A 58-year-old patient comes to the physician because of progressive pain and swelling of his left calf for the past 2 days. He has no personal or family history of serious illness. He does not smoke or drink alcohol. His last digital rectal examination and colonoscopy at the age of 50 years were normal. His vital signs are within normal limits. He is 183 cm (6 ft) tall and weighs 80 kg (176 lb); BMI is 24 kg/m2. Physical examination shows redness, warmth, and tenderness of the left calf. The circumference of the left lower leg is 4 cm greater than the right. Dorsiflexion of the left foot elicits pain in the ipsilateral calf. Laboratory studies show:
Hemoglobin 15 g/dL
Leukocyte count 9000/mm3
Platelet count 190,000/mm3
Erythrocyte sedimentation rate 12 mm/h
Serum
Urea nitrogen 18 mg/dL
Creatinine 1.0 mg/dL
Alkaline phosphatase 24 U/L
Aspartate aminotransferase (AST, GOT) 12 U/L
Alanine aminotransferase (ALT, GPT) 10 U/L
Urine
Protein negative
RBC 1/hpf
WBC none
Compression ultrasonography with Doppler shows a non-compressible left popliteal vein with a visible 0.5-cm hyperechoic mass and reduced flow. In addition to initiating anticoagulation, which of the following is the most appropriate next step in management?
Q322
A 58-year-old man is diagnosed with right lower lobe pneumonia and has been admitted to a tertiary care hospital. His laboratory investigations suggest that he acquired an infection from the hospital where he underwent an elective abdominal surgery 3 weeks ago. His past medical records reveal a history of deep vein thrombosis and pulmonary embolism one year prior. After a steady clinical improvement over 5 days of inpatient treatment, he develops a cough, breathlessness, and hemoptysis on the 6th day. His temperature is 38.6°C (101.5°F), the pulse is 112/min, the blood pressure is 130/84 mm Hg, and the respiratory rate is 28/min. A general examination shows the presence of edema over the right leg and tenderness over the right calf region. Auscultation of the chest reveals localized crackles over the left mammary region and right infrascapular region. However, his heart sounds are normal, except for the presence of tachycardia, and there are no murmurs. Which of the following is the investigation of choice as the immediate next step in this patient’s management?
Q323
A 52-year-old man is admitted directly from the clinic for a serum glucose of 980 mg/dL. He has had type 2 diabetes for 16 years, for which he was prescribed metformin and glimepiride; however, he reports not having followed his prescription due to its high cost. For the past 12 days, he has had excess urination, and has lost 6 kg in weight. He has also noted a progressively worsening cough productive of greenish-brown sputum for approximately 20 days. His temperature is 38.9°C (102.02°F), blood pressure is 97/62 mm Hg, pulse is 97/minute and respiratory rate is 26/minute. On physical examination, he is somnolent, his eyes are sunken, and there are crackles at the left lung base.
Lab results are shown:
Arterial pH: 7.33
Serum sodium: 130 mEq/L
Serum potassium: 3 mEq/L
Serum osmolality: 325 mOsm/kg
Serum beta-hydroxybutyrate: negative
Urinalysis: trace ketones
Intravenous normal saline infusion is started. Which of the following is the best next step in this patient?
Q324
A 75-year-old woman comes to the physician because of a 6-month history of fatigue. During this period, she has had fever, pain in both shoulders and her hips, and a 5-kg (11-lb) weight loss. She also reports feeling stiff for about an hour after waking up. She has a history of hypertension and hypercholesterolemia. There is no family history of serious illness. She has smoked a pack of cigarettes daily for the past 50 years. Her medications include hydrochlorothiazide and atorvastatin. She appears pale. Her temperature is 38°C (100.4°F), pulse is 90/min, and blood pressure is 135/85 mm Hg. Range of motion of the shoulders and hips is reduced due to pain. Examination shows full muscle strength. The remainder of the examination shows no abnormalities. Laboratory studies show an erythrocyte sedimentation rate of 50 mm/h and a C-reactive protein concentration of 25 mg/dL (N=0–10 mg/dL). Which of the following is the most appropriate next step in management?
Q325
An otherwise healthy 57-year-old man presents to the emergency department because of progressive shortness of breath and exercise intolerance for the past 5 days. He denies recent travel or illicit habits. His temperature is 36.7°C (98.1°F), the blood pressure is 88/57 mm Hg, and the pulse is 102/min. The radial pulse weakens with inspiration. Physical examination reveals bilateral 1+ pedal edema. There is jugular venous distention at 13 cm and muffled heart sounds. Transthoracic echocardiogram shows reciprocal respiratory ventricular inflow and ventricular diastolic collapse. Which of the following is the best next step in the management of this patient condition?
