A 27-year-old man presents to the emergency department with weakness and a fever for the past week. The patient is homeless and has a past medical history of alcohol and IV drug abuse. His temperature is 102°F (38.9°C), blood pressure is 107/68 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam is notable for a tremulous patient with antecubital scars and a murmur over the left lower sternal border. Blood cultures are drawn and the patient is started on vancomycin and ceftriaxone and is admitted to the ICU. The patient's fever and symptoms do not improve despite antibiotic therapy for which the initial identified organism is susceptible. Cultures currently reveal MRSA as one of the infective organisms. Which of the following is the best next step in management?
Q1132
A 61-year-old white man presents to the emergency department because of progressive fatigue and shortness of breath on exertion and while lying down. He has had type 2 diabetes mellitus for 25 years and hypertension for 15 years. He is taking metformin and captopril for his diabetes and hypertension. He has smoked 10 cigarettes per day for the past 12 years and drinks alcohol occasionally. His temperature is 36.7°C (98.0°F) and blood pressure is 130/60 mm Hg. On physical examination, his arterial pulse shows a rapid rise and a quick collapse. An early diastolic murmur is audible over the left upper sternal border. Echocardiography shows severe chronic aortic regurgitation with a left ventricular ejection fraction of 55%–60% and mild left ventricular hypertrophy. Which of the following is an indication for aortic valve replacement in this patient?
Q1133
A 38-year-old man is brought to the emergency department after losing consciousness upon rising from his chair at work. The patient has had progressive cough, shortness of breath, fever, and chills for 6 days but did not seek medical attention for these symptoms. He appears distressed, flushed, and diaphoretic. He is 170 cm (5 ft 7 in) tall and weighs 120 kg (265 lbs); BMI is 41.5 kg/m2. His temperature is 39.4°C (102.9°F), pulse is 129/min, respirations are 22/min, and blood pressure is 91/50 mm Hg when supine. Crackles and bronchial breath sounds are heard over the right posterior hemithorax. A 2/6 midsystolic blowing murmur is heard along the left upper sternal border. Examination shows diffuse diaphoresis, flushed extremities, and dullness to percussion over the right posterior hemithorax. The abdomen is soft and nontender. Multiple nurses and physicians have been unable to attain intravenous access. A large-bore central venous catheter is inserted into the right internal jugular vein by standard sterile procedure. Which of the following is the most appropriate next step in the management of this patient?
Q1134
A 62-year-old man comes to the physician because of increased frequency of urination. He also says that he needs to urinate 4 to 5 times nightly and has difficulty initiating a urinary stream. He has had several episodes of acute cystitis treated with ciprofloxacin during the past year. Digital rectal examination shows a firm, symmetrically enlarged, non-tender prostate. This patient is most likely to develop which of the following complications?
Q1135
A 42-year-old woman comes to the physician because of stiffness and pain in multiple joints. She says that the fingers on both of her hands have become increasingly stiff and difficult to move over the past 8 months. She also complains of nails that break easily and look spotty as well as chronic back pain. She had a urinary tract infection a year ago that was treated with antibiotics. She is sexually active with 2 male partners and uses condoms inconsistently. Her vitals are within normal limits. A photograph of her right hand is shown. There are multiple, well-demarcated red plaques with silvery-white scales over the shins and back. Serum studies show a negative rheumatoid factor and ANA. Which of the following is the most likely diagnosis?
Q1136
A 37-year-old woman is being evaluated for difficulty with swallowing for the past few months. She explains that she experiences difficulty swallowing solid foods only. Her medical history is relevant for hypothyroidism and migraines. Her current medications include daily levothyroxine and acetaminophen as needed for pain. The vital signs include blood pressure 110/90 mm Hg, pulse rate 55/min, and respiratory rate 12/min. On physical examination, her abdomen is non-tender. Her voice is hoarse, but there is no pharyngeal hyperemia on oral examination. On cardiac auscultation, an opening snap followed by an early to mid-diastolic rumble is heard over the apex. A barium swallow X-ray is performed and is unremarkable. Echocardiography shows an enlarged left atrium and abnormal blood flow through 1 of the atrioventricular valves. What is the most likely valve abnormality seen in this patient?
