A 58-year-old female presents to her primary care physician with complaints of chest pain and palpitations. A thorough past medical history reveals a diagnosis of rheumatic fever during childhood. Echocardiography is conducted and shows enlargement of the left atrium and narrowing of the mitral valve opening. Which of the following should the physician expect to hear on cardiac auscultation?
Q402
A 34-year-old male is brought to the emergency department. He has prior hospitalizations for opiate overdoses, but today presents with fever, chills, rigors and malaise. On physical exam vitals are temperature: 100.5 deg F (38.1 deg C), pulse is 105/min, blood pressure is 135/60 mmHg, and respirations are 22/min. You note the following findings on the patient's hands (Figures A and B). You note that as the patient is seated, his head bobs with each successive heart beat. Which of the following findings is most likely present in this patient?
Q403
A 47-year-old man presents for a routine physical examination as part of an insurance medical assessment. He has no complaints and has no family history of cardiac disease or sudden cardiac death. His blood pressure is 120/80 mm Hg, temperature is 36.7°C (98.1°F), and pulse is 75/min and is regular. On physical examination, he appears slim and his cardiac apex beat is of normal character and non-displaced. On auscultation, he has a midsystolic click followed by a late-systolic high-pitched murmur over the cardiac apex. On standing, the click and murmur occur earlier in systole, and the murmur is of increased intensity. While squatting, the click and murmur occur later in systole, and the murmur is softer in intensity. Echocardiography of this patient will most likely show which of the following findings?
Q404
A 44-year-old male immigrant presents to his primary care physician for a new patient visit. The patient reports chronic fatigue but states that he otherwise feels well. His past medical history is not known, and he is not currently taking any medications. The patient admits to drinking 7 alcoholic beverages per day and smoking 1 pack of cigarettes per day. His temperature is 99.4°F (37.4°C), blood pressure is 157/98 mmHg, pulse is 99/min, respirations are 18/min, and oxygen saturation is 100% on room air. Physical exam demonstrates mild pallor but is otherwise not remarkable. Laboratory studies are ordered as seen below.
Hemoglobin: 9 g/dL
Hematocrit: 33%
Leukocyte count: 6,500/mm^3 with normal differential
Platelet count: 190,000/mm^3
Mean corpuscular volume (MCV): 60 femtoliters
Free iron: 272 mcg/dL
Total iron binding capacity (TIBC): 175 mcg/dL
Ferritin: 526 ng/mL
Reticulocyte count: 2.8%
Which of the following is the most likely diagnosis?
Q405
A 46-year-old male was found unconscious in the field and brought to the emergency department by EMS. The patient was intubated in transit and given a 2 liter bolus of normal saline. On arrival, the patient's blood pressure is 80/60 mmHg and temperature is 37.5°C. Jugular veins are flat and capillary refill time is 4 seconds.
Vascular parameters are measured and are as follows:
Cardiac index - Low
Pulmonary capillary wedge pressure (PCWP) - Low
Systemic vascular resistance - High
Which of the following is the most likely diagnosis?
Q406
A 59-year-old man presents with the persistent right-sided facial droop and slurred speech for the past 2 hours. He says he had similar symptoms 6 months ago which resolved within 1 hour. His past medical history is significant for long-standing hypertension, managed with hydrochlorothiazide. He reports a 10-pack-year smoking history but denies any alcohol or recreational drug use. The vital signs include: blood pressure 145/95 mm Hg, pulse 95/min, and respiratory rate 18/min. On physical examination, the patient has an asymmetric smile and right-sided weakness of his lower facial muscles. There is a deviation of his tongue towards the right. Dysarthria is noted. His muscle strength in the upper extremities is 4/5 on the right and 5/5 on the left. The remainder of the physical exam is unremarkable. Which of the following is the next most appropriate step in the management of this patient?
Q407
A 62-year-old female presents with complaint of chronic productive cough for the last 4 months. She states that she has had 4-5 month periods of similar symptoms over the past several years. She has never smoked, but she reports significant exposure to second-hand smoke in her home. She denies any fevers, reporting only occasional shortness of breath and a persistent cough where she frequently expectorates thick, white sputum. Vital signs are as follows: T 37.1 C, HR 88, BP 136/88, RR 18, O2 sat 94% on room air. Physical exam is significant for bilateral end-expiratory wheezes, a blue tint to the patient's lips and mucous membranes of the mouth, and a barrel chest. Which of the following sets of results would be expected on pulmonary function testing in this patient?
