A 42-year-old man who is employed as a construction worker presents to his primary care physician with complaints of moderate headaches and profuse sweating. He reports the need to carry up to 3 additional shirt changes to work because they drench quickly even with tasks of low physical exertion. His coworkers have commented about his changing glove and boot sizes, which have increased at least 4 times since he joined the company 10 years ago. Physical examination is unremarkable except for blood pressure of 160/95 mm Hg, hyperhidrosis, noticeably large pores, hypertrichosis, widely spaced teeth, and prognathism. Which of the following best explains the patient’s clinical manifestations?
Q442
A 50-year-old man comes to the physician for the evaluation of recurrent episodes of chest pain, difficulty breathing, and rapid heart beating over the past two months. During this period, he has had a 4-kg (8.8-lb) weight loss, malaise, pain in both knees, and diffuse muscle pain. Five years ago, he was diagnosed with chronic hepatitis B infection and was started on tenofovir. His temperature is 38°C (100.4°F), pulse is 110/min, and blood pressure is 150/90 mm Hg. Cardiopulmonary examination shows no abnormalities except for tachycardia. There are several ulcerations around the ankle and calves bilaterally. Laboratory studies show:
Hemoglobin 11 g/dL
Leukocyte count 14,000/mm3
Erythrocyte sedimentation rate 80 mm/h
Serum
Perinuclear anti-neutrophil cytoplasmic antibodies negative
Hepatitis B surface antigen positive
Urine
Protein +2
RBC 6-7/hpf
Which of the following is the most likely diagnosis?
Q443
A 35-year-old woman presents to the emergency department for evaluation of severe central chest pain for 2 hours. She says the pain is heavy in nature and radiates to her jaw. She has no relevant past medical history. The vital signs and physical examination are non-contributory. Echocardiography is performed. Mitral valve leaflet thickening is observed with several masses attached to both surfaces of the valve leaflets. The coronary arteries appear normal on coronary angiography. Which of the following is most likely associated with this patient's condition?
Q444
A 40-year-old woman comes to the physician with a 5-day history of mild shortness of breath with exertion. She has also had a cough for 5 days that became productive of whitish non-bloody sputum 3 days ago. Initially, she had a runny nose, mild headaches, and diffuse muscle aches. She has not had fevers or chills. Three weeks ago, her 9-year-old son had a febrile illness with a cough and an exanthematous rash that resolved without treatment 1 week later. The patient has occasional migraine headaches. Her sister was diagnosed with antiphospholipid syndrome 12 years ago. The patient does not smoke; she drinks 3–4 glasses of wine per week. Her current medications include zolmitriptan as needed. Her temperature is 37.1°C (99°F), pulse is 84/min, respirations are 17/min, and blood pressure is 135/82 mm Hg. Scattered wheezes are heard at both lung bases. There are no rales. Egophony is negative. Which of the following is the most appropriate next step in management?
Q445
A 76-year-old woman presents to the primary care physician for a regular check-up. History reveals that she has had episodes of mild urinary incontinence over the past 2 years precipitated by sneezing or laughing. However, over the past week, her urinary incontinence has occurred during regular activities. Her blood pressure is 140/90 mm Hg, heart rate is 86/min, respiratory rate is 22/min, and temperature is 37.7°C (99.9°F). Physical examination is remarkable for suprapubic tenderness. Urinalysis reveals 15 WBCs/HPF, positive nitrites, and positive leukocyte esterase. Which of the following is the best next step for this patient?
Q446
In a routine medical examination, a young man is noted to be tall with slight scoliosis and pectus excavatum. He had been told that he was over the 95% percentile for height as a child. Auscultation reveals a heart murmur, and transthoracic echocardiography shows an enlarged aortic root and mitral valve prolapse. Blood screening for fibrillin-1 (FBN1) gene mutation is positive and plasma homocysteine is normal. This patient is at high risk for which of the following complications?
Q447
A 58-year-old man presents to the emergency department following a motor vehicle accident where he was an unrestrained passenger. On initial presentation in the field, he had diffuse abdominal tenderness and his blood pressure is 70/50 mmHg and pulse is 129/min. Following administration of 2 L of normal saline, his blood pressure is 74/58 mmHg. He undergoes emergency laparotomy and the source of the bleeding is controlled. On the second post-operative day, his blood pressure is 110/71 mmHg and pulse is 90/min. There is a midline abdominal scar with no erythema and mild tenderness. Cardiopulmonary examination is unremarkable. He has had 300 mL of urine output over the last 24 hours. Urinalysis shows 12-15 RBC/hpf, 2-5 WBC/hpf, and trace protein. What additional finding would you expect to see on urinalysis?
