A 45-year-old woman presents to the office with a complaint of generalized weakness that has been getting worse over the last few months. She says that she just does not have the energy for her daily activities. She gets winded quite easily when she takes her dog for a walk in the evening. She says that her mood is generally ok and she gets together with her friends every weekend. She works as a teacher at a local elementary school and used to have frequent headaches while at work. Her husband is a commercial pilot and is frequently away for extended periods of time. Her only son is a sophomore in college and visits her every other week. She has had issues in the past with hypertension, but her blood pressure is currently well-controlled because she is compliant with her medication. She is currently taking atorvastatin and lisinopril. The blood pressure is 130/80 mm Hg, the pulse is 90/min, the temperature is 36.7°C (98.0°F), and the respirations are 16/min. On examination, she appears slightly pale and lethargic. Her ECG today is normal and recent lab work shows the following:
Serum creatinine 1.5 mg/dL
Estimated GFR 37.6 mL/min
Hemoglobin (Hb%) 9 mg/dL
Mean corpuscular hemoglobin (MCH) 27 pg
Mean corpuscular hemoglobin concentration (MCHC) 36 g/dL
Mean corpuscular volume (MCV) 85 fL
Reticulocyte count 0.1%
Erythrocyte count 2.5 million/mm3
Serum iron 160 μg/dL
Serum ferritin 150 ng/mL
Total iron binding capacity 105 μg/dL
Serum vitamin B12 254 pg/mL
Serum folic acid 18 ng/mL
Thyroid stimulating hormone 3.5 μU/mL
Which of the following will most likely help her?
Q1122
A 54-year-old man presents to his primary care physician for back pain. His back pain worsens with standing for a prolonged period of time or climbing down the stairs and improves with sitting. Medical history is significant for hypertension, type II diabetes mellitus, and hypercholesterolemia. Neurologic exam demonstrates normal tone, 5/5 strength, and a normal sensory exam throughout the bilateral lower extremity. Skin exam is unremarkable and dorsalis pedis and posterior tibialis pulses are 3+. Which of the following is the best next step in management?
Q1123
A 36-year-old man presents to the physician with difficulty in breathing for 3 hours. There is no history of chest pain, cough or palpitation. He is a chronic smoker and underwent elective cholecystectomy one month back. There is no history of chronic or recurrent cough, wheezing or breathlessness. His temperature is 38.2°C (100.8°F), pulse is 108/min, blood pressure is 124/80 mm Hg, and respirations are 25/min. His arterial oxygen saturation is 98% in room air as shown by pulse oximetry. After a detailed physical examination, the physician orders a plasma D-dimer level, which was elevated. A contrast-enhanced computed tomography (CT) of the chest shows a filling defect in a segmental pulmonary artery on the left side. Which of the following signs is most likely to have been observed by the physician during the physical examination of this patient’s chest?
Q1124
A 41-year-old man presents to his primary care provider because of chest pain with activity for the past 6 months. Past medical history is significant for appendectomy at age 12 and hypertension, and diabetes mellitus type 2 that is poorly controlled. He takes metformin and lisinopril but admits that he is bad at remembering to take them everyday. His father had a heart attack at 41 and 2 stents were placed in his heart. His mother is healthy. He drinks alcohol occasionally and smokes a half of a pack of cigarettes a day. He is a sales executive and describes his work as stressful. Today, the blood pressure is 142/85 and the body mass index (BMI) is 28.5 kg/m2. A coronary angiogram shows > 75% narrowing of the left anterior descending coronary artery. Which of the following is most significant in this patient?
Q1125
A 46-year-old Caucasian male with past medical history of HIV (CD4: 77/mm^3), hypertension, hyperlipidemia, and osteoarthritis presents to the emergency department with sudden weakness of his right hand. He reports that the weakness has gradually been getting worse and that this morning he dropped his cup of coffee. He has never had anything like this happen to him before, although he was hospitalized last year for pneumonia. He reports inconsistent adherence to his home medications, which include raltegravir, tenofovir, emtricitabine, TMP-SMX, hydrochlorothiazide, pravastatin, and occasional ibuprofen. His father died of a myocardial infarction at the age of 60, and his mother suffered a stroke at the age of 72. The patient's temperature is 102.6°F (39.2°C), blood pressure is 156/92 mmHg, pulse is 88/min, and respirations are 18/min. On neurological exam, he has 3/5 strength in the distal muscles of the right extremity with preserved sensation. His neurological exam is normal in all other extremities.
