological examination reveals the patient is stuporous, with eye-opening response reacting only to pain, no verbal response, and flexion withdrawal to pain. Both pupils are symmetric, with the sluggish pupillary response to light. A noncontrast CT of the head is performed and is shown in the image. Which of the following is the most likely etiology of this patient’s condition?
A. Arteriovenous malformation rupture
B. Venous sinus thrombosis
C. Hemorrhagic transformation
D. Charcot-Bouchard aneurysm rupture (Correct Answer)
E. Dural arteriovenous fistula
Explanation: ***Charcot-Bouchard aneurysm rupture***
- The patient's history of **uncontrolled hypertension** and presentation with **intracerebral hemorrhage** in the deep brain structures (likely basal ganglia or thalamus, as seen on CT) are highly characteristic of a ruptured Charcot-Bouchard aneurysm.
- These aneurysms are caused by chronic hypertension leading to microaneurysms in the small perforating arteries, which then rupture.
*Arteriovenous malformation rupture*
- AVMs can cause intracerebral hemorrhage, but they are typically **congenital** and often present at a younger age or with other symptoms like seizures or headaches prior to rupture.
- The CT image shows a localized hematoma, not typical for the more diffuse or lobar hemorrhage often associated with AVMs.
*Venous sinus thrombosis*
- This condition involves clotting in the cerebral venous sinuses, often leading to **venous infarction** and sometimes hemorrhagic transformation.
- While it can cause neurological deficits and hemorrhage, it typically presents with different imaging findings (e.g., delta sign on contrast CT, specific MRI findings) and symptoms like severe headaches and papilledema, which are not explicitly described here.
*Hemorrhagic transformation*
- Hemorrhagic transformation refers to an **ischemic stroke** that subsequently bleeds, often within the infarcted tissue.
- While possible, the sudden onset in an elderly hypertensive patient with a singular, well-defined deep hemorrhage on CT is more indicative of a primary hypertensive hemorrhage due to aneurysmal rupture rather than a conversion from ischemia, especially without prior signs of ischemic stroke.
*Dural arteriovenous fistula*
- DAVFs are abnormal connections between dural arteries and veins, which can lead to venous hypertension and hemorrhage.
- However, they are **rarer** than hypertensive hemorrhages and often present with pulsatile tinnitus, proptosis, or specific imaging findings of dilated draining veins, which are not present in this scenario.
Question 1038: A 51-year-old woman comes to the physician because of a 3-day history of worsening shortness of breath, nonproductive cough, and sharp substernal chest pain. The chest pain worsens on inspiration and on lying down. The patient was diagnosed with breast cancer 2 months ago and was treated with mastectomy followed by adjuvant radiation therapy. She has hypertension and hyperlipidemia. Current medications include tamoxifen, valsartan, and pitavastatin. She has smoked a pack of cigarettes daily for 15 years but quit after being diagnosed with breast cancer. Her pulse is 95/min, respirations are 20/min, and blood pressure is 110/60 mm Hg. Cardiac examination shows a scratching sound best heard at the left lower sternal border. An ECG shows sinus tachycardia and ST segment elevations in leads I, II, avF, and V1–6. Which of the following is the most likely underlying cause of this patient's symptoms?
A. Inflammatory reaction of the pericardium (Correct Answer)
B. Subendothelial fibrosis of coronary arteries
C. Embolic occlusion of a pulmonary artery
D. Dystrophic calcification of the mitral valve
E. Fibrotic thickening of the pericardium
Explanation: ***Inflammatory reaction of the pericardium***
- The patient's symptoms of **sharp substernal chest pain worsening on inspiration and lying down**, a **scratching sound on cardiac auscultation** (pericardial friction rub), and widespread **ST segment elevations on ECG** are classic for **pericarditis**, which is an inflammation of the pericardium.
- The recent **radiation therapy for breast cancer** is a significant risk factor for developing pericarditis, as radiation can cause inflammation and damage to the pericardial tissue.
*Subendothelial fibrosis of coronary arteries*
- This describes **atherosclerosis** of the coronary arteries, which typically presents as **angina** (chest pain with exertion) or **myocardial infarction** (sustained chest pain, potentially with ST elevation, but usually localized and associated with cardiac enzyme elevation).
- The widespread ST elevations and pericardial friction rub are not characteristic of acute coronary syndrome or stable angina caused by subendothelial fibrosis.
*Embolic occlusion of a pulmonary artery*
- This refers to a **pulmonary embolism (PE)**, which typically presents with sudden onset of **shortness of breath**, pleuritic chest pain, and **tachycardia**.
- While shortness of breath and tachycardia are present, the widespread ST elevations and pericardial friction rub are not typical findings in PE; ECG in PE usually shows T-wave inversions in V1-V3, right axis deviation, or S1Q3T3 pattern.
*Dystrophic calcification of the mitral valve*
- This condition is related to **mitral valve stenosis** or **regurgitation**, which can lead to symptoms like shortness of breath due to heart failure.
- However, it does not typically cause sharp substernal chest pain that worsens with inspiration and lying down, or the widespread ST segment elevations and pericardial friction rub.
