A 40-year-old woman comes to the physician because of a 1-week history of fatigue, dark urine, and a feeling of heaviness in her legs. Two weeks ago, she returned from a vacation to Brazil, where she spent most of her days exploring the city of Rio de Janeiro on foot. She also gained 3 kg (7 lb) during her vacation. She has systemic lupus erythematosus. Her only medication is hydroxychloroquine. Her temperature is 37.5°C (99.5°F), pulse is 78/min, and blood pressure is 162/98 mm Hg. Physical examination shows 2+ pretibial edema bilaterally. Urinalysis shows:
Blood 3+
Protein 1+
RBC 6–8/hpf with dysmorphic features
RBC casts numerous
WBC 8/hpf
WBC casts rare
Bacteria negative
Which of the following is the most likely cause of this patient's leg findings?
Q1212
A 32-year-old woman presents to her primary care physician for a general wellness appointment. The patient has no complaints currently and just wants to be sure that she is in good health. The patient has a past medical history of asthma, hypertension, and anxiety. Her current medications include albuterol, fluticasone, hydrochlorothiazide, lisinopril, and fexofenadine. Her temperature is 99.5°F (37.5°C), blood pressure is 165/95 mmHg, pulse is 70/min, respirations are 15/min, and oxygen saturation is 98% on room air. On exam, you note a healthy young woman with a lean habitus. Cardiac exam reveals a S1 and S2 heart sound with a normal rate. Pulmonary exam is clear to auscultation bilaterally with good air movement. Abdominal exam reveals a bruit, normoactive bowel sounds, and an audible borborygmus. Neurological exam reveals cranial nerves II-XII as grossly intact with normal strength and reflexes in the upper and lower extremities. Which of the following is the best next step in management?
Q1213
A 68-year-old woman is brought to the emergency department because of fever, productive cough, and dyspnea for 3 days. She has had upper back pain for 3 months, which is worse after activity. She takes ibuprofen for pain relief. She has no history of smoking. The temperature is 39.5°C (103.1°F), the blood pressure is 100/70 mm Hg, the pulse is 95/min, and the respirations are 22/min. Lung auscultation shows rales in the left lower lobe area. Painful lymph nodes (1 × 1 cm) are palpated in the left axillary and cervical regions. There is point tenderness along several thoracic vertebrae. Laboratory studies are pending. A skull X-ray and lung window thoracic computed tomography scan are shown. Which of the following disorders most likely played a role in this patient’s acute condition?
Q1214
A 37-year-old woman presents to the emergency department complaining of generalized malaise, weakness, headache, nausea, vomiting, and diarrhea; she last felt well roughly two days ago. She is otherwise healthy, and takes no medications. Her vital signs are: T 38.0, HR 96 beats per minute, BP 110/73, and O2 sat 96% on room air. Examination reveals a somewhat ill-appearing woman; she is drowsy but arousable and has no focal neurological deficits. Initial laboratory studies are notable for hematocrit 26%, platelets of 80,000/mL, and serum creatinine of 1.5 mg/dL. Which of the following is the most appropriate treatment at this time?
Q1215
A 60-year-old man comes to the physician for an examination prior to a scheduled cholecystectomy. He has hypertension treated with hydrochlorothiazide. His mother had chronic granulomatous disease of the lung. He works in a glass manufacturing plant. He has smoked two packs of cigarettes daily for 38 years. His vital signs are within normal limits. Examination shows no abnormalities. Laboratory studies are within the reference range. An x-ray of the chest is shown. Which of the following is the most appropriate next step in management?
Q1216
A 60-year-old man seeks evaluation at a medical office due to leg pain while walking. He says the pain starts in his buttocks and extends to his thighs and down to his calves. Previously, the pain resolved with rest, but the pain now persists in his feet, even during rest. His past medical history is significant for diabetes mellitus, hypertension, and cigarette smoking. The vital signs are within normal limits. The physical examination shows an atrophied leg with bilateral loss of hair. Which of the following is the most likely cause of this patient’s condition?
Q1217
A 35-year-old woman comes to the physician because of a 1-month history of double vision, difficulty climbing stairs, and weakness when trying to brush her hair. She reports that these symptoms are worse after she exercises and disappear after she rests for a few hours. Physical examination shows drooping of her right upper eyelid that worsens when the patient is asked to gaze at the ceiling for 2 minutes. There is diminished motor strength in the upper extremities. The remainder of the examination shows no abnormalities. Which of the following is the most likely diagnosis?