Which of the following is the best next step in management?
Q1126
A 61-year-old man comes to the emergency department because of a 3-hour history of pain and redness of both eyes. He has new blurry vision and difficulty opening his eyes in bright surroundings. He has not had any recent trauma. He uses contact lenses daily. He had surgery on his left eye 6 months ago after a penetrative trauma caused by a splinter. His vital signs are within normal limits. Physical examination shows congestion of the perilimbal conjunctivae bilaterally. Visual acuity is decreased bilaterally. Ocular movements are normal. Slit-lamp examination shows a cornea with normal contours and leukocytes in the anterior chambers of both eyes. The eyelids, eyelashes, and lacrimal ducts show no abnormalities. Which of the following is the most likely cause of this patient's condition?
Q1127
A 45-year-old man presents to his primary care physician complaining of increasingly frequent headaches. He also reports that his hats and wedding ring do not fit anymore. His temperature is 99°F (37.2°C), blood pressure is 145/80 mmHg, pulse is 85/min, and respirations are 16/min. Physical examination is notable for frontal bossing, a prominent jaw, and an enlarged tongue. A chest radiograph reveals mild cardiomegaly. Serum insulin-like growth factor 1 levels are significantly elevated. Which of the following complications is this patient most likely to develop?
Q1128
A 75-year-old man is brought to the emergency room after being found unresponsive in his home. His medical history is unknown. On physical examination he does not demonstrate any spontaneous movement of his extremities and is unable to respond to voice or painful stimuli. You notice that he is able blink and move his eyes in the vertical plane. Based on these physical exam findings, you expect that magnetic resonance angiogram will most likely reveal an occlusion in which of the following vessels?
Q1129
A 78-year-old woman comes to the physician because of a 2-month history of right-sided headache and generalized fatigue. She also has pain, weakness, and stiffness of her shoulders and hips. The stiffness is worse in the morning and usually improves after 60–90 minutes of activity. Three months ago, she fell and hit her head on the kitchen countertop. Her temperature is 38.1°C (100.6°F). Examination shows normal muscle strength in bilateral upper and lower extremities; range of motion of the shoulder and hip is mildly limited by pain. Deep tendon reflexes are 2+ bilaterally. Her erythrocyte sedimentation rate is 68 mm/h and serum creatine kinase is 36 mg/dL. Which of the following is the most likely underlying cause of this patient's headache?
Q1130
A 76-year-old woman comes in for a routine checkup with her doctor. She is concerned that she feels tired most days and has difficulty doing her household chores. She complains that she gets fatigued and breathless with mild exertion. Past medical history is significant for diabetes mellitus, chronic kidney disease from prolonged elevated blood sugar, and primary biliary cirrhosis. Medications include lisinopril, insulin, and metformin. Family medicine is noncontributory. She drinks one beer every day. Today, she has a heart rate of 98/min, respiratory rate of 17/min, blood pressure of 110/65 mm Hg, and a temperature of 37.0°C (98.6°F). General examination shows that she is pale and haggard looking. She has a heartbeat with a regular rate and rhythm and her lungs are clear to auscultation bilaterally. A complete blood count (CBC) is as follows:
Leukocyte count: 12,000/mm3
Red blood cell count: 3.1 million/mm3
Hemoglobin: 11.0 g/dL
MCV: 85 fL
MCH: 27 pg/cell
Platelet count: 450,000/mm3
Fecal occult blood test is negative. What is the most likely cause of her anemia?
Cardiology US Medical PG Practice Questions and MCQs
Question 1121: A 45-year-old woman presents to the office with a complaint of generalized weakness that has been getting worse over the last few months. She says that she just does not have the energy for her daily activities. She gets winded quite easily when she takes her dog for a walk in the evening. She says that her mood is generally ok and she gets together with her friends every weekend. She works as a teacher at a local elementary school and used to have frequent headaches while at work. Her husband is a commercial pilot and is frequently away for extended periods of time. Her only son is a sophomore in college and visits her every other week. She has had issues in the past with hypertension, but her blood pressure is currently well-controlled because she is compliant with her medication. She is currently taking atorvastatin and lisinopril. The blood pressure is 130/80 mm Hg, the pulse is 90/min, the temperature is 36.7°C (98.0°F), and the respirations are 16/min. On examination, she appears slightly pale and lethargic. Her ECG today is normal and recent lab work shows the following:
Serum creatinine 1.5 mg/dL
Estimated GFR 37.6 mL/min
Hemoglobin (Hb%) 9 mg/dL
Mean corpuscular hemoglobin (MCH) 27 pg
Mean corpuscular hemoglobin concentration (MCHC) 36 g/dL
Mean corpuscular volume (MCV) 85 fL
Reticulocyte count 0.1%
Erythrocyte count 2.5 million/mm3
Serum iron 160 μg/dL
Serum ferritin 150 ng/mL
Total iron binding capacity 105 μg/dL
Serum vitamin B12 254 pg/mL
Serum folic acid 18 ng/mL
Thyroid stimulating hormone 3.5 μU/mL
Which of the following will most likely help her?
