A 59-year-old man presents to his primary care provider with the complaint of daytime fatigue. He often has a headache that is worse in the morning and feels tired when he awakes. He perpetually feels fatigued even when he sleeps in. The patient lives alone, drinks 2-3 beers daily, drinks coffee regularly, and has a 10 pack-year smoking history. His temperature is 99.0°F (37.2°C), blood pressure is 180/110 mm Hg, pulse is 80/min, respirations are 13/min, and oxygen saturation is 98% on room air. Physical exam is notable for a BMI of 39 kg/m^2. The rest of the patient's pulmonary and neurological exams are unremarkable. Which of the following is the best next step in management?
Q282
A 45-year-old woman comes to the physician because of a 3-month history of worsening fatigue, loss of appetite, itching of the skin, and progressive leg swelling. Although she has been drinking 2–3 L of water daily, she has been passing only small amounts of urine. She has type 1 diabetes mellitus, chronic kidney disease, hypertension, and diabetic polyneuropathy. Her current medications include insulin, torasemide, lisinopril, and synthetic erythropoietin. Her temperature is 36.7°C (98°F), pulse is 87/min, and blood pressure is 138/89 mm Hg. She appears pale. There is 2+ pitting edema in the lower extremities. Sensation to pinprick and light touch is decreased over the feet and legs bilaterally. Laboratory studies show:
Hemoglobin 11.4 g/dL
Leukocyte count 6000/mm3
Platelet count 280,000/mm3
Serum
Na+ 137 mEq/L
K+ 5.3 mEq/L
Cl− 100 mEq/L
HCO3− 20 mEq/L
Urea nitrogen 85 mg/dL
Creatinine 8 mg/dL
pH 7.25
Which of the following long-term treatments would best improve quality of life and maximize survival in this patient?
Q283
A 32-year-old woman is supposed to undergo tooth extraction surgery. Physical examination is unremarkable, and she has a blood pressure of 126/84 mm Hg and regular pulse of 72/min. She takes no medications. Which of the following cardiac conditions would warrant antibiotic prophylaxis to prevent infective endocarditis in this patient?
Q284
A 34-year-old man presents to his primary care provider for evaluation of nocturnal cough and dyspnea. He has been a smoker for the past 15 years with a 7.5-pack-year smoking history. He has no significant medical history and takes no medications. His blood pressure is 118/76 mm Hg, the heart rate is 84/min, the respiratory rate is 15/min, and the temperature is 37.0°C (98.6°F). A sputum sample shows Charcot-Leyden crystals and Curschmann spirals. What is the most likely diagnosis?
Q285
A 49-year-old woman presents to her primary care physician for a general check up. She has not seen a primary care physician for the past 20 years but states she has been healthy during this time frame. She had breast implants placed when she was 29 years old but otherwise has not had any surgeries. She is concerned about her risk for breast cancer given her friend was recently diagnosed. Her temperature is 97.0°F (36.1°C), blood pressure is 114/64 mmHg, pulse is 70/min, respirations are 12/min, and oxygen saturation is 98% on room air. Physical exam is unremarkable. Which of the following is the most appropriate workup for breast cancer for this patient?
Q286
A 31-year-old female presents to the clinic with excessive anxiety and palpitations for a month. She also mentions loss of 2.72 kg (6 lb) of her weight over the last month. Her past medical history is insignificant. She does not smoke nor does she drink alcohol. Her temperature is 37°C (98.6°F), pulse is 81/min, respiratory rate is 23/min, and blood pressure is 129/88 mm Hg. On examination, mild exophthalmos is noted. Heart and lung examination is normal including cardiac auscultation. What is the most likely cause of her symptoms?
Q287
A 25-year old man comes to the physician because of fatigue over the past 6 months. He has been to the emergency room several times over the past 3 years for recurrent shoulder and patella dislocations. Physical examination shows abnormal joint hypermobility and skin hyperextensibility. A high-frequency mid-systolic click is heard on auscultation. Which of the following is most likely to result in an earlier onset of this patient’s auscultation finding?
