A 69-year-old woman presents with pain in her hip and groin. She states that the pain is present in the morning, and by the end of the day it is nearly unbearable. Her past medical history is notable for a treated episode of acute renal failure, diabetes mellitus, obesity, and hypertension. Her current medications include losartan, metformin, insulin, and ibuprofen. The patient recently started taking high doses of vitamin D as she believes that it could help her symptoms. She also states that she recently fell off the treadmill while exercising at the gym. On physical exam you note an obese woman. There is pain, decreased range of motion, and crepitus on physical exam of her right hip. The patient points to the areas that cause her pain stating that it is mostly over the groin. The patient's skin turgor reveals tenting. Radiography is ordered.
Which of the following is most likely to be found on radiography?
Q1182
A 62-year-old woman presents to the emergency department with a 2-hour history of sharp chest pain. She says that the pain is worse when she inhales and is relieved by sitting up and leaning forward. Her past medical history is significant for rheumatoid arthritis, myocardial infarction status post coronary artery bypass graft, and radiation for breast cancer 20 years ago. Physical exam reveals a rubbing sound upon cardiac auscultation as well as increased jugular venous distention on inspiration. Pericardiocentesis is performed revealing grossly bloody fluid. Which of the following is most specifically associated with this patient's presentation?
Q1183
A previously healthy 44-year-old man is brought by his coworkers to the emergency department 45 minutes after he became light-headed and collapsed while working in the boiler room of a factory. He did not lose consciousness. His coworkers report that 30 minutes prior to collapsing, he told them he was nauseous and had a headache. The patient appears sweaty and lethargic. He is not oriented to time, place, or person. The patient’s vital signs are as follows: temperature 41°C (105.8°F); heart rate 133/min; respiratory rate 22/min; and blood pressure 90/52 mm Hg. Examination shows equal and reactive pupils. Deep tendon reflexes are 2+ bilaterally. His neck is supple. A 0.9% saline infusion is administered. A urinary catheter is inserted and dark brown urine is collected. The patient’s laboratory test results are as follows:
Laboratory test
Blood
Hemoglobin 15 g/dL
Leukocyte count 18,000/mm3
Platelet count 51,000/mm3
Serum
Na+ 149 mEq/L
K+ 5.0 mEq/L
Cl- 98 mEq/L
Urea nitrogen 42 mg/dL
Glucose 88 mg/dL
Creatinine 1.8 mg/dL
Aspartate aminotransferase (AST, GOT) 210
Alanine aminotransferase (ALT, GPT) 250
Creatine kinase 86,000 U/mL
Which of the following is the most appropriate next step in patient management?
Q1184
A 55-year-old woman presents to her primary care provider with a 2-month history of insidious onset of left shoulder pain. It only occurs at the extremes of her range of motion and has made it difficult to sleep on the affected side. She has noticed increasing difficulty with activities of daily living, including brushing her hair and putting on or taking off her blouse and bra. She denies a history of shoulder trauma, neck pain, arm/hand weakness, numbness, or paresthesias. Her medical history is remarkable for type 2 diabetes mellitus, for which she takes metformin and glipizide. Her physical examination reveals a marked decrease in both active and passive range of motion of the left shoulder, with forwarding flexion to 75°, abduction to 75°, external rotation to 45°, and internal rotation to 15° with significant pain. Rotator cuff strength is normal. AP, scapular Y, and axillary plain film radiographs are reported as normal. Which of the following is the most likely diagnosis?
Q1185
A 48-year-old female presents to the emergency room with mental status changes.
Laboratory analysis of the patient's serum shows:
Na 122 mEq/L
K 3.9 mEq/L
HCO3 24 mEq/L
BUN 21 mg/dL
Cr 0.9 mg/dL
Ca 8.5 mg/dL
Glu 105 mg/dL
Urinalysis shows:
Osmolality 334 mOsm/kg
Na 45 mEq/L
Glu 0 mg/dL
Which of the following is the most likely diagnosis?
Q1186
An 11-year-old boy presents with fever and joint pain for the last 3 days. His mother says that he had a sore throat 3 weeks ago but did not seek medical care at that time. The family immigrated from the Middle East 3 years ago. The patient has no past medical history. The current illness started with a fever and a swollen right knee that was very painful. The following day, his knee improved but his left elbow became swollen and painful. While in the waiting room, his left knee is also becoming swollen and painful. Vital signs include: temperature 38.7°C (101.6°F), and blood pressure 110/80 mm Hg. On physical examination, the affected joints are swollen and very tender to touch, and there are circular areas of redness on his back and left forearm (as shown in the image). Which of the following is needed to establish a diagnosis of acute rheumatic fever in this patient?