A. Start vitamin B12 with folic acid.
B. Transfuse red blood cells.
C. Start her on fluoxetine.
D. Start her on erythropoietin. (Correct Answer)
E. Start oral iron supplements.
Explanation: ***Start her on erythropoietin.***
- This patient presents with symptoms of **anemia** (weakness, fatigue, dyspnea on exertion) and has laboratory findings consistent with **normocytic, normochromic anemia** (Hb 9 mg/dL, MCV 85 fL, MCH 27 pg, normal MCHC), a **low reticulocyte count (0.1%)**, and **chronic kidney disease (CKD)** stage 3 (GFR 37.6 mL/min).
- The combination of **CKD and anemia with appropriate iron stores** (normal serum iron and ferritin, low TIBC, high transferrin saturation) strongly suggests **anemia of chronic kidney disease**, which is caused by inadequate **erythropoietin (EPO) production** by the kidneys. Therefore, exogenous erythropoietin is the most appropriate treatment.
*Start vitamin B12 with folic acid.*
- The patient's **serum vitamin B12 (254 pg/mL)** and **folic acid (18 ng/mL)** levels are within normal limits, ruling out deficiencies of these vitamins as the cause of her anemia.
- Deficiencies in B12 or folate typically cause **macrocytic anemia** (elevated MCV), which is not observed in this patient (MCV 85 fL).
*Transfuse red blood cells.*
- While red blood cell transfusion can rapidly increase hemoglobin, it is typically reserved for **symptomatic severe anemia** or in situations requiring quick correction, for example, active bleeding.
- The patient's anemia, although symptomatic, is chronic, and her cardiovascular status, including a normal ECG and stable blood pressure, does not indicate an immediate life-threatening need for transfusion. **Long-term management** with erythropoietin is safer and more appropriate.
*Start her on fluoxetine.*
- The patient reports her **mood is generally okay**, and she actively socializes, making **depression less likely** as the primary cause of her generalized weakness or fatigue. Her fatigue is primarily due to anemia.
- While chronic illness can sometimes lead to depression, there's no strong indication for antidepressant therapy based on the provided symptoms.
*Start oral iron supplements.*
- The patient's **iron studies (serum iron 160 μg/dL, serum ferritin 150 ng/mL, total iron binding capacity 105 μg/dL)** indicate that she has **adequate iron stores** and is not iron deficient.
- Iron supplementation would not be beneficial and could be harmful if there is no iron deficiency.
Question 1122: A 54-year-old man presents to his primary care physician for back pain. His back pain worsens with standing for a prolonged period of time or climbing down the stairs and improves with sitting. Medical history is significant for hypertension, type II diabetes mellitus, and hypercholesterolemia. Neurologic exam demonstrates normal tone, 5/5 strength, and a normal sensory exam throughout the bilateral lower extremity. Skin exam is unremarkable and dorsalis pedis and posterior tibialis pulses are 3+. Which of the following is the best next step in management?
A. Surgical spinal decompression
B. MRI of the lumbosacral spine (Correct Answer)
C. Ankle-brachial index
D. Radiography of the lumbosacral spine
E. Naproxen
Explanation: ***MRI of the lumbosacral spine***
- The patient's symptoms of back pain worsening with standing/climbing downstairs and improving with sitting are classic for **neurogenic claudication** due to **lumbar spinal stenosis**.
- An **MRI** is the gold standard for visualizing the spinal canal, nerve roots, and any potential compression, providing the most detailed imaging to confirm the diagnosis and guide further management.
*Surgical spinal decompression*
- This is a definitive treatment option for severe **spinal stenosis** but should only be considered after a confirmed diagnosis and failed conservative management.
- Jumping straight to surgery without proper imaging and assessment of the severity would be premature and potentially unnecessary.
*Ankle-brachial index*
- This test is primarily used to diagnose **peripheral artery disease (PAD)**, which causes **vascular claudication**.