Q448
A 34-year-old man presents to a clinic with complaints of abdominal discomfort and blood in the urine for 2 days. He has had similar abdominal discomfort during the past 5 years, although he does not remember passing blood in the urine. He has had hypertension for the past 2 years, for which he has been prescribed medication. There is no history of weight loss, skin rashes, joint pain, vomiting, change in bowel habits, and smoking. On physical examination, there are ballotable flank masses bilaterally. The bowel sounds are normal. Renal function tests are as follows:
Urea 50 mg/dL
Creatinine 1.4 mg/dL
Protein Negative
RBC Numerous
The patient underwent ultrasonography of the abdomen, which revealed enlarged kidneys and multiple anechoic cysts with well-defined walls. A CT scan confirmed the presence of multiple cysts in the kidneys. What is the most likely diagnosis?
Q449
A 76-year-old man comes to the emergency department because of an episode of seeing jagged edges followed by loss of central vision in his right eye. The episode occurred 6 hours ago and lasted approximately 5 minutes. The patient has no pain. He has a 3-month history of intermittent blurriness out of his right eye and reports a 10-minute episode of slurred speech and left-sided facial droop that occurred 2 months ago. He has hypercholesterolemia, stable angina pectoris, hypertension, and a 5-year history of type 2 diabetes mellitus. Medications include glyburide, atorvastatin, labetalol, isosorbide, lisinopril, and aspirin. He feels well. He is oriented to person, place, and time. His temperature is 37°C (98.6°F), pulse is 76/min, respirations are 12/min, and blood pressure is 154/78 mm Hg. The extremities are well perfused with strong peripheral pulses. Ophthalmologic examination shows visual acuity of 20/30 in the left eye and 20/40 in the right eye. Visual fields are normal. Fundoscopic examination shows two pale spots along the supratemporal and inferotemporal arcade. Neurologic examination shows no focal findings. Cardiopulmonary examination shows systolic rumbling at the right carotid artery. The remainder of the examination shows no abnormalities. An ECG shows normal sinus rhythm with no evidence of ischemia. Which of the following is the most appropriate next step in management?
Q450
A 69-year-old man is scheduled to undergo radical retropubic prostatectomy for prostate cancer in 2 weeks. He had a myocardial infarction at the age of 54 years. He has a history of GERD, unstable angina, hyperlipidemia, and severe osteoarthritis in the left hip. He is unable to climb up stairs or walk fast because of pain in his left hip. He had smoked one pack of cigarettes daily for 30 years but quit 25 years ago. He drinks one glass of wine daily. Current medications include aspirin, metoprolol, lisinopril, rosuvastatin, omeprazole, and ibuprofen as needed. His temperature is 36.4°C (97.5°F), pulse is 90/min, and blood pressure is 136/88 mm Hg. Physical examination shows no abnormalities. A 12-lead ECG shows Q waves and inverted T waves in leads II, III, and aVF. His B-type natriuretic protein is 84 pg/mL (N < 125). Which of the following is the most appropriate next step in management to assess this patient's perioperative cardiac risk?
Cardiology US Medical PG Practice Questions and MCQs
Question 441: A 42-year-old man who is employed as a construction worker presents to his primary care physician with complaints of moderate headaches and profuse sweating. He reports the need to carry up to 3 additional shirt changes to work because they drench quickly even with tasks of low physical exertion. His coworkers have commented about his changing glove and boot sizes, which have increased at least 4 times since he joined the company 10 years ago. Physical examination is unremarkable except for blood pressure of 160/95 mm Hg, hyperhidrosis, noticeably large pores, hypertrichosis, widely spaced teeth, and prognathism. Which of the following best explains the patient’s clinical manifestations?
