A 33-year-old woman comes to the physician because of a 3-week history of fatigue and worsening shortness of breath on exertion. There is no family history of serious illness. She does not smoke. She takes diethylpropion to control her appetite and, as a result, has had a 4.5-kg (10-lb) weight loss during the past 5 months. She is 163 cm (5 ft 4 in) tall and weighs 115 kg (254 lb); BMI is 44 kg/m2. Her pulse is 83/min and blood pressure is 125/85 mm Hg. Cardiac examination shows a loud pulmonary component of the S2. Abdominal examination shows no abnormalities. Which of the following is the most likely underlying cause of this patient's shortness of breath?
Q1102
A 25-year-old woman with bipolar disorder and schizophrenia presents to the emergency room stating that she is pregnant. She says that she has been pregnant since she was 20 years old and is expecting a baby now that she is breathing much harder and feeling more faint with chest pain caused by deep breaths. Her hospital medical record shows multiple negative pregnancy tests over the past 5 years. The patient has a 20 pack-year smoking history. Her temperature is 98°F (37°C), blood pressure is 100/60 mmHg, pulse is 110/min, respirations are 28/min, and oxygen saturation is 90% on room air. Her fingerstick glucose is 100 mg/dL. She has a large abdominal pannus which is soft and nontender. Her legs are symmetric and non-tender. Oxygen is provided via nasal cannula. Her urine pregnancy test comes back positive and an initial chest radiograph is unremarkable. What is the next best step in diagnosis?
Q1103
A 75-year-old man is brought to the emergency department 20 minutes after an episode of being unconscious. He was playing with his 3-year-old granddaughter when he suddenly fell down and was unresponsive for 1-minute. He responded normally after regaining consciousness. He has had episodes of mild chest pain and abdominal discomfort for the past 2 months, especially while working on his car. He has hypertension treated with hydrochlorothiazide. He appears alert. His temperature is 37.1°C (98.8°F), pulse is 89/min and regular, and blood pressure is 110/88 mm Hg. Examination shows a 3/6 crescendo-decrescendo systolic ejection murmur at the right sternal border that radiates to the carotids. There is no swelling or erythema of the lower extremities. Neurologic examination shows no focal findings. Which of the following is the most likely cause of this patient's symptoms?
Q1104
A 56-year-old man comes to the clinic complaining of back pain for the past 1 month. The pain is described as a dull ache that intensifies intermittently to an 8/10 in severity about 1-2 times a day. It intensified about 2 weeks ago following a fall during a ski trip. He reports that he noticed some pain at his buttocks and lower back following the fall but he wasn’t bothered by it. Hot packs and Tylenol seem to alleviate the pain somewhat. He denies lower extremity weakness, loss of sensation, fever, incontinence, or prior cancers; however, he reveals that his cousin was recently diagnosed with prostate cancer. Physical examination demonstrates normal range of motion and diffuse tenderness at the L4/L5 region with no point tenderness or vertebral step-offs. What is the next best step in the management of this patient?
Q1105
A 32-year-old man comes to the emergency department because of sharp chest pain for 3 days. The pain is retrosternal, 8 out of 10 in intensity, increases with respiration, and decreases while sitting upright and leaning forward. He has nausea and myalgia. He has not had fever or a cough. He has asthma and was treated for bronchitis 6 months ago with azithromycin. His mother has hypertension. He uses an over-the-counter inhaler. His temperature is 37.3°C (99.1°F), pulse is 110/min, and blood pressure is 130/84 mm Hg. Breath sounds are normal. Cardiac examination shows a high-pitched grating sound between S1 and S2. The remainder of the examination shows no abnormalities. Serum studies show:
Urea nitrogen 16 mg/dl
Glucose 103 mg/dL
Creatinine 0.7 mg/dL
Troponin I 0.230 ng/mL (N < 0.1 ng/mL)
An ECG shows diffuse ST elevations in all leads. The patient is at increased risk for which of the following conditions?
Q1106
A 70-year-old man presents to the clinic with right-sided chest pain and difficulty breathing for the past 10 days. When it began, the pain was mild, but as time went on, it increased to a level at which the man found it difficult to breathe. Two years ago, he was diagnosed with clear cell carcinoma of the kidney. Vital signs include: pulse rate is 72/min, blood pressure is 122/80 mm Hg, respiratory rate is 16/min, and temperature is 37.0°C (98.6°F). On physical examination, the trachea appears to have deviated to the left, respiratory movements are diminished, there is decreased resonance on percussion, and there is an absence of breath sounds over the right hemithorax. Which of the following is the most likely clinical diagnosis in this patient?