Q1218
A 53-year-old man comes to the emergency department because of severe right-sided flank pain for 3 hours. The pain is colicky, radiates towards his right groin, and he describes it as 8/10 in intensity. He has vomited once. He has no history of similar episodes in the past. Last year, he was treated with naproxen for swelling and pain of his right toe. He has a history of hypertension. He drinks one to two beers on the weekends. Current medications include amlodipine. He appears uncomfortable. His temperature is 37.1°C (99.3°F), pulse is 101/min, and blood pressure is 130/90 mm Hg. Examination shows a soft, nontender abdomen and right costovertebral angle tenderness. An upright x-ray of the abdomen shows no abnormalities. A CT scan of the abdomen and pelvis shows a 7-mm stone in the proximal ureter and grade I hydronephrosis on the right. Which of the following is most likely to be seen on urinalysis?
Q1219
A 69-year-old male presents to the emergency room with back pain. He has a history of personality disorder and metastatic prostate cancer and was not a candidate for surgical resection. He began chemotherapy but discontinued due to unremitting nausea. He denies any bowel or bladder incontinence. He has never had pain like this before and is demanding morphine. The nurse administers IV morphine and he feels more comfortable. Vital signs are stable. On physical examination you note tenderness to palpation along the lower spine, weakness in the bilateral lower extremities, left greater than right. Neurological examination is also notable for hyporeflexia in the knee and ankle jerks bilaterally. You conduct a rectal examination, which reveals saddle anesthesia. Regarding this patient, what is the most likely diagnosis and the appropriate next step in management?
Q1220
A 68-year-old man comes to the physician because of recurrent episodes of nausea and abdominal discomfort for the past 4 months. The discomfort is located in the upper abdomen and sometimes occurs after eating, especially after a big meal. He has tried to go for a walk after dinner to help with digestion, but his complaints have only increased. For the past 3 weeks he has also had symptoms while climbing the stairs to his apartment. He has type 2 diabetes mellitus, hypertension, and stage 2 peripheral arterial disease. He has smoked one pack of cigarettes daily for the past 45 years. He drinks one to two beers daily and occasionally more on weekends. His current medications include metformin, enalapril, and aspirin. He is 168 cm (5 ft 6 in) tall and weighs 126 kg (278 lb); BMI is 45 kg/m2. His temperature is 36.4°C (97.5°F), pulse is 78/min, and blood pressure is 148/86 mm Hg. On physical examination, the abdomen is soft and nontender with no organomegaly. Foot pulses are absent bilaterally. An ECG shows no abnormalities. Which of the following is the most appropriate next step in diagnosis?
Cardiology US Medical PG Practice Questions and MCQs
Question 1211: A 40-year-old woman comes to the physician because of a 1-week history of fatigue, dark urine, and a feeling of heaviness in her legs. Two weeks ago, she returned from a vacation to Brazil, where she spent most of her days exploring the city of Rio de Janeiro on foot. She also gained 3 kg (7 lb) during her vacation. She has systemic lupus erythematosus. Her only medication is hydroxychloroquine. Her temperature is 37.5°C (99.5°F), pulse is 78/min, and blood pressure is 162/98 mm Hg. Physical examination shows 2+ pretibial edema bilaterally. Urinalysis shows:
Blood 3+
Protein 1+
RBC 6–8/hpf with dysmorphic features
RBC casts numerous
WBC 8/hpf
WBC casts rare
Bacteria negative
Which of the following is the most likely cause of this patient's leg findings?
A. Venous insufficiency
B. Increased capillary permeability
C. Renal protein loss
D. Lymphatic obstruction
E. Salt retention (Correct Answer)
Explanation: ***Salt retention***
- The patient's presentation with **dark urine**, **fatigue**, new-onset **hypertension**, **pretibial edema**, **weight gain**, and a **urinalysis** consistent with **glomerulonephritis** (RBC casts, dysmorphic RBCs, proteinuria) points to **acute nephritic syndrome**.
- In acute nephritic syndrome, inflammation of the glomeruli leads to reduced glomerular filtration rate (GFR). This impaired GFR results in **decreased sodium and water excretion**, causing **volume overload**, which manifests as edema (e.g., pretibial edema) and hypertension.
*Venous insufficiency*
- While **venous insufficiency** can cause **bilateral lower extremity edema**, it typically does not present with **dark urine**, **hypertension**, or the specific **urinalysis findings** (RBC casts, proteinuria) seen in this patient.
