A 62-year-old man is brought to the emergency department because of progressive shortness of breath, mild chest pain on exertion, and a cough for 2 days. One week ago, he had a low-grade fever and nasal congestion. He has hypertension but does not adhere to his medication regimen. He has smoked one pack of cigarettes daily for 30 years and drinks 3–4 beers daily. His temperature is 37.1°C (98.8°F), pulse is 125/min, respirations are 29/min, and blood pressure is 145/86 mm Hg. He is in moderate respiratory distress while sitting. Pulmonary examination shows reduced breath sounds bilaterally. There is scattered wheezing over all lung fields. There is inward displacement of his abdomen during inspiration. Arterial blood gas analysis shows:
pH 7.29
PCO2 63 mm Hg
PO2 71 mm Hg
HCO3- 29 mEq/L
O2 saturation 89%
Which of the following is the most likely cause of this patient's symptoms?
Q272
A 45-year-old woman presents to her primary care physician for an annual checkup. She states that she feels well and has no complaints. She lives alone and works as a banker. She smokes 1 cigarette per day and drinks 2 alcoholic beverages per night. She occasionally gets symmetrical pain in her hands where they change from red to white to blue then return to normal again. Her temperature is 98.7°F (37.1°C), blood pressure is 177/118 mmHg, pulse is 82/min, respirations are 15/min, and oxygen saturation is 99% on room air. The patient's hypertension is treated, and she returns 2 weeks later complaining of weight gain in her legs and arms. On exam, bilateral edema is noted in her extremities. Which of the following is the best next step in management?
Q273
A 49-year-old man comes to the physician because of a 2-week history of increasing shortness of breath. He has also had chest pain that is exacerbated by deep inspiration. He has had recurrent episodes of pain in his fingers for the past 2 years. Two years ago, he was treated for a deep vein thrombosis. He has hypertension and anxiety. Current medications include enalapril, St John's wort, and ibuprofen. His temperature is 37°C (98.6°F), pulse is 110/min, respirations are 17/min, and blood pressure is 110/70 mm Hg. Examination shows pale conjunctiva. There is tenderness to palpation of the proximal interphalangeal and metacarpophalangeal joints of both hands. Heart sounds are distant. The lungs are clear to auscultation. Laboratory studies show:
Hemoglobin 11.9 g/dL
Leukocyte count 4200/mm3
Platelet count 330,000/mm3
Serum
Na+ 136 mEq/L
K+ 4.3 mEq/L
Antinuclear antibodies 1: 320
Anti-Sm antibodies positive
Anti-CCP antibodies negative
An x-ray of the chest is shown. Which of the following is most likely to be seen on this patient's ECG?
Q274
An 18-year-old Caucasian female presents to your clinic because of a recent increase in thirst and hunger. Urinalysis demonstrates elevated glucose. The patient's BMI is 20. Which of the following is the most common cause of death in persons suffering from this patient's illness?
Q275
A 78-year-old man presents to his primary care physician for persistent back pain. The patient states that he has had back pain for awhile; however, this past weekend he was helping his son move heavy furniture. Since the move, his symptoms have been more severe. The patient states that the pain is constant and occurs throughout the day. On review of systems, the patient endorses a recent 15 pound weight loss and constipation. His temperature is 99.5°F (37.5°C), blood pressure is 137/79 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 98% on room air. Cardiovascular exam is notable for a murmur at the right sternal border that radiates to the carotids. Pulmonary exam reveals mild bibasilar crackles. Musculoskeletal exam is notable for mild midline tenderness of the lower thoracic spine and the upper segment of the lumbar spine. No bruising or signs of external trauma are observable on the back. Symptoms are not exacerbated when the patient is lying down and his straight leg is lifted. Strength is 5/5 in the lower and upper extremities. The patient's sensation is intact bilaterally in his lower and upper extremities. Laboratory values are ordered and return as seen below.
Hemoglobin: 11 g/dL
Hematocrit: 34%
Leukocyte count: 10,500/mm^3 with normal differential
Platelet count: 288,000/mm^3
Serum:
Na+: 139 mEq/L
Cl-: 100 mEq/L
K+: 4.3 mEq/L
HCO3-: 25 mEq/L
BUN: 20 mg/dL
Glucose: 99 mg/dL
Creatinine: 1.6 mg/dL
Ca2+: 11.8 mg/dL
AST: 12 U/L
ALT: 12 U/L
Which of the following is the most likely diagnosis?