A. Increased serum cortisol
B. Increased thyroid-stimulating hormone
C. Increased serum metanephrines
D. Increased serum insulin-like growth factor 1 (IGF-1) (Correct Answer)
E. Increased serum testosterone
Explanation: ***Increased serum insulin-like growth factor 1 (IGF-1)***
- Elevated **IGF-1** levels are indicative of **acromegaly**, a condition caused by excess growth hormone (GH) secretion, which explains the gradual changes in glove and boot sizes, prognathism, widely spaced teeth, and large pores.
- The symptoms of **profuse sweating**, **hypertrichosis**, **headaches**, and **hypertension** are common clinical manifestations of acromegaly due to the systemic effects of chronic GH excess.
*Increased serum cortisol*
- **Increased cortisol** (Cushing's syndrome) would present with central obesity, moon facies, buffalo hump, and striae, which are not described in the patient.
- While hypertension and hyperhidrosis can occur in Cushing's, the characteristic physical changes related to growth are absent.
*Increased thyroid-stimulating hormone*
- Elevated **TSH** suggests **hypothyroidism**, which would typically cause fatigue, weight gain, cold intolerance, and bradycardia, rather than profuse sweating and hypertension.
- **Hyperthyroidism** (low TSH, high thyroid hormones) can cause sweating and hypertension, but it would not explain the gradual increase in body and appendage size.
*Increased serum metanephrines*
- Elevated **metanephrines** are a hallmark of **pheochromocytoma**, which typically presents with paroxysmal episodes of hypertension, palpitations, and sweating.
- While sweating and hypertension are present, the absence of episodic symptoms and the long-term changes in body size make pheochromocytoma less likely.
*Increased serum testosterone*
- **Increased testosterone** in a male would typically lead to increased muscle mass, acne, and potentially male-pattern baldness, but not the specific skeletal and soft tissue growth patterns observed, such as increased shoe and glove size or prognathism.
- While some skin changes might occur, **hyperhidrosis** and the dramatic facial and extremity changes are not characteristic features of testosterone excess.
Question 442: A 50-year-old man comes to the physician for the evaluation of recurrent episodes of chest pain, difficulty breathing, and rapid heart beating over the past two months. During this period, he has had a 4-kg (8.8-lb) weight loss, malaise, pain in both knees, and diffuse muscle pain. Five years ago, he was diagnosed with chronic hepatitis B infection and was started on tenofovir. His temperature is 38°C (100.4°F), pulse is 110/min, and blood pressure is 150/90 mm Hg. Cardiopulmonary examination shows no abnormalities except for tachycardia. There are several ulcerations around the ankle and calves bilaterally. Laboratory studies show:
Hemoglobin 11 g/dL
Leukocyte count 14,000/mm3
Erythrocyte sedimentation rate 80 mm/h
Serum
Perinuclear anti-neutrophil cytoplasmic antibodies negative
Hepatitis B surface antigen positive
Urine
Protein +2
RBC 6-7/hpf
Which of the following is the most likely diagnosis?
A. Granulomatosis with polyangiitis
B. Giant cell arteritis
C. Thromboangiitis obliterans
D. Polyarteritis nodosa (Correct Answer)
E. Takayasu arteritis
Explanation: ***Polyarteritis nodosa (PAN)***
- This patient presents with **fever**, **weight loss**, **myalgia**, and **arthralgia** along with **skin ulcerations** and **renal involvement** (proteinuria, hematuria), signs of systemic inflammation, and **medium-sized vessel vasculitis**. The history of **chronic Hepatitis B infection** is strongly associated with PAN.
- The elevated **ESR** and **leukocytosis** indicate ongoing inflammation, and the chest pain/rapid heart beating could be signs of cardiac involvement, which is common in PAN. The negative p-ANCA also helps rule out other vasculitides.
*Granulomatosis with polyangiitis*
- This condition is typically associated with **upper and lower respiratory tract involvement**, **glomerulonephritis**, and **c-ANCA positivity** (anti-PR3 antibodies).
- The patient's symptoms do not primarily involve sinusitis, pulmonary nodules, or other upper/lower airway disease, and p-ANCA is negative, rather than c-ANCA positive.
*Giant cell arteritis*
- This is a vasculitis affecting primarily **large-sized arteries**, especially the carotid artery branches, and typically occurs in patients **older than 50 years** (though this patient is 50, other symptoms rule it out).
- Key symptoms include **new-onset headache**, **jaw claudication**, **scalp tenderness**, and potential vision loss, none of which are reported here.