Q1137
A 42-year-old man comes to the physician for a routine health maintenance examination. He feels well but has had several episodes of “finger pallor” over the past 4 months. During these episodes, the 4th finger of his left hand turns white. The color usually returns within 20 minutes, followed by redness and warmth of the finger. The episodes are not painful. The complaints most commonly occur on his way to work, when it is very cold outside. One time, it happened when he was rushing to the daycare center because he was late for picking up his daughter. The patient has gastroesophageal reflux disease treated with lansoprazole. His vital signs are within normal limits. The blood flow to the hand is intact on compression of the ulnar artery at the wrist, as well as on compression of the radial artery. When the patient is asked to immerse his hands in cold water, a change in the color of the 4th digit of his left hand is seen. A photograph of the affected hand is shown. His hemoglobin concentration is 14.2 g/dL, serum creatinine is 0.9 mg/dL, and ESR is 35 mm/h. Which of the following is the most appropriate next step in management?
Q1138
A 60-year-old man comes to the physician because of a 6-month history of progressively worsening urinary frequency. He feels the urge to urinate every hour or two, which restricts his daily activities and interferes with his sleep. He has no fever, hematuria, or burning pain on micturition. He has hypertension and type 2 diabetes mellitus. Current medications include metformin and amlodipine. He does not smoke and drinks 1 to 2 beers daily. His vital signs are within normal limits. Abdominal examination shows no abnormalities. Digital rectal examination shows a nontender, firm, symmetrically enlarged prostate with no nodules. Which of the following is the most appropriate next step in management?
Q1139
A 64-year-old man presents to his primary care physician's office for a routine check-up. His past medical history is significant for type 2 diabetes mellitus, hypertension, chronic atrial fibrillation, and ischemic cardiomyopathy. On his last visit three months ago, he was found to have hyperkalemia, at which time lisinopril and spironolactone were removed from his medication regimen. Currently, his medications include coumadin, aspirin, metformin, glyburide, metoprolol, furosemide, and amlodipine. His T is 37 C (98.6 F), BP 154/92 mm Hg, HR 80/min, and RR 16/min. His physical exam is notable for elevated jugular venous pressure, an S3 heart sound, and 1+ pitting pedal edema. His repeat lab work at the current visit is as follows:
Sodium: 138 mEq/L, potassium: 5.7 mEq/L, chloride 112 mEq/L, bicarbonate 18 mEq/L, BUN 29 mg/dL, and creatinine 2.1 mg/dL.
Which of the following is the most likely cause of this patient's acid-base and electrolyte abnormalities?
Q1140
A 40-year-old man comes to the physician for a follow-up examination. He feels well. He has no urinary urgency, increased frequency, dysuria, or gross hematuria. He has a history of recurrent urinary tract infections. His last urinary tract infection was 3 months ago and was treated with ciprofloxacin. Current medications include a multivitamin. He has smoked one pack of cigarettes daily for 18 years. Vital signs are within normal limits. The abdomen is soft and nontender. There is no costovertebral angle tenderness. Laboratory studies show:
Hemoglobin 11.2 g/dL
Leukocyte count 9,500/mm3
Platelet count 170,000/mm3
Serum
Na+ 135 mEq/L
K+ 4.9 mEq/L
Cl- 101 mEq/L
Urea nitrogen 18 mg/dL
Creatinine 0.6 mg/dL
Urine
Blood 2+
Protein negative
RBC 5–7/hpf, normal shape and size
RBC casts negative
WBC 0–2/hpf
Bacteria negative
Urine cultures are negative. Urine analysis is repeated and shows similar results. A cystoscopy shows no abnormalities. Which of the following is the most appropriate next step in management?
Cardiology US Medical PG Practice Questions and MCQs
Question 1131: A 27-year-old man presents to the emergency department with weakness and a fever for the past week. The patient is homeless and has a past medical history of alcohol and IV drug abuse. His temperature is 102°F (38.9°C), blood pressure is 107/68 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam is notable for a tremulous patient with antecubital scars and a murmur over the left lower sternal border. Blood cultures are drawn and the patient is started on vancomycin and ceftriaxone and is admitted to the ICU. The patient's fever and symptoms do not improve despite antibiotic therapy for which the initial identified organism is susceptible. Cultures currently reveal MRSA as one of the infective organisms. Which of the following is the best next step in management?
A. Transesophageal echocardiography (Correct Answer)
B. Obtain new blood cultures
C. CT scan of the chest
D. Nafcillin and piperacillin-tazobactam
E. Vancomycin and gentamicin
Explanation: ***Transesophageal echocardiography***
- The patient's history of **IV drug abuse**, **fever**, **new murmur**, and identification of **MRSA** strongly suggest **infective endocarditis**.
- A Transesophageal echocardiography (TEE) is the **most sensitive and specific imaging modality** to detect vegetations, abscesses, or valvular damage, which is crucial for guiding further management.