Q276
A 55-year-old man with a history of IV drug abuse presents to the emergency department with an altered mental status. He was found unconscious in the park by police. His temperature is 100.0°F (37.8°C), blood pressure is 87/48 mmHg, pulse is 150/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam is notable for multiple scars and abscesses in the antecubital fossa. His laboratory studies are ordered as seen below.
Serum:
Na+: 139 mEq/L
Cl-: 105 mEq/L
K+: 4.3 mEq/L
HCO3-: 19 mEq/L
BUN: 20 mg/dL
Glucose: 95 mg/dL
Creatinine: 1.5 mg/dL
Ca2+: 10.2 mg/dL
Which of the following is the most appropriate treatment for this patient’s blood pressure and acid-base status?
Q277
An 85-year-old woman otherwise healthy presents with left-sided weakness. Her symptoms started 4 hours ago while she was on the phone with her niece. The patient recalls dropping the phone and not being able to pick it up with her left hand. No significant past medical history. No current medications. Physical examination reveals decreased sensation on the left side, worse in the left face and left upper extremity. There is significant weakness of the left upper extremity and weakness and drooping of the lower half of the left face. Ophthalmic examination reveals conjugate eye deviation to the right. A noncontrast CT of the head is unremarkable. The patient is started on aspirin. A repeat contrast CT of the head a few days later reveals an ischemic stroke involving the lateral convexity of right cerebral hemisphere. Which of the following additional findings would most likely be seen in this patient?
Q278
A 61-year-old man comes to the physician because of a 9-month history of progressive shortness of breath on exertion. Pulmonary examinations shows fine bibasilar end-inspiratory crackles. There is digital clubbing. Pulmonary functions tests show an FEV1:FVC ratio of 97% and a total lung capacity of 70%. An x-ray of the chest shows small bilateral reticular opacities, predominantly in the lower lobes. A photomicrograph of a specimen obtained on lung biopsy is shown. The patient most likely works in which of the following fields?
Q279
A 47-year-old man comes to the physician because of a 7-week history of cough, shortness of breath, and daily copious sputum production. He has had frequent respiratory tract infections over the past several years. Current medications include dextromethorphan and guaifenesin as needed. He does not smoke cigarettes. His temperature is 37.1°C (98.8°F), pulse is 88/min, respirations are 21/min, and blood pressure is 133/84 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 95%. Diffuse crackles and wheezing are heard on auscultation over bilateral lung fields. A CT scan of the chest is shown. The patient is at greatest risk for which of the following complications?
Q280
A 31-year-old woman comes to the physician because of a 2-day history of low-grade intermittent fever, dyspnea, and chest pain that worsens on deep inspiration. Over the past 4 weeks, she has had pain in her wrists and the fingers of both hands. During this period, she has also had difficulties working on her computer due to limited range of motion in her fingers, which tends to be more severe in the morning. Her temperature is 37.7°C (99.8°F). Physical examination shows a high-pitched scratching sound over the left sternal border. Further evaluation of this patient is most likely to reveal which of the following findings?
Cardiology US Medical PG Practice Questions and MCQs
Question 271: A 62-year-old man is brought to the emergency department because of progressive shortness of breath, mild chest pain on exertion, and a cough for 2 days. One week ago, he had a low-grade fever and nasal congestion. He has hypertension but does not adhere to his medication regimen. He has smoked one pack of cigarettes daily for 30 years and drinks 3–4 beers daily. His temperature is 37.1°C (98.8°F), pulse is 125/min, respirations are 29/min, and blood pressure is 145/86 mm Hg. He is in moderate respiratory distress while sitting. Pulmonary examination shows reduced breath sounds bilaterally. There is scattered wheezing over all lung fields. There is inward displacement of his abdomen during inspiration. Arterial blood gas analysis shows:
pH 7.29
PCO2 63 mm Hg
PO2 71 mm Hg
HCO3- 29 mEq/L
O2 saturation 89%
Which of the following is the most likely cause of this patient's symptoms?
A. Acute pulmonary embolism
B. Acute respiratory distress syndrome
C. Acute asthma exacerbation
D. Acute exacerbation of chronic obstructive pulmonary disease (Correct Answer)
E. Acute decompensation of congestive heart failure
Explanation: ***Acute exacerbation of chronic obstructive pulmonary disease***
- The patient's history of heavy smoking, chronic cough, and recent respiratory infection, coupled with acute shortness of breath, wheezing, and hypercapnic respiratory acidosis, is highly suggestive of an **acute exacerbation of COPD**. The inward displacement of the abdomen during inspiration indicates increased work of breathing and **diaphragmatic fatigue**.
- The arterial blood gas (ABG) showing **pH 7.29, PCO2 63 mm Hg, PO2 71 mm Hg, and HCO3- 29 mEq/L** points to an uncompensated or partially compensated **respiratory acidosis with hypoxemia**, characteristic of severe COPD exacerbation.