Q288
A 41-year-old woman presents to urgent care with complaints of a new rash. On review of systems, she endorses ankle pain bilaterally. Otherwise, she has no additional localized complaints. Physical examination reveals numerous red subcutaneous nodules overlying her shins, bilaterally. Complete blood count shows leukocytes 7,300, Hct 42.0%, Hgb 14.0 g/dL, mean corpuscular volume (MCV) 88 fL, and platelets 209. Chest radiography demonstrates bilateral hilar adenopathy with clear lungs. Which of the following is the most likely diagnosis?
Q289
A 37-year-old man presents to the clinic for evaluation of a chronic cough that has increased in frequency and severity for the past 2 days. His cough began 2 weeks ago but was not as bothersome as now. He states that he can hardly get to sleep because he is coughing all the time. Upon further questioning, he says that he had a low-grade fever, runny nose, and fatigue. However, everything resolved except for his cough. He has a history of hyperlipidemia and takes simvastatin. His vital signs are within normal limits. On physical examination, the patient is in no apparent distress and is alert and oriented. His head is normocephalic with non-tender sinuses. Sclerae are not jaundiced and there are no signs of conjunctivitis. Nares are clear without erythema. Examination of the pharynx shows erythematous mucosa without exudate. Lungs are clear to auscultation bilaterally. Posteroanterior chest X-ray shows no regions of consolidation, hypervascularity or effusion. Which of the following is the next best step in the management of this patient?
Q290
A 75-year-old man comes to the physician because of fatigue and decreased urine output for 1 week. He takes ibuprofen as needed for lower back pain and docusate for constipation. Physical examination shows tenderness to palpation over the lumbar spine. There is pedal edema. Laboratory studies show a hemoglobin concentration of 8.7 g/dL, a serum creatinine concentration of 2.3 mg/dL, and a serum calcium concentration of 12.6 mg/dL. Urine dipstick is negative for blood and protein. Which of the following is the most likely underlying cause of this patient's symptoms?
Cardiology US Medical PG Practice Questions and MCQs
Question 281: A 59-year-old man presents to his primary care provider with the complaint of daytime fatigue. He often has a headache that is worse in the morning and feels tired when he awakes. He perpetually feels fatigued even when he sleeps in. The patient lives alone, drinks 2-3 beers daily, drinks coffee regularly, and has a 10 pack-year smoking history. His temperature is 99.0°F (37.2°C), blood pressure is 180/110 mm Hg, pulse is 80/min, respirations are 13/min, and oxygen saturation is 98% on room air. Physical exam is notable for a BMI of 39 kg/m^2. The rest of the patient's pulmonary and neurological exams are unremarkable. Which of the following is the best next step in management?
A. Caffeine avoidance
B. Screening for depression
C. Alcohol avoidance in the evening
D. CT head
E. Weight loss (Correct Answer)
Explanation: ***Weight Loss***
- The patient's **BMI of 39 kg/m²** indicates **class III obesity**, which is the strongest modifiable risk factor for **obstructive sleep apnea (OSA)**. The clinical presentation—**daytime fatigue**, morning headaches, unrefreshing sleep despite adequate sleep duration, and hypertension—strongly suggests OSA.
- While **polysomnography** is the gold standard for confirming OSA, the clinical diagnosis is evident in this case. **Weight loss** is the most important initial therapeutic intervention, as even modest weight reduction (10% of body weight) can significantly improve or resolve OSA in obese patients.
- Weight loss reduces upper airway collapse by decreasing fatty tissue deposition around the pharynx and improving lung volumes. This addresses the underlying pathophysiology rather than just treating symptoms.
- This intervention also addresses his **hypertension** (180/110 mm Hg), which is commonly associated with and exacerbated by OSA.