- The edema from venous insufficiency is primarily due to **increased hydrostatic pressure** in the venous system, often accompanied by skin changes like hyperpigmentation or varicosities, which are not mentioned.
*Increased capillary permeability*
- **Increased capillary permeability** can lead to edema by allowing more fluid and protein to leak into the interstitial space. However, this is typically associated with conditions like **sepsis**, **allergic reactions**, or **severe inflammation** and would not explain the specific kidney findings like **RBC casts** and **hypertension** in this context.
- While inflammation in glomerulonephritis does involve capillary damage, the primary mechanism for significant edema and hypertension is **fluid retention due to impaired renal excretion**, not just localized permeability increase.
*Renal protein loss*
- Significant **renal protein loss** (e.g., in nephrotic syndrome) leads to **hypoalbuminemia**, which reduces plasma oncotic pressure and causes **edema**.
- However, this patient's urinalysis shows only **1+ protein**, which is not indicative of the massive proteinuria typically seen in nephrotic syndrome that causes edema primarily through hypoalbuminemia. Her primary renal pathology is consistent with **nephritic syndrome**, not nephrotic syndrome.
*Lymphatic obstruction*
- **Lymphatic obstruction** causes **lymphedema**, which is typically **non-pitting**, often unilateral (though bilateral can occur), and does not improve significantly with elevation.
- It would not explain the systemic symptoms (fatigue, hypertension), dark urine, or the characteristic **glomerular findings** like **RBC casts** and **hypertension** associated with acute nephritic syndrome.
Question 1212: A 32-year-old woman presents to her primary care physician for a general wellness appointment. The patient has no complaints currently and just wants to be sure that she is in good health. The patient has a past medical history of asthma, hypertension, and anxiety. Her current medications include albuterol, fluticasone, hydrochlorothiazide, lisinopril, and fexofenadine. Her temperature is 99.5°F (37.5°C), blood pressure is 165/95 mmHg, pulse is 70/min, respirations are 15/min, and oxygen saturation is 98% on room air. On exam, you note a healthy young woman with a lean habitus. Cardiac exam reveals a S1 and S2 heart sound with a normal rate. Pulmonary exam is clear to auscultation bilaterally with good air movement. Abdominal exam reveals a bruit, normoactive bowel sounds, and an audible borborygmus. Neurological exam reveals cranial nerves II-XII as grossly intact with normal strength and reflexes in the upper and lower extremities. Which of the following is the best next step in management?
A. CT of the abdomen
B. No additional management needed
C. Ultrasound with Doppler (Correct Answer)
D. Raise lisinopril dose
E. Add furosemide
Explanation: ***Ultrasound with Doppler***
- The presence of an **abdominal bruit** in a young woman with **hypertension refractory to multiple medications** (lisinopril, HCTZ), suggests **renal artery stenosis** as a potential cause of secondary hypertension.
- An ultrasound with Doppler is a non-invasive, initial diagnostic study to evaluate for renal artery stenosis by assessing blood flow and velocity in the renal arteries.
*CT of the abdomen*
- While a CT angiography can diagnose renal artery stenosis, it involves **radiation exposure** and **contrast dye**, which should ideally be avoided as a first-line diagnostic in a young patient, especially when a less invasive option is available.
- A standard CT of the abdomen without contrast may not adequately visualize renal artery stenosis.
*No additional management needed*
- The patient has **uncontrolled hypertension** (165/95 mmHg) despite being on two antihypertensive medications, and presents with an **abdominal bruit**, which is a significant physical exam finding indicating a potential underlying pathology.
- Ignoring these findings would be poor medical practice as it leaves the cause of hypertension unaddressed and potentially reversible conditions undiagnosed.
*Raise lisinopril dose*
- Raising the dose of an ACE inhibitor like lisinopril without investigating the cause of uncontrolled hypertension, especially in the presence of a **bruit**, could worsen renal function if **bilateral renal artery stenosis** is present.
- The priority should be to *diagnose the underlying cause* of resistant hypertension, not just empirically increase medication dosage.
*Add furosemide*
- Furosemide is a loop diuretic primarily used for volume overload and edema, or sometimes as an add-on for severe hypertension, but it does **not address the underlying cause** of resistant hypertension suggested by the abdominal bruit.
- Adding another medication without evaluating for secondary causes would be inappropriate and potentially mask the diagnosis.