Q408
A 32-year-old man is brought into the emergency department by his friends. The patient was playing soccer when he suddenly became short of breath. The patient used his albuterol inhaler with minimal improvement in his symptoms. He is currently struggling to breathe. The patient has a past medical history of asthma and a 25 pack-year smoking history. His current medications include albuterol, fluticasone, and oral prednisone. His temperature is 99.5°F (37.5°C), blood pressure is 137/78 mmHg, pulse is 120/min, respirations are 27/min, and oxygen saturation is 88% on room air. On pulmonary exam, the patient exhibits no wheezing with bilateral minimal air movement. The patient’s laboratory values are ordered as seen below.
Hemoglobin: 15 g/dL
Hematocrit: 43%
Leukocyte count: 5,500/mm^3 with normal differential
Platelet count: 194,000/mm^3
Serum:
Na+: 138 mEq/L
Cl-: 102 mEq/L
K+: 4.4 mEq/L
HCO3-: 24 mEq/L
BUN: 20 mg/dL
Glucose: 120 mg/dL
Creatinine: 1.0 mg/dL
Ca2+: 10.2 mg/dL
pH: 7.44
PaCO2: 10 mmHg
PaO2: 60 mmHg
AST: 12 U/L
ALT: 10 U/L
The patient is started on an albuterol nebulizer, magnesium sulfate, and tiotropium bromide. Repeat vitals reveal an oxygen saturation of 90% with a pulse of 115/min. Laboratory values are repeated as seen below.
pH: 7.40
PaCO2: 44 mmHg
PaO2: 64 mmHg
Which of the following is the next best step in management of this patient?
Q409
A 71-year-old man comes to the physician for routine health maintenance examination. He feels well. He has hypertension and gastroesophageal reflux disease. Current medications include metoprolol and pantoprazole. He does not smoke or drink alcohol. Temperature is 37.3°C (99.1°F), pulse is 75/min, and blood pressure 135/87 mm Hg. Examination shows no abnormalities. Laboratory studies show:
Hematocrit 43%
Leukocyte count 32,000/mm3
Segmented neutrophils 22%
Basophils 1%
Eosinophils 2%
Lymphocytes 74%
Monocytes 1%
Platelet count 190,000/mm3
Blood smear shows small, mature lymphocytes and several smudge cells. Immunophenotypic analysis with flow cytometry shows B-cells that express CD19, CD20 and CD23. Which of the following is the most appropriate next step in management?
Q410
A 24-year-old man comes to the physician for a 1-week history of a painless swelling on the right side of his neck that he noticed while showering. He is 203 cm (6 ft 8 in) tall and weighs 85 kg (187 lb); BMI is 21 kg/m2. Physical examination shows long, thin fingers and an increased arm-length to body-height ratio. Examination of the neck shows a single 2-cm firm nodule. Ultrasonography of the neck shows a hypoechoic thyroid lesion with irregular margins. A core needle biopsy of the thyroid lesion shows sheets of polygonal cells surrounded by Congo red-stained amorphous tissue. Which of the following additional findings is most likely in this patient?
Cardiology US Medical PG Practice Questions and MCQs
Question 401: A 58-year-old female presents to her primary care physician with complaints of chest pain and palpitations. A thorough past medical history reveals a diagnosis of rheumatic fever during childhood. Echocardiography is conducted and shows enlargement of the left atrium and narrowing of the mitral valve opening. Which of the following should the physician expect to hear on cardiac auscultation?
A. Continuous, machine-like murmur
B. Holosystolic murmur that radiates to the axilla
C. Opening snap following S2 (Correct Answer)
D. High-pitched, blowing decrescendo murmur in early diastole
E. Mid-systolic click
Explanation: ***Opening snap following S2***
- The patient's history of **rheumatic fever** and echocardiographic findings of **left atrial enlargement** and **mitral valve narrowing** (mitral stenosis) are classic for this condition.
- An **opening snap** is a high-pitched, sharp sound that occurs shortly after **S2** (the second heart sound) and is pathognomonic for **mitral stenosis**, caused by the sudden tensing of the stenotic mitral valve leaflets as they open during diastole.
- The **S2-OS interval** indicates severity: a shorter interval suggests more severe stenosis.
*Continuous, machine-like murmur*
- This type of murmur is characteristic of a **patent ductus arteriosus (PDA)**, which is a congenital heart defect.
- The patient's symptoms and echocardiographic findings are not consistent with PDA.