*Caffeine avoidance*
- While excessive caffeine can disrupt sleep architecture, the patient's symptoms—particularly **morning headaches** and **unrefreshing sleep despite sleeping in**—are not characteristic of caffeine-induced insomnia, which typically presents with difficulty initiating sleep.
- These symptoms, combined with obesity and hypertension, point strongly to a sleep-related breathing disorder rather than a stimulant effect.
*Screening for depression*
- Fatigue is indeed a cardinal symptom of major depressive disorder, but the specific pattern here—**morning headaches** (from nocturnal hypercapnia/hypoxemia), **unrefreshing sleep**, and **obesity with hypertension**—is far more consistent with OSA.
- Depression screening could be considered if symptoms persist after addressing the sleep disorder, as untreated OSA can contribute to or worsen mood disorders.
*Alcohol avoidance in the evening*
- **Alcohol consumption** (2-3 beers daily) does worsen OSA by relaxing upper airway dilator muscles and suppressing arousal responses to hypoxemia. Evening alcohol avoidance would be a beneficial **adjunctive measure**.
- However, while helpful, this intervention is less impactful than weight loss. The patient's **severe obesity** (BMI 39 kg/m²) is the predominant and most modifiable risk factor, making weight loss the priority intervention that will have the greatest effect on reducing OSA severity.
*CT head*
- CT head would be indicated if there were focal neurological deficits, papilledema, or features suggesting increased intracranial pressure or structural brain pathology.
- This patient's **neurological exam is unremarkable**, and his headaches are characteristic of OSA (worse in the morning due to nocturnal CO₂ retention, improving throughout the day). Imaging is not warranted.
Question 282: A 45-year-old woman comes to the physician because of a 3-month history of worsening fatigue, loss of appetite, itching of the skin, and progressive leg swelling. Although she has been drinking 2–3 L of water daily, she has been passing only small amounts of urine. She has type 1 diabetes mellitus, chronic kidney disease, hypertension, and diabetic polyneuropathy. Her current medications include insulin, torasemide, lisinopril, and synthetic erythropoietin. Her temperature is 36.7°C (98°F), pulse is 87/min, and blood pressure is 138/89 mm Hg. She appears pale. There is 2+ pitting edema in the lower extremities. Sensation to pinprick and light touch is decreased over the feet and legs bilaterally. Laboratory studies show:
Hemoglobin 11.4 g/dL
Leukocyte count 6000/mm3
Platelet count 280,000/mm3
Serum
Na+ 137 mEq/L
K+ 5.3 mEq/L
Cl− 100 mEq/L
HCO3− 20 mEq/L
Urea nitrogen 85 mg/dL
Creatinine 8 mg/dL
pH 7.25
Which of the following long-term treatments would best improve quality of life and maximize survival in this patient?
A. Peritoneal dialysis
B. Living donor kidney transplant (Correct Answer)
C. Cadaveric kidney transplant
D. Hemofiltration
E. Fluid restriction
Explanation: ***Living donor kidney transplant***
- A **living donor kidney transplant** offers the best outcomes for **quality of life and survival** in eligible patients with end-stage renal disease (ESRD), particularly when compared to dialysis, due to better graft survival rates and reduced complications.
- The patient's symptoms (fatigue, itching, leg swelling, oliguria, high urea nitrogen, creatinine, hyperkalemia, metabolic acidosis) are consistent with **ESRD**, and while she has several comorbidities, she is not explicitly stated to have contraindications for transplantation.
*Peritoneal dialysis*
- While an effective treatment for ESRD, **dialysis generally provides lower quality of life** and survival benefits compared to successful kidney transplantation.
- She already has significant fluid overload symptoms and **oliguria**, making adequate fluid removal through peritoneal dialysis potentially challenging without strict management and impacting her overall well-being.
*Cadaveric kidney transplant*
- A **cadaveric kidney transplant** is a viable option and offers better outcomes than dialysis, but it generally has **poorer graft survival** and a longer wait time compared to a living donor transplant due to delayed graft function and cold ischemia time.