Question 1213: A 68-year-old woman is brought to the emergency department because of fever, productive cough, and dyspnea for 3 days. She has had upper back pain for 3 months, which is worse after activity. She takes ibuprofen for pain relief. She has no history of smoking. The temperature is 39.5°C (103.1°F), the blood pressure is 100/70 mm Hg, the pulse is 95/min, and the respirations are 22/min. Lung auscultation shows rales in the left lower lobe area. Painful lymph nodes (1 × 1 cm) are palpated in the left axillary and cervical regions. There is point tenderness along several thoracic vertebrae. Laboratory studies are pending. A skull X-ray and lung window thoracic computed tomography scan are shown. Which of the following disorders most likely played a role in this patient’s acute condition?
A. Multiple myeloma (Correct Answer)
B. Primary hyperparathyroidism
C. Metastatic breast cancer
D. Paget’s disease
E. Non-small cell lung cancer
Explanation: ***Multiple myeloma***
- The imaging findings of **lytic bone lesions** on skull X-ray and CT scans (often described as "punched-out" lesions) are highly characteristic of **multiple myeloma**. This condition causes diffuse skeletal involvement, leading to bone pain and increased fracture risk.
- Patients with multiple myeloma are **immunocompromised**, often due to impaired antibody production and neutropenia, making them highly susceptible to recurrent infections such as **pneumonia**, as suggested by the fever, productive cough, dyspnea, and lung rales in this patient.
*Primary hyperparathyroidism*
- While primary hyperparathyroidism can cause **bone demineralization** (osteitis fibrosa cystica), it typically presents with **"brown tumors"** rather than diffuse lytic lesions on imaging.
- It does not directly cause **immune suppression** leading to an increased risk of severe infections like pneumonia.
*Metastatic breast cancer*
- Metastatic breast cancer can cause bone pain and lesions, but these are often **mixed lytic and blastic** or purely blastic, unlike the purely lytic lesions seen in multiple myeloma.
- Although it can spread to lymph nodes, the systemic immunocompromised state leading to a severe infection like this patient's pneumonia is less typical than with multiple myeloma.
*Paget’s disease*
- Paget's disease is characterized by **disorganized bone remodeling**, leading to thickened, sclerotic, and deformed bones, rather than the diffuse lytic lesions seen in this patient.
- It does not cause a state of **immunodeficiency** that would predispose to severe infections like pneumonia.
*Non-small cell lung cancer*
- While non-small cell lung cancer can cause a productive cough and dyspnea, and may lead to bone metastases, the primary presentation would involve a **lung mass** or nodule.
- Bone metastases from lung cancer are typically **mixed lytic and blastic**, and lung cancer does not typically cause the generalized **immunodeficiency** seen in multiple myeloma that predisposes to severe opportunistic infections.
Question 1214: A 37-year-old woman presents to the emergency department complaining of generalized malaise, weakness, headache, nausea, vomiting, and diarrhea; she last felt well roughly two days ago. She is otherwise healthy, and takes no medications. Her vital signs are: T 38.0, HR 96 beats per minute, BP 110/73, and O2 sat 96% on room air. Examination reveals a somewhat ill-appearing woman; she is drowsy but arousable and has no focal neurological deficits. Initial laboratory studies are notable for hematocrit 26%, platelets of 80,000/mL, and serum creatinine of 1.5 mg/dL. Which of the following is the most appropriate treatment at this time?
A. Cyclophosphamide and rituximab
B. Vancomycin and cefepime
C. High-dose glucocorticoids
D. Plasma exchange therapy (Correct Answer)
E. Urgent laparoscopic splenectomy
Explanation: ***Plasma exchange therapy***
- This patient presents with symptoms suggestive of **Thrombotic Thrombocytopenic Purpura (TTP)**, characterized by the pentad of microangiopathic hemolytic anemia, thrombocytopenia, neurological symptoms, renal impairment, and fever.
- **Plasma exchange therapy** is the cornerstone of treatment for TTP, as it removes antibodies against **ADAMTS13** and replaces depleted ADAMTS13 enzyme.
*Cyclophosphamide and rituximab*
- These are **immunosuppressive agents** typically used in autoimmune conditions or certain vasculitides, but they are not first-line for acute TTP.
- While TTP has an autoimmune basis, these agents are usually reserved for refractory cases or given as adjuncts after initial plasma exchange.