- While it's important to differentiate vascular from neurogenic claudication, the patient's symptoms (pain relief with sitting, no mention of exertional leg pain specifically) and normal pulses make vascular claudication less likely, and an MRI is more directly indicated for the suspected neurogenic cause.
*Radiography of the lumbosacral spine*
- While X-rays can show bone anomalies and degenerative changes like **osteophytes** and decreased disc space, they do not visualize soft tissues (spinal cord, nerve roots) or the extent of spinal canal narrowing.
- Therefore, X-rays are insufficient for diagnosing **spinal stenosis** and its impact on neural structures.
*Naproxen*
- **Naproxen**, an NSAID, can provide symptomatic relief for musculoskeletal pain but does not address the underlying structural issue of **spinal stenosis**.
- It would be a component of conservative management but not the definitive "next step" for diagnosing the cause of neurogenic claudication as described.
Question 1123: A 36-year-old man presents to the physician with difficulty in breathing for 3 hours. There is no history of chest pain, cough or palpitation. He is a chronic smoker and underwent elective cholecystectomy one month back. There is no history of chronic or recurrent cough, wheezing or breathlessness. His temperature is 38.2°C (100.8°F), pulse is 108/min, blood pressure is 124/80 mm Hg, and respirations are 25/min. His arterial oxygen saturation is 98% in room air as shown by pulse oximetry. After a detailed physical examination, the physician orders a plasma D-dimer level, which was elevated. A contrast-enhanced computed tomography (CT) of the chest shows a filling defect in a segmental pulmonary artery on the left side. Which of the following signs is most likely to have been observed by the physician during the physical examination of this patient’s chest?
A. Pleural friction rub
B. Bilateral wheezing
C. Systolic murmur at the left sternal border
D. Localized rales (Correct Answer)
E. S3 gallop
Explanation: ***Localized rales***
- The patient's presentation with **sudden onset dyspnea**, risk factors (recent surgery, smoking), elevated D-dimer, and a CT scan showing a filling defect in the pulmonary artery strongly points to a **pulmonary embolism (PE)**.
- While PE often presents with normal lung auscultation, localized rales or crackles can be heard if there is an associated **pulmonary infarction** or local inflammation.
*Pleural friction rub*
- A **pleural friction rub** indicates inflammation of the pleura, which can occur in PE if the infarct involves the pleural surface.
- However, it is a less common finding than localized rales and is more characteristic of conditions like pleurisy or pneumonia.
*Bilateral wheezing*
- **Bilateral wheezing** is typically associated with diffuse airway obstruction, as seen in asthma or chronic obstructive pulmonary disease (COPD).
- This patient has no history of chronic respiratory conditions and the presentation is acute dyspnea, making diffuse airway obstruction less likely.
*Systolic murmur at the left sternal border*
- A **systolic murmur at the left sternal border** can be indicative of tricuspid regurgitation, often seen in the setting of **pulmonary hypertension** and right heart strain associated with a massive PE.
- However, with a stable blood pressure and moderate heart rate, severe right heart strain leading to a murmur is less likely in this scenario of a segmental PE.
*S3 gallop*
- An **S3 gallop** is a low-pitched sound heard during early diastole, often indicating **volume overload** or **ventricular dysfunction**.
- In the context of PE, an S3 often suggests significant **right ventricular dysfunction** due to acute pressure overload; this is more common with large or massive PEs causing hemodynamic instability, which is not indicated here.
Question 1124: A 41-year-old man presents to his primary care provider because of chest pain with activity for the past 6 months. Past medical history is significant for appendectomy at age 12 and hypertension, and diabetes mellitus type 2 that is poorly controlled. He takes metformin and lisinopril but admits that he is bad at remembering to take them everyday. His father had a heart attack at 41 and 2 stents were placed in his heart. His mother is healthy. He drinks alcohol occasionally and smokes a half of a pack of cigarettes a day. He is a sales executive and describes his work as stressful. Today, the blood pressure is 142/85 and the body mass index (BMI) is 28.5 kg/m2. A coronary angiogram shows > 75% narrowing of the left anterior descending coronary artery. Which of the following is most significant in this patient?
A. Obesity
B. Family history
C. Hypertension
D. Smoking
E. Diabetes mellitus (Correct Answer)
Explanation: ***Diabetes mellitus***
- **Diabetes mellitus** is a significant risk factor for **atherosclerosis** and contributes to accelerated progression of **coronary artery disease (CAD)**, often leading to more widespread and severe disease.