Q1107
A 66-year-old white man comes to the physician because of a 10-day history of fatigue and lower leg swelling. Over the past 6 months, he has had a 3.6-kg (8-lb) weight loss. He has chronic bronchitis and uses an albuterol inhaler as needed. He has smoked one pack of cigarettes daily for 44 years and drinks one alcoholic beverage daily. His temperature is 37°C (98.6°F), pulse is 88/min, and blood pressure is 120/75 mm Hg. He appears thin. Examination shows 2+ pretibial edema bilaterally. Cardiopulmonary examination shows no abnormalities. Laboratory studies show:
Hemoglobin 11.2 g/dL
Leukocyte count 8500/mm3
Platelet count 130,000/mm3
Serum
Urea nitrogen 23 mg/dL
Glucose 77 mg/dL
Creatinine 1.6 mg/dL
Albumin 1.8 mg/dL
Total cholesterol 475 mg/dL
Urine
Blood negative
Glucose negative
Protein 4+
WBC 0–1/hpf
Fatty casts numerous
An x-ray of the chest shows a right upper lobe density. A CT scan of the chest shows a 2.5 x 3.5 x 2-cm right upper lobe mass. Which of the following is the most likely diagnosis?
Q1108
A 17-year-old African-American male presents to his family physician after noticing red-tinged urine the week before, when he was suffering from a cold. The patient states that he had experienced that before. His father is with him and says that this happens to him on occasion as well. What is the most likely diagnosis for this patient?
Q1109
An 80-year-old male with known metastatic prostate cancer presents to your office with vague complaints of "achy bones." Strangely, he refers to you using the name of another physician. On physical exam, he is afebrile, but mildly tachycardic at 100 beats/min. Mucous membranes are dry. Cardiac exam shows regular rhythm and no murmurs. The patient has diffuse, nonfocal abdominal pain. He cannot articulate the correct date. You check the patient's serum calcium level, which is found to be 15.3 mg/dL. What is the best next step in management?
Q1110
A 78-year-old man presents to the emergency department because of confusion that started 2 hours ago. The patient’s daughter says that he has had blurred vision for several days. His right leg became weak 10 days ago, and he couldn’t walk for a few days before recovering. He was diagnosed with monoclonal gammopathy of undetermined significance 2 years ago. His temperature is 36.2°C (97.2°F), pulse is 75/min, respirations are 13/min, and blood pressure is 125/70 mm Hg. He also has gingival bleeding. Cervical lymphadenopathy is palpated on physical exam. Both the liver and spleen are palpated 5 cm below the costal margins. The serum protein electrophoresis with immunofixation is shown. Urine electrophoresis shows no abnormalities. A skeletal survey shows no abnormalities. Which of the following best explains these findings?
Cardiology US Medical PG Practice Questions and MCQs
Question 1101: A 33-year-old woman comes to the physician because of a 3-week history of fatigue and worsening shortness of breath on exertion. There is no family history of serious illness. She does not smoke. She takes diethylpropion to control her appetite and, as a result, has had a 4.5-kg (10-lb) weight loss during the past 5 months. She is 163 cm (5 ft 4 in) tall and weighs 115 kg (254 lb); BMI is 44 kg/m2. Her pulse is 83/min and blood pressure is 125/85 mm Hg. Cardiac examination shows a loud pulmonary component of the S2. Abdominal examination shows no abnormalities. Which of the following is the most likely underlying cause of this patient's shortness of breath?
A. Hypertrophy of interventricular septum
B. Calcification of the pulmonary valve
C. Blockade of the right bundle branch
D. Hyperplasia of pulmonary vascular walls (Correct Answer)
E. Fibrosis of pulmonary interstitium
Explanation: ***Hyperplasia of pulmonary vascular walls***
- **Diethylpropion** is an anorectic agent (appetite suppressant) that, like fenfluramine derivatives, is associated with **drug-induced pulmonary arterial hypertension (PAH)**.
- The mechanism involves **hyperplasia and remodeling of pulmonary vascular walls** (medial hypertrophy, intimal proliferation), leading to increased pulmonary vascular resistance.