*Holosystolic murmur that radiates to the axilla*
- This murmur describes **mitral regurgitation**, which is a leaky mitral valve. While rheumatic fever can cause mitral regurgitation, the echocardiogram shows **narrowing** of the mitral valve, not leakage.
- The radiation to the axilla is classical for the regurgitant jet flowing into the left atrium during systole.
*High-pitched, blowing decrescendo murmur in early diastole*
- This murmur is typical for **aortic regurgitation**, indicating a leaky aortic valve.
- The patient's presentation and echocardiogram findings specifically point to **mitral valve involvement** rather than aortic valve issues.
*Mid-systolic click*
- A **mid-systolic click** is characteristic of **mitral valve prolapse**, often followed by a late systolic murmur.
- The echocardiogram findings of **mitral valve narrowing** are not consistent with mitral valve prolapse.
Question 402: A 34-year-old male is brought to the emergency department. He has prior hospitalizations for opiate overdoses, but today presents with fever, chills, rigors and malaise. On physical exam vitals are temperature: 100.5 deg F (38.1 deg C), pulse is 105/min, blood pressure is 135/60 mmHg, and respirations are 22/min. You note the following findings on the patient's hands (Figures A and B). You note that as the patient is seated, his head bobs with each successive heart beat. Which of the following findings is most likely present in this patient?
A. A holosystolic murmur at the 4th intercostal midclavicular line
B. A water-hammer pulse when palpating the radial artery (Correct Answer)
C. Decreased blood pressure as measured in the lower extremities compared to the upper extremities
D. A harsh crescendo-decrescendo systolic murmur in the right second intercostal space
E. A consistent gallop with an S4 component
Explanation: ***A water-hammer pulse when palpating the radial artery***
- The patient's history of **opiate overdose**, fever, chills, and the presence of **Janeway lesions** (Figures A and B) on the hands strongly suggest **infective endocarditis**. The head bobbing (Musset's sign) indicates **severe aortic regurgitation**.
- **Water-hammer pulse** (Corrigan's pulse) is a classic sign of **severe aortic regurgitation**, characterized by a rapid, forceful arterial pulse that quickly collapses due to a large stroke volume and rapid diastolic runoff.
*A holosystolic murmur at the 4th intercostal midclavicular line*
- A holosystolic murmur at the 4th intercostal midclavicular line is typically associated with **mitral regurgitation**, which is less likely given the prominent signs of aortic regurgitation.
- While endocarditis can affect the mitral valve, the specific clinical signs point towards **aortic valve involvement**.
*Decreased blood pressure as measured in the lower extremities compared to the upper extremities*
- This finding is characteristic of **coarctation of the aorta**, a congenital heart defect, which is not suggested by the patient's presentation or risk factors.
- The patient's symptoms are more consistent with an acute infectious process affecting the heart valves.
*A harsh crescendo-decrescendo systolic murmur in the right second intercostal space*
- A harsh crescendo-decrescendo systolic murmur in the right second intercostal space is typical of **aortic stenosis**.
- While aortic insufficiency is present, the murmur for uncomplicated aortic insufficiency is usually a **diastolic decrescendo murmur**, not a harsh systolic murmur.
*A consistent gallop with an S4 component*
- An S4 gallop is typically heard in conditions involving **decreased ventricular compliance** (e.g., severe hypertension, aortic stenosis, hypertrophic cardiomyopathy).
- While endocarditis can cause heart failure, an S4 gallop is not a direct or primary sign of **aortic regurgitation**. An S3 gallop is more commonly associated with **volume overload** and heart failure, which might develop in severe aortic regurgitation.
Question 403: A 47-year-old man presents for a routine physical examination as part of an insurance medical assessment. He has no complaints and has no family history of cardiac disease or sudden cardiac death. His blood pressure is 120/80 mm Hg, temperature is 36.7°C (98.1°F), and pulse is 75/min and is regular. On physical examination, he appears slim and his cardiac apex beat is of normal character and non-displaced. On auscultation, he has a midsystolic click followed by a late-systolic high-pitched murmur over the cardiac apex. On standing, the click and murmur occur earlier in systole, and the murmur is of increased intensity. While squatting, the click and murmur occur later in systole, and the murmur is softer in intensity. Echocardiography of this patient will most likely show which of the following findings?