Q1187
A 52-year-old woman presents to her primary care physician with a chief complaint of diarrhea. She states that it has been going on for the past month and started after she ate a burger cooked over a campfire. She endorses having lost 10 pounds during this time. The patient has no other complaints other than hoarseness which has persisted during this time. The patient has a past medical history of obesity, hypothyroidism, diabetes, and anxiety. Her current medications include insulin, metformin, levothyroxine, and fluoxetine. She currently drinks 4 to 5 alcoholic beverages per day. Her temperature is 99.5°F (37.5°C), blood pressure is 157/98 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 98% on room air. On physical exam, you note a healthy obese woman. Cardiopulmonary exam is within normal limits. HEENT exam is notable for a mass on the thyroid. Abdominal exam is notable for a candida infection underneath the patient's pannus. Pelvic exam is notable for a white, fish-odored discharge. Laboratory values are as follows:
Hemoglobin: 12 g/dL
Hematocrit: 36%
Leukocyte count: 4,500 cells/mm^3 with normal differential
Platelet count: 190,000/mm^3
Serum:
Na+: 141 mEq/L
Cl-: 102 mEq/L
K+: 5.5 mEq/L
HCO3-: 24 mEq/L
Glucose: 122 mg/dL
Ca2+: 7.1 mg/dL
Which of the following could also be found in this patient?
Q1188
A 28-year-old male presents with sharp, stabbing chest pain that worsens when lying flat and improves when sitting forward. He reports a recent viral upper respiratory infection 2 weeks ago. On examination, a friction rub is heard on auscultation. His vital signs are stable.
An ECG is most likely to show which of the following findings in this patient?
Q1189
An 82-year-old woman is brought to the emergency department after losing consciousness at her nursing home. She had been watching TV for several hours and while getting up to use the bathroom, she fell and was unconscious for several seconds. She felt dizzy shortly before the fall. She does not have a headache or any other pain. She has a history of hypertension, intermittent atrial fibrillation, and stable angina pectoris. Current medications include warfarin, aspirin, hydrochlorothiazide, and a nitroglycerin spray as needed. Her temperature is 36.7°C (98.1°F), pulse is 100/min and regular, and blood pressure is 102/56 mm Hg. Physical exam shows a dry tongue. A fold of skin that is pinched on the back of her hand unfolds after 2 seconds. Cardiopulmonary examination shows no abnormalities. Further evaluation of this patient is most likely to show which of the following findings?
Q1190
A 24-year-old man presents to his primary care physician for a persistent and low grade headache as well as trouble focusing. The patient was seen in the emergency department 3 days ago after hitting his head on a branch while biking under the influence of alcohol. His head CT at the time was normal, and the patient was sent home with follow up instructions. Since the event, he has experienced trouble focusing on his school work and feels confused at times while listening to lectures. He states that he can’t remember the lectures and also says he has experienced a sensation of vertigo at times. On review of systems, he states that he has felt depressed lately and has had trouble sleeping, though he denies any suicidal or homicidal ideation. His temperature is 98.2°F (36.8°C), blood pressure is 122/65 mmHg, pulse is 70/min, respirations are 12/min, and oxygen saturation is 98% on room air. The patient’s neurological and cardiopulmonary exam are within normal limits. Which of the following is the best next step in management?
Cardiology US Medical PG Practice Questions and MCQs
Question 1181: A 69-year-old woman presents with pain in her hip and groin. She states that the pain is present in the morning, and by the end of the day it is nearly unbearable. Her past medical history is notable for a treated episode of acute renal failure, diabetes mellitus, obesity, and hypertension. Her current medications include losartan, metformin, insulin, and ibuprofen. The patient recently started taking high doses of vitamin D as she believes that it could help her symptoms. She also states that she recently fell off the treadmill while exercising at the gym. On physical exam you note an obese woman. There is pain, decreased range of motion, and crepitus on physical exam of her right hip. The patient points to the areas that cause her pain stating that it is mostly over the groin. The patient's skin turgor reveals tenting. Radiography is ordered.
Which of the following is most likely to be found on radiography?
A. Loss of joint space and osteophytes (Correct Answer)
B. Posterior displacement of the femoral head
C. Hyperdense foci in the ureters
D. Femoral neck fracture
E. Normal radiography
Explanation: ***Loss of joint space and osteophytes***
- The patient's presentation with **hip and groin pain worsened by activity**, improved with rest, and associated with **crepitus** and **decreased range of motion**, is highly suggestive of **osteoarthritis**.