Q326
A 70-year-old man presents to a physician with a cough and difficulty breathing during the last 7 years. He has smoked since his teenage years and regularly inhales tiotropium, formoterol, and budesonide and takes oral theophylline. The number of exacerbations has been increasing over the last 6 months. His temperature is 37.2°C (99°F), the heart rate is 92/min, the blood pressure is 134/88 mm Hg and the respiratory rate is 26/min. On chest auscultation breath sounds are diffusely decreased and bilateral rhonchi are present. Pulse oximetry shows his resting oxygen saturation to be 88%. Chest radiogram shows a flattened diaphragm, hyperlucency of the lungs, and a long, narrow heart shadow. The physician explains this condition to the patient and emphasizes the importance of smoking cessation. In addition to this, which of the following is most likely to reduce the risk of mortality from the condition?
Q327
A 62-year-old man comes to the physician because of a 1-day history of dull pain and stiffness of the right knee. He takes chlorthalidone for hypertension. Physical examination of the right knee shows a large effusion and mild erythema; range of motion is limited by pain. Arthrocentesis of right knee yields a cloudy aspirate. Gram stain is negative. Analysis of the synovial fluid shows a leukocyte count of 15,000/mm3 and 55% neutrophils. Microscopic examination of the synovial fluid under polarized light shows positively birefringent rhomboid crystals. Further evaluation of this patient is most likely to show which of the following findings?
Q328
A 75-year-old man is evaluated in the emergency department for increasing shortness of breath for the last 8 months. He also complains of a dry cough for the last 6 months. Initially, his shortness of breath occurs with exertion, but now he feels it at rest as well. He has no other complaints. He has a sedentary lifestyle and had a hip replacement surgery recently. The past medical history is significant for hypertension for which he is taking lisinopril. The patient is a lifetime non-smoker. The blood pressure is 135/85 mm Hg, pulse rate is 85/min, and the temperature is 36.6°C (97.9°F). Physical examination reveals fine inspiratory crackles and digital clubbing. A chest X-ray reveals peripheral reticular opacities associated with traction bronchiectasis predominantly at the lung bases. The pulmonary function test results reveal a decreased FEV1, a decreased FVC, and a preserved FEV1/FVC ratio. High-resolution CT scan of the chest is shown. Which of the following is the most likely diagnosis?
Q329
A 58-year-old man is brought to the emergency department by his wife 30 minutes after the sudden onset of severe retrosternal chest pain radiating to his back. He has a history of hyperlipidemia, hypertension, and type 2 diabetes mellitus. He has smoked one-half pack of cigarettes daily for 20 years. Medications include aspirin, captopril, atorvastatin, and metformin. His pulse is 80/min and blood pressure is 160/60 mm Hg. A CT scan of the chest is shown. Which of the following is the strongest predisposing factor for this patient's current condition?
Q330
A 37-year old man is being evaluated due to a recent history of fatigue that started 3 weeks ago. The patient presents with a history of HIV, which was first diagnosed 7 years ago. He has been on an antiretroviral regimen and takes it regularly. His CD4+ count is 350 cells/mm3. According to the patient, his partner passed away from a "blood cancer", and he is worried that his fatigue might be connected to a similar pathology. The physician clarifies that there is an increased risk for HIV patients to develop certain kinds of lymphomas. Which one of the conditions below is the patient more likely to develop based on his medical history?
Cardiology US Medical PG Practice Questions and MCQs
Question 321: A 58-year-old patient comes to the physician because of progressive pain and swelling of his left calf for the past 2 days. He has no personal or family history of serious illness. He does not smoke or drink alcohol. His last digital rectal examination and colonoscopy at the age of 50 years were normal. His vital signs are within normal limits. He is 183 cm (6 ft) tall and weighs 80 kg (176 lb); BMI is 24 kg/m2. Physical examination shows redness, warmth, and tenderness of the left calf. The circumference of the left lower leg is 4 cm greater than the right. Dorsiflexion of the left foot elicits pain in the ipsilateral calf. Laboratory studies show:
Hemoglobin 15 g/dL
Leukocyte count 9000/mm3
Platelet count 190,000/mm3
Erythrocyte sedimentation rate 12 mm/h
Serum
Urea nitrogen 18 mg/dL
Creatinine 1.0 mg/dL
Alkaline phosphatase 24 U/L
Aspartate aminotransferase (AST, GOT) 12 U/L
Alanine aminotransferase (ALT, GPT) 10 U/L
Urine
Protein negative
RBC 1/hpf
WBC none
Compression ultrasonography with Doppler shows a non-compressible left popliteal vein with a visible 0.5-cm hyperechoic mass and reduced flow. In addition to initiating anticoagulation, which of the following is the most appropriate next step in management?