*Thromboangiitis obliterans*
- This condition is strongly linked to **heavy tobacco use** and results in **segmental thrombosis and inflammation of small and medium-sized arteries and veins** in the extremities.
- It primarily causes **ischemia of the digits** (fingers and toes), leading to pain, ulcerations, and gangrene, which is not fully consistent with the patient's widespread systemic symptoms and organ involvement.
*Takayasu arteritis*
- This is a **large-vessel vasculitis** primarily affecting the **aorta and its major branches**, typically seen in **younger women**.
- Symptoms often include **claudication**, **absent or diminished pulses**, and **discrepancies in blood pressure between limbs**, which are not described in this patient.
Question 443: A 35-year-old woman presents to the emergency department for evaluation of severe central chest pain for 2 hours. She says the pain is heavy in nature and radiates to her jaw. She has no relevant past medical history. The vital signs and physical examination are non-contributory. Echocardiography is performed. Mitral valve leaflet thickening is observed with several masses attached to both surfaces of the valve leaflets. The coronary arteries appear normal on coronary angiography. Which of the following is most likely associated with this patient's condition?
A. Dermatomyositis
B. Churg-Strauss syndrome
C. Systemic lupus erythematosus (Correct Answer)
D. Fibromyalgia
E. Temporal arteritis
Explanation: ***Systemic lupus erythematosus***
- **Libman-Sacks endocarditis**, characterized by **sterile vegetations on both surfaces of the heart valve leaflets** (often the mitral valve), is a classic cardiac manifestation of SLE.
- The key diagnostic feature is the presence of vegetations on **both the atrial and ventricular surfaces** of the valve, distinguishing it from infectious endocarditis.
- The patient's presentation with **chest pain radiating to the jaw** (possibly due to embolic phenomena or associated pericarditis) and the echocardiographic finding of **mitral valve leaflet thickening** and **masses (vegetations)** without evidence of coronary artery disease strongly point to this condition.
*Dermatomyositis*
- This is an inflammatory myopathy primarily affecting the **skin and muscles**, leading to weakness and characteristic rashes (heliotrope rash, Gottron's papules).
- While it can have cardiac involvement (e.g., myocarditis, arrhythmias), **valvular vegetations** like those described are not a typical feature.
*Churg-Strauss syndrome*
- Also known as **Eosinophilic Granulomatosis with Polyangiitis (EGPA)**, this is a rare systemic vasculitis primarily affecting the respiratory tract.
- It involves **asthma, eosinophilia, and granulomatous inflammation**, but valvular heart disease with vegetations is not its hallmark cardiac manifestation.
*Fibromyalgia*
- This is a chronic disorder characterized by widespread musculoskeletal pain, fatigue, and tenderness.
- It is a **functional pain syndrome** and does not involve structural heart abnormalities like valvular vegetations.
*Temporal arteritis*
- This is a **large-vessel vasculitis** (Giant Cell Arteritis) primarily affecting the arteries of the head and neck, typically presenting with headache, jaw claudication, and visual disturbances.
- It does not cause valvular vegetations or the type of chest pain described in this case.
Question 444: A 40-year-old woman comes to the physician with a 5-day history of mild shortness of breath with exertion. She has also had a cough for 5 days that became productive of whitish non-bloody sputum 3 days ago. Initially, she had a runny nose, mild headaches, and diffuse muscle aches. She has not had fevers or chills. Three weeks ago, her 9-year-old son had a febrile illness with a cough and an exanthematous rash that resolved without treatment 1 week later. The patient has occasional migraine headaches. Her sister was diagnosed with antiphospholipid syndrome 12 years ago. The patient does not smoke; she drinks 3–4 glasses of wine per week. Her current medications include zolmitriptan as needed. Her temperature is 37.1°C (99°F), pulse is 84/min, respirations are 17/min, and blood pressure is 135/82 mm Hg. Scattered wheezes are heard at both lung bases. There are no rales. Egophony is negative. Which of the following is the most appropriate next step in management?