- **Osteoarthritis** is characterized radiographically by **loss of joint space**, **osteophytes** (bone spurs), subchondral sclerosis, and subchondral cysts.
*Posterior displacement of the femoral head*
- This finding is characteristic of a **posterior hip dislocation**, which usually presents with severe pain and an inability to bear weight after a significant traumatic event.
- While the patient fell, her symptoms are chronic and progressive, and she has signs of arthritis rather than acute dislocation.
*Hyperdense foci in the ureters*
- These would indicate **kidney stones**, which typically present with acute, severe flank pain radiating to the groin, and hematuria.
- The patient's symptoms are chronic and localized to the hip joint, making kidney stones an unlikely cause of her primary complaint.
*Femoral neck fracture*
- A **femoral neck fracture** would cause acute, severe hip pain, inability to bear weight, and often external rotation and shortening of the leg, usually following a fall.
- Although she fell, her chronic, activity-related pain and crepitus are more indicative of a degenerative process.
*Normal radiography*
- Given the patient's age, chronic and worsening hip pain, physical exam findings of crepitus and decreased range of motion, and risk factors like obesity, it is highly improbable that her hip X-rays would be normal.
- These symptoms are classic for **osteoarthritis**, which shows distinct radiographic changes.
Question 1182: A 62-year-old woman presents to the emergency department with a 2-hour history of sharp chest pain. She says that the pain is worse when she inhales and is relieved by sitting up and leaning forward. Her past medical history is significant for rheumatoid arthritis, myocardial infarction status post coronary artery bypass graft, and radiation for breast cancer 20 years ago. Physical exam reveals a rubbing sound upon cardiac auscultation as well as increased jugular venous distention on inspiration. Pericardiocentesis is performed revealing grossly bloody fluid. Which of the following is most specifically associated with this patient's presentation?
A. Myocardial infarction
B. Malignancy (Correct Answer)
C. Uremia
D. Rheumatoid arthritis
E. Viral illness
Explanation: ***Malignancy***
- The presence of **grossly bloody (hemorrhagic) pericardial fluid** is the key finding that most specifically points to **malignancy** as the underlying cause.
- **Hemorrhagic pericardial effusion** is most commonly associated with: (1) malignancy, (2) tuberculosis, or (3) trauma. Given the patient's **history of radiation therapy for breast cancer 20 years ago**, malignancy (either metastatic breast cancer or radiation-induced secondary malignancy) is the most likely cause.
- Clinical features like **chest pain** worse on inspiration and relieved by leaning forward, a **pericardial friction rub**, and **increased jugular venous distention on inspiration (Kussmaul sign)** indicate pericarditis with possible cardiac tamponade.
*Myocardial infarction*
- While myocardial infarction can lead to pericarditis (acute post-MI pericarditis or delayed Dressler's syndrome), the pericardial fluid is typically **serous or serosanguinous, not grossly bloody**.
- The patient's history of prior MI and CABG makes this less likely to be the cause of this acute presentation with hemorrhagic effusion.
- Post-MI pericarditis usually occurs within days to weeks after the MI event.
*Uremia*
- **Uremic pericarditis** occurs in patients with severe kidney failure (uremia) and typically presents with **serofibrinous exudate**, not grossly bloody effusion.
- There is no clinical indication of renal failure or uremia in this patient's presentation.
*Rheumatoid arthritis*
- **Rheumatoid pericarditis** can occur in patients with RA, but the pericardial effusion is usually **sterile and serofibrinous**, rarely resulting in frankly hemorrhagic fluid.
- While this patient has RA, the **grossly bloody fluid** and **history of breast cancer radiation** make malignancy a much more specific and likely diagnosis.
*Viral illness*
- **Viral pericarditis** is a common cause of acute pericarditis and typically presents with chest pain and a pericardial friction rub.
- However, viral pericarditis usually produces **serous or serofibrinous effusions, not grossly bloody fluid**.
- There is no mention of prodromal viral symptoms, and the hemorrhagic nature of the fluid strongly argues against a viral etiology.