A. Streptokinase therapy
B. Colonoscopy
C. Inferior vena cava filter
D. X-ray of the chest
E. CT pulmonary angiogram (Correct Answer)
Explanation: ***CT pulmonary angiogram***
- The patient has confirmed **deep vein thrombosis (DVT)** of the left popliteal vein. After initiating anticoagulation, the most appropriate next step is to **evaluate for pulmonary embolism (PE)** with a **CT pulmonary angiogram (CTPA)**.
- **Up to 40-50% of patients with proximal DVT have asymptomatic or minimally symptomatic PE**, making screening important for risk stratification and treatment planning.
- The presence or absence of PE symptoms does not reliably exclude PE, and detecting PE affects prognosis, treatment duration, and management decisions.
- DVT and PE are part of the same disease spectrum (**venous thromboembolism**), and concurrent PE is common enough to warrant investigation.
*Streptokinase therapy*
- **Thrombolytic therapy** is reserved for **massive PE with hemodynamic instability** or **limb-threatening DVT** (phlegmasia cerulea dolens).
- This patient is hemodynamically stable with an uncomplicated DVT, making thrombolysis inappropriate and unnecessarily risky (major bleeding complications).
- Standard anticoagulation is the appropriate treatment and has already been initiated.
*X-ray of the chest*
- While **unprovoked DVT** can be associated with occult malignancy, extensive cancer screening beyond **age-appropriate screening** is **not routinely recommended** by current guidelines.
- This patient had a normal colonoscopy 8 years ago (appropriate for his age).
- If cancer screening were indicated, **chest X-ray is insensitive for detecting occult malignancy** - low-dose CT would be more appropriate, but even this is not standard practice without other clinical indicators.
- The immediate priority is evaluating for PE, not cancer screening.
*Colonoscopy*
- The patient had a **normal colonoscopy 8 years ago** at age 50, which is within the 10-year screening interval for colorectal cancer.
- There are no gastrointestinal symptoms or signs to suggest colorectal pathology.
- Repeat colonoscopy is not indicated at this time.
*Inferior vena cava filter*
- An **IVC filter** is indicated only when there is an **absolute contraindication to anticoagulation** (e.g., active bleeding, recent neurosurgery) or **recurrent PE despite adequate anticoagulation**.
- This patient has no contraindication to anticoagulation, and anticoagulation has been successfully initiated.
- IVC filters carry risks including filter migration, IVC thrombosis, and filter fracture, so they should only be used when absolutely necessary.
Question 322: A 58-year-old man is diagnosed with right lower lobe pneumonia and has been admitted to a tertiary care hospital. His laboratory investigations suggest that he acquired an infection from the hospital where he underwent an elective abdominal surgery 3 weeks ago. His past medical records reveal a history of deep vein thrombosis and pulmonary embolism one year prior. After a steady clinical improvement over 5 days of inpatient treatment, he develops a cough, breathlessness, and hemoptysis on the 6th day. His temperature is 38.6°C (101.5°F), the pulse is 112/min, the blood pressure is 130/84 mm Hg, and the respiratory rate is 28/min. A general examination shows the presence of edema over the right leg and tenderness over the right calf region. Auscultation of the chest reveals localized crackles over the left mammary region and right infrascapular region. However, his heart sounds are normal, except for the presence of tachycardia, and there are no murmurs. Which of the following is the investigation of choice as the immediate next step in this patient’s management?
A. Ventilation-perfusion scanning
B. Echocardiography
C. Contrast-enhanced computed tomography (CECT) of chest (Correct Answer)
D. Serum brain natriuretic peptide
E. Plasma D-dimer
Explanation: ***Contrast-enhanced computed tomography (CECT) of chest***
- This patient presents with an acute onset of **cough, breathlessness, and hemoptysis** along with signs of **deep vein thrombosis (DVT)**, including leg edema and calf tenderness. This clinical picture, especially with a history of DVT and pulmonary embolism, is highly suggestive of a **pulmonary embolism (PE)**.
- **CT pulmonary angiography (CTPA)**, performed as a contrast-enhanced CT of the chest, is the **gold standard** for diagnosing PE, as it directly visualizes thrombi within the pulmonary arteries and provides detailed anatomical information.