- Given the option, a **living donor transplant is superior** in terms of long-term outcomes and reduces the time spent on dialysis.
*Hemofiltration*
- **Hemofiltration is a form of renal replacement therapy**, similar to hemodialysis, often used in acute settings or for critically ill patients with severe fluid overload or electrolyte imbalances.
- While it can manage her symptoms, it is not a long-term treatment that **improves quality of life or maximizes survival** better than transplantation for ESRD.
*Fluid restriction*
- **Fluid restriction** is a supportive measure to manage fluid overload in patients with ESRD; however, it addresses symptoms rather than the underlying progressive renal failure.
- While necessary as part of supportive care, it does not offer a definitive long-term solution or improve survival for ESRD, which requires **renal replacement therapy or transplantation**.
Question 283: A 32-year-old woman is supposed to undergo tooth extraction surgery. Physical examination is unremarkable, and she has a blood pressure of 126/84 mm Hg and regular pulse of 72/min. She takes no medications. Which of the following cardiac conditions would warrant antibiotic prophylaxis to prevent infective endocarditis in this patient?
A. Hypertrophic obstructive cardiomyopathy (HOCM)
B. Mitral regurgitation
C. Past history of infective endocarditis (Correct Answer)
D. Ventricular septal defect (VSD)
E. Implantable cardioverter defibrillator (ICD)
Explanation: ***Past history of infective endocarditis***
- A **history of infective endocarditis** is a definite indication for **antibiotic prophylaxis** before dental procedures that involve manipulation of gingival tissue, periapical region of teeth, or perforation of the oral mucosa due to the high risk of recurrence.
- This condition creates a predisposition to subsequent episodes of endocarditis, even with minor bacteremia.
*Hypertrophic obstructive cardiomyopathy (HOCM)*
- While HOCM is a significant cardiac condition, it is **no longer an indication** for routine infective endocarditis prophylaxis in the absence of other high-risk features like a prosthetic valve.
- Current guidelines have narrowed the criteria for prophylaxis due to the low absolute risk and potential for side effects from antibiotics.
*Mitral regurgitation*
- **Mitral valve regurgitation**, in the absence of a prosthetic valve or a previous history of endocarditis, generally **does not warrant antibiotic prophylaxis** for routine dental procedures.
- Only specific types of valvular heart disease with high risk (e.g., prosthetic valves, certain congenital heart diseases) require prophylaxis.
*Ventricular septal defect (VSD)*
- **Most ventricular septal defects do not require prophylaxis**. Only **unrepaired cyanotic VSD** or **repaired VSD with residual defects adjacent to prosthetic material** would warrant prophylaxis.
- Completely repaired VSDs without residual defects do not require prophylaxis after the initial 6 months post-repair.
- In this case, with an unremarkable physical examination and normal vital signs, there is no indication of cyanotic heart disease.
*Implantable cardioverter defibrillator (ICD)*
- An **implantable cardioverter defibrillator (ICD)** itself is a device and does not inherently increase the risk for infective endocarditis to warrant prophylaxis for dental procedures.
- The risk of infection is primarily associated with the device insertion procedure itself, not with subsequent dental interventions.
Question 284: A 34-year-old man presents to his primary care provider for evaluation of nocturnal cough and dyspnea. He has been a smoker for the past 15 years with a 7.5-pack-year smoking history. He has no significant medical history and takes no medications. His blood pressure is 118/76 mm Hg, the heart rate is 84/min, the respiratory rate is 15/min, and the temperature is 37.0°C (98.6°F). A sputum sample shows Charcot-Leyden crystals and Curschmann spirals. What is the most likely diagnosis?
A. Chronic obstructive pulmonary disease
B. Pneumonia
C. Atopic asthma (Correct Answer)
D. Bronchiectasis
E. Panacinar emphysema
Explanation: ***Atopic asthma***
- The presence of **Charcot-Leyden crystals** and **Curschmann spirals** in the sputum is pathognomonic for asthma, indicating a chronic inflammatory airway process with eosinophilic infiltration and mucus plugging.