*Obtain new blood cultures*
- While repeating blood cultures can be useful to confirm eradication or identify new pathogens, the initial blood cultures already revealed MRSA, which is a common cause of **endocarditis in IV drug users**.
- The immediate priority given the lack of improvement and high suspicion of endocarditis is to visualize the heart valves for vegetations.
*CT scan of the chest*
- A CT scan of the chest would be useful to look for complications such as **septic emboli in the lungs** or other pulmonary pathologies.
- However, it would not provide the detailed visualization of heart valves necessary to diagnose or rule out valvular vegetations characteristic of endocarditis.
*Nafcillin and piperacillin-tazobactam*
- **Nafcillin** is active against **methicillin-susceptible Staphylococcus aureus (MSSA)**, but the patient's cultures already identified **MRSA**.
- **Piperacillin-tazobactam** is a broad-spectrum antibiotic but not a first-line treatment for MRSA infections and would not be appropriate given the identified pathogen.
*Vancomycin and gentamicin*
- The patient is already on **Vancomycin**, which is appropriate for MRSA, but adding **gentamicin** without clear indication would not be the best next step.
- While gentamicin is sometimes used as an adjunct in specific endocarditis regimens (e.g., enterococcal), the primary concern here is the lack of clinical improvement despite appropriate MRSA coverage, pointing towards a structural cardiac issue.
Question 1132: A 61-year-old white man presents to the emergency department because of progressive fatigue and shortness of breath on exertion and while lying down. He has had type 2 diabetes mellitus for 25 years and hypertension for 15 years. He is taking metformin and captopril for his diabetes and hypertension. He has smoked 10 cigarettes per day for the past 12 years and drinks alcohol occasionally. His temperature is 36.7°C (98.0°F) and blood pressure is 130/60 mm Hg. On physical examination, his arterial pulse shows a rapid rise and a quick collapse. An early diastolic murmur is audible over the left upper sternal border. Echocardiography shows severe chronic aortic regurgitation with a left ventricular ejection fraction of 55%–60% and mild left ventricular hypertrophy. Which of the following is an indication for aortic valve replacement in this patient?
A. Old age
B. Ejection fraction > 55%
C. Long history of diabetes mellitus
D. Presence of symptoms of left ventricular dysfunction (Correct Answer)
E. Long history of systemic hypertension
Explanation: ***Presence of symptoms of left ventricular dysfunction***
- The patient's symptoms of **progressive fatigue**, **shortness of breath on exertion**, and **orthopnea** (shortness of breath while lying down) are clear indicators of **left ventricular dysfunction** due to severe aortic regurgitation.
- In patients with **severe chronic aortic regurgitation**, the development of symptoms is a Class I indication for **aortic valve replacement**, regardless of the ejection fraction.
*Old age*
- While age can influence surgical risk, it is **not an independent indication** for aortic valve replacement in the absence of severe symptoms or significant ventricular dysfunction.
- The decision for surgery is primarily based on **symptom status** and objective measures of cardiac function.
*Ejection fraction > 55%*
- An ejection fraction of 55%-60% is considered **normal** or mildly reduced, indicating that the left ventricle still effectively pumps blood.
- Aortic valve replacement is typically indicated when the **ejection fraction falls below 50%**, even in asymptomatic patients, or with symptoms.
*Long history of diabetes mellitus*
- A long history of diabetes mellitus is a significant **comorbidity** that increases surgical risk and cardiovascular complications but is **not an independent indication** for valve replacement itself.
- The decision to operate is based on valve disease severity and its impact on cardiac function, not the duration of other chronic illnesses.
*Long history of systemic hypertension*
- Similar to diabetes, hypertension is a significant **comorbidity** that can exacerbate cardiac disease and increase surgical risk but does **not directly indicate** the need for aortic valve replacement.
- Hypertension management is crucial, but the primary indication for surgery stems from the **severity of aortic regurgitation** and its symptomatic consequences.
Question 1133: A 38-year-old man is brought to the emergency department after losing consciousness upon rising from his chair at work. The patient has had progressive cough, shortness of breath, fever, and chills for 6 days but did not seek medical attention for these symptoms. He appears distressed, flushed, and diaphoretic. He is 170 cm (5 ft 7 in) tall and weighs 120 kg (265 lbs); BMI is 41.5 kg/m2. His temperature is 39.4°C (102.9°F), pulse is 129/min, respirations are 22/min, and blood pressure is 91/50 mm Hg when supine. Crackles and bronchial breath sounds are heard over the right posterior hemithorax. A 2/6 midsystolic blowing murmur is heard along the left upper sternal border. Examination shows diffuse diaphoresis, flushed extremities, and dullness to percussion over the right posterior hemithorax. The abdomen is soft and nontender. Multiple nurses and physicians have been unable to attain intravenous access. A large-bore central venous catheter is inserted into the right internal jugular vein by standard sterile procedure. Which of the following is the most appropriate next step in the management of this patient?