*Acute pulmonary embolism*
- While pulmonary embolism can cause dyspnea and hypoxemia, the presence of diffuse wheezing, a history of heavy smoking consistent with chronic lung disease, and hypercapnic respiratory acidosis (elevated PCO2) make it less likely.
- A **pulmonary embolism** typically presents with sudden onset dyspnea, pleuritic chest pain, and often significant hypoxemia, but usually without diffuse wheezing or hypercapnia unless there is underlying severe lung disease.
*Acute respiratory distress syndrome*
- ARDS is characterized by severe hypoxemia refractory to oxygen therapy and bilateral pulmonary infiltrates on chest imaging, often in the setting of a direct or indirect lung injury.
- The patient's symptoms are more consistent with an obstructive process, and the ABG showing hypercapnia with some bicarbonate compensation is not typical of ARDS, which generally presents with **respiratory alkalosis** early on, due to tachypnea.
*Acute asthma exacerbation*
- While an asthma exacerbation can cause wheezing and shortness of breath, this patient's long smoking history and chronic cough make COPD a more probable diagnosis, especially given his age.
- Although the symptoms are similar, the significant smoking history makes **COPD** more likely, and patients with long-standing asthma often respond well to bronchodilators, which is not mentioned here.
*Acute decompensation of congestive heart failure*
- **Congestive heart failure** typically presents with orthopnea, paroxysmal nocturnal dyspnea, and bilateral crackles on lung examination, often with peripheral edema. Wheezing, known as "cardiac asthma," can occur but is usually accompanied by other signs of fluid overload.
- The primary respiratory findings in this patient are wheezing and reduced breath sounds, with inward abdominal displacement, which point more towards an **obstructive lung process** rather than fluid overload.
Question 272: A 45-year-old woman presents to her primary care physician for an annual checkup. She states that she feels well and has no complaints. She lives alone and works as a banker. She smokes 1 cigarette per day and drinks 2 alcoholic beverages per night. She occasionally gets symmetrical pain in her hands where they change from red to white to blue then return to normal again. Her temperature is 98.7°F (37.1°C), blood pressure is 177/118 mmHg, pulse is 82/min, respirations are 15/min, and oxygen saturation is 99% on room air. The patient's hypertension is treated, and she returns 2 weeks later complaining of weight gain in her legs and arms. On exam, bilateral edema is noted in her extremities. Which of the following is the best next step in management?
A. Metoprolol
B. Lisinopril
C. Furosemide (Correct Answer)
D. Compression stockings
E. Increase current medication dose
Explanation: ***Furosemide***
- The patient developed **bilateral extremity edema** shortly after initiating antihypertensive therapy, presenting 2 weeks after treatment initiation.
- While **calcium channel blocker (CCB)-induced edema** is a common cause of peripheral edema developing after starting antihypertensive treatment, the question asks for the "best next step in management" among the given options.
- **Furosemide** (a loop diuretic) can provide symptomatic relief of the edema and also helps address the **persistently elevated blood pressure**.
- The patient also demonstrates **Raynaud's phenomenon**, which may suggest underlying connective tissue disease that could contribute to renal involvement and secondary hypertension with fluid retention.
- In clinical practice, if CCB-induced edema is suspected, the preferred approach would be discontinuing or switching the medication, or adding an ACE inhibitor; however, among the options provided, furosemide addresses both the edema and hypertension.
*Lisinopril*
- **Lisinopril** (an ACE inhibitor) is an excellent antihypertensive agent and can actually **reduce CCB-induced peripheral edema** when used in combination therapy.
- However, ACE inhibitors are not first-line for managing acute bilateral edema and work more slowly than diuretics for symptom resolution.
- This would be a reasonable alternative if the edema is medication-induced and additional BP control is needed.
*Metoprolol*
- **Metoprolol** (a beta-blocker) provides antihypertensive effects but does **not address peripheral edema**.
- Beta-blockers can actually worsen peripheral circulation in some patients and may exacerbate Raynaud's phenomenon.
- This medication would not resolve the patient's presenting complaint of new-onset edema.
*Compression stockings*
- Compression stockings are useful for **chronic venous insufficiency** or **mild localized edema**.
- They do not address the underlying cause of **acute bilateral edema** developing after medication initiation, nor do they help with hypertension management.
- This is a supportive measure, not definitive management for this clinical scenario.
*Increase current medication dose*
- Simply increasing the dose of the current antihypertensive medication may **worsen the edema** if it is medication-induced (particularly if the patient is on a CCB).