A. Left atrial mass arising from the region of the septal fossa ovalis
B. Doming of the mitral valve leaflets in diastole
C. Prolapse of a mitral valve leaflet of ≥2 mm above the level of the annulus in systole (Correct Answer)
D. Retrograde blood flow into the right atrium
E. High pressure gradient across the aortic valve
Explanation: ***Prolapse of a mitral valve leaflet of ≥2 mm above the level of the annulus in systole***
- The clinical presentation with a **midsystolic click** followed by a **late-systolic high-pitched murmur over the cardiac apex** is characteristic of **mitral valve prolapse (MVP)**.
- The changes in the click and murmur timing and intensity with **standing (earlier, louder)** and **squatting (later, softer)** are classic findings, reflecting changes in left ventricular volume that affect the onset of valve prolapse.
*Left atrial mass arising from the region of the septal fossa ovalis*
- This description is highly suggestive of a **myxoma**, typically found in the left atrium, which can cause symptoms of **obstructive heart failure** or **embolism**.
- A myxoma would not typically present with the characteristic **midsystolic click** and **late-systolic murmur** that changes with position.
*Doming of the mitral valve leaflets in diastole*
- **Doming of the mitral valve leaflets in diastole** is characteristic of **mitral stenosis**, where the valve fails to open properly.
- Mitral stenosis would present with a **diastolic murmur**, not a midsystolic click and late-systolic murmur.
*Retrograde blood flow into the right atrium*
- **Retrograde blood flow into the right atrium** indicates **tricuspid regurgitation**, which would typically manifest as a **holosystolic murmur** best heard at the lower left sternal border, often with prominent jugular venous pulsations.
- This finding is inconsistent with the patient's auscultatory findings at the cardiac apex.
*High pressure gradient across the aortic valve*
- A **high pressure gradient across the aortic valve** signifies **aortic stenosis**, which is characterized by a **systolic ejection murmur** best heard at the right upper sternal border with radiation to the carotids.
- This condition would not produce a midsystolic click or a late-systolic murmur at the apex.
Question 404: A 44-year-old male immigrant presents to his primary care physician for a new patient visit. The patient reports chronic fatigue but states that he otherwise feels well. His past medical history is not known, and he is not currently taking any medications. The patient admits to drinking 7 alcoholic beverages per day and smoking 1 pack of cigarettes per day. His temperature is 99.4°F (37.4°C), blood pressure is 157/98 mmHg, pulse is 99/min, respirations are 18/min, and oxygen saturation is 100% on room air. Physical exam demonstrates mild pallor but is otherwise not remarkable. Laboratory studies are ordered as seen below.
Hemoglobin: 9 g/dL
Hematocrit: 33%
Leukocyte count: 6,500/mm^3 with normal differential
Platelet count: 190,000/mm^3
Mean corpuscular volume (MCV): 60 femtoliters
Free iron: 272 mcg/dL
Total iron binding capacity (TIBC): 175 mcg/dL
Ferritin: 526 ng/mL
Reticulocyte count: 2.8%
Which of the following is the most likely diagnosis?
A. Folate deficiency
B. Beta-thalassemia (Correct Answer)
C. Iron deficiency
D. B12 deficiency
E. Hemolytic anemia
Explanation: ***Beta-thalassemia***
- The patient presents with **microcytic anemia** (MCV 60 fL) and **elevated ferritin**, **high free iron**, and **low TIBC**, which are characteristic of thalassemia due to ineffective erythropoiesis and iron overload.
- A **reticulocyte count of 2.8%** (elevated for the degree of anemia) indicates the bone marrow is attempting to compensate, consistent with a hemolytic process like thalassemia.
*Folate deficiency*
- Folate deficiency typically causes **macrocytic anemia** (elevated MCV), which is not seen here; the patient has microcytic anemia.
- Alcohol abuse can cause folate deficiency, but the lab values for iron studies and MCV are inconsistent with this diagnosis.
*Iron deficiency*
- Iron deficiency anemia would present with **low ferritin**, **low free iron**, and **high TIBC**, which are opposite to the patient's lab results.
- Although the patient has microcytic anemia, the iron study profile rules out iron deficiency.
*B12 deficiency*
- Vitamin B12 deficiency also causes **macrocytic anemia** (elevated MCV), often with neurological symptoms, neither of which are observed in this patient.
- The patient's microcytic anemia and iron study results contradict a diagnosis of B12 deficiency.
*Hemolytic anemia*
- While beta-thalassemia is a form of hemolytic anemia, the term "hemolytic anemia" alone is too broad and does not specify the underlying cause, especially with the provided iron studies and MCV.