- This manifests clinically as a **loud pulmonary component of S2** (loud P2 from elevated pulmonary artery pressure) and **exertional dyspnea** due to right ventricular strain and reduced cardiac output.
- The patient's **obesity** is an additional risk factor for developing pulmonary hypertension.
*Hypertrophy of interventricular septum*
- While obesity can lead to **cardiac remodeling**, isolated interventricular septal hypertrophy without other signs of hypertrophic cardiomyopathy is less likely to be the primary cause of these symptoms.
- This condition is often associated with **genetic mutations** or severe, longstanding **systemic hypertension**, not specifically linked to diethylpropion or the loud P2 finding.
*Calcification of the pulmonary valve*
- **Pulmonary valve calcification** leading to significant stenosis is rare in adults, particularly in a 33-year-old with no history of congenital heart disease or rheumatic fever.
- This would typically cause a systolic ejection murmur, which is not described in this case.
*Blockade of the right bundle branch*
- A **right bundle branch block (RBBB)** is an electrical conduction abnormality that does not directly cause shortness of breath or a loud P2.
- While RBBB can be associated with right ventricular strain from pulmonary hypertension, it is a consequence or co-occurring finding, not the underlying pathophysiologic cause.
*Fibrosis of pulmonary interstitium*
- **Pulmonary interstitial fibrosis** would typically be suggested by a history of autoimmune disease, environmental exposures, or specific drug toxicities (diethylpropion is not a common cause).
- It would often present with **bibasilar crackles** on lung auscultation and characteristic findings on chest imaging, none of which are mentioned in this case.
Question 1102: A 25-year-old woman with bipolar disorder and schizophrenia presents to the emergency room stating that she is pregnant. She says that she has been pregnant since she was 20 years old and is expecting a baby now that she is breathing much harder and feeling more faint with chest pain caused by deep breaths. Her hospital medical record shows multiple negative pregnancy tests over the past 5 years. The patient has a 20 pack-year smoking history. Her temperature is 98°F (37°C), blood pressure is 100/60 mmHg, pulse is 110/min, respirations are 28/min, and oxygen saturation is 90% on room air. Her fingerstick glucose is 100 mg/dL. She has a large abdominal pannus which is soft and nontender. Her legs are symmetric and non-tender. Oxygen is provided via nasal cannula. Her urine pregnancy test comes back positive and an initial chest radiograph is unremarkable. What is the next best step in diagnosis?
A. Ultrasound
B. D-dimer
C. Ventilation-perfusion scan (Correct Answer)
D. CT angiogram
E. Psychiatry consult for pseudocyesis
Explanation: ***Ventilation-perfusion scan***
- The patient presents with **dyspnea, chest pain exacerbated by deep breaths, tachypnea, tachycardia**, and **hypoxia**, all suggestive of a **pulmonary embolism (PE)**. Despite a positive pregnancy test, the long history of claimed pregnancy without prior confirmation and an unremarkable chest X-ray prioritizes immediate investigation for PE.
- While other imaging modalities exist, a **V/Q scan** is a safer initial choice for evaluating PE in pregnant patients compared to a CT angiogram, as it involves less radiation exposure to the fetus, especially when the chest X-ray is normal.
*Ultrasound*
- An ultrasound would confirm **intrauterine pregnancy** and fetal viability, but it would not address the patient's acute respiratory symptoms or rule out a life-threatening pulmonary embolism.
- While important for obstetrical management, it is not the most immediate next step for the patient's acute respiratory distress.
*D-dimer*
- A D-dimer test can be **falsely elevated in pregnancy**, making it less reliable for ruling out acute pulmonary embolism in this context.
- While a negative D-dimer can rule out PE in low-risk patients, a positive D-dimer is nonspecific during pregnancy and would not definitively confirm or exclude PE in this symptomatic patient.
*CT angiogram*
- A **CT pulmonary angiogram (CTPA)** is highly sensitive for PE but involves a higher radiation dose to the fetus compared to a V/Q scan.
- Given the patient's acute symptoms and the availability of a less invasive imaging option (V/Q scan) for PE in pregnant patients with a normal chest X-ray, CTPA is typically reserved if a V/Q scan is nondiagnostic or unavailable.
*Psychiatry consult for pseudocyesis*
- While the patient's history of claiming pregnancy for years and her psychiatric conditions (bipolar and schizophrenia) raise suspicion for **pseudocyesis (false pregnancy)**, her current positive urine pregnancy test means a true pregnancy cannot be immediately ruled out.