Question 1183: A previously healthy 44-year-old man is brought by his coworkers to the emergency department 45 minutes after he became light-headed and collapsed while working in the boiler room of a factory. He did not lose consciousness. His coworkers report that 30 minutes prior to collapsing, he told them he was nauseous and had a headache. The patient appears sweaty and lethargic. He is not oriented to time, place, or person. The patient’s vital signs are as follows: temperature 41°C (105.8°F); heart rate 133/min; respiratory rate 22/min; and blood pressure 90/52 mm Hg. Examination shows equal and reactive pupils. Deep tendon reflexes are 2+ bilaterally. His neck is supple. A 0.9% saline infusion is administered. A urinary catheter is inserted and dark brown urine is collected. The patient’s laboratory test results are as follows:
Laboratory test
Blood
Hemoglobin 15 g/dL
Leukocyte count 18,000/mm3
Platelet count 51,000/mm3
Serum
Na+ 149 mEq/L
K+ 5.0 mEq/L
Cl- 98 mEq/L
Urea nitrogen 42 mg/dL
Glucose 88 mg/dL
Creatinine 1.8 mg/dL
Aspartate aminotransferase (AST, GOT) 210
Alanine aminotransferase (ALT, GPT) 250
Creatine kinase 86,000 U/mL
Which of the following is the most appropriate next step in patient management?
A. Dantrolene
B. Acetaminophen therapy
C. Hemodialysis
D. Ice water immersion (Correct Answer)
E. Evaporative cooling
Explanation: ***Ice water immersion***
- This patient presents with signs and symptoms consistent with **heat stroke**, including high body temperature (41°C), altered mental status, and a history of working in a hot environment (boiler room). **Rapid aggressive cooling** is the most critical immediate intervention to prevent organ damage.
- **Ice water immersion** is the fastest and most effective cooling method for heat stroke, aiming to reduce core body temperature to less than 39°C (102.2°F) within 30 minutes.
*Dantrolene*
- **Dantrolene** is primarily used to treat **malignant hyperthermia** and **neuroleptic malignant syndrome**, conditions caused by abnormal calcium release in muscle cells, not environmental heat exposure.
- While both conditions involve hyperthermia, the underlying pathophysiology and triggers are different from heat stroke.
*Acetaminophen therapy*
- **Acetaminophen** is an antipyretic that works by inhibiting prostaglandin synthesis in the central nervous system, affecting the hypothalamic thermoregulatory center.
- It is **ineffective** for the hyperthermia seen in heat stroke, which is due to a failure of thermoregulation rather than an altered hypothalamic set point, and could potentially worsen liver injury.
*Hemodialysis*
- **Hemodialysis** is indicated for severe **renal failure**, drug overdose, or certain electrolyte imbalances. Although this patient has acute kidney injury (elevated BUN and creatinine, dark urine suggestive of rhabdomyolysis), aggressive cooling is the immediate life-saving intervention for heat stroke.
- While renal support might be necessary later if kidney injury progresses, it is not the most appropriate *initial* next step for hyperthermia and altered mental status.
*Evaporative cooling*
- **Evaporative cooling** (e.g., spraying with lukewarm water and using fans) is a cooling method that can be effective, particularly in environments with low humidity.
- However, for severe heat stroke with a temperature as high as 41°C, **ice water immersion** provides a more rapid and aggressive temperature reduction, which is crucial for improving outcomes.
Question 1184: A 55-year-old woman presents to her primary care provider with a 2-month history of insidious onset of left shoulder pain. It only occurs at the extremes of her range of motion and has made it difficult to sleep on the affected side. She has noticed increasing difficulty with activities of daily living, including brushing her hair and putting on or taking off her blouse and bra. She denies a history of shoulder trauma, neck pain, arm/hand weakness, numbness, or paresthesias. Her medical history is remarkable for type 2 diabetes mellitus, for which she takes metformin and glipizide. Her physical examination reveals a marked decrease in both active and passive range of motion of the left shoulder, with forwarding flexion to 75°, abduction to 75°, external rotation to 45°, and internal rotation to 15° with significant pain. Rotator cuff strength is normal. AP, scapular Y, and axillary plain film radiographs are reported as normal. Which of the following is the most likely diagnosis?
A. Degenerative cervical spine disease
B. Glenohumeral arthritis
C. Subacromial impingement syndrome
D. Rotator cuff injury
E. Adhesive capsulitis (Correct Answer)
Explanation: **Adhesive capsulitis**
- The patient's presentation of **insidious onset of shoulder pain**, progressive loss of both **active and passive range of motion**, difficulty with activities of daily living, and a history of **diabetes mellitus** are classic for adhesive capsulitis, also known as **frozen shoulder**.
- **Normal rotator cuff strength** and **normal plain film radiographs** further support this diagnosis by ruling out other common shoulder pathologies.
*Degenerative cervical spine disease*
- While cervical spine issues can cause referred shoulder pain, they typically present with **neurological symptoms** like numbness, tingling, or weakness in the arm/hand, which are absent here.