A. Bronchoscopy
B. Chest X-ray
C. CT scan of the chest
D. Echocardiogram
E. Administer intravenous levofloxacin (Correct Answer)
Explanation: ***Correct: Administer intravenous levofloxacin***
- This patient has **septic shock from severe community-acquired pneumonia**, evidenced by hypotension (91/50 mmHg), tachycardia (129/min), fever (39.4°C), and respiratory findings (crackles, bronchial breath sounds, dullness to percussion).
- **Surviving Sepsis Campaign guidelines** mandate **broad-spectrum antibiotics within 1 hour** of recognizing septic shock, as each hour of delay increases mortality by approximately 7-10%.
- The clinical diagnosis of pneumonia is already established by physical examination; central venous access is now secured, making immediate antibiotic administration the priority.
- **Levofloxacin** provides appropriate coverage for community-acquired pneumonia including atypical organisms, though combination therapy (e.g., with ceftriaxone) would be ideal.
- Chest X-ray should be obtained **concurrently** but must **not delay** antibiotic administration in septic shock.
*Incorrect: Chest X-ray*
- While chest X-ray is important for confirming pneumonia and assessing complications, it should **never delay antibiotic administration** in a patient with septic shock.
- The physical examination findings (crackles, bronchial breath sounds, dullness to percussion) already provide strong clinical evidence of pneumonia.
- Chest X-ray can be obtained **simultaneously** with or immediately after starting antibiotics, but the time-sensitive nature of septic shock management makes antibiotics the priority.
- In sepsis protocols, imaging should not delay the "hour-1 bundle" which includes blood cultures and antibiotics.
*Incorrect: Bronchoscopy*
- This is an **invasive procedure** not indicated as an immediate intervention in unstable septic shock.
- Bronchoscopy may be considered later if the patient fails to respond to antibiotics or if there are specific diagnostic uncertainties, but it has no role in initial emergency management.
- The procedure would further delay critical antibiotic therapy and carries risks in a hemodynamically unstable patient.
*Incorrect: Echocardiogram*
- While the patient has a murmur, the **primary clinical picture is septic shock from pneumonia**, not primary cardiac pathology.
- The murmur is likely a **flow murmur** from fever, tachycardia, and hyperdynamic circulation in sepsis.
- Echocardiography may be considered later if endocarditis is suspected or if the patient has refractory shock, but it should not precede immediate antibiotic therapy.
- Treating the underlying infection takes precedence over cardiac evaluation in this presentation.
*Incorrect: CT scan of the chest*
- CT provides more detailed imaging than chest X-ray but is **not appropriate** as the immediate next step in an unstable patient with septic shock.
- Moving a critically ill, hypotensive patient to the CT scanner delays time-sensitive interventions and poses safety risks.
- CT scan may be useful later if complications arise (empyema, abscess) or if initial therapy fails, but has no role before antibiotic administration in acute septic shock.
Question 1134: A 62-year-old man comes to the physician because of increased frequency of urination. He also says that he needs to urinate 4 to 5 times nightly and has difficulty initiating a urinary stream. He has had several episodes of acute cystitis treated with ciprofloxacin during the past year. Digital rectal examination shows a firm, symmetrically enlarged, non-tender prostate. This patient is most likely to develop which of the following complications?
A. Inflammation of the renal interstitium
B. Blastic bone lesions
C. Abscess formation in the prostate
D. Impaired intracavernosal blood flow
E. Irreversible decrease in renal function (Correct Answer)
Explanation: ***Irreversible decrease in renal function***
- The patient's symptoms of **increased urinary frequency**, **nocturia**, **difficulty initiating stream**, and **recurrent cystitis** in the context of a **symmetrically enlarged, firm prostate** are highly suggestive of **benign prostatic hyperplasia (BPH)** with progressive outflow obstruction.
- Chronic urinary outflow obstruction can lead to **hydronephrosis** and **backpressure on the kidneys**, eventually causing **renal parenchymal damage** and an irreversible decrease in renal function.