- Addressing her acute respiratory symptoms and potential pulmonary embolism takes precedence over a psychiatric consultation, as PE is a medical emergency.
Question 1103: A 75-year-old man is brought to the emergency department 20 minutes after an episode of being unconscious. He was playing with his 3-year-old granddaughter when he suddenly fell down and was unresponsive for 1-minute. He responded normally after regaining consciousness. He has had episodes of mild chest pain and abdominal discomfort for the past 2 months, especially while working on his car. He has hypertension treated with hydrochlorothiazide. He appears alert. His temperature is 37.1°C (98.8°F), pulse is 89/min and regular, and blood pressure is 110/88 mm Hg. Examination shows a 3/6 crescendo-decrescendo systolic ejection murmur at the right sternal border that radiates to the carotids. There is no swelling or erythema of the lower extremities. Neurologic examination shows no focal findings. Which of the following is the most likely cause of this patient's symptoms?
A. Fibrosis of the sinus node
B. Asymmetric septal hypertrophy
C. Rupture of the chordae tendineae
D. Embolus in the pulmonary artery
E. Calcification of the aortic valve (Correct Answer)
Explanation: ***Calcification of the aortic valve***
- The patient's presentation with **syncope** following exertion, combined with a **late systolic murmur radiating to the carotids**, is highly suggestive of **aortic stenosis**.
- In an elderly patient, the most common cause of aortic stenosis is **degenerative calcification of the aortic valve**.
*Fibrosis of the sinus node*
- **Sick sinus syndrome** due to fibrosis of the sinus node typically causes bradycardia, pauses, or tachy-brady syndrome.
- While it can cause syncope, it wouldn't explain the characteristic **cardiac murmur** described in the patient.
*Asymmetric septal hypertrophy*
- **Hypertrophic obstructive cardiomyopathy (HOCM)** can cause syncope and a systolic murmur, but the murmur typically **increases with Valsalva** and is due to dynamic outflow tract obstruction.
- HOCM commonly presents at a younger age and lacks the strong association with a **late systolic murmur radiating to the carotids** seen in aortic stenosis.
*Rupture of the chordae tendineae*
- Rupture of the chordae tendineae primarily affects the **mitral valve**, leading to acute **mitral regurgitation**.
- This would typically present with a **holosystolic murmur** best heard at the apex and signs of acute heart failure, which are not depicted in this case.
*Embolus in the pulmonary artery*
- A pulmonary embolus would cause sudden onset **dyspnea, pleuritic chest pain, and hypoxemia**, with potential for syncope due to right heart strain.
- It would not explain the **cardiac murmur** and history of exertional chest pain and abdominal discomfort observed over months.
Question 1104: A 56-year-old man comes to the clinic complaining of back pain for the past 1 month. The pain is described as a dull ache that intensifies intermittently to an 8/10 in severity about 1-2 times a day. It intensified about 2 weeks ago following a fall during a ski trip. He reports that he noticed some pain at his buttocks and lower back following the fall but he wasn’t bothered by it. Hot packs and Tylenol seem to alleviate the pain somewhat. He denies lower extremity weakness, loss of sensation, fever, incontinence, or prior cancers; however, he reveals that his cousin was recently diagnosed with prostate cancer. Physical examination demonstrates normal range of motion and diffuse tenderness at the L4/L5 region with no point tenderness or vertebral step-offs. What is the next best step in the management of this patient?
A. Exercise therapy with NSAIDs/acetaminophen (Correct Answer)
B. Morphine as needed
C. Back bracing
D. Bed rest with return to activity in 1 week
E. Radiograph of lumbar spine
Explanation: ***Exercise therapy with NSAIDs/acetaminophen***
- This patient presents with acute **non-radicular low back pain** with no red flags (fever, weakness, saddle anesthesia, incontinence) or signs of specific underlying pathology (no vertebral step-offs or point tenderness suggesting fracture).
- For such cases, **conservative management** including exercise, maintaining activity, and pain relief with NSAIDs or acetaminophen is the first-line treatment.
*Morphine as needed*
- **Opioids like morphine** are generally avoided as first-line treatment for acute low back pain due to risks of dependence and limited long-term efficacy compared to other modalities.
- Their use is typically reserved for severe, intractable pain unresponsive to less potent analgesics, and under careful consideration.