*Fibrotic thickening of the pericardium*
- This describes **constrictive pericarditis**, a chronic condition where the pericardium becomes fibrotic and thickened, leading to impaired diastolic filling and signs of right-sided heart failure (e.g., elevated JVP, peripheral edema).
- While radiation therapy can cause this, the acute onset of sharp chest pain, pericardial friction rub, and widespread ST elevations are more indicative of acute inflammation rather than chronic constriction.
Question 1039: A 35-year-old African-American female presents to the emergency room complaining of chest pain. She also complains of recent onset arthritis and increased photosensitivity. Physical examination reveals bilateral facial rash. Which of the following is most likely to be observed in this patient?
A. Pain improves with inspiration
B. High-pitched diastolic murmur
C. Fixed and split S2
D. Mid-systolic click
E. Pain relieved by sitting up and leaning forward (Correct Answer)
Explanation: ***Pain relieved by sitting up and leaning forward***
- This patient's symptoms (chest pain, arthritis, photosensitivity, facial rash) are highly suggestive of **systemic lupus erythematosus (SLE)**.
- Among the cardiac manifestations of SLE, **pericarditis** is common. The chest pain of pericarditis is typically relieved by sitting up and leaning forward, as this decreases pressure on the inflamed pericardial sac.
*Pain improves with inspiration*
- This describes **pleuritic chest pain**, which is often associated with conditions like pleurisy or pneumothorax, where inspiration causes stretching of inflamed pleura.
- While pleurisy can occur in SLE, the relief by sitting up and leaning forward is a more classic sign of pericarditis.
*High-pitched diastolic murmur*
- A high-pitched diastolic murmur is characteristic of **aortic regurgitation** or **pulmonic regurgitation**.
- While SLE can cause valvular heart disease (e.g., Libman-Sacks endocarditis, often leading to mitral valve involvement), aortic or pulmonic regurgitation is not the most typical acute cardiac finding associated with these specific chest pain characteristics.
*Fixed and split S2*
- A fixed and split S2 is a classic finding in an **atrial septal defect (ASD)**.
- While rare, SLE can be associated with some congenital heart abnormalities or pulmonary hypertension, but ASD is not a typical direct complication leading to this S2 finding in the context of acute chest pain.
*Mid-systolic click*
- A mid-systolic click is characteristic of **mitral valve prolapse (MVP)**.
- Mitral valve abnormalities, including MVP and mitral regurgitation (due to Libman-Sacks endocarditis), are relatively common in SLE. However, the chest pain associated with pericarditis (relieved by sitting up) is a more direct and common finding given the constellation of symptoms than a mid-systolic click alone.
Question 1040: A 67-year-old man with a 55-pack-year smoking history, diabetes type II, and hyperlipidemia presents to his primary care clinic for an annual exam. He has no complaints. He reports that his blood glucose has been under tight control and that he has not smoked a cigarette for the past 5 months. His temperature is 97.5°F (36.4°C), blood pressure is 182/112 mmHg, pulse is 85/min, respirations are 15/min, and oxygen saturation is 95% on room air. Physical examination is notable for bruits bilaterally just lateral of midline near his umbilicus. The patient is started on anti-hypertensive medications including a beta-blocker, a thiazide diuretic, and a calcium channel blocker. He returns 1 month later with no change in his blood pressure. Which of the following is the best next step in management?
A. Increase dose of current blood pressure medications
B. Renal ultrasound with Doppler (Correct Answer)
C. Surgical revascularization
D. CT abdomen/pelvis
E. Lisinopril
Explanation: ***Renal ultrasound with Doppler***
- The patient presents with **resistant hypertension** (uncontrolled despite three antihypertensive medications from different classes) and **abdominal bruits**, strongly suggesting renovascular hypertension due to **renal artery stenosis**.
- A **renal ultrasound with Doppler** is the initial, non-invasive diagnostic test of choice to assess for renal artery stenosis by measuring blood flow velocities.
*Increase dose of current blood pressure medications*
- While adjusting medication doses is a common step, the presence of **abdominal bruits** and **resistant hypertension** warrants investigation for a secondary cause before simply escalating current therapy.
- Doing so without a definitive diagnosis risks ineffective treatment and delayed identification of the underlying issue.
*Surgical revascularization*
- **Surgical revascularization** or percutaneous intervention may be indicated if renal artery stenosis is confirmed and severe, but it is not the *next step* in management.
- Diagnostic imaging is required first to confirm the diagnosis and assess the severity before considering invasive procedures.
*CT abdomen/pelvis*
- A **CT scan of the abdomen/pelvis** could identify renal artery stenosis but is not the preferred initial imaging modality in this context.
- It involves **radiation exposure** and may require contrast, which could be problematic if renal function is impaired.
*Lisinopril*
- **Lisinopril**, an ACE inhibitor, could potentially manage hypertension by reducing angiotensin II.
- However, in cases of **bilateral renal artery stenosis**, ACE inhibitors can lead to a significant **drop in glomerular filtration rate (GFR)** and acute kidney injury, making it a high-risk choice without prior imaging.
