A 19-year-old basketball player unexpectedly collapses on the court. Several minutes later he returns to consciousness and is able to continue playing. This has happened several times before with similar outcomes. He had no significant past medical history. Which of the following is most likely to be found in this patient?
Q352
A 67-year-old man with a past medical history of poorly-controlled type 2 diabetes mellitus (T2DM) is brought to the emergency department for acute onset nausea and vomiting. According to the patient, he suddenly experienced vertigo and began vomiting 3 hours ago while watching TV. He reports hiking in New Hampshire with his wife 2 days ago. Past medical history is significant for a myocardial infarction (MI) that was treated with cardiac stenting, T2DM, and hypertension. Medications include lisinopril, aspirin, atorvastatin, warfarin, and insulin. Physical examination demonstrates left-sided facial droop and decreased pinprick sensation at the right arm and leg. What is the most likely etiology of this patient’s symptoms?
Q353
A 19-year-old woman presents to her gynecologist’s office stating that she has never had a period. She is slightly alarmed because most of her friends in college have been menstruating for years. She is also concerned about her short stature. When she previously visited her family physician during early puberty, she was told that she will gain the appropriate height during her final teenage years. However, over the past few years, she has gained only a couple of inches. On examination, she has a wide chest and short neck. Her breast development is at Tanner stage 1. Her external genitalia is normal with sparse hair distribution over the mons pubis. Her gynecologist suspects a genetic condition and sends her for genetic counseling. Based on her clinical findings, which of the following diseases is she most likely to develop?
Q354
A 29-year-old woman presents to the emergency department with joint pain and a notable rash. She has had joint pain for the past 12 months but noticed the rash recently as well as generalized malaise. She states her joint pain is symmetric, in her upper extremities, and is worse in the morning. Her temperature is 97.6°F (36.4°C), blood pressure is 111/74 mmHg, pulse is 83/min, respirations are 14/min, and oxygen saturation is 98% on room air. Laboratory studies are ordered as seen below.
Hemoglobin: 10 g/dL
Hematocrit: 30%
Leukocyte count: 6,800/mm^3 with normal differential
Platelet count: 207,000/mm^3
Serum:
Na+: 140 mEq/L
Cl-: 101 mEq/L
K+: 4.9 mEq/L
HCO3-: 21 mEq/L
BUN: 30 mg/dL
Glucose: 120 mg/dL
Creatinine: 1.8 mg/dL
The patient is ultimately admitted to the hospital. Which of the following is the most appropriate test to monitor her disease progression?
Q355
A 72-year-old woman comes to the emergency department 1 hour after the sudden onset of a diffuse, dull, throbbing headache. She also reports blurred vision, nausea, and one episode of vomiting. She has a history of poorly controlled hypertension. A photograph of her fundoscopic examination is shown. Which of the following is the most likely underlying cause of this patient's symptoms?
Q356
A 63-year-old man undergoes workup for nocturnal dyspnea and what he describes as a "choking" sensation while sleeping. He also endorses fatigue and dyspnea on exertion. Physical exam reveals a normal S1, loud P2, and a neck circumference of 17 inches (43 cm) (normal < 14 inches (< 35 cm)). His temperature is 98.8°F (37°C), blood pressure is 128/82 mmHg, pulse is 86/min, and respirations are 19/min. He undergoes spirometry, which is unrevealing, and polysomnography, which shows 16 hypopneic and apneic events per hour. Mean pulmonary arterial pressure is 30 mmHg. Which of the following complications is this patient most at risk for?
Q357
A 22-year-old man comes to the emergency department because of several episodes of blood in his urine and decreased urine output for 5 days. His blood pressure is 158/94 mm Hg. Examination shows bilateral lower extremity edema. Urinalysis shows 3+ protein and red blood cell casts. Mass spectrometry analysis of the urinary protein detects albumin, transferrin, and IgG. Which of the following best describes this type of proteinuria?