*Back bracing*
- **Back bracing** is not recommended for acute non-specific low back pain, as it can lead to muscle deconditioning and does not accelerate recovery.
- Braces may be considered in specific cases like spinal fractures or post-operative stabilization, which are not suggested here.
*Bed rest with return to activity in 1 week*
- **Prolonged bed rest** is largely discouraged for acute low back pain because it can lead to deconditioning, stiffness, and delayed recovery.
- Current guidelines emphasize maintaining **activity as tolerated** and early mobilization to prevent chronicity.
*Radiograph of lumbar spine*
- **Imaging (radiographs)** is generally not indicated for acute low back pain without specific red flags (e.g., suspicious for fracture, infection, malignancy) because it rarely changes management in uncomplicated cases.
- The patient has no neurological deficits, history of cancer, or signs of fracture, making immediate imaging unnecessary.
Question 1105: A 32-year-old man comes to the emergency department because of sharp chest pain for 3 days. The pain is retrosternal, 8 out of 10 in intensity, increases with respiration, and decreases while sitting upright and leaning forward. He has nausea and myalgia. He has not had fever or a cough. He has asthma and was treated for bronchitis 6 months ago with azithromycin. His mother has hypertension. He uses an over-the-counter inhaler. His temperature is 37.3°C (99.1°F), pulse is 110/min, and blood pressure is 130/84 mm Hg. Breath sounds are normal. Cardiac examination shows a high-pitched grating sound between S1 and S2. The remainder of the examination shows no abnormalities. Serum studies show:
Urea nitrogen 16 mg/dl
Glucose 103 mg/dL
Creatinine 0.7 mg/dL
Troponin I 0.230 ng/mL (N < 0.1 ng/mL)
An ECG shows diffuse ST elevations in all leads. The patient is at increased risk for which of the following conditions?
A. Cardiac tamponade (Correct Answer)
B. Papillary muscle rupture
C. Pulmonary infarction
D. Ventricular aneurysm
E. Mediastinitis
Explanation: ***Cardiac tamponade***
- The patient's symptoms (sharp chest pain relieving with sitting upright and leaning forward, pericardial friction rub on exam, diffuse ST elevations on ECG, and elevated troponin) are highly suggestive of **acute pericarditis**.
- **Cardiac tamponade** is a serious complication of pericarditis, occurring when excessive fluid accumulation in the pericardial sac compresses the heart, impairing its filling and leading to hemodynamic compromise.
*Papillary muscle rupture*
- **Papillary muscle rupture** is typically a complication of acute myocardial infarction, leading to severe **mitral regurgitation** and acute heart failure.
- The patient's ECG shows diffuse ST elevations, not localized changes indicative of transmural infarction, and there is no mention of a new murmur or signs of heart failure.
*Pulmonary infarction*
- **Pulmonary infarction** usually presents with pleuritic chest pain, dyspnea, and hemoptysis, often in the context of a **pulmonary embolism**.
- The patient's current presentation, including the characteristic pain relief with leaning forward and the ECG findings, is not consistent with pulmonary infarction.
*Ventricular aneurysm*
- A **ventricular aneurysm** is a late complication of a transmural myocardial infarction, typically manifesting weeks to months after the event with persistent ST elevation on ECG in the affected leads.
- While there are diffuse ST elevations, the acute onset of symptoms and pericardial rub point away from a chronic complication like a ventricular aneurysm.
*Mediastinitis*
- **Mediastinitis** is a severe infection of the mediastinum, often presenting with fever, severe chest pain (usually constant), and systemic signs of infection.
- The patient is afebrile, and his chest pain characteristics, physical exam (pericardial rub), and ECG findings are not typical for mediastinitis.
Question 1106: A 70-year-old man presents to the clinic with right-sided chest pain and difficulty breathing for the past 10 days. When it began, the pain was mild, but as time went on, it increased to a level at which the man found it difficult to breathe. Two years ago, he was diagnosed with clear cell carcinoma of the kidney. Vital signs include: pulse rate is 72/min, blood pressure is 122/80 mm Hg, respiratory rate is 16/min, and temperature is 37.0°C (98.6°F). On physical examination, the trachea appears to have deviated to the left, respiratory movements are diminished, there is decreased resonance on percussion, and there is an absence of breath sounds over the right hemithorax. Which of the following is the most likely clinical diagnosis in this patient?