*Vancomycin and cefepime*
- These are **broad-spectrum antibiotics** used to treat bacterial infections.
- While the patient has a low-grade fever, her symptoms and lab findings (anemia, thrombocytopenia, renal failure, neurological changes) are more characteristic of TTP than a primary bacterial sepsis.
*High-dose glucocorticoids*
- **Glucocorticoids** can be used as an adjunct in TTP, but they are not the primary treatment.
- They alone are insufficient to address the underlying mechanism of TTP, which requires prompt removal of inhibitory antibodies and replacement of ADAMTS13 via plasma exchange.
*Urgent laparoscopic splenectomy*
- **Splenectomy** is generally considered a treatment option for **refractory immune thrombocytopenia (ITP)** that does not respond to medical management.
- It is not indicated for acute TTP, where the pathology is related to ADAMTS13 deficiency and microthrombi formation, not splenic platelet destruction.
Question 1215: A 60-year-old man comes to the physician for an examination prior to a scheduled cholecystectomy. He has hypertension treated with hydrochlorothiazide. His mother had chronic granulomatous disease of the lung. He works in a glass manufacturing plant. He has smoked two packs of cigarettes daily for 38 years. His vital signs are within normal limits. Examination shows no abnormalities. Laboratory studies are within the reference range. An x-ray of the chest is shown. Which of the following is the most appropriate next step in management?
A. Perform diffusion capacity of the lung for carbon monoxide
B. Perform arterial blood gas analysis
C. Request previous chest x-ray (Correct Answer)
D. Perform CT-guided biopsy
E. Measure angiotensin-converting enzyme
Explanation: ***Request previous chest x-ray***
- Comparing the current chest X-ray with previous ones is crucial to determine if the findings are **new or chronic**, which significantly impacts further management.
- Given the patient's age, smoking history, and occupational exposure, a nodule or infiltrates could be present for a long time without causing symptoms, and a **stable finding** would alleviate immediate concern.
*Perform diffusion capacity of the lung for carbon monoxide*
- **DLCO** measures the lung's ability to transfer gas from inhaled air to the bloodstream and is primarily used to assess **interstitial lung disease** or emphysema.
- While the patient has risk factors for lung disease (smoking, occupational exposure), without a specific indication of interstitial lung disease or significant respiratory symptoms, it is not the most immediate next step, especially before understanding the chronicity of any X-ray findings.
*Perform arterial blood gas analysis*
- **ABG analysis** assesses oxygenation, ventilation, and acid-base balance, typically performed in patients with acute respiratory distress, significant dyspnea, or to monitor severe lung pathology.
- The patient is **asymptomatic** with normal vital signs, and there is no indication that his gas exchange is compromised, making ABG analysis premature.
*Perform CT-guided biopsy*
- A **CT-guided biopsy** is an invasive procedure used to obtain tissue for histological diagnosis, typically reserved when a lesion is highly suspicious for malignancy or infection and non-invasive methods are insufficient.
- It is an aggressive initial step without first characterizing the X-ray findings further or determining if the lesion is new or chronic.
*Measure angiotensin-converting enzyme*
- **ACE levels** are primarily used in the diagnosis and monitoring of **sarcoidosis**, a granulomatous disease.
- While the patient's mother had "chronic granulomatous disease of the lung," implying a possible genetic link or predisposition to granulomatous conditions, there are no specific findings on the history or presentation to directly suggest sarcoidosis, and it would be a secondary investigation after initial X-ray comparison.
Question 1216: A 60-year-old man seeks evaluation at a medical office due to leg pain while walking. He says the pain starts in his buttocks and extends to his thighs and down to his calves. Previously, the pain resolved with rest, but the pain now persists in his feet, even during rest. His past medical history is significant for diabetes mellitus, hypertension, and cigarette smoking. The vital signs are within normal limits. The physical examination shows an atrophied leg with bilateral loss of hair. Which of the following is the most likely cause of this patient’s condition?
A. Thrombus formation
B. Weakening of vessel wall
C. Narrowing and calcification of vessels (Correct Answer)
D. Decreased permeability of endothelium
E. Peripheral emboli formation
Explanation: ***Narrowing and calcification of vessels***
- This describes **atherosclerosis**, the most common cause of **peripheral artery disease (PAD)**, which presents with **intermittent claudication** (leg pain with walking, improving with rest) progressing to **rest pain**, especially in the feet.