*Inflammation of the renal interstitium*
- While chronic obstruction can lead to **chronic pyelonephritis**, which involves interstitial inflammation, **irreversible renal function decrease** is a more encompassing and severe long-term complication of sustained BPH with urinary retention.
- **Acute interstitial nephritis** is typically associated with drug reactions or systemic diseases, rather than primarily BPH.
*Blastic bone lesions*
- **Blastic bone lesions** are characteristic of **metastatic prostate cancer**, which typically presents with an **asymmetrically firm or nodular prostate** on DRE, unlike the symmetric enlargement described here.
- Although the patient's age and prostate exam warrant consideration of prostate cancer, the clinical picture strongly favors BPH, making blastic bone lesions less likely as the primary complication.
*Abscess formation in the prostate*
- **Prostatic abscesses** typically present with acute systemic symptoms like **fever, chills, and perineal pain**, which are not mentioned in this patient's presentation.
- While recurrent urinary tract infections can increase the risk of prostatic abscess, the dominant concern here is the long-term impact of chronic obstruction.
*Impaired intracavernosal blood flow*
- **Impaired intracavernosal blood flow** is a common cause of **erectile dysfunction**, which can coexist with BPH due to shared risk factors or age, but it's not a direct complication of the urinary outflow obstruction itself.
- The patient's reported symptoms are primarily related to urination and bladder emptying, not sexual function.
Question 1135: A 42-year-old woman comes to the physician because of stiffness and pain in multiple joints. She says that the fingers on both of her hands have become increasingly stiff and difficult to move over the past 8 months. She also complains of nails that break easily and look spotty as well as chronic back pain. She had a urinary tract infection a year ago that was treated with antibiotics. She is sexually active with 2 male partners and uses condoms inconsistently. Her vitals are within normal limits. A photograph of her right hand is shown. There are multiple, well-demarcated red plaques with silvery-white scales over the shins and back. Serum studies show a negative rheumatoid factor and ANA. Which of the following is the most likely diagnosis?
A. Rheumatoid arthritis
B. Secondary syphilis
C. Psoriatic arthritis (Correct Answer)
D. Systemic lupus erythematosus
E. Ankylosing spondylitis
Explanation: ***Psoriatic arthritis***
- The patient presents with **polyarticular joint pain and stiffness**, particularly in the hands, along with characteristic **nail changes** (onycholysis, pitting) and **psoriasis** (red plaques with silvery scales on shins and back).
- The **negative rheumatoid factor (RF)** and **ANA** help rule out rheumatoid arthritis and systemic lupus erythematosus, respectively, making psoriatic arthritis the most likely diagnosis given the constellation of skin, nail, and joint findings.
*Rheumatoid arthritis*
- While it causes polyarticular joint pain and stiffness, **rheumatoid arthritis typically presents with symmetric synovitis**, often spares the distal interphalangeal joints, and is frequently associated with a **positive rheumatoid factor** or anti-CCP antibodies.
- The presence of **psoriatic skin lesions** and nail changes, and a **negative RF**, make this diagnosis less likely.
*Secondary syphilis*
- Secondary syphilis can present with various skin manifestations and arthralgia, but it rarely causes the **erosive arthritis of the small joints** or the specific **nail changes** seen in psoriatic arthritis.
- The patient's history of inconsistent condom use is a risk factor, however, the specific clinical findings point away from syphilis.
*Systemic lupus erythematosus*
- This condition can cause **polyarthralgia/arthritis** and **skin rashes**, but the characteristic scaly plaques on the shins and back, and the **specific nail involvement** (onycholysis, pitting), are not typical features.
- A **negative ANA** also makes systemic lupus erythematosus an unlikely diagnosis.
*Ankylosing spondylitis*
- While **ankylosing spondylitis** can cause chronic back pain and stiffness, it primarily affects the **axial skeleton** (spine and sacroiliac joints) and typically presents with inflammatory back pain that improves with activity.
- It does not usually involve peripheral joints with the mentioned **nail changes** or **psoriatic skin lesions**.
Question 1136: A 37-year-old woman is being evaluated for difficulty with swallowing for the past few months. She explains that she experiences difficulty swallowing solid foods only. Her medical history is relevant for hypothyroidism and migraines. Her current medications include daily levothyroxine and acetaminophen as needed for pain. The vital signs include blood pressure 110/90 mm Hg, pulse rate 55/min, and respiratory rate 12/min. On physical examination, her abdomen is non-tender. Her voice is hoarse, but there is no pharyngeal hyperemia on oral examination. On cardiac auscultation, an opening snap followed by an early to mid-diastolic rumble is heard over the apex. A barium swallow X-ray is performed and is unremarkable. Echocardiography shows an enlarged left atrium and abnormal blood flow through 1 of the atrioventricular valves. What is the most likely valve abnormality seen in this patient?