- This approach does not address the new symptom of bilateral edema and could potentially exacerbate the problem.
- The development of new symptoms after starting therapy suggests the need for a different management approach rather than dose escalation.
Question 273: A 49-year-old man comes to the physician because of a 2-week history of increasing shortness of breath. He has also had chest pain that is exacerbated by deep inspiration. He has had recurrent episodes of pain in his fingers for the past 2 years. Two years ago, he was treated for a deep vein thrombosis. He has hypertension and anxiety. Current medications include enalapril, St John's wort, and ibuprofen. His temperature is 37°C (98.6°F), pulse is 110/min, respirations are 17/min, and blood pressure is 110/70 mm Hg. Examination shows pale conjunctiva. There is tenderness to palpation of the proximal interphalangeal and metacarpophalangeal joints of both hands. Heart sounds are distant. The lungs are clear to auscultation. Laboratory studies show:
Hemoglobin 11.9 g/dL
Leukocyte count 4200/mm3
Platelet count 330,000/mm3
Serum
Na+ 136 mEq/L
K+ 4.3 mEq/L
Antinuclear antibodies 1: 320
Anti-Sm antibodies positive
Anti-CCP antibodies negative
An x-ray of the chest is shown. Which of the following is most likely to be seen on this patient's ECG?
A. Deep Q wave
B. Pseudo right bundle branch block
C. Increased QT interval
D. S1Q3T3 pattern
E. Electrical alternans (Correct Answer)
Explanation: ***Electrical alternans***
- **Electrical alternans** is the classic ECG finding in **pericardial effusion with cardiac tamponade**, which this patient likely has based on distant heart sounds, dyspnea, and pleuritic chest pain
- This phenomenon reflects **beat-to-beat variations in QRS complex amplitude or axis**, caused by the heart swinging within a large pericardial effusion
- The patient has **systemic lupus erythematosus (SLE)** evidenced by positive ANA and anti-Sm antibodies, which commonly causes **serositis including pericarditis**
- **Distant heart sounds** are a key physical exam finding indicating significant pericardial effusion
*Deep Q wave*
- Deep Q waves typically indicate **prior myocardial infarction** due to transmural myocardial necrosis
- The patient's clinical presentation with distant heart sounds, pleuritic pain, and SLE points to a **pericardial process rather than ischemic heart disease**
- No clinical features suggest acute or chronic MI in this case
*Pseudo right bundle branch block*
- Pseudo RBBB patterns can be seen in conditions like **pulmonary embolism** (S1Q3T3 pattern) or Brugada syndrome
- While the patient has a history of DVT, the **primary findings of distant heart sounds and SLE-related serositis** make pericardial effusion the more likely diagnosis
- No signs of acute right heart strain from PE
*Increased QT interval*
- A prolonged QT interval is associated with increased risk of **torsades de pointes** and can be caused by medications or electrolyte abnormalities
- This is **not a characteristic finding of pericardial effusion or cardiac tamponade**
- The patient's medications (enalapril, St John's wort, ibuprofen) are not typical causes of QT prolongation
*S1Q3T3 pattern*
- The S1Q3T3 pattern (deep S wave in lead I, Q wave in lead III, inverted T wave in lead III) is suggestive of **acute pulmonary embolism**
- While the patient has a history of DVT, the **absence of hypoxemia, presence of distant heart sounds, and SLE diagnosis** make pericardial effusion with tamponade a more fitting diagnosis
- PE would typically present with more prominent respiratory symptoms and signs of right heart strain
Question 274: An 18-year-old Caucasian female presents to your clinic because of a recent increase in thirst and hunger. Urinalysis demonstrates elevated glucose. The patient's BMI is 20. Which of the following is the most common cause of death in persons suffering from this patient's illness?
A. Coma
B. Peripheral neuropathy
C. Infection
D. Renal failure
E. Myocardial infarction (Correct Answer)
Explanation: ***Myocardial infarction***
- **Cardiovascular disease, particularly myocardial infarction, is the leading cause of death in Type 1 Diabetes Mellitus**, accounting for approximately 40% of mortality.
- Patients with Type 1 diabetes develop **accelerated atherosclerosis** due to chronic hyperglycemia, dyslipidemia, endothelial dysfunction, and increased oxidative stress.
- Even young patients with T1DM have significantly elevated cardiovascular risk compared to age-matched controls, with risk increasing proportionally with disease duration and glycemic control.
- While acute complications like DKA are immediately life-threatening, modern medical management has reduced DKA mortality to <1%, making chronic cardiovascular complications the predominant cause of death.