- Given the **high pre-test probability** (prior DVT/PE, clinical signs of DVT, recent surgery, hemoptysis, tachycardia), immediate imaging with CTPA is indicated without need for D-dimer testing.
*Ventilation-perfusion scanning*
- **Ventilation-perfusion (V/Q) scanning** is an alternative for diagnosing PE, but it is less sensitive and specific than CTPA, especially in the presence of **pre-existing lung disease** (like the pneumonia this patient has), which can lead to indeterminate results.
- It is usually reserved for patients with **renal insufficiency** or **contrast allergy** who cannot undergo CTPA.
*Echocardiography*
- **Echocardiography** can show signs of **right heart strain** in massive PE, but it is not diagnostic for PE itself, as it cannot directly visualize the emboli in the pulmonary arteries.
- It is more useful in assessing **cardiac function** and ruling out other cardiac causes of breathlessness, or for risk stratification in confirmed PE.
*Serum brain natriuretic peptide*
- **Serum brain natriuretic peptide (BNP)** levels can be elevated in patients with **right heart strain** due to PE, but it is a **non-specific marker** and cannot confirm the diagnosis of PE.
- Elevated BNP can also indicate other cardiac conditions, such as **heart failure**.
*Plasma D-dimer*
- **Plasma D-dimer** is a useful test to **exclude PE** in patients with a **low or intermediate pre-test probability**, but a **positive D-dimer** is non-specific and can be elevated in many conditions, including infection, surgery, and inflammation.
- Given the patient's **high clinical probability** for PE (prior DVT/PE, current DVT signs, recent surgery, hemoptysis) and active pneumonia, D-dimer testing is **not indicated** as it would not change management—imaging with CTPA is already warranted regardless of D-dimer result.
Question 323: A 52-year-old man is admitted directly from the clinic for a serum glucose of 980 mg/dL. He has had type 2 diabetes for 16 years, for which he was prescribed metformin and glimepiride; however, he reports not having followed his prescription due to its high cost. For the past 12 days, he has had excess urination, and has lost 6 kg in weight. He has also noted a progressively worsening cough productive of greenish-brown sputum for approximately 20 days. His temperature is 38.9°C (102.02°F), blood pressure is 97/62 mm Hg, pulse is 97/minute and respiratory rate is 26/minute. On physical examination, he is somnolent, his eyes are sunken, and there are crackles at the left lung base.
Lab results are shown:
Arterial pH: 7.33
Serum sodium: 130 mEq/L
Serum potassium: 3 mEq/L
Serum osmolality: 325 mOsm/kg
Serum beta-hydroxybutyrate: negative
Urinalysis: trace ketones
Intravenous normal saline infusion is started. Which of the following is the best next step in this patient?
A. Adding sodium bicarbonate infusion
B. Starting basal-bolus insulin
C. Adding dopamine infusion
D. Adding potassium to the intravenous fluids (Correct Answer)
E. Starting regular insulin infusion
Explanation: ***Adding potassium to the intravenous fluids***
- This patient presents with **hypokalemia** (serum potassium 3 mEq/L) and is receiving aggressive fluid resuscitation, which will further dilute his potassium and drive potassium into cells, potentially worsening the hypokalemia. **Potassium replacement** is critical to prevent cardiac arrhythmias.
- While fluids and insulin will be necessary, **correcting potassium** should be initiated early, especially with symptoms of hypokalemia or if the level is <3.3 mEq/L, to prevent serious complications and before starting insulin.
*Adding sodium bicarbonate infusion*
- The patient's arterial pH of 7.33 indicates only **mild acidosis**, likely due to hypovolemic lactic acidosis or other underlying issues, but not severe enough to warrant bicarbonate infusion.
- Additionally, his serum beta-hydroxybutyrate is negative and ketones are only trace, ruling out **diabetic ketoacidosis (DKA)**, which is typically the primary indication for bicarbonate in diabetic emergencies.
*Starting basal-bolus insulin*
- The patient requires insulin for his **hyperglycemia**, but **basal-bolus insulin** is usually started once the patient is stable, able to eat, and out of the acute hyperosmolar state.
- In this emergency setting, **intravenous regular insulin infusion** is preferred for precise titration and rapid glucose control.
*Adding dopamine infusion*
- Dopamine is a **vasopressor** used to support blood pressure in cases of **hypotensive shock** refractory to fluid resuscitation.
- While the patient is hypotensive (BP 97/62 mm Hg), his primary problem is severe dehydration, so initial management focuses on **fluid resuscitation** with normal saline rather than immediate pressors.