- The patient's risk factors (**diabetes, hypertension, smoking**) and physical findings (**atrophied leg, hair loss**) are highly consistent with chronic ischemia due to atherosclerosis.
*Thrombus formation*
- While thrombus formation can cause acute limb ischemia, the patient's symptoms are chronic and progressive, evolving over time from claudication to rest pain, which is more characteristic of gradual **atherosclerotic narrowing**.
- Acute thrombosis typically leads to a sudden onset of severe pain, pallor, pulselessness, paresthesias, and paralysis, which are not described here.
*Weakening of vessel wall*
- Weakening of the vessel wall is associated with conditions like **aneurysms** or dissections, which typically present with different symptoms (e.g., pulsatile masses, sudden severe chest/back pain).
- It does not directly explain the progressive ischemic symptoms described, such as claudication and rest pain from inadequate blood flow.
*Decreased permeability of endothelium*
- Decreased permeability of the endothelium generally implies difficulty in substances passing through the vessel wall, which is not directly linked to the pathophysiology of ischemic pain and tissue atrophy observed in this patient.
- Conditions affecting endothelial permeability often relate to inflammation, edema, or microvascular dysfunction, but not the macrovascular obstruction causing PAD.
*Peripheral emboli formation*
- Emboli can cause acute peripheral artery occlusion, leading to sudden onset severe limb pain and signs of ischemia.
- However, the patient's symptoms have progressed chronically over time, starting with intermittent claudication and worsening to rest pain, which is more indicative of a gradual atherosclerotic process rather than an acute embolic event.
Question 1217: A 35-year-old woman comes to the physician because of a 1-month history of double vision, difficulty climbing stairs, and weakness when trying to brush her hair. She reports that these symptoms are worse after she exercises and disappear after she rests for a few hours. Physical examination shows drooping of her right upper eyelid that worsens when the patient is asked to gaze at the ceiling for 2 minutes. There is diminished motor strength in the upper extremities. The remainder of the examination shows no abnormalities. Which of the following is the most likely diagnosis?
A. Amyotrophic lateral sclerosis
B. Myasthenia gravis (Correct Answer)
C. Polymyositis
D. Guillain-Barré syndrome
E. Multiple sclerosis
Explanation: ***Myasthenia gravis***
- The patient's symptoms of **double vision (diplopia)**, **difficulty climbing stairs**, **weakness exacerbated by activity**, and **ptosis (drooping eyelid)** are classic presentations of myasthenia gravis, a disorder of the **neuromuscular junction**.
- The improvement of symptoms after rest and worsening after activity (**fatigability**) is a hallmark feature, as is the positive **Cogan's lid twitch sign** (worsening ptosis on sustained upward gaze).
*Amyotrophic lateral sclerosis*
- This is a disease of both **upper and lower motor neurons**, leading to progressive muscle weakness, atrophy, and spasticity.
- ALS typically does not present with fluctuating weakness or ocular symptoms like **diplopia and ptosis**, and sensory function is usually spared.
*Polymyositis*
- Polymyositis is an **inflammatory myopathy** characterized by **proximal muscle weakness** (e.g., difficulty climbing stairs, brushing hair) that is typically progressive and constant, not fluctuating with activity and rest.
- It does not involve ocular muscles or present with **fatigability** of symptoms.
*Guillain-Barré syndrome*
- This is an **acute demyelinating polyradiculoneuropathy** characterized by **ascending paralysis**, often following an infection.
- Symptoms are usually rapid in onset and progressive, not fluctuating or limited primarily to specific muscle groups that worsen with exertion.
*Multiple sclerosis*
- MS is a **demyelinating disease** of the central nervous system, which can cause varied neurological symptoms depending on the location of lesions.
- While it can cause **diplopia** and **fatigue**, the characteristic fluctuating weakness that improves with rest and specific ocular motor findings like **ptosis** that worsen with sustained gaze are not typical primary features of MS.
Question 1218: A 53-year-old man comes to the emergency department because of severe right-sided flank pain for 3 hours. The pain is colicky, radiates towards his right groin, and he describes it as 8/10 in intensity. He has vomited once. He has no history of similar episodes in the past. Last year, he was treated with naproxen for swelling and pain of his right toe. He has a history of hypertension. He drinks one to two beers on the weekends. Current medications include amlodipine. He appears uncomfortable. His temperature is 37.1°C (99.3°F), pulse is 101/min, and blood pressure is 130/90 mm Hg. Examination shows a soft, nontender abdomen and right costovertebral angle tenderness. An upright x-ray of the abdomen shows no abnormalities. A CT scan of the abdomen and pelvis shows a 7-mm stone in the proximal ureter and grade I hydronephrosis on the right. Which of the following is most likely to be seen on urinalysis?