*Coma*
- **Diabetic ketoacidosis (DKA)** leading to coma is indeed a serious acute complication of Type 1 diabetes.
- However, with contemporary medical care and improved access to insulin, DKA mortality is less than 1% in developed countries.
- While DKA may be the presenting feature or an immediate threat, it is not the most common cause of death over the lifetime of T1DM patients.
*Peripheral neuropathy*
- Diabetic peripheral neuropathy is a common chronic complication affecting up to 50% of long-standing diabetics.
- While it significantly impacts quality of life and can lead to foot ulcers, infections, and amputations, it is not a direct cause of death.
- Autonomic neuropathy can contribute to sudden cardiac death, but this is still categorized under cardiovascular mortality.
*Infection*
- Diabetes does increase susceptibility to certain infections due to impaired neutrophil function, reduced chemotaxis, and hyperglycemia promoting bacterial growth.
- While infections can be serious (e.g., necrotizing fasciitis, mucormycosis), they are not the leading cause of mortality in T1DM.
- Infection-related deaths are far less common than cardiovascular deaths.
*Renal failure*
- **Diabetic nephropathy** is the second most common cause of death in Type 1 diabetes, affecting approximately 20-30% of patients.
- End-stage renal disease develops over many years and contributes significantly to mortality.
- However, cardiovascular disease remains more common, and many patients with diabetic nephropathy ultimately die from cardiovascular events rather than renal failure alone.
Question 275: A 78-year-old man presents to his primary care physician for persistent back pain. The patient states that he has had back pain for awhile; however, this past weekend he was helping his son move heavy furniture. Since the move, his symptoms have been more severe. The patient states that the pain is constant and occurs throughout the day. On review of systems, the patient endorses a recent 15 pound weight loss and constipation. His temperature is 99.5°F (37.5°C), blood pressure is 137/79 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 98% on room air. Cardiovascular exam is notable for a murmur at the right sternal border that radiates to the carotids. Pulmonary exam reveals mild bibasilar crackles. Musculoskeletal exam is notable for mild midline tenderness of the lower thoracic spine and the upper segment of the lumbar spine. No bruising or signs of external trauma are observable on the back. Symptoms are not exacerbated when the patient is lying down and his straight leg is lifted. Strength is 5/5 in the lower and upper extremities. The patient's sensation is intact bilaterally in his lower and upper extremities. Laboratory values are ordered and return as seen below.
Hemoglobin: 11 g/dL
Hematocrit: 34%
Leukocyte count: 10,500/mm^3 with normal differential
Platelet count: 288,000/mm^3
Serum:
Na+: 139 mEq/L
Cl-: 100 mEq/L
K+: 4.3 mEq/L
HCO3-: 25 mEq/L
BUN: 20 mg/dL
Glucose: 99 mg/dL
Creatinine: 1.6 mg/dL
Ca2+: 11.8 mg/dL
AST: 12 U/L
ALT: 12 U/L
Which of the following is the most likely diagnosis?
A. Piriformis muscle inflammation
B. Muscle strain
C. Herniated nucleus pulposus
D. Plasma cell dyscrasia (Correct Answer)
E. Sciatic nerve irritation
Explanation: **Plasma cell dyscrasia**
- The patient's presentation with **persistent back pain**, **unexplained weight loss**, and **constipation** are concerning "red flag" symptoms for a serious underlying condition.
- The laboratory findings of **anemia (Hb 11 g/dL)**, **elevated calcium (Ca2+ 11.8 mg/dL)**, and **impaired renal function (Creatinine 1.6 mg/dL)** in an older patient strongly suggest a diagnosis of **multiple myeloma**, a type of plasma cell dyscrasia.
*Piriformis muscle inflammation*
- This condition typically presents with **buttock pain** that can radiate down the leg, often mimicking sciatica.
- It is usually associated with **local tenderness** in the piriformis muscle and may be exacerbated by specific movements, none of which are explicitly described as primary features.
*Muscle strain*
- While the patient's symptoms worsened after moving furniture, a simple muscle strain would typically improve over time and with rest, not cause **persistent, severe pain** with systemic symptoms like **weight loss, anemia, and hypercalcemia**.
- Muscle strains do not explain the consistent, constant pain nor the abnormal laboratory findings.
*Herniated nucleus pulposus*
- A herniated disc usually causes **radicular pain** (sciatica) that radiates down the leg, often accompanied by **neurological deficits** such as weakness, numbness, or diminished reflexes, which are absent in this patient.
- The patient's negative straight leg raise test makes a significant disc herniation less likely, and it does not account for the systemic symptoms or lab abnormalities.