- Poorly controlled diabetes can cause **endothelial dysfunction**, increasing oxidative stress and inflammation, which are key processes in **plaque formation** and destabilization.
*Obesity*
- **Obesity** (BMI 28.5 kg/m2) is a risk factor for **CAD** but often acts through associated conditions like **hypertension**, **diabetes**, and **dyslipidemia**.
- While it contributes to overall cardiovascular risk, it is less directly pathogenic than diabetes which independently accelerates **atherosclerosis**.
*Family history*
- The patient's father had a **heart attack at 41**, which is a significant risk factor for **early-onset CAD**.
- However, the patient has multiple modifiable risk factors (smoking, hypertension, diabetes) that are independently and more directly contributing to his current presentation.
*Hypertension*
- **Hypertension** (142/85 mmHg) is a major modifiable risk factor that causes **endothelial damage** and promotes **atherosclerosis**.
- While important, the patient's **poorly controlled diabetes mellitus** often creates a more aggressive environment for plaque formation and progression compared to hypertension alone.
*Smoking*
- **Smoking** is a potent, modifiable risk factor that causes direct vascular injury, promotes **thrombogenesis**, and contributes to **atherosclerosis**.
- Although highly detrimental, smoking is one of several significant risk factors; **diabetes mellitus**, with its systemic metabolic impact, can be considered more broadly influential in the severity and diffuse nature of **CAD**.
Question 1125: A 46-year-old Caucasian male with past medical history of HIV (CD4: 77/mm^3), hypertension, hyperlipidemia, and osteoarthritis presents to the emergency department with sudden weakness of his right hand. He reports that the weakness has gradually been getting worse and that this morning he dropped his cup of coffee. He has never had anything like this happen to him before, although he was hospitalized last year for pneumonia. He reports inconsistent adherence to his home medications, which include raltegravir, tenofovir, emtricitabine, TMP-SMX, hydrochlorothiazide, pravastatin, and occasional ibuprofen. His father died of a myocardial infarction at the age of 60, and his mother suffered a stroke at the age of 72. The patient's temperature is 102.6°F (39.2°C), blood pressure is 156/92 mmHg, pulse is 88/min, and respirations are 18/min. On neurological exam, he has 3/5 strength in the distal muscles of the right extremity with preserved sensation. His neurological exam is normal in all other extremities.
Which of the following is the best next step in management?
A. Serology for Toxoplasma-specific IgG antibodies
B. Empiric treatment with pyrimethamine-sulfadiazine
C. Head CT (Correct Answer)
D. Empiric treatment with itraconazole
E. Lumbar puncture
Explanation: ***Head CT***
- The patient presents with **focal neurological deficits** (right hand weakness) and has several risk factors, including poorly controlled **HIV with a low CD4 count** (increased risk of opportunistic infections or CNS lesions) and uncontrolled hypertension (increased risk of stroke). A **head CT** is crucial to rapidly identify potential causes like a mass lesion, hemorrhage, or infarct, which would guide immediate management.
- The **fever** and **subacute onset** of weakness (gradually worsening with acute exacerbation) also point towards an intracranial process that needs urgent imaging.
*Serology for Toxoplasma-specific IgG antibodies*
- While **Toxoplasmosis** is a strong consideration given the patient's low CD4 count, **serology alone is not the best initial step** for acute neurological deficits.
- A positive IgG indicates past exposure but not necessarily active infection, and it doesn't provide real-time information on the cause of the focal neurological symptoms. Imaging is needed first to identify a lesion.
*Empiric treatment with pyrimethamine-sulfadiazine*
- This is the treatment for **cerebral toxoplasmosis**, but **empiric treatment should only be initiated after imaging** (CT or MRI) confirms the presence of a lesion consistent with toxoplasmosis, especially in a patient with acute focal deficits.
- Starting treatment without imaging may delay diagnosis of other potentially critical conditions like a brain abscess, lymphoma, or stroke.
*Empiric treatment with itraconazole*
- **Itraconazole** is an antifungal medication, typically used for histoplasmosis, blastomycosis, or aspergillosis, which are less common causes of acute focal neurological deficits in HIV than toxoplasmosis or lymphoma.
- There is no specific clinical indication or risk factor (e.g., endemic area for fungal infections) that would make **empiric antifungal treatment** the best next step compared to diagnostic imaging for this presentation.
*Lumbar puncture*
- A **lumbar puncture** can be useful in diagnosing CNS infections (e.g., cryptococcal meningitis, viral encephalitis) or other inflammatory conditions, but it is typically performed *after* ruling out a mass lesion or increased intracranial pressure with imaging (CT or MRI) to prevent herniation.