A. Supportive treatment only (Correct Answer)
B. Obtain D-dimer
C. Perform Bordetella pertussis PCR
D. Administer clarithromycin
E. Conduct a high-resolution chest CT
Explanation: ***Supportive treatment only***
- This patient presents with symptoms highly suggestive of an **acute viral bronchitis**, characterized by an antecedent upper respiratory infection, **non-bloody productive cough**, mild shortness of breath, and scattered wheezes without signs of bacterial pneumonia (e.g., fever, rales, egophony). Acute bronchitis is typically **self-limiting** and managed with symptomatic care.
- The history of her son's **febrile illness with cough and rash** (possibly a viral infection) supports a viral etiology for her current respiratory symptoms.
*Obtain D-dimer*
- A D-dimer test is used to rule out **venous thromboembolism (VTE)**, such as **pulmonary embolism (PE)**. While shortness of breath is a PE symptom, the patient's presentation with a prominent cough, preceding viral symptoms, and absence of high-risk features for PE makes acute viral bronchitis much more likely.
- Although the patient's sister has **antiphospholipid syndrome** (which increases risk for both arterial and venous thrombosis), the patient herself has no personal history of thrombosis, and her clinical presentation with gradual onset dyspnea, prominent cough, wheezes, and preceding URI symptoms is typical for **viral bronchitis** rather than PE.
- A PE typically causes **acute onset dyspnea** and pleuritic chest pain, which differs from the gradual onset and prominent cough seen here.
*Perform Bordetella pertussis PCR*
- While *Bordetella pertussis* can cause a prolonged cough (whooping cough), the patient's symptoms are inconsistent with typical pertussis. Pertussis is characterized by **paroxysmal cough** followed by an inspiratory "whoop" and **post-tussive emesis**, which are not reported.
- The illness has only been present for 5 days, whereas pertussis often involves a **catarrhal stage** followed by several weeks of paroxysmal cough.
*Administer clarithromycin*
- **Clarithromycin is an antibiotic** usually prescribed for bacterial infections. Given the patient's likely viral bronchitis, antibiotics are **not indicated** and could contribute to **antibiotic resistance** and adverse effects.
- The absence of fever, normal vital signs, and lack of signs of bacterial pneumonia (e.g., rales, egophony, purulent sputum) rule out the immediate need for antibiotic therapy.
*Conduct a high-resolution chest CT*
- A **high-resolution chest CT (HRCT)** is typically used for diagnosing **interstitial lung diseases** or evaluating persistent, unexplained respiratory symptoms.
- In this case, the patient's symptoms are acute and consistent with a **viral respiratory infection**, making an HRCT an **overly aggressive and unnecessary diagnostic step** at this time.
Question 445: A 76-year-old woman presents to the primary care physician for a regular check-up. History reveals that she has had episodes of mild urinary incontinence over the past 2 years precipitated by sneezing or laughing. However, over the past week, her urinary incontinence has occurred during regular activities. Her blood pressure is 140/90 mm Hg, heart rate is 86/min, respiratory rate is 22/min, and temperature is 37.7°C (99.9°F). Physical examination is remarkable for suprapubic tenderness. Urinalysis reveals 15 WBCs/HPF, positive nitrites, and positive leukocyte esterase. Which of the following is the best next step for this patient?
A. Pelvic floor muscle training
B. Ultrasound scan of the kidneys, urinary tract, and bladder
C. Cystoscopy
D. Urine culture (Correct Answer)
E. Start empirical antibiotic therapy
Explanation: ***Urine culture***
- The patient presents with classic **signs of a urinary tract infection (UTI)**: new onset urinary incontinence worsening, suprapubic tenderness, and urinalysis positive for **WBCs, nitrites, and leukocyte esterase**.
- A urine culture is essential to **confirm the diagnosis of UTI**, identify the causative organism, and determine antibiotic sensitivity before initiating targeted treatment.
*Pelvic floor muscle training*
- This intervention is appropriate for **stress urinary incontinence (SUI)**, which the patient initially experienced, but it will not address the acute infection.
- While it may be considered after UTI treatment for managing chronic incontinence, it's NOT the immediate priority given the acute infectious symptoms.
*Ultrasound scan of the kidneys, urinary tract, and bladder*
- An ultrasound might be considered if there were concerns for **obstruction**, **pyelonephritis**, or recurrent UTIs after treatment, but it is not the immediate diagnostic step for an acute, uncomplicated UTI.
- The primary goal is to identify and treat the infection first.