Q358
A 28-year-old woman comes to the emergency department for a rash that began 3 days ago. She has low-grade fever and muscle aches. She has no history of serious illness and takes no medications. She has had 5 male sexual partners over the past year and uses condoms inconsistently. Her temperature is 38.1°C (100.6° F), pulse is 85/min, and blood pressure is 126/89 mm Hg. Examination shows a diffuse maculopapular rash that includes the palms and soles. The remainder of the examination shows no abnormalities. A venereal disease research laboratory (VDRL) test is positive. Which of the following is the next appropriate step in management?
Q359
A 34-year-old man with a 2-year history of rheumatoid arthritis is being evaluated on a follow-up visit. He is currently on methotrexate and celecoxib for pain management and has shown a good response until now. However, on this visit, he mentions that the morning stiffness has been getting progressively worse. On physical examination, both his wrists are erythematous and swollen, nodules on his elbows are also noted. Rheumatoid factor is 30 (normal reference values: < 15 IU/mL), ESR is 50 mm/h, anti-citrullinated protein antibodies is 55 (normal reference values: < 20). What is the next best step in the management of this patient?
Q360
A 62-year-old man comes to the physician in May for a routine health maintenance examination. He feels well. He underwent a right inguinal hernia repair 6 months ago. He has hypertension and type 2 diabetes mellitus. There is no family history of serious illness. Current medications include metformin, sitagliptin, enalapril, and metoprolol. He received the zoster vaccine 1 year ago. He received the PPSV23 vaccine 4 years ago. His last colonoscopy was 7 years ago and was normal. He smoked a pack of cigarettes a day for 20 years but quit 17 years ago. He drinks two to three alcoholic beverages on weekends. He is allergic to amoxicillin. He is scheduled to visit Australia and New Zealand in 2 weeks to celebrate his 25th wedding anniversary. He appears healthy. Vital signs are within normal limits. An S4 is heard at the apex. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate recommendation at this time?
Cardiology US Medical PG Practice Questions and MCQs
Question 351: A 19-year-old basketball player unexpectedly collapses on the court. Several minutes later he returns to consciousness and is able to continue playing. This has happened several times before with similar outcomes. He had no significant past medical history. Which of the following is most likely to be found in this patient?
A. Cardiac myxoma
B. Atheromatous plaque rupture
C. Postductal coarctation of the aorta
D. Coagulation necrosis with loss of nuclei and striations
E. Septal hypertrophy (Correct Answer)
Explanation: ***Septal hypertrophy***
- The history of a young, otherwise healthy athlete collapsing during exertion and then recovering suggests a **cardiac arrhythmia** due to **hypertrophic cardiomyopathy (HCM)**.
- HCM is characterized by **left ventricular hypertrophy**, especially of the septum, leading to **outflow tract obstruction** and **diastolic dysfunction**, predisposing to arrhythmias.
*Cardiac myxoma*
- While a myxoma can cause embolic events or obstruction, it typically presents with more insidious symptoms or acute heart failure due to **valvular obstruction**.
- Recurrent syncope with immediate recovery is less characteristic of a **primary cardiac tumor**.
*Atheromatous plaque rupture*
- This is a common cause of **myocardial infarction** or **stroke** in older individuals with risk factors for atherosclerosis.
- It is highly unlikely in a 19-year-old athlete without significant medical history.
*Postductal coarctation of the aorta*
- This congenital heart defect would typically present with **hypertension**, **discrepancy in blood pressure between upper and lower extremities**, or symptoms of heart failure.
- It is not a common cause of sudden collapse during sport with rapid recovery.
*Coagulation necrosis with loss of nuclei and striations*
- This describes the histological changes seen in acute **myocardial infarction**.
- While a severe cardiac event, it is unlikely to allow for immediate full recovery and continuation of play, especially in a young, previously healthy individual.