- Cervical spine disease would not typically cause such a **marked restriction in both active and passive glenohumeral range of motion**.
*Glenohumeral arthritis*
- Although glenohumeral arthritis can cause stiffness and pain, it would likely show **degenerative changes on plain film radiographs**, which were reported as normal in this case.
- The **insidious, progressive loss of all ranges of motion** in a diabetic patient is more characteristic of adhesive capsulitis than primary arthritis.
*Subacromial impingement syndrome*
- This condition typically causes pain with overhead activities and specific movements, but usually spares **full passive range of motion** and doesn't result in the global, severe stiffness seen here.
- Impingement syndrome is also commonly associated with rotator cuff tendinopathy, but this patient has **normal rotator cuff strength**.
*Rotator cuff injury*
- A rotator cuff injury would primarily affect **active range of motion** and strength, often with specific weakness on examination, but usually would not cause the significant loss of **passive range of motion** described.
- The patient's **normal rotator cuff strength** directly contradicts a significant rotator cuff injury.
Question 1185: A 48-year-old female presents to the emergency room with mental status changes.
Laboratory analysis of the patient's serum shows:
Na 122 mEq/L
K 3.9 mEq/L
HCO3 24 mEq/L
BUN 21 mg/dL
Cr 0.9 mg/dL
Ca 8.5 mg/dL
Glu 105 mg/dL
Urinalysis shows:
Osmolality 334 mOsm/kg
Na 45 mEq/L
Glu 0 mg/dL
Which of the following is the most likely diagnosis?
A. Diabetes insipidus
B. Aspirin overdose
C. Primary polydipsia
D. Diarrhea
E. Lung cancer (Correct Answer)
Explanation: ***Lung cancer***
- The patient presents with **hyponatremia** (Na 122 mEq/L) and **mental status changes**, along with a **euvolemic state** (normal BUN, creatinine, and potassium), which are characteristic of **Syndrome of Inappropriate Antidiuretic Hormone (SIADH)**.
- **Small cell lung cancer** is a common cause of **ectopic ADH production**, leading to SIADH.
*Diabetes insipidus*
- Characterized by **hypernatremia** and the excretion of **large volumes of dilute urine** (low urine osmolality), which contradicts the patient's hyponatremia and relatively concentrated urine (334 mOsm/kg).
- This condition involves insufficient ADH or renal unresponsiveness to ADH, leading to free water loss, not retention.
*Aspirin overdose*
- Typically causes an **acid-base disturbance**, often a mixed respiratory alkalosis and metabolic acidosis, and may lead to **tinnitus** and **hyperthermia**.
- While it can affect mental status, it does not directly explain the specific pattern of **hyponatremia** and urine osmolality observed.
*Primary polydipsia*
- Usually results in **hyponatremia** due to excessive water intake, but the urine would be **maximally dilute** (urine osmolality < 100 mOsm/kg) as the kidneys try to excrete the excess water.
- The patient's urine osmolality of 334 mOsm/kg indicates that the kidneys are still able to concentrate urine somewhat, making primary polydipsia less likely.
*Diarrhea*
- Causes **volume depletion** and can lead to various electrolyte abnormalities, but typically results in **hypernatremia** or isotonic hyponatremia with signs of dehydration.
- The patient's lab values do not show signs of dehydration or a primary gastrointestinal disturbance.
Question 1186: An 11-year-old boy presents with fever and joint pain for the last 3 days. His mother says that he had a sore throat 3 weeks ago but did not seek medical care at that time. The family immigrated from the Middle East 3 years ago. The patient has no past medical history. The current illness started with a fever and a swollen right knee that was very painful. The following day, his knee improved but his left elbow became swollen and painful. While in the waiting room, his left knee is also becoming swollen and painful. Vital signs include: temperature 38.7°C (101.6°F), and blood pressure 110/80 mm Hg. On physical examination, the affected joints are swollen and very tender to touch, and there are circular areas of redness on his back and left forearm (as shown in the image). Which of the following is needed to establish a diagnosis of acute rheumatic fever in this patient?
A. Elevated erythrocyte sedimentation rate (ESR)
B. Positive anti-streptococcal serology (Correct Answer)
C. Elevated leukocyte count
D. No other criterion is needed to establish the diagnosis of acute rheumatic fever
E. Prolonged PR interval
Explanation: ***Positive anti-streptococcal serology***
- A positive anti-streptococcal serology (e.g., elevated ASO titer or anti-DNase B) is a mandatory component for diagnosing **acute rheumatic fever** (ARF) when using the updated Jones criteria, as it confirms a preceding Group A Streptococcal infection.