*Cystoscopy*
- **Cystoscopy** is an invasive procedure generally reserved for investigating causes of recurrent UTIs, hematuria, or bladder abnormalities after initial treatment failures or in specific clinical scenarios, not for initial diagnosis of an apparent UTI.
- It would be premature and unnecessary at this stage without ruling out a simple infection.
*Start empirical antibiotic therapy*
- While antibiotics are indeed needed, starting empirical therapy without a culture could lead to **antibiotic resistance** or ineffective treatment if the causative organism is not susceptible to the chosen antibiotic.
- Given the suprapubic tenderness and urinalysis findings, a UTI is highly likely, but **culture and sensitivity guided therapy** is the best practice for optimal patient outcomes and to prevent resistance, especially in an elderly patient.
Question 446: In a routine medical examination, a young man is noted to be tall with slight scoliosis and pectus excavatum. He had been told that he was over the 95% percentile for height as a child. Auscultation reveals a heart murmur, and transthoracic echocardiography shows an enlarged aortic root and mitral valve prolapse. Blood screening for fibrillin-1 (FBN1) gene mutation is positive and plasma homocysteine is normal. This patient is at high risk for which of the following complications?
A. Intravascular thrombosis
B. Infertility
C. Aortic dissection (Correct Answer)
D. Spontaneous pneumothorax
E. Mucosal neuromas
Explanation: ***Aortic dissection***
- The constellation of **tall stature**, **scoliosis**, **pectus excavatum**, **enlarged aortic root**, **mitral valve prolapse**, and a **positive FBN1 gene mutation** is highly indicative of **Marfan syndrome**.
- **Aortic dissection** is the most life-threatening complication of Marfan syndrome due to the weakened connective tissue in the aortic wall, a direct consequence of the FBN1 mutation affecting fibrillin-1 protein.
- Patients with Marfan syndrome require regular cardiovascular surveillance and prophylactic beta-blocker therapy to reduce aortic wall stress.
*Intravascular thrombosis*
- This complication is more characteristic of conditions like **homocystinuria**, which is ruled out by the **normal plasma homocysteine** level.
- Marfan syndrome primarily affects connective tissue strength, not coagulation pathways or endothelial function.
*Infertility*
- Marfan syndrome does not inherently cause **infertility** in males or females.
- The primary health risks for Marfan patients are cardiovascular, musculoskeletal, and ophthalmologic (lens dislocation).
*Spontaneous pneumothorax*
- While **spontaneous pneumothorax** can occur in Marfan syndrome due to apical blebs and weakened pleural tissue, it is far less immediately life-threatening than aortic dissection.
- The question asks for the "high risk" complication, and cardiovascular complications (particularly aortic dissection and rupture) are the leading cause of mortality in Marfan syndrome.
*Mucosal neuromas*
- **Mucosal neuromas** are characteristic of **Multiple Endocrine Neoplasia type 2B (MEN2B)**, not Marfan syndrome.
- MEN2B involves RET proto-oncogene mutations and is associated with medullary thyroid cancer, pheochromocytoma, and a marfanoid habitus, which can be mistaken for Marfan syndrome.
Question 447: A 58-year-old man presents to the emergency department following a motor vehicle accident where he was an unrestrained passenger. On initial presentation in the field, he had diffuse abdominal tenderness and his blood pressure is 70/50 mmHg and pulse is 129/min. Following administration of 2 L of normal saline, his blood pressure is 74/58 mmHg. He undergoes emergency laparotomy and the source of the bleeding is controlled. On the second post-operative day, his blood pressure is 110/71 mmHg and pulse is 90/min. There is a midline abdominal scar with no erythema and mild tenderness. Cardiopulmonary examination is unremarkable. He has had 300 mL of urine output over the last 24 hours. Urinalysis shows 12-15 RBC/hpf, 2-5 WBC/hpf, and trace protein. What additional finding would you expect to see on urinalysis?
A. WBC casts
B. RBC casts
C. Fatty casts
D. Hyaline casts
E. Muddy brown casts (Correct Answer)
Explanation: ***Muddy brown casts***
- The patient's history of **post-traumatic hypovolemic shock** leading to prolonged hypotension, coupled with **oliguria** and an elevated blood pressure on post-operative day 2, are highly suggestive of **acute tubular necrosis (ATN)**.