*Starting regular insulin infusion*
- While **regular insulin infusion** is appropriate for managing severe hyperglycemia in hyperosmolar hyperglycemic state (HHS), it should be initiated **after initial fluid resuscitation** and after ensuring potassium is ≥3.3 mEq/L.
- Administering insulin without adequate potassium replacement could precipitate severe and life-threatening **hypokalemia**, as insulin drives potassium into cells.
Question 324: A 75-year-old woman comes to the physician because of a 6-month history of fatigue. During this period, she has had fever, pain in both shoulders and her hips, and a 5-kg (11-lb) weight loss. She also reports feeling stiff for about an hour after waking up. She has a history of hypertension and hypercholesterolemia. There is no family history of serious illness. She has smoked a pack of cigarettes daily for the past 50 years. Her medications include hydrochlorothiazide and atorvastatin. She appears pale. Her temperature is 38°C (100.4°F), pulse is 90/min, and blood pressure is 135/85 mm Hg. Range of motion of the shoulders and hips is reduced due to pain. Examination shows full muscle strength. The remainder of the examination shows no abnormalities. Laboratory studies show an erythrocyte sedimentation rate of 50 mm/h and a C-reactive protein concentration of 25 mg/dL (N=0–10 mg/dL). Which of the following is the most appropriate next step in management?
A. Chest x-ray
B. Electromyography
C. Muscle biopsy
D. Low-dose of oral prednisone (Correct Answer)
E. Antibody screening
Explanation: ***Low-dose of oral prednisone***
- The patient presents with classic symptoms of **polymyalgia rheumatica (PMR)**, including bilateral shoulder and hip pain, significant morning stiffness (over 1 hour), fatigue, fever, and weight loss, in an elderly individual with elevated **ESR** and **CRP**.
- PMR responds dramatically to **low-dose corticosteroids**, making prednisone the most appropriate first-line treatment.
*Chest x-ray*
- While recommended in patients with unexplained **constitutional symptoms** and **elevated inflammatory markers** to rule out malignancy or infection, it is not the most immediate or specific next step given the clear picture of PMR.
- A chest X-ray should be considered during the initial work-up of PMR if there are **pulmonary symptoms** or suspected **malignancy**, but PMR treatment should not be delayed.
*Electromyography*
- **Electromyography (EMG)** is used to differentiate between **myopathic** and **neuropathic** causes of muscle weakness.
- This patient exhibits **painful limitation of range of motion** rather than true muscle weakness, and her muscle strength is full.
*Muscle biopsy*
- A **muscle biopsy** is useful for diagnosing inflammatory myopathies like **polymyositis** or **dermatomyositis**.
- However, the patient's presentation of pain and stiffness without objective muscle weakness, coupled with the age and inflammatory markers, makes PMR much more likely than an inflammatory myopathy.
*Antibody screening*
- **Autoantibody screening** (e.g., ANA, RF, anti-CCP) is typically performed to evaluate for conditions like **rheumatoid arthritis** or **lupus**.
- While these can cause joint symptoms and fatigue, the characteristic **proximal stiffness** and dramatic inflammatory markers in an elderly patient make PMR the more probable diagnosis, and these tests are usually negative in PMR.
Question 325: An otherwise healthy 57-year-old man presents to the emergency department because of progressive shortness of breath and exercise intolerance for the past 5 days. He denies recent travel or illicit habits. His temperature is 36.7°C (98.1°F), the blood pressure is 88/57 mm Hg, and the pulse is 102/min. The radial pulse weakens with inspiration. Physical examination reveals bilateral 1+ pedal edema. There is jugular venous distention at 13 cm and muffled heart sounds. Transthoracic echocardiogram shows reciprocal respiratory ventricular inflow and ventricular diastolic collapse. Which of the following is the best next step in the management of this patient condition?
A. Pericardiectomy
B. Pericardial drainage (Correct Answer)
C. Cardiac catheterization
D. Cardiac MRI
E. Chest X-ray
Explanation: ***Pericardial drainage***
- The clinical presentation, including progressive **shortness of breath**, **hypotension**, **tachycardia**, **pulsus paradoxus** (weak radial pulse with inspiration), **jugular venous distention**, **muffled heart sounds**, and **bilateral pedal edema**, strongly suggests **cardiac tamponade** due to a pericardial effusion.
- Prompt **pericardial drainage** (pericardiocentesis) is a life-saving intervention for cardiac tamponade, as it relieves the pressure on the heart and restores cardiac output.
*Pericardiectomy*
- This is a surgical procedure to remove part or all of the pericardium, typically performed in cases of **constrictive pericarditis** or recurrent effusions that fail conservative management.