- Other common causes of hemolytic anemia, like autoimmune hemolytic anemia or G6PD deficiency, would require different diagnostic presentations or specific tests not consistent with the given lab values.
Question 405: A 46-year-old male was found unconscious in the field and brought to the emergency department by EMS. The patient was intubated in transit and given a 2 liter bolus of normal saline. On arrival, the patient's blood pressure is 80/60 mmHg and temperature is 37.5°C. Jugular veins are flat and capillary refill time is 4 seconds.
Vascular parameters are measured and are as follows:
Cardiac index - Low
Pulmonary capillary wedge pressure (PCWP) - Low
Systemic vascular resistance - High
Which of the following is the most likely diagnosis?
A. Septic shock
B. Anaphylactic shock
C. Cardiogenic shock
D. Hypovolemic shock (Correct Answer)
E. Neurogenic shock
Explanation: ***Hypovolemic shock***
- The patient presents with **hypotension**, **flat jugular veins**, **prolonged capillary refill**, and a **low cardiac index** and **low pulmonary capillary wedge pressure (PCWP)**, all indicative of inadequate intravascular volume.
- The **high systemic vascular resistance** is a compensatory mechanism to maintain blood pressure in the setting of decreased circulating volume.
*Septic shock*
- Septic shock typically presents with **vasodilation**, leading to a **low systemic vascular resistance**, which contradicts the findings in this patient.
- While patients can be hypotensive, the vascular parameters, especially SVR, do not align with septic shock.
*Anaphylactic shock*
- This type of shock is characterized by widespread **vasodilation** and increased capillary permeability, leading to a **low systemic vascular resistance** and often significant **edema** or **urticaria**, none of which are suggested here.
- While it can cause hypotension and low PCWP due to fluid shifts, the high SVR makes it less likely.
*Cardiogenic shock*
- Cardiogenic shock is characterized by **pump failure**, leading to a **low cardiac index** but a **high PCWP** due to fluid backup in the pulmonary circulation.
- This directly contrasts the patient's low PCWP.
*Neurogenic shock*
- Neurogenic shock involves a loss of **sympathetic tone**, resulting in widespread **vasodilation** and a **low systemic vascular resistance**, often accompanied by **bradycardia**.
- The high SVR in this patient rules out neurogenic shock.
Question 406: A 59-year-old man presents with the persistent right-sided facial droop and slurred speech for the past 2 hours. He says he had similar symptoms 6 months ago which resolved within 1 hour. His past medical history is significant for long-standing hypertension, managed with hydrochlorothiazide. He reports a 10-pack-year smoking history but denies any alcohol or recreational drug use. The vital signs include: blood pressure 145/95 mm Hg, pulse 95/min, and respiratory rate 18/min. On physical examination, the patient has an asymmetric smile and right-sided weakness of his lower facial muscles. There is a deviation of his tongue towards the right. Dysarthria is noted. His muscle strength in the upper extremities is 4/5 on the right and 5/5 on the left. The remainder of the physical exam is unremarkable. Which of the following is the next most appropriate step in the management of this patient?
A. T1/T2 MRI of the head
B. CT of the head without contrast (Correct Answer)
C. CT of the head with contrast
D. IV tPA
E. CT angiography of the brain
Explanation: ***CT of the head without contrast***
- This patient presents with acute neurological deficits suggestive of a **stroke**, and a rapid **CT scan without contrast** is the **initial imaging modality** of choice to differentiate between **ischemic stroke** and **hemorrhagic stroke**.
- A non-contrast CT can quickly rule out a hemorrhage, which is crucial for determining eligibility for **thrombolytic therapy** like IV tPA.
*T1/T2 MRI of the head*
- While an MRI can provide more detailed imaging of brain tissue and is better for detecting smaller or older ischemic strokes, it is typically **more time-consuming** and **less readily available** in an emergency setting compared to CT.
- It is not the initial go-to for acute stroke evaluation because the priority is to rule out hemorrhage quickly.
*CT of the head with contrast*
- A CT scan with contrast is not indicated for the initial evaluation of acute stroke as it primarily helps visualize **vascular structures** or **brain tumors** and could potentially obscure a subtle hemorrhage in the hyperacute phase.
- Contrast administration can also delay the imaging process and potentially cause **nephrotoxicity**, which is undesirable in an emergency.
*IV tPA*
- **Intravenous tissue plasminogen activator (IV tPA)** is a treatment for **ischemic stroke**, but it can only be administered **after a hemorrhagic stroke has been ruled out** by imaging.