Question 352: A 67-year-old man with a past medical history of poorly-controlled type 2 diabetes mellitus (T2DM) is brought to the emergency department for acute onset nausea and vomiting. According to the patient, he suddenly experienced vertigo and began vomiting 3 hours ago while watching TV. He reports hiking in New Hampshire with his wife 2 days ago. Past medical history is significant for a myocardial infarction (MI) that was treated with cardiac stenting, T2DM, and hypertension. Medications include lisinopril, aspirin, atorvastatin, warfarin, and insulin. Physical examination demonstrates left-sided facial droop and decreased pinprick sensation at the right arm and leg. What is the most likely etiology of this patient’s symptoms?
A. Hypoperfusion of the anterior spinal artery (ASA)
B. Labyrinthitis
C. Early disseminated Lyme disease
D. Thrombotic stroke at the anterior inferior cerebellar artery (AICA)
E. Embolic stroke at the posterior inferior cerebellar artery (PICA) (Correct Answer)
Explanation: ***Embolic stroke at the posterior inferior cerebellar artery (PICA)***
- The constellation of left-sided **facial droop** (cranial nerve impairment) and **contralateral decreased pinprick sensation** (spinothalamic tract deficit) in the context of acute vertigo, nausea, and vomiting is classic for a **lateral medullary syndrome (Wallenberg syndrome)**.
- Wallenberg syndrome is most commonly caused by an **ischemic stroke in the PICA territory**, often embolic, especially in patients with risk factors like **atrial fibrillation** (implied by warfarin use) or a history of MI.
*Hypoperfusion of the anterior spinal artery (ASA)*
- **ASA syndrome** typically presents with sudden onset **flaccid paraplegia, loss of pain and temperature sensation below the level of the lesion**, and preservation of proprioception and vibration sense.
- It does not typically cause **facial droop** or **vertigo**, as these are signs of brainstem involvement.
*Labyrinthitis*
- **Labyrinthitis** is an inflammation of the inner ear, causing acute onset **vertigo, nausea, vomiting**, and sometimes hearing loss or tinnitus.
- It would **not cause neurological deficits** like facial droop or contralateral sensory loss in the extremities, which are indicative of a central neurological event.
*Early disseminated Lyme disease*
- **Early disseminated Lyme disease** can cause neurological symptoms, including **facial nerve palsy** (often bilateral), but it typically presents with other symptoms like **meningitis, radiculopathy, or carditis**.
- The **hyperacute onset (3 hours)** strongly favors an acute vascular event over Lyme disease, which takes **days to weeks** to develop neurological manifestations after tick exposure.
*Thrombotic stroke at the anterior inferior cerebellar artery (AICA)*
- An **AICA stroke** typically presents with **ipsilateral facial paralysis, ipsilateral hearing loss**, vertigo, nystagmus, and sometimes contralateral loss of pain and temperature sensation.
- While it can cause vertigo and facial weakness, the specific pattern of **contralateral body sensory loss** combined with facial droop strongly points to a PICA distribution affecting the lateral medulla, not AICA.
Question 353: A 19-year-old woman presents to her gynecologist’s office stating that she has never had a period. She is slightly alarmed because most of her friends in college have been menstruating for years. She is also concerned about her short stature. When she previously visited her family physician during early puberty, she was told that she will gain the appropriate height during her final teenage years. However, over the past few years, she has gained only a couple of inches. On examination, she has a wide chest and short neck. Her breast development is at Tanner stage 1. Her external genitalia is normal with sparse hair distribution over the mons pubis. Her gynecologist suspects a genetic condition and sends her for genetic counseling. Based on her clinical findings, which of the following diseases is she most likely to develop?
A. Cystic medial necrosis
B. Coarctation of aorta (Correct Answer)
C. Supravalvular aortic stenosis
D. Intellectual disability
E. Endocardial cushion defects
Explanation: ***Coarctation of aorta***
- The patient's presentation with **primary amenorrhea**, **short stature**, a **wide chest**, and **short neck** are classic signs of **Turner syndrome (45, XO)**.