- Given the history of a recent **sore throat** and clinical manifestations suggestive of ARF (migratory polyarthritis, fever, erythema marginatum), confirmation of a preceding streptococcal infection is crucial.
*Elevated erythrocyte sedimentation rate (ESR)*
- An elevated **ESR** is one of the **minor criteria** for ARF and indicates general inflammation, but it is not sufficient on its own to confirm the diagnosis.
- While supportive of an inflammatory process, it does not confirm the specific etiology of ARF, which requires evidence of a recent **streptococcal infection**.
*Elevated leukocyte count*
- An elevated **leukocyte count** (leukocytosis) is a non-specific indicator of inflammation or infection and is also considered a **minor criterion** for ARF.
- It does not definitively point to ARF or a preceding streptococcal infection and thus cannot solely establish the diagnosis.
*No other criterion is needed to establish the diagnosis of acute rheumatic fever*
- This statement is incorrect because the diagnosis of ARF requires fulfilling specific Jones criteria, which include evidence of a preceding **Group A Streptococcal infection** along with major and/or minor clinical manifestations.
- While the patient exhibits several major criteria (migratory polyarthritis, erythema marginatum), the diagnosis is incomplete without confirming the **streptococcal trigger**.
*Prolonged PR interval*
- A **prolonged PR interval** on an ECG is a sign of **carditis**, which is a **major criterion** for ARF.
- Although carditis can be a significant manifestation, it is not always present in every case and does not replace the requirement for evidence of a preceding **streptococcal infection** for diagnosis.
Question 1187: A 52-year-old woman presents to her primary care physician with a chief complaint of diarrhea. She states that it has been going on for the past month and started after she ate a burger cooked over a campfire. She endorses having lost 10 pounds during this time. The patient has no other complaints other than hoarseness which has persisted during this time. The patient has a past medical history of obesity, hypothyroidism, diabetes, and anxiety. Her current medications include insulin, metformin, levothyroxine, and fluoxetine. She currently drinks 4 to 5 alcoholic beverages per day. Her temperature is 99.5°F (37.5°C), blood pressure is 157/98 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 98% on room air. On physical exam, you note a healthy obese woman. Cardiopulmonary exam is within normal limits. HEENT exam is notable for a mass on the thyroid. Abdominal exam is notable for a candida infection underneath the patient's pannus. Pelvic exam is notable for a white, fish-odored discharge. Laboratory values are as follows:
Hemoglobin: 12 g/dL
Hematocrit: 36%
Leukocyte count: 4,500 cells/mm^3 with normal differential
Platelet count: 190,000/mm^3
Serum:
Na+: 141 mEq/L
Cl-: 102 mEq/L
K+: 5.5 mEq/L
HCO3-: 24 mEq/L
Glucose: 122 mg/dL
Ca2+: 7.1 mg/dL
Which of the following could also be found in this patient?
A. Bitemporal hemianopsia
B. Acute liver failure
C. Schistocytes
D. Acute renal failure
E. Episodic hypertension and headaches (Correct Answer)
Explanation: ***Episodic hypertension and headaches***
- The patient presents with a **palpable thyroid mass**, **hoarseness**, and **chronic diarrhea**, which are classic signs of **medullary thyroid cancer (MTC)**. MTC secretes **calcitonin** and can produce other peptides causing secretory diarrhea.
- MTC can occur as part of **MEN 2 syndromes (MEN 2A or 2B)**, which are associated with **pheochromocytoma** in approximately 50% of cases.
- Pheochromocytoma causes **episodic catecholamine release**, leading to **paroxysmal hypertension and headaches**.
- Her current blood pressure is elevated (157/98 mmHg), and the clinical context strongly supports screening for pheochromocytoma.
- The **hypocalcemia (7.1 mg/dL)** may be related to hypoparathyroidism (part of MEN 2A) or other metabolic factors, though calcitonin itself typically does not cause significant hypocalcemia.
*Bitemporal hemianopsia*
- This visual field defect is typically associated with **pituitary adenomas** pressing on the optic chiasm.
- Pituitary adenomas are part of **MEN 1 syndrome** (along with parathyroid adenomas and pancreatic tumors), not MEN 2.
- The patient's presentation with a thyroid mass and diarrhea points to **medullary thyroid cancer**, which is characteristic of **MEN 2**, not MEN 1.
*Schistocytes*
- **Schistocytes** are fragmented red blood cells seen in **microangiopathic hemolytic anemia (MAHA)**, such as in **thrombotic thrombocytopenic purpura (TTP)** or **hemolytic uremic syndrome (HUS)**.