- Administering tPA in the presence of hemorrhage would be catastrophic.
*CT angiography of the brain*
- CT angiography (CTA) is useful for identifying **large vessel occlusions** in the brain, which can guide treatment options like **endovascular thrombectomy**.
- However, it is not the very first step; a non-contrast CT is performed initially to rule out hemorrhage before proceeding with CTA or other advanced imaging.
Question 407: A 62-year-old female presents with complaint of chronic productive cough for the last 4 months. She states that she has had 4-5 month periods of similar symptoms over the past several years. She has never smoked, but she reports significant exposure to second-hand smoke in her home. She denies any fevers, reporting only occasional shortness of breath and a persistent cough where she frequently expectorates thick, white sputum. Vital signs are as follows: T 37.1 C, HR 88, BP 136/88, RR 18, O2 sat 94% on room air. Physical exam is significant for bilateral end-expiratory wheezes, a blue tint to the patient's lips and mucous membranes of the mouth, and a barrel chest. Which of the following sets of results would be expected on pulmonary function testing in this patient?
A. Normal FEV1, Normal FEV1/FVC, Normal TLC, Normal DLCO
B. Decreased FEV1, Normal FEV1/FVC, Decreased TLC, Decreased DLCO
C. Decreased FEV1, Decreased FEV1/FVC ratio, Increased TLC, Normal DLCO (Correct Answer)
D. Decreased FEV1, Increased FEV1/FVC ratio, Decreased TLC, Normal DLCO
E. Decreased FEV1, Decreased FEV1/FVC ratio, Increased TLC, Decreased DLCO
Explanation: ***Decreased FEV1, Decreased FEV1/FVC ratio, Increased TLC, Normal DLCO***
- This patient presents with **chronic bronchitis**, a form of COPD characterized by **chronic productive cough** with sputum production for at least 3 months in 2 consecutive years. The clinical picture of **cyanosis** ("blue bloater"), **productive cough with thick white sputum**, and **wheezing** points to chronic bronchitis as the predominant pathology.
- COPD is an **obstructive lung disease**, characterized by **decreased FEV1** and **decreased FEV1/FVC ratio** (<0.70).
- **Increased TLC** occurs due to **air trapping** seen in obstructive diseases.
- **Normal DLCO** is characteristic of **chronic bronchitis** where the alveolar-capillary membrane remains relatively intact, unlike in emphysema. Although the patient has a barrel chest (suggesting some hyperinflation), the predominant clinical features favor chronic bronchitis, making normal DLCO the expected finding.
*Normal FEV1, Normal FEV1/FVC, Normal TLC, Normal DLCO*
- This represents **normal pulmonary function**, which is inconsistent with the patient's clinical presentation.
- The **chronic productive cough**, **cyanosis**, **wheezes**, and **barrel chest** clearly indicate underlying obstructive pulmonary disease.
*Decreased FEV1, Normal FEV1/FVC, Decreased TLC, Decreased DLCO*
- This pattern is characteristic of **restrictive lung disease** (decreased TLC with preserved or increased FEV1/FVC ratio).
- A **normal FEV1/FVC ratio** excludes obstructive disease, which is clearly present in this patient based on clinical findings.
- Does not match the obstructive picture presented.
*Decreased FEV1, Increased FEV1/FVC ratio, Decreased TLC, Normal DLCO*
- An **increased FEV1/FVC ratio** with decreased FEV1 is physiologically implausible and not seen in any standard lung disease pattern.
- This would require FVC to be disproportionately more reduced than FEV1, which doesn't occur in typical disease states.
*Decreased FEV1, Decreased FEV1/FVC ratio, Increased TLC, Decreased DLCO*
- This pattern is most consistent with **emphysema-predominant COPD**, where destruction of alveolar-capillary membranes causes **decreased DLCO**.
- While this patient has some features suggestive of emphysema (barrel chest, air trapping), the **predominant clinical picture** of **chronic productive cough**, **cyanosis** ("blue bloater"), and **thick sputum production** points to **chronic bronchitis** as the primary pathology, where DLCO is typically preserved.
- Emphysema patients ("pink puffers") typically present with minimal cough, dyspnea on exertion, and pursed-lip breathing, which are not prominent in this case.