- **Coarctation of the aorta** is a common cardiovascular anomaly associated with Turner syndrome, occurring in approximately 10-20% of affected individuals.
*Cystic medial necrosis*
- This condition is associated with conditions like **Marfan syndrome** or **Ehlers-Danlos syndrome**, which present with different physical features, such as tall stature and joint hypermobility.
- While it can lead to aortic dissection, it is not a characteristic cardiovascular anomaly of Turner syndrome.
*Supravalvular aortic stenosis*
- This is a feature more commonly associated with **Williams syndrome**, which involves distinct facial features, intellectual disability, and a cheerful personality, none of which are described in this patient.
- It involves narrowing of the ascending aorta above the aortic valve, but is not typically linked to Turner syndrome.
*Intelligence disability*
- Patients with **Turner syndrome typically have normal intelligence**, although they may experience specific learning difficulties, particularly in visuospatial tasks.
- Significant intellectual disability is not a characteristic feature of this syndrome.
*Endocardial cushion defects*
- These defects, particularly **atrioventricular septal defects**, are classically associated with **Down syndrome (Trisomy 21)**.
- They are not a common cardiovascular defect seen in Turner syndrome.
Question 354: A 29-year-old woman presents to the emergency department with joint pain and a notable rash. She has had joint pain for the past 12 months but noticed the rash recently as well as generalized malaise. She states her joint pain is symmetric, in her upper extremities, and is worse in the morning. Her temperature is 97.6°F (36.4°C), blood pressure is 111/74 mmHg, pulse is 83/min, respirations are 14/min, and oxygen saturation is 98% on room air. Laboratory studies are ordered as seen below.
Hemoglobin: 10 g/dL
Hematocrit: 30%
Leukocyte count: 6,800/mm^3 with normal differential
Platelet count: 207,000/mm^3
Serum:
Na+: 140 mEq/L
Cl-: 101 mEq/L
K+: 4.9 mEq/L
HCO3-: 21 mEq/L
BUN: 30 mg/dL
Glucose: 120 mg/dL
Creatinine: 1.8 mg/dL
The patient is ultimately admitted to the hospital. Which of the following is the most appropriate test to monitor her disease progression?
A. Rheumatoid factor
B. Anti-topoisomerase
C. Anti-dsDNA (Correct Answer)
D. Anti-CCP
E. Anti-nuclear antibody
Explanation: ***Anti-dsDNA***
- The patient's presentation with **symmetric polyarthritis**, a **rash**, and **renal involvement** (elevated BUN and creatinine) is highly suggestive of **Systemic Lupus Erythematosus (SLE)**.
- **Anti-dsDNA antibodies** correlate well with disease activity, especially **lupus nephritis**, making them an excellent marker for monitoring disease progression and response to therapy in SLE.
*Rheumatoid factor*
- **Rheumatoid factor** is primarily associated with **Rheumatoid Arthritis** and is generally not used for monitoring SLE activity.
- While some SLE patients may test positive for RF, it is not a specific marker for SLE.
*Anti-topoisomerase*
- **Anti-topoisomerase I (Scl-70) antibodies** are characteristic of **systemic sclerosis (scleroderma)**, particularly the diffuse cutaneous form.
- This antibody is not typically seen in SLE and does not help monitor its progression.
*Anti-CCP*
- **Anti-cyclic citrullinated peptide (anti-CCP) antibodies** are highly specific for **Rheumatoid Arthritis**.
- They are useful for diagnosis and prognosis in RA but have no role in monitoring SLE.
*Anti-nuclear antibody*
- **Antinuclear antibodies (ANA)** are present in almost all patients with SLE and are essential for diagnosis, but they do not correlate with disease activity.
- A positive ANA test is a screening tool but cannot be used to monitor disease progression or response to treatment.
Question 355: A 72-year-old woman comes to the emergency department 1 hour after the sudden onset of a diffuse, dull, throbbing headache. She also reports blurred vision, nausea, and one episode of vomiting. She has a history of poorly controlled hypertension. A photograph of her fundoscopic examination is shown. Which of the following is the most likely underlying cause of this patient's symptoms?