- The patient's blood counts show **normal hemoglobin (12 g/dL), hematocrit (36%), and platelet count (190,000/mm³)**, making MAHA unlikely.
*Acute liver failure*
- The patient reports significant alcohol consumption (4-5 drinks/day), which could predispose to alcoholic liver disease.
- However, there are **no clinical signs** (jaundice, encephalopathy, coagulopathy) or **laboratory findings** (elevated AST/ALT, prolonged PT/INR) to suggest acute liver failure in this presentation.
*Acute renal failure*
- The patient's **potassium is mildly elevated (5.5 mEq/L)**, which can be seen in renal failure.
- However, there are **no other indicators** of acute renal failure, such as elevated creatinine, oliguria, or uremic symptoms provided in the clinical scenario.
Question 1188: A 28-year-old male presents with sharp, stabbing chest pain that worsens when lying flat and improves when sitting forward. He reports a recent viral upper respiratory infection 2 weeks ago. On examination, a friction rub is heard on auscultation. His vital signs are stable.
An ECG is most likely to show which of the following findings in this patient?
A. Diffuse, concave ST-segment elevations (Correct Answer)
B. Peaked T waves and ST-segment elevations in leads V1-V6
C. Sawtooth-appearance of P waves
D. S waves in lead I, Q waves in lead III, and inverted T waves in lead III
E. Alternating high and low amplitude QRS complexes
Explanation: ***Diffuse, concave ST-segment elevations***
- This is a hallmark ECG finding in **acute pericarditis**, along with **PR segment depression**, due to widespread inflammation of the epicardium.
- The chest pain described here (sharp, stabbing, worse when lying flat, improved by sitting forward) paired with a recent viral infection and a pericardial friction rub, is highly characteristic of **pericarditis**.
*Peaked T waves and ST-segment elevations in leads V1-V6*
- **Peaked T waves** are typically seen in early stages of hyperkalemia or myocardial ischemia, while **ST-segment elevations in specific leads (V1-V6)** are more indicative of an **ST-elevation myocardial infarction (STEMI)** involving the anterior wall.
- The diffuse nature of ST elevation in pericarditis, as opposed to regional changes, along with **PR depression**, differentiates it from STEMI.
*Sawtooth-appearance of P waves*
- A **sawtooth appearance of P waves** (often referred to as 'f waves') is characteristic of **atrial flutter**, a type of supraventricular tachycardia.
- This finding is unrelated to pericarditis, which primarily affects the pericardium and not the atrial electrical activity in this specific manner.
*S waves in lead I, Q waves in lead III, and inverted T waves in lead III*
- This pattern, known as the **S1Q3T3 pattern**, is a classic (though not always present) ECG finding suggestive of **acute pulmonary embolism**.
- While pulmonary embolism can cause chest pain, its presentation differs significantly from the positional relief and friction rub seen in pericarditis.
*Alternating high and low amplitude QRS complexes*
- This ECG finding, known as **electrical alternans**, is highly specific for a large **pericardial effusion** or **cardiac tamponade**, where the heart swings within the fluid-filled pericardial sac.
- Although pericarditis can lead to effusion, the presence of a friction rub and stable vital signs suggests acute pericarditis without significant tamponade at this stage, making diffuse ST elevation a more likely initial finding.
Question 1189: An 82-year-old woman is brought to the emergency department after losing consciousness at her nursing home. She had been watching TV for several hours and while getting up to use the bathroom, she fell and was unconscious for several seconds. She felt dizzy shortly before the fall. She does not have a headache or any other pain. She has a history of hypertension, intermittent atrial fibrillation, and stable angina pectoris. Current medications include warfarin, aspirin, hydrochlorothiazide, and a nitroglycerin spray as needed. Her temperature is 36.7°C (98.1°F), pulse is 100/min and regular, and blood pressure is 102/56 mm Hg. Physical exam shows a dry tongue. A fold of skin that is pinched on the back of her hand unfolds after 2 seconds. Cardiopulmonary examination shows no abnormalities. Further evaluation of this patient is most likely to show which of the following findings?
A. Elevated serum concentration of cardiac enzymes
B. Elevated serum creatine kinase concentration
C. Absent P waves on ECG
D. Elevated blood urea nitrogen concentration (Correct Answer)
E. Hypodense lesions on CT scan of the head
Explanation: ***Elevated blood urea nitrogen concentration***
- The patient presents with symptoms of **dehydration**, including a dry tongue, decreased skin turgor (skin fold taking 2 seconds to unfold), and **orthostatic hypotension** (dizziness upon standing, low blood pressure).