Question 408: A 32-year-old man is brought into the emergency department by his friends. The patient was playing soccer when he suddenly became short of breath. The patient used his albuterol inhaler with minimal improvement in his symptoms. He is currently struggling to breathe. The patient has a past medical history of asthma and a 25 pack-year smoking history. His current medications include albuterol, fluticasone, and oral prednisone. His temperature is 99.5°F (37.5°C), blood pressure is 137/78 mmHg, pulse is 120/min, respirations are 27/min, and oxygen saturation is 88% on room air. On pulmonary exam, the patient exhibits no wheezing with bilateral minimal air movement. The patient’s laboratory values are ordered as seen below.
Hemoglobin: 15 g/dL
Hematocrit: 43%
Leukocyte count: 5,500/mm^3 with normal differential
Platelet count: 194,000/mm^3
Serum:
Na+: 138 mEq/L
Cl-: 102 mEq/L
K+: 4.4 mEq/L
HCO3-: 24 mEq/L
BUN: 20 mg/dL
Glucose: 120 mg/dL
Creatinine: 1.0 mg/dL
Ca2+: 10.2 mg/dL
pH: 7.44
PaCO2: 10 mmHg
PaO2: 60 mmHg
AST: 12 U/L
ALT: 10 U/L
The patient is started on an albuterol nebulizer, magnesium sulfate, and tiotropium bromide. Repeat vitals reveal an oxygen saturation of 90% with a pulse of 115/min. Laboratory values are repeated as seen below.
pH: 7.40
PaCO2: 44 mmHg
PaO2: 64 mmHg
Which of the following is the next best step in management of this patient?
A. Continue current management with close observation
B. Begin IV steroids
C. Intubation (Correct Answer)
D. Begin oral steroids
E. Terbutaline
Explanation: ***Intubation***
- The patient presents with **severe asthma exacerbation** indicated by minimal air movement despite no wheezing, **hypoxia (SpO2 88%)**, and respiratory distress (RR 27/min, HR 120/min).
- The initial **PaCO2 of 10 mmHg** suggests hyperventilation due to severe distress; the subsequent rise to **44 mmHg** after treatment, despite clinical deterioration, indicates **impending respiratory failure** and exhaustion, necessitating intubation.
*Continue current management with close observation*
- The patient's **oxygen saturation remains low (90%)** and **PaCO2 has dangerously normalized from 10 to 44 mmHg**, indicating worsening respiratory failure, not improvement.
- **Close observation without escalation** is inappropriate given the signs of treatment failure and impending decompensation.
*Begin IV steroids*
- The patient is already on **oral prednisone** and is likely receiving IV steroids in the ED; however, steroids have a **delayed onset of action** and will not acutely address the respiratory failure.
- While important for managing asthma exacerbation, **steroids alone are insufficient** to prevent immediate respiratory collapse in this critical scenario.
*Begin oral steroids*
- The patient is already on **oral prednisone**, and in an acute, severe exacerbation requiring hospitalization, **IV steroids are preferred** for faster absorption if steroids haven't been initiated.
- **Oral steroids will not provide the rapid therapeutic effect** needed to reverse acute respiratory failure and may lead to aspiration in a patient with respiratory distress.
*Terbutaline*
- **Terbutaline is a beta-2 agonist** similar to albuterol, and the patient has already shown **minimal improvement with albuterol and other bronchodilators**.
- While it can be considered, it is **unlikely to provide significant additional benefit** or resolve impending respiratory failure when conventional bronchodilators have failed.
Question 409: A 71-year-old man comes to the physician for routine health maintenance examination. He feels well. He has hypertension and gastroesophageal reflux disease. Current medications include metoprolol and pantoprazole. He does not smoke or drink alcohol. Temperature is 37.3°C (99.1°F), pulse is 75/min, and blood pressure 135/87 mm Hg. Examination shows no abnormalities. Laboratory studies show:
Hematocrit 43%
Leukocyte count 32,000/mm3
Segmented neutrophils 22%
Basophils 1%
Eosinophils 2%
Lymphocytes 74%
Monocytes 1%
Platelet count 190,000/mm3
Blood smear shows small, mature lymphocytes and several smudge cells. Immunophenotypic analysis with flow cytometry shows B-cells that express CD19, CD20 and CD23. Which of the following is the most appropriate next step in management?
A. Stem cell transplantation
B. Fludarabine, cyclophosphamide, and rituximab
C. All-trans retinoic acid
D. Imatinib
E. Observation and follow-up (Correct Answer)
Explanation: ***Observation and follow-up***
- The patient's presentation, including marked **lymphocytosis** (leukocyte count 32,000/mm³ with 74% lymphocytes), **small mature lymphocytes** and **smudge cells** on blood smear, and **CD19, CD20, CD23 expression** on B-cells, is highly suggestive of **Chronic Lymphocytic Leukemia (CLL)**.