- Given the patient's focal neurological deficit and potential for a mass or hemorrhage, **LP carries a risk of brain herniation** and is not the best initial step.
Question 1126: A 61-year-old man comes to the emergency department because of a 3-hour history of pain and redness of both eyes. He has new blurry vision and difficulty opening his eyes in bright surroundings. He has not had any recent trauma. He uses contact lenses daily. He had surgery on his left eye 6 months ago after a penetrative trauma caused by a splinter. His vital signs are within normal limits. Physical examination shows congestion of the perilimbal conjunctivae bilaterally. Visual acuity is decreased bilaterally. Ocular movements are normal. Slit-lamp examination shows a cornea with normal contours and leukocytes in the anterior chambers of both eyes. The eyelids, eyelashes, and lacrimal ducts show no abnormalities. Which of the following is the most likely cause of this patient's condition?
A. Impaired drainage of aqueous humor
B. Age-related denaturation of lens proteins
C. Reactivation of herpes zoster virus
D. Corneal infection with Pseudomonas aeruginosa
E. Autoimmune reaction against retinal antigens (Correct Answer)
Explanation: ***Autoimmune reaction against retinal antigens***
- The patient's history of **penetrating ocular trauma** (splinter injury) in the left eye 6 months ago, followed by bilateral eye symptoms (pain, redness, blurry vision, photophobia) and **uveitis** (leukocytes in the anterior chambers), is highly suggestive of **sympathetic ophthalmia**.
- **Sympathetic ophthalmia** is an autoimmune process where trauma to one eye exposes hidden retinal antigens, triggering a delayed-type hypersensitivity reaction that affects both the injured (exciting) and the uninjured (sympathizing) eye.
*Impaired drainage of aqueous humor*
- **Impaired drainage of aqueous humor** is characteristic of **glaucoma**, which typically presents with elevated intraocular pressure, optic nerve damage, and visual field loss.
- While blurry vision can occur, the acute pain, redness, and **leukocytes in the anterior chamber** (uveitis) are not typical features of primary glaucoma.
*Age-related denaturation of lens proteins*
- **Age-related denaturation of lens proteins** describes the formation of cataracts, which cause gradually progressive, painless blurry vision and glare.
- The acute onset of pain, redness, and significant inflammation (leukocytes in the anterior chamber) are inconsistent with a straightforward cataract presentation.
*Reactivation of herpes zoster virus*
- **Reactivation of herpes zoster virus** (herpes zoster ophthalmicus) would typically present with a vesicular rash in the dermatomal distribution of the trigeminal nerve (often affecting the forehead and nose), along with eye involvement.
- The absence of a characteristic skin rash makes this diagnosis less likely, and while it can cause uveitis, the historical context strongly points elsewhere.
*Corneal infection with Pseudomonas aeruginosa*
- **Corneal infection with Pseudomonas aeruginosa**, especially in contact lens wearers, can cause severe and rapid corneal damage, pain, redness, and vision loss.
- However, the slit-lamp examination specifically notes a **cornea with normal contours**, which rules out significant corneal ulceration or infection as the primary cause here; the inflammation is in the anterior chamber.
Question 1127: A 45-year-old man presents to his primary care physician complaining of increasingly frequent headaches. He also reports that his hats and wedding ring do not fit anymore. His temperature is 99°F (37.2°C), blood pressure is 145/80 mmHg, pulse is 85/min, and respirations are 16/min. Physical examination is notable for frontal bossing, a prominent jaw, and an enlarged tongue. A chest radiograph reveals mild cardiomegaly. Serum insulin-like growth factor 1 levels are significantly elevated. Which of the following complications is this patient most likely to develop?
A. Medullary thyroid carcinoma
B. Pheochromocytoma
C. Osteoid osteoma
D. Osteosarcoma
E. Carpal tunnel syndrome (Correct Answer)
Explanation: ***Carpal tunnel syndrome***
- This patient presents with classic signs and symptoms of **acromegaly**, including new-onset headaches, increasing hat and ring size, frontal bossing, prominent jaw, enlarged tongue, and elevated **insulin-like growth factor 1 (IGF-1)**. Acromegaly results from excess **growth hormone**, typically from a pituitary adenoma.
- **Carpal tunnel syndrome** is one of the **most common complications** of acromegaly, affecting approximately **50% of patients**. The increased soft tissue and bone growth leads to narrowing of the carpal tunnel and compression of the **median nerve**.