A. Atelectasis
B. Pneumothorax
C. Pleural effusion (Correct Answer)
D. Pulmonary embolism
E. Pneumonia
Explanation: **Pleural effusion**
- The presence of **chest pain**, **dyspnea**, **tracheal deviation away from the affected side**, diminished respiratory movements, **decreased resonance on percussion**, and absence of breath sounds are classic signs of a large **pleural effusion**.
- The patient's history of **clear cell carcinoma** of the kidney suggests a metastatic cause, like **malignant pleural effusion**, contributing to the progressive symptoms.
*Atelectasis*
- While atelectasis presents with **dyspnea** and **decreased breath sounds**, the trachea typically deviates **towards the affected side** due to volume loss, which contradicts the presented leftward deviation.
- Percussion in atelectasis would typically yield **dullness**, but not necessarily decreased resonance with the degree of tracheal shift seen in a large effusion.
*Pneumothorax*
- A pneumothorax would present with **hyperresonance on percussion** due to air accumulation, not decreased resonance.
- Tracheal deviation in a tension pneumothorax would be **away from the affected side**, but the characteristic percussion finding differentiates it from pleural effusion.
*Pulmonary embolism*
- Pulmonary embolism primarily causes **acute dyspnea** and **pleuritic chest pain**, but typically does not produce the pronounced physical exam findings of tracheal deviation, decreased resonance, and absent breath sounds associated with a large space-occupying lesion in the pleural space.
- While it can cause a small pleural effusion, the extensive findings point against PE as the primary diagnosis.
*Pneumonia*
- Pneumonia presents with **fever**, **cough**, and usually **bronchial breath sounds** or **crackles** over the affected area, with **dullness to percussion**.
- It does not typically cause significant tracheal deviation, nor the complete absence of breath sounds over an entire hemithorax.
Question 1107: A 66-year-old white man comes to the physician because of a 10-day history of fatigue and lower leg swelling. Over the past 6 months, he has had a 3.6-kg (8-lb) weight loss. He has chronic bronchitis and uses an albuterol inhaler as needed. He has smoked one pack of cigarettes daily for 44 years and drinks one alcoholic beverage daily. His temperature is 37°C (98.6°F), pulse is 88/min, and blood pressure is 120/75 mm Hg. He appears thin. Examination shows 2+ pretibial edema bilaterally. Cardiopulmonary examination shows no abnormalities. Laboratory studies show:
Hemoglobin 11.2 g/dL
Leukocyte count 8500/mm3
Platelet count 130,000/mm3
Serum
Urea nitrogen 23 mg/dL
Glucose 77 mg/dL
Creatinine 1.6 mg/dL
Albumin 1.8 mg/dL
Total cholesterol 475 mg/dL
Urine
Blood negative
Glucose negative
Protein 4+
WBC 0–1/hpf
Fatty casts numerous
An x-ray of the chest shows a right upper lobe density. A CT scan of the chest shows a 2.5 x 3.5 x 2-cm right upper lobe mass. Which of the following is the most likely diagnosis?
A. Thin basement membrane disease
B. Granulomatosis with polyangiitis
C. Rapidly progressive glomerulonephritis
D. Membranous nephropathy (Correct Answer)
E. Focal segmental glomerulosclerosis
Explanation: ***Membranous nephropathy***
- This patient presents with signs of **nephrotic syndrome**: pronounced **proteinuria (4+)**, **hypoalbuminemia** (1.8 mg/dL), **hyperlipidemia** (total cholesterol 475 mg/dL), and **edema**.
- The chest x-ray and CT findings of a **right upper lobe mass** in a long-term smoker raise suspicion for a **paraneoplastic syndrome**, with **membranous nephropathy** being a common cause of nephrotic syndrome associated with solid tumors, particularly lung cancer.
*Thin basement membrane disease*
- This condition is typically associated with **microscopic hematuria** but usually **not significant proteinuria** leading to nephrotic syndrome.
- It is often asymptomatic or presents with recurrent hematuria, not the systemic symptoms of nephrotic syndrome seen here.
*Granulomatosis with polyangiitis*
- This is a **vasculitis** often affecting the kidneys, presenting as **rapidly progressive glomerulonephritis** with hematuria, red cell casts, and mild proteinuria.
- It would typically cause **systemic vasculitic symptoms** (e.g., upper and lower respiratory tract involvement, skin lesions), and the proteinuria would not typically be in the nephrotic range.