- It is a more invasive procedure and not the immediate life-saving intervention required for acute cardiac tamponade.
*Cardiac catheterization*
- This procedure involves inserting a catheter into a blood vessel to measure pressures within the heart chambers and great vessels, often used for diagnosing **coronary artery disease** or valvular heart disease.
- While it can provide hemodynamic data, it is not the most immediate or direct therapeutic intervention for cardiac tamponade.
*Cardiac MRI*
- **Cardiac MRI** provides detailed anatomical imaging of the heart and pericardium, useful for characterizing pericardial effusions or detecting myocardial abnormalities.
- Although it could confirm the diagnosis, it takes time and is not the emergent therapeutic step needed for an unstable patient with cardiac tamponade.
*Chest X-ray*
- A **chest X-ray** might show an enlarged cardiac silhouette (water bottle sign) in cases of large pericardial effusions.
- However, it is not sufficiently sensitive or specific for diagnosing cardiac tamponade and does not provide detailed information about ventricular collapse or hemodynamic compromise.
Question 326: A 70-year-old man presents to a physician with a cough and difficulty breathing during the last 7 years. He has smoked since his teenage years and regularly inhales tiotropium, formoterol, and budesonide and takes oral theophylline. The number of exacerbations has been increasing over the last 6 months. His temperature is 37.2°C (99°F), the heart rate is 92/min, the blood pressure is 134/88 mm Hg and the respiratory rate is 26/min. On chest auscultation breath sounds are diffusely decreased and bilateral rhonchi are present. Pulse oximetry shows his resting oxygen saturation to be 88%. Chest radiogram shows a flattened diaphragm, hyperlucency of the lungs, and a long, narrow heart shadow. The physician explains this condition to the patient and emphasizes the importance of smoking cessation. In addition to this, which of the following is most likely to reduce the risk of mortality from the condition?
A. Roflumilast
B. Low-dose oral prednisone
C. Pulmonary rehabilitation
D. Supplemental oxygen (Correct Answer)
E. Prophylactic azithromycin
Explanation: ***Supplemental oxygen***
- The patient's **resting oxygen saturation of 88%** indicates significant hypoxemia, which, if chronic, places a high burden on the cardiovascular system and is a strong predictor of premature mortality in **COPD**.
- **Long-term oxygen therapy (LTOT)** for at least 15 hours a day has been shown to improve survival in patients with severe chronic hypoxemia due to COPD.
*Roflumilast*
- **Roflumilast** is a phosphodiesterase-4 inhibitor that reduces inflammation and is used to decrease exacerbations in severe COPD associated with chronic bronchitis and a history of frequent exacerbations.
- While it can improve lung function and reduce exacerbations, it has not been shown to reduce mortality directly.
*Low-dose oral prednisone*
- **Oral corticosteroids** are primarily used for acute exacerbations of COPD, not for long-term maintenance due to significant systemic side effects like osteoporosis, muscle weakness, and increased infection risk.
- While they can temporarily reduce inflammation, chronic low-dose use is not recommended for mortality benefit and may cause harm in the long run.
*Pulmonary rehabilitation*
- **Pulmonary rehabilitation** is a comprehensive program that improves exercise tolerance, dyspnea, and quality of life in patients with COPD.
- It does not directly reduce mortality but significantly improves functional status and potentially reduces hospitalizations.
*Prophylactic azithromycin*
- **Prophylactic azithromycin** can reduce the frequency of exacerbations in select patients with severe COPD, likely due to its anti-inflammatory and immunomodulatory properties, as well as its bactericidal effect.
- Similar to roflumilast, it reduces exacerbations but has not been shown to reduce mortality directly in COPD patients.
Question 327: A 62-year-old man comes to the physician because of a 1-day history of dull pain and stiffness of the right knee. He takes chlorthalidone for hypertension. Physical examination of the right knee shows a large effusion and mild erythema; range of motion is limited by pain. Arthrocentesis of right knee yields a cloudy aspirate. Gram stain is negative. Analysis of the synovial fluid shows a leukocyte count of 15,000/mm3 and 55% neutrophils. Microscopic examination of the synovial fluid under polarized light shows positively birefringent rhomboid crystals. Further evaluation of this patient is most likely to show which of the following findings?
A. Chalky nodules on the external ear
B. Expression of human leukocyte antigen-B27
C. Thickening of the synovia at the metacarpophalangeal joints
D. Calcification of the meniscal cartilage (Correct Answer)
E. Elevation of serum uric acid concentration
Explanation: ***Calcification of the meniscal cartilage***
- The presence of **positively birefringent rods and rhomboid crystals** in synovial fluid is pathognomonic for **calcium pyrophosphate deposition disease (CPPD)**, also known as pseudogout.