A. Urinary pH: 4.7 (Correct Answer)
B. Positive nitrites test
C. Hexagon shaped crystals
D. Urinary pH: 7.3
E. Largely positive urinary protein
Explanation: ***Urinary pH: 4.7***
- The patient's history of right toe pain and swelling treated with naproxen, despite no confirmed gout diagnosis, suggests a predisposition to **hyperuricemia** and uric acid stone formation.
- **Uric acid stones** are the only common kidney stone type that is radiolucent (explaining the normal X-ray) and characteristically form in acidic urine (pH < 5.5).
*Positive nitrites test*
- A positive nitrites test indicates the presence of **nitrate-reducing bacteria**, suggesting a **urinary tract infection (UTI)**.
- While UTIs can complicate kidney stones, the patient's presentation with acute, severe pain and no fever makes a primary UTI with positive nitrites less likely as the most prominent finding.
*Hexagon shaped crystals*
- **Hexagonal crystals** in urine are pathognomonic for **cystine stones**.
- Cystine stones are rare, inherited metabolic disorders, and there is nothing in this patient's history to suggest cystinuria.
*Urinary pH: 7.3*
- An alkaline urinary pH (e.g., 7.3) is typically associated with **struvite stones** (magnesium ammonium phosphate), which form in the presence of urease-producing bacteria (often causing UTIs), or sometimes with calcium phosphate stones.
- This is inconsistent with the patient's likely uric acid stone, which forms in acidic urine.
*Largely positive urinary protein*
- Significant proteinuria (largely positive urinary protein) usually indicates **glomerular or severe renal parenchymal disease**.
- While microscopic hematuria is common with kidney stones, gross proteinuria is not a typical finding in simple nephrolithiasis and implies a different underlying renal pathology.
Question 1219: A 69-year-old male presents to the emergency room with back pain. He has a history of personality disorder and metastatic prostate cancer and was not a candidate for surgical resection. He began chemotherapy but discontinued due to unremitting nausea. He denies any bowel or bladder incontinence. He has never had pain like this before and is demanding morphine. The nurse administers IV morphine and he feels more comfortable. Vital signs are stable. On physical examination you note tenderness to palpation along the lower spine, weakness in the bilateral lower extremities, left greater than right. Neurological examination is also notable for hyporeflexia in the knee and ankle jerks bilaterally. You conduct a rectal examination, which reveals saddle anesthesia. Regarding this patient, what is the most likely diagnosis and the appropriate next step in management?
A. The most likely diagnosis is cauda equina syndrome and the patient should be rushed to radiation
B. The most likely diagnosis is conus medullaris syndrome and steroids should be started prior to MRI
C. The most likely diagnosis is cauda equina syndrome and steroids should be started prior to MRI (Correct Answer)
D. The most likely diagnosis is conus medullaris syndrome and steroids should be started after MRI
E. The most likely diagnosis is cauda equina syndrome and steroids should be started after MRI
Explanation: ***The most likely diagnosis is cauda equina syndrome and steroids should be started prior to MRI***
- The patient's presentation with **back pain**, **bilateral lower extremity weakness** (left > right), **hyporeflexia**, and **saddle anesthesia** are classic signs of **cauda equina syndrome**. This is often caused by compression of the nerve roots below the spinal cord, commonly from metastasis in patients with a history of prostate cancer.
- Given the suspected **spinal cord compression** due to metastatic disease, initiating **high-dose corticosteroids** (like dexamethasone) before imaging is crucial to reduce edema around the spinal cord and preserve neurological function. An **urgent MRI** is the next step to confirm the diagnosis and localize the compression.
*The most likely diagnosis is cauda equina syndrome and the patient should be rushed to radiation*
- While **cauda equina syndrome** is the correct diagnosis, **radiation** is typically a definitive treatment modality for metastatic compression, not an immediate next step before confirming the extent and location of compression with imaging.
- **Corticosteroids** are the immediate priority to reduce swelling and improve neurological outcomes while awaiting definitive imaging and treatment planning.