*Sciatic nerve irritation*
- **Sciatica** typically involves radicular pain stemming from compression or irritation of the sciatic nerve, usually characterized by pain radiating below the knee, often with neurological findings.
- The absence of **neurological deficits** (normal strength and sensation) and a negative straight leg raise test make primary sciatic nerve irritation less probable, and it does not explain the systemic symptoms of weight loss, anemia, and hypercalcemia.
Question 276: A 55-year-old man with a history of IV drug abuse presents to the emergency department with an altered mental status. He was found unconscious in the park by police. His temperature is 100.0°F (37.8°C), blood pressure is 87/48 mmHg, pulse is 150/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam is notable for multiple scars and abscesses in the antecubital fossa. His laboratory studies are ordered as seen below.
Serum:
Na+: 139 mEq/L
Cl-: 105 mEq/L
K+: 4.3 mEq/L
HCO3-: 19 mEq/L
BUN: 20 mg/dL
Glucose: 95 mg/dL
Creatinine: 1.5 mg/dL
Ca2+: 10.2 mg/dL
Which of the following is the most appropriate treatment for this patient’s blood pressure and acid-base status?
A. Ringer lactate (Correct Answer)
B. Dextrose 5% normal saline
C. Sodium bicarbonate
D. Hypertonic saline
E. Normal saline
Explanation: ***Ringer lactate***
- This patient presents with **hypotension** (BP 87/48 mmHg) and **metabolic acidosis** (HCO3- 19 mEq/L, with an elevated anion gap if calculated). Ringer lactate is a **balanced crystalloid solution** that contains lactate, which is metabolized to bicarbonate in the liver, helping to correct metabolic acidosis while providing fluid resuscitation.
- The patient's history of **IV drug abuse**, fever, and altered mental status suggests a possible underlying infection (e.g., sepsis), which often presents with hypotension and metabolic acidosis requiring aggressive fluid resuscitation with a balanced solution.
*Dextrose 5% normal saline*
- While it provides fluids and some sodium, Dextrose 5% normal saline contains **free water**, which is not ideal for a patient with hypotension and may exacerbate cerebral edema if present.
- It does not contain bicarbonate precursors and therefore would not directly address the patient's **metabolic acidosis**.
*Sodium bicarbonate*
- Administering sodium bicarbonate directly might be considered for severe metabolic acidosis, but **fluid resuscitation with a balanced solution** like Ringer lactate is usually the initial step to address both hypotension and acidosis.
- Excessive or rapid administration of sodium bicarbonate can lead to **alkalosis**, worsening intracellular acidosis, and fluid overload.
*Hypertonic saline*
- **Hypertonic saline** is primarily used to treat severe **hyponatremia** or to reduce intracranial pressure.
- It would not be appropriate for a patient with normal sodium levels and hypotension, as it could lead to further dehydration or worsen hypernatremia.
*Normal saline*
- **Normal saline (0.9% NaCl)** is an isotonic crystalloid often used for fluid resuscitation, but it has a high chloride content.
- Large volumes of normal saline can worsen or induce **hyperchloremic metabolic acidosis**, which would be detrimental to a patient who already has metabolic acidosis.
Question 277: An 85-year-old woman otherwise healthy presents with left-sided weakness. Her symptoms started 4 hours ago while she was on the phone with her niece. The patient recalls dropping the phone and not being able to pick it up with her left hand. No significant past medical history. No current medications. Physical examination reveals decreased sensation on the left side, worse in the left face and left upper extremity. There is significant weakness of the left upper extremity and weakness and drooping of the lower half of the left face. Ophthalmic examination reveals conjugate eye deviation to the right. A noncontrast CT of the head is unremarkable. The patient is started on aspirin. A repeat contrast CT of the head a few days later reveals an ischemic stroke involving the lateral convexity of right cerebral hemisphere. Which of the following additional findings would most likely be seen in this patient?
A. Homonymous hemianopsia (Correct Answer)
B. Horner's syndrome
C. Amaurosis fugax
D. Profound lower limb weakness
E. Prosopagnosia
Explanation: ***Homonymous hemianopsia***
- The patient has an ischemic stroke affecting the **right cerebral hemisphere**, specifically the **lateral convexity**. This suggests involvement of the **middle cerebral artery (MCA)** territory.
- The **optic radiations** carrying visual information from the contralateral visual field pass through the parietal and temporal lobes to the occipital cortex. Damage to these radiations in the right hemisphere would result in a **left homonymous hemianopsia**.
*Horner's syndrome*
- Characterized by **ptosis**, **miosis**, and **anhidrosis** on one side of the face.