A. Hemorrhagic lacunar stroke
B. Transient ischemic attack
C. Giant cell arteritis
D. Hypertensive emergency (Correct Answer)
E. Epidural hematoma
Explanation: ***Hypertensive emergency***
- The patient's presentation of a **sudden headache**, along with **blurred vision** and nausea, suggests increased intracranial pressure due to severely elevated blood pressure.
- Poorly controlled hypertension is a significant risk factor, leading to possible **end-organ damage** such as hypertensive retinopathy with papilledema or hypertensive encephalopathy.
- Fundoscopic examination showing **papilledema** confirms elevated intracranial pressure, consistent with malignant hypertension.
*Hemorrhagic lacunar stroke*
- Lacunar strokes are **small subcortical infarcts** caused by occlusion of penetrating arteries and are typically **ischemic, not hemorrhagic**.
- They present with focal neurological deficits (pure motor stroke, pure sensory stroke, ataxic hemiparesis) rather than the **diffuse symptoms** and papilledema seen here.
- While hypertension is a risk factor, lacunar infarcts do not cause increased intracranial pressure or papilledema.
*Transient ischemic attack*
- Characterized by temporary neurological deficits that resolve within 24 hours, typically without severe headaches or sustained symptoms.
- Patients may experience **focal weakness or sensory changes** but would not have papilledema or signs of increased intracranial pressure.
- The persistent nature of this patient's symptoms makes TIA unlikely.
*Giant cell arteritis*
- This condition usually presents with **temporal headaches**, jaw claudication, and potential vision loss from arteritic anterior ischemic optic neuropathy.
- Vision loss in GCA is due to ischemic optic nerve damage, not papilledema from increased intracranial pressure.
- More common in older adults but is associated with systemic symptoms like fever, malaise, and elevated ESR/CRP.
*Epidural hematoma*
- Typically follows head trauma and presents with a **lucid interval**, followed by rapid deterioration from expanding hematoma.
- Usually caused by middle meningeal artery injury with classic lens-shaped hematoma on CT.
- The lack of trauma history and the chronic hypertension make this diagnosis unlikely.
Question 356: A 63-year-old man undergoes workup for nocturnal dyspnea and what he describes as a "choking" sensation while sleeping. He also endorses fatigue and dyspnea on exertion. Physical exam reveals a normal S1, loud P2, and a neck circumference of 17 inches (43 cm) (normal < 14 inches (< 35 cm)). His temperature is 98.8°F (37°C), blood pressure is 128/82 mmHg, pulse is 86/min, and respirations are 19/min. He undergoes spirometry, which is unrevealing, and polysomnography, which shows 16 hypopneic and apneic events per hour. Mean pulmonary arterial pressure is 30 mmHg. Which of the following complications is this patient most at risk for?
A. Left ventricular failure
B. Right ventricular failure (Correct Answer)
C. Pulmonary embolism
D. Aspiration pneumonia
E. Chronic obstructive pulmonary disease
Explanation: ***Right ventricular failure***
- The patient's symptoms (nocturnal dyspnea, choking sensation, fatigue, exertional dyspnea), risk factors (large neck circumference), and polysomnography results (16 hypopneic/apneic events/hour) are consistent with **obstructive sleep apnea (OSA)**.
- OSA leads to **chronic intermittent hypoxia** and hypercapnia, causing **pulmonary vasoconstriction** and increased pulmonary arterial pressure (mean PAP 30 mmHg), which can result in **pulmonary hypertension** and eventually **right ventricular failure**.
*Left ventricular failure*
- While OSA can exacerbate cardiovascular conditions, the primary cardiac complication directly resulting from ongoing pulmonary hypertension due to OSA is typically right-sided, not primarily left-sided, failure.
- There are no specific findings in the description (e.g., S3 gallop, crackles) that strongly point to left ventricular dysfunction as the most immediate and direct complication.