A. Aortic valve stenosis
B. Mitral valve regurgitation
C. Mitral valve prolapse
D. Mitral valve stenosis (Correct Answer)
E. Aortic valve regurgitation
Explanation: ***Mitral valve stenosis***
- The classic auscultation findings of an **opening snap** followed by an **early to mid-diastolic rumble** at the apex are pathognomonic for **mitral stenosis**.
- **Dysphagia** (difficulty swallowing) in this context is likely due to the **enlarged left atrium compressing the esophagus**, and the patient's hoarse voice suggests possible **recurrent laryngeal nerve compression (Ortner’s syndrome)**, both common complications of severe mitral stenosis.
*Aortic valve stenosis*
- Typically presents with a **systolic ejection murmur**, often radiating to the carotid arteries, and usually associated with symptoms like syncope, angina, and dyspnea on exertion.
- While it can cause left ventricular hypertrophy, it does not directly lead to **left atrial enlargement** or the auscultation findings described.
*Mitral valve regurgitation*
- Characterized by a **holosystolic murmur** best heard at the apex and radiating to the axilla; it does not produce a diastolic rumble or an opening snap.
- While it can cause left atrial enlargement, the murmur and other clinical findings like dysphagia from esophageal compression are not characteristic.
*Mitral valve prolapse*
- Typically presents with a **mid-systolic click** and often a **late systolic murmur**, not a diastolic rumble or opening snap.
- It usually does not lead to the degree of left atrial enlargement that would cause dysphagia or hoarseness.
*Aortic valve regurgitation*
- Produces a **diastolic decrescendo murmur** best heard at the left sternal border and is associated with a wide pulse pressure and hyperdynamic circulation.
- It does not cause an opening snap or a diastolic rumble, nor does it typically lead to significant left atrial enlargement causing esophageal compression.
Question 1137: A 42-year-old man comes to the physician for a routine health maintenance examination. He feels well but has had several episodes of “finger pallor” over the past 4 months. During these episodes, the 4th finger of his left hand turns white. The color usually returns within 20 minutes, followed by redness and warmth of the finger. The episodes are not painful. The complaints most commonly occur on his way to work, when it is very cold outside. One time, it happened when he was rushing to the daycare center because he was late for picking up his daughter. The patient has gastroesophageal reflux disease treated with lansoprazole. His vital signs are within normal limits. The blood flow to the hand is intact on compression of the ulnar artery at the wrist, as well as on compression of the radial artery. When the patient is asked to immerse his hands in cold water, a change in the color of the 4th digit of his left hand is seen. A photograph of the affected hand is shown. His hemoglobin concentration is 14.2 g/dL, serum creatinine is 0.9 mg/dL, and ESR is 35 mm/h. Which of the following is the most appropriate next step in management?
A. Discontinue lansoprazole
B. Oral aspirin
C. Topical nitroglycerin
D. Digital subtraction angiography
E. Serologic testing (Correct Answer)
Explanation: ***Serologic testing***
- The patient exhibits symptoms consistent with **Raynaud phenomenon**, characterized by color changes (pallor, cyanosis, redness) in response to cold or stress. The elevated **ESR (35 mm/h)** raises suspicion for an underlying **secondary cause**, such as a connective tissue disease.
- Given the elevated ESR, which suggests systemic inflammation, **serologic testing** (e.g., antinuclear antibodies, rheumatoid factor, anti-centromere antibodies, anti-Scl-70 antibodies) is crucial to evaluate for **underlying autoimmune or rheumatologic conditions** that may be causing secondary Raynaud phenomenon.
- This is the most appropriate next step before initiating treatment, as identifying an underlying condition will guide management.
*Discontinue lansoprazole*
- **Lansoprazole** is a proton pump inhibitor used to treat **gastroesophageal reflux disease (GERD)**. There is no known direct causal link between lansoprazole use and Raynaud phenomenon.
- Discontinuing this medication would not address the patient's digital symptoms and could worsen his **GERD**.
*Oral aspirin*
- **Aspirin** is an antiplatelet agent used for cardiovascular protection or mild pain relief. It is not indicated for the primary management of Raynaud phenomenon.
- While it may be considered in cases of severe digital ischemia or ulceration, there's no evidence of such complications here, and it won't prevent vasospasms.