- It results from damage to the **sympathetic pathway**, typically in the brainstem, spinal cord above T1, or sympathetic chain, which is not the primary location of this stroke.
*Amaurosis fugax*
- This is a **transient monocular vision loss** ("curtain coming down") due to temporary interruption of blood flow to the retina, usually from an **ipsilateral carotid artery embolus**.
- It is typically a symptom of impending stroke or TIA, not a direct neurological deficit resulting from a cerebral hemisphere stroke.
*Profound lower limb weakness*
- The described stroke involves the **lateral convexity of the right cerebral hemisphere**, fed by the **middle cerebral artery (MCA)**.
- The MCA primarily supplies the upper limb and facial motor/sensory cortices, leading to more pronounced **upper limb and facial weakness** rather than profound lower limb weakness, which is more characteristic of an **anterior cerebral artery (ACA)** stroke.
*Prosopagnosia*
- This is the inability to recognize familiar faces, often due to damage to the **fusiform gyrus** in the temporal and occipital lobes, usually on the **right side**.
- While it can occur with right hemisphere strokes, it is a specific higher-order cognitive deficit and not the *most likely* additional finding in this presentation focused on motor and sensory deficits and conjugate eye deviation.
Question 278: A 61-year-old man comes to the physician because of a 9-month history of progressive shortness of breath on exertion. Pulmonary examinations shows fine bibasilar end-inspiratory crackles. There is digital clubbing. Pulmonary functions tests show an FEV1:FVC ratio of 97% and a total lung capacity of 70%. An x-ray of the chest shows small bilateral reticular opacities, predominantly in the lower lobes. A photomicrograph of a specimen obtained on lung biopsy is shown. The patient most likely works in which of the following fields?
A. Coal mining
B. Cattle farming
C. Shipbuilding (Correct Answer)
D. Sandblasting
E. Aerospace manufacturing
Explanation: ***Shipbuilding***
- The patient's presentation with progressive shortness of breath, **bibasilar end-inspiratory crackles**, **digital clubbing**, and **restrictive lung disease** (normal FEV1:FVC, reduced TLC) along with **bilateral reticular opacities** on X-ray, points towards **pulmonary fibrosis**.
- **Shipbuilding** is a common occupation associated with **asbestos exposure**, which is a well-known cause of **pulmonary fibrosis** (asbestosis). The photomicrograph would likely show **asbestos bodies** or **fibrotic changes**.
*Coal mining*
- **Coal workers' pneumoconiosis** typically presents with diffuse small nodular opacities on chest X-ray and can also cause restrictive lung disease.
- However, digital clubbing is less common in uncomplicated coal workers' pneumoconiosis, and the primary pathological finding would be **macules and nodules** rather than diffuse fibrosis with asbestos bodies.
*Cattle farming*
- **Hypersensitivity pneumonitis** (farmer's lung) due to exposure to organic dusts from hay or mold is associated with cattle farming.
- While it can cause restrictive lung disease and crackles, it often presents with acute or subacute episodes, and chronic forms might show **centrilobular nodules** or ground-glass opacities, not typically the diffuse lower lobe reticular pattern seen with asbestosis.
*Sandblasting*
- **Silicosis** is associated with sandblasting, causing **nodular opacities** predominantly in the upper lobes, and can lead to progressive massive fibrosis.
- While it causes restrictive lung disease, the radiographic pattern and typical distribution (upper lobe predominance) differ from the presented case.
*Aerospace manufacturing*
- This field can involve exposure to various substances, including **beryllium**, leading to **berylliosis**.
- Berylliosis can cause granulomatous lung disease, with findings such as hilar lymphadenopathy and nodular infiltrates, which do not align with the described lower lobe reticular opacities and digital clubbing, which are hallmarks of asbestos exposure.
Question 279: A 47-year-old man comes to the physician because of a 7-week history of cough, shortness of breath, and daily copious sputum production. He has had frequent respiratory tract infections over the past several years. Current medications include dextromethorphan and guaifenesin as needed. He does not smoke cigarettes. His temperature is 37.1°C (98.8°F), pulse is 88/min, respirations are 21/min, and blood pressure is 133/84 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 95%. Diffuse crackles and wheezing are heard on auscultation over bilateral lung fields. A CT scan of the chest is shown. The patient is at greatest risk for which of the following complications?
A. Dysfunction of left ventricle
B. Infection with Rhizopus species
C. Neoplastic growth of pleural cells
D. Damage to bronchial vessels (Correct Answer)
E. Rupture of pulmonary blebs
Explanation: ***Damage to bronchial vessels***
- The patient's presentation with chronic cough, copious sputum, frequent infections, and diffuse crackles/wheezing, along with the CT scan findings suggestive of **bronchiectasis**, indicates severe and chronic airway inflammation and dilation.