- **Nocturnal cough** and **dyspnea** are classic symptoms of asthma, particularly when associated with airway hyper-responsiveness.
*Chronic obstructive pulmonary disease*
- While a 7.5-pack-year smoking history is notable, **Charcot-Leyden crystals** and **Curschmann spirals** are not typically seen in COPD sputum and are more characteristic of asthma.
- COPD usually presents with persistent and progressive dyspnea and cough, which is continuously present in contrast to episodic nocturnal symptoms in asthma.
*Pneumonia*
- Pneumonia is an **acute infection** of the lungs, typically presenting with fever, productive cough with purulent sputum, and often systemic signs of infection, which are absent here.
- Sputum microscopy in pneumonia usually shows bacteria, neutrophils, and inflammatory cells, not Charcot-Leyden crystals or Curschmann spirals.
*Bronchiectasis*
- Characterized by **permanent dilation of the bronchi** due to chronic inflammation and infection, leading to chronic cough with copious, purulent sputum.
- While it can cause dyspnea, the sputum findings of Charcot-Leyden crystals and Curschmann spirals are not typical for bronchiectasis, which often features bacterial cultures.
*Panacinar emphysema*
- A type of COPD primarily affecting the **respiratory bronchioles and alveolar ducts and sacs**, often associated with alpha-1 antitrypsin deficiency or smoking.
- While smoking is a risk factor, the sputum findings in this case are not consistent with emphysema, which primarily involves alveolar destruction and less sputum production, and not these specific crystalline and spiral formations.
Question 285: A 49-year-old woman presents to her primary care physician for a general check up. She has not seen a primary care physician for the past 20 years but states she has been healthy during this time frame. She had breast implants placed when she was 29 years old but otherwise has not had any surgeries. She is concerned about her risk for breast cancer given her friend was recently diagnosed. Her temperature is 97.0°F (36.1°C), blood pressure is 114/64 mmHg, pulse is 70/min, respirations are 12/min, and oxygen saturation is 98% on room air. Physical exam is unremarkable. Which of the following is the most appropriate workup for breast cancer for this patient?
A. No intervention indicated at this time
B. Sentinel node biopsy
C. BRCA genetic testing
D. Mammography (Correct Answer)
E. Ultrasound
Explanation: ***Mammography***
- The patient is 49 years old, making regular screening **mammography** the most appropriate initial workup for breast cancer, as guidelines recommend screening for women over 40.
- While breast implants can make mammograms more challenging, specialized techniques like **Eklund views** can be used to visualize breast tissue effectively.
*No intervention indicated at this time*
- This is incorrect because the patient's age (49) places her in the demographic for routine **breast cancer screening**.
- Delaying screening in this age group would increase the risk of detecting cancer at a later, less treatable stage.
*Sentinel node biopsy*
- **Sentinel node biopsy** is a procedure typically performed after a breast cancer diagnosis to stage the disease and determine lymph node involvement.
- It is not a screening tool and is therefore inappropriate as an initial workup in an asymptomatic patient without a known mass.
*BRCA genetic testing*
- **BRCA genetic testing** is indicated for individuals with a strong family history of breast or ovarian cancer, or those diagnosed with specific types of breast cancer at a young age.
- This patient has no such risk factors mentioned, making genetic testing unnecessary as a first-line screening step.
*Ultrasound*
- **Ultrasound** is often used as a follow-up to an abnormal mammogram or to evaluate specific palpable masses, especially in younger women with dense breasts.
- It is not typically recommended as a primary screening tool for breast cancer in a 49-year-old woman, especially without prior mammographic findings.