- Other common complications of acromegaly include **diabetes mellitus, hypertension, cardiomegaly, sleep apnea, arthropathy, and colon polyps**.
*Medullary thyroid carcinoma*
- This condition is associated with **Multiple Endocrine Neoplasia type 2 (MEN 2)** and is characterized by elevated **calcitonin** levels, not IGF-1.
- It does not present with the characteristic physical findings of acromegaly such as frontal bossing and jaw enlargement.
*Pheochromocytoma*
- This is a tumor of the adrenal medulla that secretes **catecholamines**, leading to symptoms like **paroxysmal hypertension**, palpitations, diaphoresis, and headaches.
- While it can be associated with MEN 2, it is not a complication of acromegaly and does not explain the progressive growth-related symptoms.
*Osteoid osteoma*
- This is a **benign bone tumor** characterized by localized bone pain that is typically worse at night and relieved by **NSAIDs**.
- It is not associated with acromegaly or systemic hormone excess, and does not explain the generalized overgrowth features.
*Osteosarcoma*
- This is a **malignant bone tumor** that typically presents with localized bone pain and swelling, often near the **metaphysis of long bones** in adolescents and young adults.
- While acromegaly may carry a slightly increased risk of certain malignancies (particularly colon cancer), osteosarcoma is not a recognized complication of this condition.
Question 1128: A 75-year-old man is brought to the emergency room after being found unresponsive in his home. His medical history is unknown. On physical examination he does not demonstrate any spontaneous movement of his extremities and is unable to respond to voice or painful stimuli. You notice that he is able blink and move his eyes in the vertical plane. Based on these physical exam findings, you expect that magnetic resonance angiogram will most likely reveal an occlusion in which of the following vessels?
A. Basilar artery (Correct Answer)
B. Anterior cerebral artery
C. Anterior spinal artery
D. Posterior cerebral artery
E. Anterior inferior cerebellar artery
Explanation: ***Basilar artery***
- The patient's presentation with **quadriplegia**, inability to respond to stimuli, and preserved **vertical eye movements** and blinking is characteristic of **locked-in syndrome**.
- **Locked-in syndrome** is most commonly caused by an **occlusion of the basilar artery**, leading to infarction of the ventral pons while sparing the tegmentum.
*Anterior cerebral artery*
- Occlusion of the **anterior cerebral artery** typically causes **contralateral leg weakness** and sensory loss, and sometimes **abulia** or urinary incontinence.
- It does not explain the widespread motor paralysis affecting all four limbs or the preservation of vertical eye movements in an otherwise unresponsive patient.
*Anterior spinal artery*
- Occlusion of the **anterior spinal artery** causes an **anterior spinal cord syndrome**, characterized by bilateral weakness and loss of pain/temperature sensation below the lesion, with preserved proprioception and vibration sense.
- This presentation does not include the characteristic signs of **brainstem dysfunction** seen in locked-in syndrome.
*Posterior cerebral artery*
- An occlusion in the **posterior cerebral artery** typically leads to **contralateral homonymous hemianopia**, and depending on the branch occluded, can also cause memory deficits or thalamic pain.
- It does not account for the extensive motor paralysis or the pattern of preserved vertical eye movements seen in locked-in syndrome.
*Anterior inferior cerebellar artery*
- Occlusion of the **anterior inferior cerebellar artery (AICA)** typically results in **lateral pontine syndrome**, which includes ipsilateral facial weakness, hearing loss, cerebellar ataxia, and contralateral loss of pain and temperature sensation.
- While it affects the pons, AICA occlusion does not typically cause the complete quadriplegia and preservation of vertical eye movements characteristic of locked-in syndrome.
Question 1129: A 78-year-old woman comes to the physician because of a 2-month history of right-sided headache and generalized fatigue. She also has pain, weakness, and stiffness of her shoulders and hips. The stiffness is worse in the morning and usually improves after 60–90 minutes of activity. Three months ago, she fell and hit her head on the kitchen countertop. Her temperature is 38.1°C (100.6°F). Examination shows normal muscle strength in bilateral upper and lower extremities; range of motion of the shoulder and hip is mildly limited by pain. Deep tendon reflexes are 2+ bilaterally. Her erythrocyte sedimentation rate is 68 mm/h and serum creatine kinase is 36 mg/dL. Which of the following is the most likely underlying cause of this patient's headache?