- Given the patient is **asymptomatic** and has **no signs of end-organ damage** or disease progression, the most appropriate initial management for CLL is "watch and wait" or observation. Treatment is typically initiated only when symptoms develop or there are signs of advanced disease.
*Stem cell transplantation*
- **Stem cell transplantation** is a highly intensive treatment, usually reserved for young, fit patients with **high-risk CLL refractory to conventional chemotherapy** or for those with transformation to aggressive lymphoma.
- It is not indicated for an asymptomatic 71-year-old man with newly diagnosed, likely early-stage CLL.
*Fludarabine, cyclophosphamide, and rituximab*
- This combination, known as **FCR regimen**, is a common and effective first-line chemotherapy for **symptomatic CLL** patients who require treatment.
- However, for asymptomatic patients fulfilling the diagnostic criteria for CLL but without indications for treatment (e.g., progressive lymphadenopathy, splenomegaly, anemia, thrombocytopenia, B symptoms), initiating chemotherapy is not recommended.
*All-trans retinoic acid*
- **All-trans retinoic acid (ATRA)** is a specific differentiating agent used primarily in the treatment of **Acute Promyelocytic Leukemia (APL)**, a subtype of acute myeloid leukemia.
- It has no role in the management of Chronic Lymphocytic Leukemia (CLL).
*Imatinib*
- **Imatinib** is a tyrosine kinase inhibitor used primarily in the treatment of **Chronic Myeloid Leukemia (CML)**, which is characterized by the Philadelphia chromosome (BCR-ABL fusion gene).
- While sometimes used in other malignancies with specific kinase mutations, it is not indicated for CLL.
Question 410: A 24-year-old man comes to the physician for a 1-week history of a painless swelling on the right side of his neck that he noticed while showering. He is 203 cm (6 ft 8 in) tall and weighs 85 kg (187 lb); BMI is 21 kg/m2. Physical examination shows long, thin fingers and an increased arm-length to body-height ratio. Examination of the neck shows a single 2-cm firm nodule. Ultrasonography of the neck shows a hypoechoic thyroid lesion with irregular margins. A core needle biopsy of the thyroid lesion shows sheets of polygonal cells surrounded by Congo red-stained amorphous tissue. Which of the following additional findings is most likely in this patient?
A. Gastric ulcers
B. Kidney stones
C. Oral tumors (Correct Answer)
D. Recurrent hypoglycemia
E. Breast enlargement
Explanation: **Oral tumors**
- The patient's presentation with a **painless thyroid nodule**, tall stature, **long, thin fingers**, and a **hypoechoic thyroid lesion with irregular margins** suggests **multiple endocrine neoplasia type 2B (MEN2B)**.
- **MEN2B** is characterized by **medullary thyroid carcinoma**, **pheochromocytoma**, and **mucosal neuromas (oral tumors)** and a **Marfanoid habitus**.
*Gastric ulcers*
- **Gastric ulcers** are more commonly associated with **Zollinger-Ellison syndrome**, often seen in **MEN1**, which presents with pituitary tumors, parathyroid hyperplasia, and pancreatic islet cell tumors (e.g., gastrinomas).
- The patient's morphologic features and thyroid pathology are not consistent with **MEN1** or typical causes of gastric ulcers.
*Kidney stones*
- **Kidney stones** are often associated with **hyperparathyroidism**, which is characteristic of **MEN1** and sometimes **MEN2A**.
- The patient's specific presentation, particularly the **Marfanoid habitus** and evidence of **medullary thyroid carcinoma** with amyloid deposition, points more strongly to **MEN2B**.
*Recurrent hypoglycemia*
- **Recurrent hypoglycemia** can occur with **insulinomas**, often part of **MEN1**.
- This patient's findings, including the **thyroid lesion** with **amyloid** and **Marfanoid features**, are not consistent with an insulinoma or **MEN1**.
*Breast enlargement*
- **Breast enlargement (gynecomastia)** can be associated with various hormonal imbalances, including certain tumors, but it is not a primary component of **MEN2B** or suggested by the patient's other symptoms.
- While some endocrine disorders can lead to gynecomastia, it is not a characteristic feature that helps differentiate this patient's underlying condition from the given choices.