*Pulmonary embolism*
- Although obesity (suggested by large neck circumference) is a risk factor for pulmonary embolism, there are no acute symptoms (e.g., sudden onset dyspnea, pleuritic chest pain, hemoptysis) or signs (e.g., tachycardia, hypoxemia) to suggest a pulmonary embolism.
- The patient's symptoms are chronic and related to sleep-disordered breathing and pulmonary hypertension.
*Aspiration pneumonia*
- While a "choking" sensation could potentially lead to aspiration, there's no evidence of infection (e.g., fever, productive cough, crackles) or recurrent aspiration events.
- The primary respiratory pathology is clearly defined by the polysomnography and elevated pulmonary pressures.
*Chronic obstructive pulmonary disease*
- Spirometry was reported as "unrevealing," which rules out significant airflow limitation characteristic of COPD.
- The patient's symptoms are more indicative of sleep-disordered breathing and its cardiovascular consequences rather than an intrinsic obstructive lung disease like COPD.
Question 357: A 22-year-old man comes to the emergency department because of several episodes of blood in his urine and decreased urine output for 5 days. His blood pressure is 158/94 mm Hg. Examination shows bilateral lower extremity edema. Urinalysis shows 3+ protein and red blood cell casts. Mass spectrometry analysis of the urinary protein detects albumin, transferrin, and IgG. Which of the following best describes this type of proteinuria?
A. Tubular
B. Selective glomerular
C. Nonselective glomerular (Correct Answer)
D. Postrenal
E. Overflow
Explanation: ***Nonselective glomerular***
- The presence of **albumin**, **transferrin**, and **IgG** indicates a loss of molecular control by the glomerulus, allowing both small and larger proteins to pass.
- This pattern, particularly with significant proteinuria (3+ protein) and **red blood cell casts**, is characteristic of a severe **glomerular injury** leading to nonselective filtration.
*Tubular*
- **Tubular proteinuria** results from impaired reabsorption of low-molecular-weight proteins by the renal tubules, typically due to **tubulointerstitial damage**.
- It would primarily involve smaller proteins like **beta-2 microglobulin** or **retinol-binding protein**, not significant amounts of albumin and IgG.
*Selective glomerular*
- **Selective glomerular proteinuria** involves the loss of smaller proteins, primarily **albumin**, due to damage to the glomerular charge barrier, while larger proteins like IgG are retained.
- The detection of **IgG** in the urine indicates a loss of both charge and size selectivity, ruling out selective proteinuria.
*Postrenal*
- **Postrenal proteinuria** is due to inflammation or bleeding in the urinary tract below the kidneys, such as the ureters, bladder, or urethra.
- It is typically associated with conditions like **urinary tract infections** or **stones** and would not cause the significant systemic symptoms (hypertension, edema) or protein profile seen here.
*Overflow*
- **Overflow proteinuria** occurs when there is an overproduction of low-molecular-weight proteins (e.g., **Bence Jones proteins** in multiple myeloma) that overwhelm the reabsorptive capacity of the tubules.
- This patient presents with **glomerular injury** features (red blood cell casts, hypertension, edema) and the presence of albumin and IgG, not an overproduction of single-type low-molecular-weight proteins.
Question 358: A 28-year-old woman comes to the emergency department for a rash that began 3 days ago. She has low-grade fever and muscle aches. She has no history of serious illness and takes no medications. She has had 5 male sexual partners over the past year and uses condoms inconsistently. Her temperature is 38.1°C (100.6° F), pulse is 85/min, and blood pressure is 126/89 mm Hg. Examination shows a diffuse maculopapular rash that includes the palms and soles. The remainder of the examination shows no abnormalities. A venereal disease research laboratory (VDRL) test is positive. Which of the following is the next appropriate step in management?