A. Hyperthyroidism
B. Cluster headache
C. Tension headache
D. Polyarteritis nodosa
E. Large-vessel vasculitis (Correct Answer)
Explanation: ***Large-vessel vasculitis***
- The patient's age (78 years), new-onset **right-sided headache**, and elevated **ESR** (68 mm/h) are highly suggestive of **giant cell arteritis (GCA)**, which is a form of large-vessel vasculitis.
- The associated symptoms of **polymyalgia rheumatica** (pain, weakness, and stiffness in shoulders and hips, worse in the morning, improving with activity) further support this diagnosis.
*Hyperthyroidism*
- While hyperthyroidism can cause fatigue and muscle weakness, it is typically associated with **tachycardia**, **weight loss**, and **tremors**, which are not reported here.
- An elevated **ESR** and localized headache would not be primary features of hyperthyroidism.
*Cluster headache*
- Characterized by **severe, unilateral periorbital or temporal pain**, often accompanied by ipsilateral **autonomic symptoms** (e.g., lacrimation, nasal congestion, ptosis).
- It typically occurs in younger men and does not present with systemic symptoms like elevated ESR or polymyalgia rheumatica.
*Tension headache*
- Usually described as a **bilateral, pressing or tightening pain** of mild to moderate intensity, without associated systemic symptoms.
- It is not associated with an elevated **ESR** or the symptoms of polymyalgia rheumatica.
*Polyarteritis nodosa*
- This is a **necrotizing vasculitis** primarily affecting medium-sized arteries, often presenting with symptoms like **skin lesions**, **neuropathy**, and **renal involvement**.
- It does not typically cause headache from direct cranial artery inflammation or polymyalgia rheumatica, as seen in GCA.
Question 1130: A 76-year-old woman comes in for a routine checkup with her doctor. She is concerned that she feels tired most days and has difficulty doing her household chores. She complains that she gets fatigued and breathless with mild exertion. Past medical history is significant for diabetes mellitus, chronic kidney disease from prolonged elevated blood sugar, and primary biliary cirrhosis. Medications include lisinopril, insulin, and metformin. Family medicine is noncontributory. She drinks one beer every day. Today, she has a heart rate of 98/min, respiratory rate of 17/min, blood pressure of 110/65 mm Hg, and a temperature of 37.0°C (98.6°F). General examination shows that she is pale and haggard looking. She has a heartbeat with a regular rate and rhythm and her lungs are clear to auscultation bilaterally. A complete blood count (CBC) is as follows:
Leukocyte count: 12,000/mm3
Red blood cell count: 3.1 million/mm3
Hemoglobin: 11.0 g/dL
MCV: 85 fL
MCH: 27 pg/cell
Platelet count: 450,000/mm3
Fecal occult blood test is negative. What is the most likely cause of her anemia?
A. Chronic kidney disease (Correct Answer)
B. Acute bleeding
C. Alcoholism
D. Liver disease
E. Colorectal cancer
Explanation: ***Chronic kidney disease***
- **Chronic kidney disease (CKD)** is a common cause of **normocytic, normochromic anemia** due to decreased production of **erythropoietin** by the kidneys.
- This patient's history of CKD, alongside her **normocytic anemia (MCV 85 fL)**, makes this the most likely cause.
*Acute bleeding*
- Acute bleeding would typically present with signs of **hypovolemia** (e.g., hypotension, tachycardia) and potentially a **reticulocytosis** as the bone marrow compensates, neither of which are seen here.
- The **negative fecal occult blood test** and stable vital signs also argue against acute or chronic gastrointestinal bleeding.
*Alcoholism*
- Chronic alcoholism can lead to anemia, often **macrocytic** due to **folate deficiency**, or less commonly microcytic if associated with iron deficiency from GI bleeding.
- While she drinks one beer daily, this amount is unlikely to directly cause significant anemia, especially given her **normocytic MCV**.
*Liver disease*
- **Primary biliary cirrhosis (PBC)** can cause anemia through various mechanisms, including **hemolysis**, **folate deficiency**, or bleeding from **portal hypertension**.
- However, PBC-related anemia is often microcytic or macrocytic, and her **normocytic MCV** and the more direct link to CKD make it less likely to be the primary cause.
*Colorectal cancer*
- **Colorectal cancer** can cause anemia due to **chronic blood loss**, which would typically lead to **iron deficiency anemia** (microcytic anemia).
- The patient has a **normocytic anemia (MCV 85 fL)** and a **negative fecal occult blood test**, making this diagnosis highly unlikely.