*Rapidly progressive glomerulonephritis*
- Characterized by **rapid decline in renal function** and a **nephritic urine sediment** (hematuria, red cell casts, mild proteinuria), not nephrotic-range proteinuria with fatty casts.
- While lung involvement can occur (e.g., Goodpasture syndrome, vasculitis), the presentation here is strongly indicative of nephrotic syndrome.
*Focal segmental glomerulosclerosis*
- While it causes **nephrotic syndrome**, it does not typically present with a clear **underlying malignancy** as a paraneoplastic manifestation.
- The presence of a lung mass strongly suggests a secondary cause for the glomerulopathy, making membranous nephropathy a more direct fit.
Question 1108: A 17-year-old African-American male presents to his family physician after noticing red-tinged urine the week before, when he was suffering from a cold. The patient states that he had experienced that before. His father is with him and says that this happens to him on occasion as well. What is the most likely diagnosis for this patient?
A. Hemophilia
B. Sickle cell trait (Correct Answer)
C. Acute interstitial nephritis
D. Acute glomerulonephritis
E. Acute cystitis
Explanation: ***Sickle cell trait***
- Patients with **sickle cell trait** (heterozygous for the sickle hemoglobin gene) can experience recurrent, painless **hematuria**, especially under conditions of low oxygen tension or dehydration, as seen during a **cold** or illness.
- The patient's **African-American ethnicity**, the recurrent nature of the hematuria often triggered by illness, and a positive **family history** strongly suggest sickle cell trait, which is typically benign but can manifest with hematuria.
*Hemophilia*
- Hemophilia causes **spontaneous bleeding** into joints, muscles, and internal organs, and while it can cause hematuria, the presentation is typically more severe, with prolonged bleeding episodes rather than isolated, red-tinged urine during a cold.
- Hemophilia is an **X-linked recessive disorder** affecting primarily males, but the characteristic symptoms of **easy bruising** or **prolonged bleeding** from minor cuts are not mentioned, and sickle cell trait is a more common cause of painless hematuria in this demographic.
*Acute interstitial nephritis*
- **Acute interstitial nephritis** typically presents with acute kidney injury, fever, rash, and eosinophilia, often triggered by drugs (e.g., NSAIDs, antibiotics) or infections.
- The isolated, recurrent **hematuria** associated with a cold and a family history makes this diagnosis less likely, as it primarily involves inflammation of the renal tubules and interstitium.
*Acute glomerulonephritis*
- **Acute glomerulonephritis** often presents with hematuria, proteinuria, edema, hypertension, and reduced GFR, usually occurring **7-10 days after a strep infection** (post-streptococcal glomerulonephritis) or immediately after a concurrent infection (IgA nephropathy).
- While **IgA nephropathy** can present with gross hematuria during a cold, its recurrent nature in multiple family members points more towards an underlying genetic predisposition like sickle cell trait, also the patient's symptoms are generally milder and resolve quickly in sickle cell trait compared to glomerulonephritis.
*Acute cystitis*
- **Acute cystitis** is a **urinary tract infection** that typically causes dysuria, frequency, urgency, and suprapubic pain, in addition to hematuria.
- The lack of other urinary symptoms, the recurrent nature associated with illness, and the family history make a simple infection like cystitis less likely as the primary diagnosis.
Question 1109: An 80-year-old male with known metastatic prostate cancer presents to your office with vague complaints of "achy bones." Strangely, he refers to you using the name of another physician. On physical exam, he is afebrile, but mildly tachycardic at 100 beats/min. Mucous membranes are dry. Cardiac exam shows regular rhythm and no murmurs. The patient has diffuse, nonfocal abdominal pain. He cannot articulate the correct date. You check the patient's serum calcium level, which is found to be 15.3 mg/dL. What is the best next step in management?
A. Calcitonin
B. Intravenous normal saline (Correct Answer)
C. Furosemide
D. Pamidronate
E. Hemodialysis
Explanation: ***Intravenous normal saline***
- The patient exhibits classic symptoms of **hypercalcemia** (vague bone aches, confusion, dry mucous membranes, tachycardia, diffuse nonfocal abdominal pain) in the context of metastatic prostate cancer and a severely elevated serum calcium level of 15.3 mg/dL.
- **Volume expansion with intravenous normal saline** is the initial and most crucial step in managing severe hypercalcemia, as it helps to restore hydration and promote renal calcium excretion.