Question 286: A 31-year-old female presents to the clinic with excessive anxiety and palpitations for a month. She also mentions loss of 2.72 kg (6 lb) of her weight over the last month. Her past medical history is insignificant. She does not smoke nor does she drink alcohol. Her temperature is 37°C (98.6°F), pulse is 81/min, respiratory rate is 23/min, and blood pressure is 129/88 mm Hg. On examination, mild exophthalmos is noted. Heart and lung examination is normal including cardiac auscultation. What is the most likely cause of her symptoms?
A. Thyroid stimulating antibodies (Correct Answer)
B. Inadequate iodine in her diet
C. Lithium use
D. Use of propylthiouracil
E. Medullary carcinoma of the thyroid
Explanation: ***Thyroid stimulating antibodies***
- The patient's symptoms of **anxiety**, **palpitations**, **weight loss**, and **exophthalmos** are characteristic of **hyperthyroidism**, specifically **Graves' disease**.
- **Graves' disease** is an autoimmune condition caused by **thyroid-stimulating immunoglobulins (TSI)**, which act as agonists at the TSH receptor, leading to excessive thyroid hormone production.
*Inadequate iodine in her diet*
- **Iodine deficiency** is a common cause of **hypothyroidism** and **goiter**, where the thyroid gland is unable to produce sufficient thyroid hormones.
- This condition presents with symptoms such as **fatigue, weight gain, constipation**, and **cold intolerance**, which are opposite to the patient's presentation.
*Lithium use*
- **Lithium** is primarily used as a mood stabilizer and is known to cause **hypothyroidism** or, less commonly, euthyroid goiter due to its interference with thyroid hormone synthesis and release.
- This would not explain the patient's hyperthyroid symptoms of anxiety, palpitations, and weight loss.
*Use of propylthiouracil*
- **Propylthiouracil (PTU)** is an **antithyroid medication** used to treat hyperthyroidism by inhibiting thyroid hormone synthesis.
- Its use would lead to a reduction in thyroid hormone levels and would not be the cause of the patient's hyperthyroid symptoms.
*Medullary carcinoma of the thyroid*
- **Medullary thyroid carcinoma** is a neuroendocrine tumor that arises from parafollicular C cells and secretes **calcitonin**.
- It typically presents as a thyroid nodule and usually does not cause symptoms of hyperthyroidism unless very advanced and aggressive.
Question 287: A 25-year old man comes to the physician because of fatigue over the past 6 months. He has been to the emergency room several times over the past 3 years for recurrent shoulder and patella dislocations. Physical examination shows abnormal joint hypermobility and skin hyperextensibility. A high-frequency mid-systolic click is heard on auscultation. Which of the following is most likely to result in an earlier onset of this patient’s auscultation finding?
A. Hand grip
B. Rapid squatting
C. Leaning forward
D. Abrupt standing (Correct Answer)
E. Valsalva release phase
Explanation: ***Abrupt standing***
- Abrupt standing reduces **preload** (venous return), leading to a smaller left ventricle and earlier prolapse of the mitral valve, causing an **earlier systolic click**.
- This maneuver decreases **left ventricular volume**, thereby reducing the tension on the chordae tendineae and facilitating earlier mitral valve billowing into the atrium.
*Hand grip*
- Hand grip is an **isometric exercise** that increases **afterload** and **left ventricular volume**.
- Increased left ventricular volume would cause the mitral valve leaflets to become taut earlier in systole, thus **delaying** the click rather than making it earlier.
*Rapid squatting*
- Rapid squatting rapidly increases **venous return** and **systemic vascular resistance**, increasing **preload** and **afterload**.
- This leads to increased left ventricular volume, which would **delay** the onset of the systolic click as the mitral valve takes longer to prolapse.
*Leaning forward*
- Leaning forward is typically used to accentuate the murmur of **aortic regurgitation** or **pericardial friction rubs**, not to alter the timing of a mitral valve prolapse click.
- It can sometimes make heart sounds clearer by bringing the heart closer to the chest wall but does not directly affect cardiac preload or afterload significantly to change click timing.