- **Calcification of articular cartilage (chondrocalcinosis)**, particularly in the meniscal cartilage of the knee, is a characteristic radiographic finding in CPPD and would be expected on further evaluation.
*Chalky nodules on the external ear*
- **Chalky nodules (tophi)**, often found on the external ear, are characteristic of **gout**, which is caused by monosodium urate crystal deposition.
- The synovial fluid crystals described (**positively birefringent rods and rhomboid crystals**) are indicative of CPPD, not gout.
*Expression of human leukocyte antigen-B27*
- **HLA-B27** is strongly associated with **spondyloarthropathies** such as ankylosing spondylitis and reactive arthritis.
- This patient's symptoms and synovial fluid analysis are not consistent with a spondyloarthropathy.
*Thickening of the synovia at the metacarpophalangeal joints*
- **Synovial thickening and swelling** in the **metacarpophalangeal (MCP) joints** are characteristic features of **rheumatoid arthritis**.
- This patient presents with an acute monoarticular arthritis of the knee and synovial fluid findings consistent with CPPD, not rheumatoid arthritis.
*Elevation of serum uric acid concentration*
- **Elevated serum uric acid** is typically associated with **gout**, indicating hyperuricemia.
- While chlorothalidone can increase uric acid, the synovial fluid findings of **positively birefringent rods and rhomboid crystals** specifically point to CPPD, not gout.
Question 328: A 75-year-old man is evaluated in the emergency department for increasing shortness of breath for the last 8 months. He also complains of a dry cough for the last 6 months. Initially, his shortness of breath occurs with exertion, but now he feels it at rest as well. He has no other complaints. He has a sedentary lifestyle and had a hip replacement surgery recently. The past medical history is significant for hypertension for which he is taking lisinopril. The patient is a lifetime non-smoker. The blood pressure is 135/85 mm Hg, pulse rate is 85/min, and the temperature is 36.6°C (97.9°F). Physical examination reveals fine inspiratory crackles and digital clubbing. A chest X-ray reveals peripheral reticular opacities associated with traction bronchiectasis predominantly at the lung bases. The pulmonary function test results reveal a decreased FEV1, a decreased FVC, and a preserved FEV1/FVC ratio. High-resolution CT scan of the chest is shown. Which of the following is the most likely diagnosis?
A. Pulmonary embolism
B. Chronic obstructive pulmonary disease
C. Drug-induced pulmonary fibrosis
D. Idiopathic pulmonary fibrosis (Correct Answer)
E. Chlamydia pneumoniae
Explanation: ***Idiopathic pulmonary fibrosis***
- The patient shows **chronic shortness of breath** and a **dry cough**, with findings of **fine inspiratory crackles** and **digital clubbing**, which are classic signs of idiopathic pulmonary fibrosis.
- The chest X-ray and pulmonary function tests indicate **restrictive lung disease** with preserved FEV1/FVC ratio, consistent with this diagnosis.
- The HRCT findings of **peripheral reticular opacities with traction bronchiectasis** at the lung bases represent the typical **usual interstitial pneumonia (UIP) pattern** seen in IPF.
*Pulmonary embolism*
- Typically presents with **acute onset** shortness of breath and may include **pleuritic chest pain**, which is not described in this case.
- While the patient has risk factors (recent hip replacement), the **8-month progressive course** does not fit the acute presentation of PE.
*Chronic obstructive pulmonary disease*
- Characterized by a **reduced FEV1/FVC ratio**, unlike this patient, who has a preserved ratio indicative of restrictive lung disease.
- Symptoms usually include a more chronic cough with **sputum production**, which is absent in this patient.
- The patient is a **lifetime non-smoker**, making COPD unlikely.
*Drug-induced pulmonary fibrosis*
- While certain medications can cause pulmonary fibrosis (e.g., **amiodarone, bleomycin, methotrexate, nitrofurantoin**), **lisinopril (an ACE inhibitor) is not associated with pulmonary fibrosis**.
- ACE inhibitors can cause a **dry cough** through bradykinin accumulation, but this does not lead to interstitial lung disease.
- The imaging findings and restrictive pattern support idiopathic rather than drug-induced fibrosis.
*Chlamydia pneumoniae*
- Usually associated with **acute atypical pneumonia**, presenting with fever, productive cough, and constitutional symptoms.