*Calcitonin*
- **Calcitonin** can rapidly lower serum calcium by inhibiting osteoclastic bone resorption and increasing renal calcium excretion, but its effect is typically transient and less potent than initial hydration.
- It is often used as an adjunct to saline and bisphosphonates, especially in cases where a rapid but temporary decrease in calcium is needed.
*Furosemide*
- **Furosemide** (a loop diuretic) should only be considered *after* adequate volume repletion has been achieved, as it can worsen dehydration and electrolyte abnormalities if given prematurely.
- It works by inhibiting calcium reabsorption in the loop of Henle, but **dehydration must be corrected first** to ensure effective GFR and avoid electrolyte imbalance.
*Pamidronate*
- **Pamidronate** (a bisphosphonate) is a potent inhibitor of osteoclast-mediated bone resorption and is effective in long-term management of hypercalcemia of malignancy.
- However, its onset of action is slow (2-4 days) and therefore it is not the best *initial step* for acutely symptomatic and severely hypercalcemic patients.
*Hemodialysis*
- **Hemodialysis** is reserved for severe, refractory hypercalcemia, particularly in patients with **renal failure** who cannot handle large fluid loads or excrete calcium effectively.
- While effective, it is an invasive procedure and not typically the first-line treatment for hypercalcemia of malignancy in a patient with presumably intact renal function capable of responding to hydration.
Question 1110: A 78-year-old man presents to the emergency department because of confusion that started 2 hours ago. The patient’s daughter says that he has had blurred vision for several days. His right leg became weak 10 days ago, and he couldn’t walk for a few days before recovering. He was diagnosed with monoclonal gammopathy of undetermined significance 2 years ago. His temperature is 36.2°C (97.2°F), pulse is 75/min, respirations are 13/min, and blood pressure is 125/70 mm Hg. He also has gingival bleeding. Cervical lymphadenopathy is palpated on physical exam. Both the liver and spleen are palpated 5 cm below the costal margins. The serum protein electrophoresis with immunofixation is shown. Urine electrophoresis shows no abnormalities. A skeletal survey shows no abnormalities. Which of the following best explains these findings?
A. Waldenstrom’s macroglobulinemia (Correct Answer)
B. Multiple myeloma
C. Monoclonal gammopathy of undetermined significance
D. Diffuse large B-cell lymphoma
E. Chronic lymphocytic leukemia
Explanation: ***Waldenstrom's macroglobulinemia***
- This condition is characterized by the production of a **monoclonal IgM protein**, which aligns with the serum protein electrophoresis showing an increase in M and lambda chains.
- Clinical features such as **hyperviscosity syndrome** (blurred vision, confusion), **neuropathy** (weak leg), **lymphadenopathy**, **hepatosplenomegaly**, and **gingival bleeding** are all consistent with Waldenstrom's macroglobulinemia.
*Multiple myeloma*
- Multiple myeloma primarily involves **bone lesions** and kidney dysfunction, which are suggested by the absence of abnormalities in the skeletal survey and urine electrophoresis.
- It typically produces **IgG or IgA monoclonal proteins**, not IgM as indicated by the electrophoresis.
*Monoclonal gammopathy of undetermined significance*
- While the patient was previously diagnosed with MGUS, his current presentation with **significant systemic symptoms** and organ involvement indicates progression to a more aggressive disorder.
- MGUS is asymptomatic and lacks evidence of **end-organ damage**, unlike this patient's confusion, blurred vision, and hepatosplenomegaly.
*Diffuse large B-cell lymphoma*
- DLBCL is an aggressive lymphoma, but it typically presents with rapidly growing **lymphadenopathy** and B-symptoms, and usually does not produce a significant **monoclonal protein** or cause hyperviscosity syndrome as seen here.
- While it can cause hepatosplenomegaly, the distinct IgM monoclonal gammopathy points away from DLBCL as the primary explanation.
*Chronic lymphocytic leukemia*
- CLL is generally characterized by **lymphocytosis**, generalized lymphadenopathy, and splenomegaly, but typically presents with **hypogammaglobulinemia** or, less commonly, a monoclonal protein that is usually IgM, but not associated with the constellation of severe B symptoms, hyperviscosity or neuropathy seen in this patient.
- The elevated IgM and associated systemic symptoms are more characteristic of Waldenstrom's macroglobulinemia than CLL.