- In **bronchiectasis**, the bronchial arteries undergo **hypertrophy and neovascularization** in response to chronic inflammation, becoming tortuous and fragile.
- These hypertrophied bronchial vessels are at **systemic arterial pressure** (unlike low-pressure pulmonary vessels) and are prone to rupture, leading to **hemoptysis** (can be life-threatening massive hemoptysis in severe cases).
- This is the **most serious acute complication** of bronchiectasis, accounting for 50-90% of massive hemoptysis cases.
*Dysfunction of left ventricle*
- While chronic respiratory illness can lead to **right ventricular dysfunction (cor pulmonale)** due to pulmonary hypertension, it's less directly associated with **left ventricular dysfunction** as a primary complication of bronchiectasis itself.
- The patient's vital signs and oxygen saturation do not immediately indicate acute cardiac compromise.
*Infection with Rhizopus species*
- **Rhizopus** species cause **mucormycosis**, an opportunistic fungal infection primarily seen in immunocompromised individuals (e.g., diabetics, neutropenic patients, those on immunosuppressants).
- There is no information in the vignette to suggest the patient is immunocompromised or has risk factors for mucormycosis.
*Neoplastic growth of pleural cells*
- **Pleural cell neoplasia (mesothelioma)** is typically associated with a history of **asbestos exposure**, which is not mentioned in the patient's history.
- The clinical picture and CT findings are more consistent with chronic inflammatory airway disease than with pleural malignancy.
*Rupture of pulmonary blebs*
- **Pulmonary blebs** are typically associated with **emphysema** or other lung conditions that cause air trapping and are a risk factor for **spontaneous pneumothorax**.
- While the patient has respiratory symptoms, the primary features point towards **bronchiectasis**, and bleb rupture is not the most direct or common complication of this condition.
Question 280: A 31-year-old woman comes to the physician because of a 2-day history of low-grade intermittent fever, dyspnea, and chest pain that worsens on deep inspiration. Over the past 4 weeks, she has had pain in her wrists and the fingers of both hands. During this period, she has also had difficulties working on her computer due to limited range of motion in her fingers, which tends to be more severe in the morning. Her temperature is 37.7°C (99.8°F). Physical examination shows a high-pitched scratching sound over the left sternal border. Further evaluation of this patient is most likely to reveal which of the following findings?
A. Mutation of the HFE gene
B. Blood urea nitrogen level > 60 mg/dL
C. Increased titer of anti-citrullinated peptide antibodies (Correct Answer)
D. Coxsackie virus RNA
E. Decreased C3 complement levels
Explanation: ***Increased titer of anti-citrullinated peptide antibodies***
- The patient's symptoms, including **polyarthralgia affecting wrists and fingers, morning stiffness, and pericarditis (pericardial friction rub, chest pain, dyspnea)**, are highly suggestive of **rheumatoid arthritis (RA)**.
- **Anti-citrullinated peptide antibodies (ACPA)** are specific and sensitive markers for RA, often present early in the disease and associated with more aggressive forms.
*Mutation of the HFE gene*
- **HFE gene mutations** are associated with **hereditary hemochromatosis**, a disorder of iron overload.
- While hemochromatosis can cause arthropathy, it typically affects larger joints and is not associated with pericarditis or rheumatoid-like morning stiffness.
*Blood urea nitrogen level > 60 mg/dL*
- A **BUN level > 60 mg/dL** indicates significant **renal dysfunction**, often seen in conditions like **uremia**.
- While uremia can cause pericarditis (uremic pericarditis) and sometimes arthralgia, the joint symptoms are not typically inflammatory with morning stiffness, and there's no other evidence of kidney disease.
*Coxsackie virus RNA*
- **Coxsackievirus infection** can cause **myocarditis and pericarditis**, but it less commonly causes chronic inflammatory polyarthralgia with morning stiffness.
- While viral infections can trigger reactive arthritis, the specific presentation here points more strongly to an autoimmune connective tissue disease.
*Decreased C3 complement levels*
- **Decreased C3 complement levels** are typically seen in immune complex-mediated diseases such as **systemic lupus erythematosus (SLE)**, certain **glomerulonephritides**, and some **bacteremias**.
- While SLE can cause polyarthralgia and pericarditis, the absence of other SLE features (e.g., malar rash, photosensitivity, renal involvement, cytopenias) makes RA a more likely primary diagnosis given the specific joint and morning stiffness pattern, though SLE can serologically overlap.