A. Intravenous penicillin G
B. Dark field microscopy
C. Treponemal culture
D. Oral doxycycline
E. Fluorescent treponemal antibody absorption test (Correct Answer)
Explanation: ***Fluorescent treponemal antibody absorption test***
- A positive **VDRL** (a non-treponemal test) should be confirmed with a **treponemal-specific test** like the **fluorescent treponemal antibody absorption (FTA-ABS)** test or **Treponema pallidum particle agglutination (TPPA)** assay to definitively diagnose syphilis.
- This confirmatory step helps differentiate true syphilis from false-positive VDRL results, which can occur in autoimmune diseases (SLE, antiphospholipid syndrome), other infections (malaria, mononucleosis), pregnancy, or recent vaccination.
- While this patient's presentation is highly suggestive of **secondary syphilis** (diffuse maculopapular rash involving palms and soles, fever, myalgias, positive VDRL), confirmatory testing is the standard next step before initiating treatment.
- Note: In some clinical settings with classic secondary syphilis, immediate treatment may be initiated, but confirmatory testing remains the most appropriate next diagnostic step.
*Intravenous penicillin G*
- IV aqueous penicillin G is the treatment for **neurosyphilis**, not uncomplicated secondary syphilis.
- **Secondary syphilis** is treated with **intramuscular benzathine penicillin G 2.4 million units** as a single dose.
- Treatment should follow confirmed diagnosis with treponemal-specific testing.
*Dark field microscopy*
- This technique visualizes spirochetes directly from **primary lesions** (chancres) or moist secondary lesions (condyloma lata, mucous patches).
- It is not practical for this patient who has a diffuse maculopapular rash without obvious mucosal or genital lesions.
- Dark-field microscopy requires specialized equipment and expertise not readily available in most emergency departments.
*Treponemal culture*
- **Treponema pallidum** cannot be cultured on artificial media because it is an **obligate pathogen** that requires living host cells.
- Culture is not a diagnostic option for syphilis.
*Oral doxycycline*
- **Doxycycline 100 mg twice daily for 14 days** is an alternative treatment for early syphilis in **penicillin-allergic patients**.
- Treatment should only be initiated after diagnosis is confirmed with treponemal-specific testing.
- This is not the next appropriate step; confirmatory testing comes first.
Question 359: A 34-year-old man with a 2-year history of rheumatoid arthritis is being evaluated on a follow-up visit. He is currently on methotrexate and celecoxib for pain management and has shown a good response until now. However, on this visit, he mentions that the morning stiffness has been getting progressively worse. On physical examination, both his wrists are erythematous and swollen, nodules on his elbows are also noted. Rheumatoid factor is 30 (normal reference values: < 15 IU/mL), ESR is 50 mm/h, anti-citrullinated protein antibodies is 55 (normal reference values: < 20). What is the next best step in the management of this patient?
A. Sulfasalazine
B. Adalimumab monotherapy
C. Methotrexate and Corticosteroids
D. Methotrexate and Infliximab (Correct Answer)
E. Infliximab monotherapy
Explanation: **Methotrexate and Infliximab**
- The patient is experiencing a **flare-up of rheumatoid arthritis** despite being on methotrexate, indicated by worsening morning stiffness, active synovitis (erythematous and swollen wrists), elevated ESR, and positive rheumatoid factor and anti-CCP. This suggests a need for more aggressive therapy, and adding a **biologic agent like infliximab (an anti-TNF agent)** to methotrexate is a standard approach for moderate to severe RA that is not adequately controlled by methotrexate monotherapy.
- Combination therapy with **methotrexate and a biologic DMARD** (e.g., TNF inhibitors like infliximab) has been shown to be more effective than monotherapy for controlling disease activity and preventing joint damage in refractory RA.
*Sulfasalazine*
- **Sulfasalazine** is a conventional synthetic DMARD that is generally used as a **first-line agent or in combination therapy** for mild to moderate RA.
- Given the patient's ongoing active disease despite methotrexate and the severity of his symptoms, sulfasalazine is unlikely to be sufficient to achieve disease control.