- The patient's **chronic, progressive symptoms over 8 months** and imaging findings indicate a fibrotic lung condition rather than an infectious process.
Question 329: A 58-year-old man is brought to the emergency department by his wife 30 minutes after the sudden onset of severe retrosternal chest pain radiating to his back. He has a history of hyperlipidemia, hypertension, and type 2 diabetes mellitus. He has smoked one-half pack of cigarettes daily for 20 years. Medications include aspirin, captopril, atorvastatin, and metformin. His pulse is 80/min and blood pressure is 160/60 mm Hg. A CT scan of the chest is shown. Which of the following is the strongest predisposing factor for this patient's current condition?
A. History of smoking
B. Genetic collagen disorder
C. Hypertension (Correct Answer)
D. Diabetes mellitus
E. Age
Explanation: ***Hypertension***
- **Hypertension** is the strongest predisposing factor for **aortic dissection**, as chronically elevated blood pressure puts shear stress on the aortic wall, leading to intimal tear.
- The patient's history of **hypertension** and the clinical presentation of sudden, severe retrosternal chest pain radiating to the back are highly consistent with this diagnosis.
*History of smoking*
- **Smoking** is a risk factor for general atherosclerosis and vascular disease but is less directly linked to the acute onset of **aortic dissection** compared to uncontrolled hypertension.
- While smoking contributes to vascular wall damage, its role is indirect and usually secondary to the direct mechanical stress caused by high blood pressure.
*Genetic collagen disorder*
- Genetic collagen disorders like **Marfan syndrome** or **Ehlers-Danlos syndrome** predispose individuals to aortic dissection due to weakened connective tissue.
- However, there is no mention of such a disorder in the patient's history, making **hypertension** a much more likely and demonstrable risk factor in this case.
*Diabetes mellitus*
- **Diabetes mellitus** is a major risk factor for microvascular and macrovascular complications, including **atherosclerosis**.
- While it contributes to overall cardiovascular risk, it is not as direct and strong a predisposing factor for the acute mechanical stress leading to **aortic dissection** as hypertension.
*Age*
- **Advancing age** is a general risk factor for many cardiovascular diseases, including aortic dissection, due to degenerative changes in the aorta.
- However, in a 58-year-old with a significant history of **hypertension**, the chronic high blood pressure is a more specific and potent risk factor than age alone.
Question 330: A 37-year old man is being evaluated due to a recent history of fatigue that started 3 weeks ago. The patient presents with a history of HIV, which was first diagnosed 7 years ago. He has been on an antiretroviral regimen and takes it regularly. His CD4+ count is 350 cells/mm3. According to the patient, his partner passed away from a "blood cancer", and he is worried that his fatigue might be connected to a similar pathology. The physician clarifies that there is an increased risk for HIV patients to develop certain kinds of lymphomas. Which one of the conditions below is the patient more likely to develop based on his medical history?
A. Diffuse large B cell lymphoma (Correct Answer)
B. Follicular lymphoma
C. Burkitt’s lymphoma
D. Extranodal marginal zone lymphoma
E. Small lymphocytic lymphoma
Explanation: ***Diffuse large B cell lymphoma***
- **Diffuse large B-cell lymphoma (DLBCL)** is the most common type of lymphoma diagnosed in HIV-positive patients, accounting for about 50% of cases.
- The increased risk of DLBCL in HIV patients is related to chronic immune stimulation and dysregulation, often exacerbated by co-infection with viruses like **Epstein-Barr virus (EBV)**.
*Follicular lymphoma*
- **Follicular lymphoma** is generally *less common* in HIV-positive patients compared to the general population.
- Its incidence does not significantly increase in the context of HIV infection.
*Burkitt’s lymphoma*
- **Burkitt's lymphoma** is also more common in HIV patients, but typically presents in those with *more severe immunosuppression* (lower CD4 counts) and is specifically associated with **Epstein-Barr virus (EBV)** co-infection.
- While a possibility, DLBCL is the *overall most likely* lymphoma.
*Extranodal marginal zone lymphoma*
- **Extranodal marginal zone lymphoma** is *not typically associated* with an increased incidence in HIV-positive individuals.
- It often correlates with chronic inflammation or specific infections (e.g., *H. pylori* in gastric MALT lymphoma).
*Small lymphocytic lymphoma*
- **Small lymphocytic lymphoma (SLL)**, which is essentially the nodal form of chronic lymphocytic leukemia (CLL), is *not increased* in incidence in HIV-positive patients.
- CLL/SLL is generally considered to be *less common* or have no increased risk in HIV-infected individuals.