*Valsalva release phase*
- The release phase of Valsalva maneuver is characterized by an **increase in venous return** and **cardiac output** after the initial decrease during straining.
- This increase in left ventricular volume would **delay** the mitral valve prolapse click, as it increases the tension on the mitral valve apparatus.
Question 288: A 41-year-old woman presents to urgent care with complaints of a new rash. On review of systems, she endorses ankle pain bilaterally. Otherwise, she has no additional localized complaints. Physical examination reveals numerous red subcutaneous nodules overlying her shins, bilaterally. Complete blood count shows leukocytes 7,300, Hct 42.0%, Hgb 14.0 g/dL, mean corpuscular volume (MCV) 88 fL, and platelets 209. Chest radiography demonstrates bilateral hilar adenopathy with clear lungs. Which of the following is the most likely diagnosis?
A. Yersiniosis
B. Coccidioidomycosis
C. Histoplasmosis
D. Chlamydophila pneumoniae
E. Sarcoidosis (Correct Answer)
Explanation: ***Sarcoidosis***
- The combination of **erythema nodosum** (red subcutaneous nodules on shins), **bilateral hilar adenopathy**, and **ankle arthralgia** (ankle pain) in a young woman is highly characteristic of **Lofgren's syndrome**, a common acute presentation of sarcoidosis.
- While other conditions can cause hilar adenopathy or erythema nodosum, the triad presented makes sarcoidosis the most likely diagnosis.
*Yersiniosis*
- Can cause **erythema nodosum** and arthralgia, but **bilateral hilar adenopathy** is not a typical feature of *Yersinia* infection.
- Often associated with **gastrointestinal symptoms** (e.g., diarrhea) which are not mentioned here.
*Coccidioidomycosis*
- Can cause **erythema nodosum** and affect the lungs, but typically presents with **pulmonary infiltrates** or **nodules**, not just isolated bilateral hilar adenopathy.
- Endemic to specific geographic regions (e.g., southwestern US), which is not specified but relevant for exposure.
*Histoplasmosis*
- Can cause **hilar adenopathy** and **erythema nodosum**, especially in acute disseminated forms.
- However, it's more common in individuals exposed to **bird or bat droppings** (Ohio and Mississippi River valleys), and a fungal infection would likely present with more systemic symptoms or specific lung findings beyond just hilar adenopathy.
*Chlamydophila pneumoniae*
- This atypical bacterial infection can cause respiratory symptoms and, rarely, reactive arthritis or erythema nodosum.
- However, **bilateral hilar adenopathy** is not a typical prominent feature of *Chlamydophila pneumoniae* infection.
Question 289: A 37-year-old man presents to the clinic for evaluation of a chronic cough that has increased in frequency and severity for the past 2 days. His cough began 2 weeks ago but was not as bothersome as now. He states that he can hardly get to sleep because he is coughing all the time. Upon further questioning, he says that he had a low-grade fever, runny nose, and fatigue. However, everything resolved except for his cough. He has a history of hyperlipidemia and takes simvastatin. His vital signs are within normal limits. On physical examination, the patient is in no apparent distress and is alert and oriented. His head is normocephalic with non-tender sinuses. Sclerae are not jaundiced and there are no signs of conjunctivitis. Nares are clear without erythema. Examination of the pharynx shows erythematous mucosa without exudate. Lungs are clear to auscultation bilaterally. Posteroanterior chest X-ray shows no regions of consolidation, hypervascularity or effusion. Which of the following is the next best step in the management of this patient?
A. Azithromycin
B. Amoxicillin
C. Levofloxacin
D. Azithromycin with amoxicillin-clavulanate
E. Supportive treatment (Correct Answer)
Explanation: ***Supportive treatment***
- This patient likely has a **post-viral cough**, which is a self-limiting condition that typically resolves on its own without specific medication. His history of a recent common cold and the absence of bacterial infection signs (normal vital signs, clear chest X-ray, no purulent sputum) support this.