*Adalimumab monotherapy*
- While adalimumab (another anti-TNF biologic) is an effective treatment for RA, **biologic monotherapy is generally less effective** than combination therapy with methotrexate.
- Current guidelines and clinical practice favor combining biologic DMARDs with methotrexate for optimal outcomes in RA management, especially in patients with active disease.
*Methotrexate and Corticosteroids*
- **Corticosteroids** are effective in rapidly reducing inflammation and can be used for **short-term management of RA flares**.
- However, corticosteroids are not recommended for long-term use due to significant side effects and do not address the underlying disease progression as comprehensively as biologic DMARDs in patients refractory to methotrexate.
*Infliximab monotherapy*
- Similar to adalimumab monotherapy, **infliximab is typically more effective when combined with methotrexate**.
- Using infliximab alone would be a less optimal choice for this patient whose disease is clearly not controlled by methotrexate, as it may lead to a suboptimal response and potentially increase the risk of developing anti-drug antibodies.
Question 360: A 62-year-old man comes to the physician in May for a routine health maintenance examination. He feels well. He underwent a right inguinal hernia repair 6 months ago. He has hypertension and type 2 diabetes mellitus. There is no family history of serious illness. Current medications include metformin, sitagliptin, enalapril, and metoprolol. He received the zoster vaccine 1 year ago. He received the PPSV23 vaccine 4 years ago. His last colonoscopy was 7 years ago and was normal. He smoked a pack of cigarettes a day for 20 years but quit 17 years ago. He drinks two to three alcoholic beverages on weekends. He is allergic to amoxicillin. He is scheduled to visit Australia and New Zealand in 2 weeks to celebrate his 25th wedding anniversary. He appears healthy. Vital signs are within normal limits. An S4 is heard at the apex. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate recommendation at this time?
A. Colonoscopy
B. Influenza vaccine (Correct Answer)
C. Pneumococcal conjugate vaccine 13
D. Cardiac stress test
E. Abdominal ultrasound
Explanation: ***Influenza vaccine***
- Current guidelines recommend annual **influenza vaccination** for all adults, particularly those over 60 years old and those with chronic medical conditions like diabetes and hypertension.
- **Critical timing consideration**: The patient is traveling to Australia and New Zealand (Southern Hemisphere) in 2 weeks, where it will be **winter season** (May-September) with peak influenza activity.
- He is a **high-risk patient** (age >60, diabetes, hypertension, cardiovascular disease) who should receive influenza vaccine before travel to areas experiencing influenza season.
- This is the **most appropriate and time-sensitive recommendation** at this visit.
*Colonoscopy*
- The patient had a normal colonoscopy 7 years ago; current guidelines suggest a repeat colonoscopy every **10 years** for average-risk individuals.
- There are no new symptoms, family history, or risk factors that would necessitate an earlier repeat colonoscopy at this time.
*Pneumococcal conjugate vaccine 13*
- The patient received **PPSV23** four years ago at approximately age 58.
- Per **current CDC guidelines (2019+)**, PCV13 is **no longer routinely recommended** for immunocompetent adults ≥65 years old.
- PPSV23 alone is now the standard recommendation for adults ≥65, which this patient has already received.
- PCV13 may be considered through **shared decision-making** in specific circumstances, but is not a routine or urgent recommendation.
*Cardiac stress test*
- Although the patient has risk factors for cardiovascular disease (hypertension, diabetes, former smoker) and an **S4 heart sound** (indicating **left ventricular hypertrophy**), he is asymptomatic.
- Routine **screening stress tests** are not recommended for asymptomatic individuals without signs of active cardiac ischemia.
*Abdominal ultrasound*
- There are **no symptoms** or specific indications (e.g., abdominal aortic aneurysm screening criteria not met - would need age 65-75 with smoking history).
- The patient is 62 years old and quit smoking 17 years ago, so AAA screening criteria are not yet met.
- Routine screening abdominal ultrasounds are not indicated.