*The most likely diagnosis is conus medullaris syndrome and steroids should be started prior to MRI*
- **Conus medullaris syndrome** typically presents with more symmetrical symptoms, often including early-onset **bladder and bowel dysfunction** and **hyperreflexia** (or mixed reflexes), which are not fully consistent with this patient's presentation of hyporeflexia and lack of incontinence.
- Although steroids would be appropriate for suspected compression before MRI for either syndrome, the specific symptom profile strongly favors cauda equina over conus.
*The most likely diagnosis is conus medullaris syndrome and steroids should be started after MRI*
- The patient's symptoms (weakness, hyporeflexia, saddle anesthesia) are more indicative of **cauda equina syndrome** rather than **conus medullaris syndrome** (which often involves hyperreflexia and earlier bowel/bladder dysfunction).
- Delaying **corticosteroids** until after the MRI in suspected spinal cord compression can lead to irreversible neurological damage, as they help reduce edema immediately.
*The most likely diagnosis is cauda equina syndrome and steroids should be started after MRI*
- While **cauda equina syndrome** is the correct diagnosis, waiting for an **MRI** before initiating **corticosteroids** would be a critical delay.
- **Early administration of steroids** is vital in cases of suspected spinal cord compression to reduce inflammation and preserve neurological function, even before definitive imaging.
Question 1220: A 68-year-old man comes to the physician because of recurrent episodes of nausea and abdominal discomfort for the past 4 months. The discomfort is located in the upper abdomen and sometimes occurs after eating, especially after a big meal. He has tried to go for a walk after dinner to help with digestion, but his complaints have only increased. For the past 3 weeks he has also had symptoms while climbing the stairs to his apartment. He has type 2 diabetes mellitus, hypertension, and stage 2 peripheral arterial disease. He has smoked one pack of cigarettes daily for the past 45 years. He drinks one to two beers daily and occasionally more on weekends. His current medications include metformin, enalapril, and aspirin. He is 168 cm (5 ft 6 in) tall and weighs 126 kg (278 lb); BMI is 45 kg/m2. His temperature is 36.4°C (97.5°F), pulse is 78/min, and blood pressure is 148/86 mm Hg. On physical examination, the abdomen is soft and nontender with no organomegaly. Foot pulses are absent bilaterally. An ECG shows no abnormalities. Which of the following is the most appropriate next step in diagnosis?
A. CT scan of the abdomen
B. Abdominal ultrasonography of the right upper quadrant
C. Esophagogastroduodenoscopy
D. Hydrogen breath test
E. Cardiac stress test (Correct Answer)
Explanation: ***Cardiac stress test***
- The patient's **epigastric discomfort** that is exacerbated by exertion (walking, climbing stairs) and presents with several **cardiovascular risk factors** (obesity, type 2 diabetes mellitus, hypertension, smoking, peripheral arterial disease) strongly suggests **ischemic heart disease** as the cause of his abdominal symptoms.
- A **cardiac stress test** is the most appropriate next step to evaluate for **exercise-induced myocardial ischemia**, which can manifest as referred pain to the epigastrium (angina equivalent).
- This patient has a high pretest probability of coronary artery disease, making functional cardiac testing essential before pursuing other diagnostic workup.
*CT scan of the abdomen*
- A CT scan of the abdomen would be indicated for evaluating structural abnormalities of abdominal organs, but the **exertional nature** of the patient's symptoms makes **cardiac ischemia** a more pressing concern.
- While it could rule out other abdominal pathologies, it would not address the likely cardiac origin of his symptoms.
*Abdominal ultrasonography of the right upper quadrant*
- Abdominal ultrasonography is used to evaluate organs like the **gallbladder, liver, and pancreas** for conditions such as **cholelithiasis or cholecystitis**.
- The patient's symptoms are more consistent with **exertional pain** rather than typical biliary colic, making cardiac evaluation a higher priority.
*Esophagogastroduodenoscopy*
- An **EGD** is used to visualize the **esophagus, stomach, and duodenum** to diagnose conditions like **peptic ulcer disease, esophagitis, or gastritis**.
- While **upper GI symptoms** are present, the exacerbation with exertion shifts the focus away from primary gastrointestinal pathology toward cardiac causes.
*Hydrogen breath test*
- A **hydrogen breath test** is primarily used to diagnose **small intestinal bacterial overgrowth (SIBO)** or **carbohydrate malabsorption** (e.g., lactose intolerance).
- The patient's symptoms are not classic for SIBO or malabsorption, and the **exertional component** makes this a less probable diagnosis.