- Dehydration leads to **prerenal acute kidney injury**, characterized by an elevated blood urea nitrogen (BUN) concentration, often with an elevated BUN:creatinine ratio.
*Elevated serum concentration of cardiac enzymes*
- While the patient has a history of angina, there are no classic symptoms of an acute coronary syndrome such as **chest pain**, radiation, or ECG changes that would suggest myocardial injury warranting elevated cardiac enzymes.
- The syncope is more consistent with a **hemodynamic cause** (dehydration/hypotension) rather than a primary cardiac event like an MI.
*Elevated serum creatine kinase concentration*
- This is a non-specific marker for muscle damage and would be elevated if the patient experienced significant muscle injury from the fall.
- However, there is no mention of **trauma** or prolonged immobilization that would lead to rhabdomyolysis or significant muscle breakdown.
*Absent P waves on ECG*
- The patient has a history of **intermittent atrial fibrillation**, but her pulse is currently 100/min and **regular**, which indicates her current rhythm is likely not atrial fibrillation.
- Absence of P waves would specifically indicate **atrial fibrillation** or another atrial arrhythmia, but her regular pulse suggests a more sinus or junctional rhythm.
*Hypodense lesions on CT scan of the head*
- A CT scan of the head would be indicated to rule out **intracranial hemorrhage** or other structural brain lesions, especially given the fall and syncope.
- However, there are no focal neurological deficits, severe headache, or other signs strongly suggestive of a new stroke or hemorrhage, and the primary cause of syncope appears to be orthostatic hypotension due to hypovolemia.
Question 1190: A 24-year-old man presents to his primary care physician for a persistent and low grade headache as well as trouble focusing. The patient was seen in the emergency department 3 days ago after hitting his head on a branch while biking under the influence of alcohol. His head CT at the time was normal, and the patient was sent home with follow up instructions. Since the event, he has experienced trouble focusing on his school work and feels confused at times while listening to lectures. He states that he can’t remember the lectures and also says he has experienced a sensation of vertigo at times. On review of systems, he states that he has felt depressed lately and has had trouble sleeping, though he denies any suicidal or homicidal ideation. His temperature is 98.2°F (36.8°C), blood pressure is 122/65 mmHg, pulse is 70/min, respirations are 12/min, and oxygen saturation is 98% on room air. The patient’s neurological and cardiopulmonary exam are within normal limits. Which of the following is the best next step in management?
A. Thiamine
B. Cognitive behavioral therapy
C. Rest and primary care follow up (Correct Answer)
D. CT scan of the head without contrast
E. Fluoxetine
Explanation: ***Rest and primary care follow up***
- The patient's symptoms of **headache**, **confusion**, **vertigo**, **difficulty concentrating**, and **sleep disturbances** following a minor head injury are highly suggestive of a **concussion** or **post-concussive syndrome**.
- For concussion, the primary management involves **physical and cognitive rest** to allow the brain to heal, along with close follow-up to monitor symptom resolution or worsening.
*Thiamine*
- **Thiamine** (vitamin B1) is primarily indicated for conditions such as **Wernicke encephalopathy** or **Korsakoff syndrome**, often associated with chronic alcohol abuse and malnutrition.
- While the patient had a history of alcohol use, his acute symptoms are more consistent with head trauma, and there's no indication of a **thiamine deficiency**-related neurological syndrome.
*Cognitive behavioral therapy*
- **Cognitive Behavioral Therapy (CBT)** is a psychotherapeutic intervention used for conditions like **depression**, **anxiety disorders**, and **insomnia**.
- While the patient reports feeling depressed and having trouble sleeping, these symptoms can be part of post-concussive syndrome, and initial management should prioritize brain rest before focusing solely on CBT for mood and sleep.
*CT scan of the head without contrast*
- A **CT scan of the head without contrast** was already performed 3 days ago and was normal, effectively ruling out acute intracranial hemorrhage or major structural damage immediately after the injury.
- Given the normal initial CT and the constellation of symptoms consistent with **concussion**, a repeat CT scan is unlikely to provide additional useful information and is not the best immediate next step.
*Fluoxetine*
- **Fluoxetine** is a Selective Serotonin Reuptake Inhibitor (SSRI) used to treat **depression** and **anxiety disorders**.
- While the patient reports feeling depressed, initiating an antidepressant is not the immediate best step for a suspected concussion; depression and sleep issues can be sequelae of a concussion, and management should initially focus on concussion recovery.