*Topical nitroglycerin*
- **Topical nitroglycerin** can induce vasodilation and may be used to treat acute vasospastic episodes or ulcers in severe Raynaud phenomenon.
- However, it is typically reserved for patients experiencing **severe, frequent, or complicated episodes**, or those with **digital ulcers**, as a targeted treatment rather than an initial diagnostic step, especially when an underlying cause is suspected.
*Digital subtraction angiography*
- **Digital subtraction angiography** is an invasive imaging technique used to visualize blood vessels and identify stenoses or occlusions.
- While it can assess vascular patency, this patient's physical examination already suggests **intact blood flow** to the hand (positive Allen's test), making an invasive procedure unnecessary as an initial step for diagnosing the cause of Raynaud phenomenon.
Question 1138: A 60-year-old man comes to the physician because of a 6-month history of progressively worsening urinary frequency. He feels the urge to urinate every hour or two, which restricts his daily activities and interferes with his sleep. He has no fever, hematuria, or burning pain on micturition. He has hypertension and type 2 diabetes mellitus. Current medications include metformin and amlodipine. He does not smoke and drinks 1 to 2 beers daily. His vital signs are within normal limits. Abdominal examination shows no abnormalities. Digital rectal examination shows a nontender, firm, symmetrically enlarged prostate with no nodules. Which of the following is the most appropriate next step in management?
A. Uroflowmetry
B. Urine cytology
C. Urinalysis (Correct Answer)
D. Prostate ultrasonography
E. Serum prostate-specific antigen level
Explanation: ***Urinalysis***
- A **urinalysis** is the most appropriate initial diagnostic test to rule out urinary tract infection (UTI), hematuria, and other urinary pathologies before proceeding with further investigations for **benign prostatic hyperplasia (BPH)**.
- Although the patient has no fever or dysuria, **urinary frequency** is a common symptom of UTIs, and ruling it out is essential for appropriate diagnosis and treatment.
*Uroflowmetry*
- **Uroflowmetry** measures the rate of urine flow and can assess the degree of obstruction, but it is typically performed after a basic workup, including urinalysis, to further evaluate the cause of **lower urinary tract symptoms (LUTS)**.
- While useful for BPH evaluation, it is not the initial step when infection or other causes of frequency have not been excluded.
*Urine cytology*
- **Urine cytology** is used to detect malignant cells in the urine and is usually reserved for patients with risk factors for bladder cancer, such as **gross hematuria**, irritative voiding symptoms, or a history of smoking, which are not primary concerns here.
- Given the patient's symptoms and physical exam findings suggestive of BPH, cancer is less likely to be the initial concern.
*Prostate ultrasonography*
- **Prostate ultrasonography** can determine prostate size and screen for nodules, but it is more invasive and typically reserved for later stages of investigation if BPH is suspected and symptoms are severe, or if the digital rectal exam (DRE) is concerning.
- A **nontender, firm, symmetrically enlarged prostate** on DRE is consistent with BPH, but an ultrasound is not the first diagnostic step.
*Serum prostate-specific antigen level*
- **Serum prostate-specific antigen (PSA)** level is used for prostate cancer screening and monitoring, but it is not recommended as an initial test solely for evaluating LUTS unless there are other risk factors or findings suggestive of prostate cancer (e.g., nodularity on DRE).
- Given the symmetrical enlargement and absence of nodules, initial cancer screening with PSA is not the most immediate priority.
Question 1139: A 64-year-old man presents to his primary care physician's office for a routine check-up. His past medical history is significant for type 2 diabetes mellitus, hypertension, chronic atrial fibrillation, and ischemic cardiomyopathy. On his last visit three months ago, he was found to have hyperkalemia, at which time lisinopril and spironolactone were removed from his medication regimen. Currently, his medications include coumadin, aspirin, metformin, glyburide, metoprolol, furosemide, and amlodipine. His T is 37 C (98.6 F), BP 154/92 mm Hg, HR 80/min, and RR 16/min. His physical exam is notable for elevated jugular venous pressure, an S3 heart sound, and 1+ pitting pedal edema. His repeat lab work at the current visit is as follows:
Sodium: 138 mEq/L, potassium: 5.7 mEq/L, chloride 112 mEq/L, bicarbonate 18 mEq/L, BUN 29 mg/dL, and creatinine 2.1 mg/dL.
Which of the following is the most likely cause of this patient's acid-base and electrolyte abnormalities?