- Management involves **symptomatic relief** with measures like cough suppressants, lozenges, and hydration, rather than antibiotics which are ineffective against viral infections.
*Azithromycin*
- Azithromycin is an **antibiotic** used to treat bacterial infections, particularly atypical respiratory pathogens.
- There is no clinical or radiological evidence suggesting a bacterial infection (e.g., fever, crackles, consolidation on X-ray) in this patient, making antibiotic therapy inappropriate.
*Amoxicillin*
- Amoxicillin is a **beta-lactam antibiotic** primarily used for common bacterial respiratory infections like strep throat or sinusitis.
- The patient's symptoms are inconsistent with a bacterial infection requiring amoxicillin; his cough is likely viral in origin and there are no signs of bacterial sinusitis or pneumonia.
*Levofloxacin*
- Levofloxacin is a **fluoroquinolone antibiotic** typically reserved for more severe bacterial infections or when resistance to other antibiotics is suspected.
- Using a broad-spectrum antibiotic like levofloxacin without clear evidence of a bacterial infection is inappropriate and contributes to **antibiotic resistance**.
*Azithromycin with amoxicillin-clavulanate*
- This combination represents broad-spectrum antibiotic coverage, often indicated for atypical and typical bacterial co-infections.
- Prescribing multiple antibiotics without any indication of a bacterial infection is **unnecessary** and carries risks of side effects and promoting antibiotic resistance.
Question 290: A 75-year-old man comes to the physician because of fatigue and decreased urine output for 1 week. He takes ibuprofen as needed for lower back pain and docusate for constipation. Physical examination shows tenderness to palpation over the lumbar spine. There is pedal edema. Laboratory studies show a hemoglobin concentration of 8.7 g/dL, a serum creatinine concentration of 2.3 mg/dL, and a serum calcium concentration of 12.6 mg/dL. Urine dipstick is negative for blood and protein. Which of the following is the most likely underlying cause of this patient's symptoms?
A. Immunoglobulin light chains (Correct Answer)
B. Hypersensitivity reaction
C. Antiglomerular basement membrane antibodies
D. Anti double-stranded DNA antibodies
E. Renal deposition of AL amyloid
Explanation: ***Immunoglobulin light chains***
- The patient's symptoms (fatigue, decreased urine output, **anemia**, **hypercalcemia**, **elevated creatinine**, and **lumbar spine tenderness**) are highly suggestive of **multiple myeloma**.
- **Immunoglobulin light chains** (**Bence Jones proteins**) are overproduced in multiple myeloma and are nephrotoxic, leading to **cast nephropathy** and acute kidney injury.
*Hypersensitivity reaction*
- A hypersensitivity reaction involving the kidneys typically presents as **acute interstitial nephritis** with fever, rash, and eosinophilia, which are absent in this patient.
- While NSAIDs can cause interstitial nephritis, the presence of **hypercalcemia** and **anemia** points away from this as the primary cause.
*Antiglomerular basement membrane antibodies*
- These antibodies cause **Goodpasture syndrome**, characterized by rapidly progressive glomerulonephritis, often with pulmonary hemorrhage.
- The urine dipstick negative for blood and protein makes glomerulonephritis less likely, and the co-occurrence of **hypercalcemia** and **anemia** does not fit.
*Anti double-stranded DNA antibodies*
- These antibodies are characteristic of **systemic lupus erythematosus (SLE)**, which can cause **lupus nephritis**.
- While SLE can cause kidney dysfunction and anemia, the prominent **hypercalcemia** and specific bone pain are not typical features of SLE-related kidney disease.
*Renal deposition of AL amyloid*
- **AL amyloidosis** can present with kidney dysfunction and fatigue. However, significant **hypercalcemia** and a hemoglobin of 8.7 g/dL without other signs of chronic disease are less typical of amyloidosis alone.
- The combination of **anemia, hypercalcemia, renal failure**, and bone pain points more specifically to **multiple myeloma**.