A. Furosemide
B. Amlodipine
C. Renal tubular acidosis
D. Glyburide
E. Chronic renal failure (Correct Answer)
Explanation: ***Chronic renal failure***
- This patient presents with **hyperkalemia**, **metabolic acidosis** (low bicarbonate), **elevated BUN and creatinine**, and signs of fluid overload, all consistent with **worsening renal function**.
- **Chronic kidney disease** impairs the kidneys' ability to excrete potassium and acids, leading to these electrolyte and acid-base disturbances.
*Furosemide*
- **Furosemide** is a loop diuretic that typically causes **hypokalemia** and **metabolic alkalosis** due to increased potassium and hydrogen ion excretion.
- While it can worsen renal function in hypovolemic states, it primarily causes **potassium wasting**, not retention.
*Amlodipine*
- **Amlodipine** is a calcium channel blocker that may cause **peripheral edema** but is not directly associated with hyperkalemia or metabolic acidosis.
- It does not directly impact **renal electrolyte handling** or acid-base balance in this manner.
*Renal tubular acidosis*
- **Renal tubular acidosis (RTA)** specifically refers to impaired tubular handling of acid or bicarbonate, but it is not the most likely cause here given the **elevated BUN and creatinine** indicative of overall renal failure.
- While RTA can cause metabolic acidosis, it typically doesn't fully explain the degree of hyperkalemia or the overall picture of **reduced GFR**.
*Glyburide*
- **Glyburide** is a sulfonylurea used to manage type 2 diabetes by increasing **insulin secretion**.
- It is not directly associated with **hyperkalemia**, **metabolic acidosis**, or the observed renal function abnormalities.
Question 1140: A 40-year-old man comes to the physician for a follow-up examination. He feels well. He has no urinary urgency, increased frequency, dysuria, or gross hematuria. He has a history of recurrent urinary tract infections. His last urinary tract infection was 3 months ago and was treated with ciprofloxacin. Current medications include a multivitamin. He has smoked one pack of cigarettes daily for 18 years. Vital signs are within normal limits. The abdomen is soft and nontender. There is no costovertebral angle tenderness. Laboratory studies show:
Hemoglobin 11.2 g/dL
Leukocyte count 9,500/mm3
Platelet count 170,000/mm3
Serum
Na+ 135 mEq/L
K+ 4.9 mEq/L
Cl- 101 mEq/L
Urea nitrogen 18 mg/dL
Creatinine 0.6 mg/dL
Urine
Blood 2+
Protein negative
RBC 5–7/hpf, normal shape and size
RBC casts negative
WBC 0–2/hpf
Bacteria negative
Urine cultures are negative. Urine analysis is repeated and shows similar results. A cystoscopy shows no abnormalities. Which of the following is the most appropriate next step in management?
A. Annual urinalysis
B. Reassurance
C. CT urography (Correct Answer)
D. Voided urine cytology
E. Transrectal ultrasound
Explanation: ***CT urography***
- The patient has **microscopic hematuria** with **2+ blood on urinalysis** and **5-7 RBCs/hpf**, in the absence of infection or other identifiable causes, which warrants further investigation for potential malignancy.
- Given the patient's **smoking history** (18 pack-years) and age, which are significant risk factors for **urothelial carcinoma** (bladder, renal pelvis, ureters), imaging with CT urography is crucial to visualize the entire urinary tract for tumors or other structural abnormalities.
*Annual urinalysis*
- This option represents a passive approach to monitoring, which is inadequate given the presence of **unexplained microscopic hematuria** and risk factors for malignancy.
- Delaying definitive investigation could lead to a missed or delayed diagnosis of a potentially treatable condition like **urothelial cancer**.
*Reassurance*
- Reassurance is inappropriate when **microscopic hematuria** is present without a clear benign cause, especially in a patient with risk factors like **smoking history**.
- This could lead to a false sense of security and delay the diagnosis and treatment of a serious underlying condition.
*Voided urine cytology*
- **Urine cytology** has a low sensitivity for detecting low-grade bladder cancers, though it can be useful for high-grade cancers and carcinoma in situ.
- While it may be considered in conjunction with imaging, it is not the most appropriate *initial* next step to identify the source of hematuria throughout the entire urinary tract, especially when imaging can detect other pathologies.
*Transrectal ultrasound*
- A **transrectal ultrasound** is primarily used to evaluate the **prostate gland**, typically in the context of prostate-specific antigen elevation or prostatic symptoms.
- It would not effectively visualize the bladder, ureters, or kidneys, which are the primary concerns for microscopic hematuria in this patient's demographic and risk factors.