- **Muddy brown granular casts** are a hallmark finding of ATN, representing sloughed renal tubular cells and heme pigments.
*WBC casts*
- **WBC casts** are characteristic of **pyelonephritis** or **interstitial nephritis**, often accompanied by fever, flank pain, and significant pyuria, none of which are the primary presentation here.
- While there are some WBCs in the urine, the overall clinical picture does not point towards an infectious or inflammatory renal process as the primary cause of renal dysfunction.
*RBC casts*
- **RBC casts** indicate **glomerulonephritis** or severe tubular damage with hemorrhage, suggesting glomerular inflammation or a vasculitic process.
- While the urinalysis shows 12-15 RBC/hpf, the absence of other strong indicators of glomerular disease and the prominent history of shock make ATN a more likely diagnosis than glomerulonephritis.
*Fatty casts*
- **Fatty casts** are typically seen in **nephrotic syndrome**, associated with significant proteinuria (>3.5g/day), hyperlipidemia, and edema.
- The patient's trace proteinuria and the absence of other nephrotic syndrome features make this finding unlikely.
*Hyaline casts*
- **Hyaline casts** are composed of Tamm-Horsfall mucoprotein and can be found in **healthy individuals** as well as in states of **dehydration** or mild renal injury.
- While the patient was likely dehydrated, hyaline casts are non-specific and do not explain the degree of renal dysfunction and oliguria observed in this case.
Question 448: A 34-year-old man presents to a clinic with complaints of abdominal discomfort and blood in the urine for 2 days. He has had similar abdominal discomfort during the past 5 years, although he does not remember passing blood in the urine. He has had hypertension for the past 2 years, for which he has been prescribed medication. There is no history of weight loss, skin rashes, joint pain, vomiting, change in bowel habits, and smoking. On physical examination, there are ballotable flank masses bilaterally. The bowel sounds are normal. Renal function tests are as follows:
Urea 50 mg/dL
Creatinine 1.4 mg/dL
Protein Negative
RBC Numerous
The patient underwent ultrasonography of the abdomen, which revealed enlarged kidneys and multiple anechoic cysts with well-defined walls. A CT scan confirmed the presence of multiple cysts in the kidneys. What is the most likely diagnosis?
A. Simple renal cysts
B. Acquired cystic kidney disease
C. Autosomal recessive polycystic kidney disease (ARPKD)
D. Medullary cystic disease
E. Autosomal dominant polycystic kidney disease (ADPKD) (Correct Answer)
Explanation: ***Autosomal dominant polycystic kidney disease (ADPKD)***
- The patient's presentation with **bilateral ballotable flank masses**, **hypertension**, **recurrent abdominal discomfort**, **hematuria**, and imaging findings of **enlarged kidneys with multiple anechoic cysts** are highly characteristic of ADPKD.
- ADPKD is a **heritable systemic disorder** characterized by the progressive development and enlargement of cysts in the kidneys and other organs, often leading to chronic kidney disease and hypertension in adulthood.
*Simple renal cysts*
- **Simple renal cysts** are typically solitary or few in number and usually do not cause symptoms or significant kidney enlargement.
- They are generally **benign** and do not explain the patient's extensive cystic burden, hypertension, or progressive symptoms.
*Acquired cystic kidney disease*
- **Acquired cystic kidney disease** typically develops in patients with **long-standing end-stage renal disease** or on dialysis, which is not indicated by the patient's current renal function tests (Urea 50 mg/dL, Creatinine 1.4 mg/dL).
- The cysts are usually smaller and less numerous than in ADPKD and are not associated with the extensive systemic manifestations seen here.
*Autosomal recessive polycystic kidney disease (ARPKD)*
- **ARPKD** is a rare and severe form of polycystic kidney disease that usually presents in **infancy or childhood** with significant renal impairment, liver involvement, and often pulmonary hypoplasia.
- The patient's age and clinical history, including the onset of symptoms in adulthood, do not align with the typical presentation of ARPKD.
*Medullary cystic disease*
- **Medullary cystic disease** is a group of inherited kidney disorders characterized by the presence of **cysts primarily in the renal medulla** and tubules, leading to progressive renal failure and salt wasting.
- It does not typically present with the striking bilateral flank masses or the large, numerous cortical cysts observed on imaging in this patient.
Question 449: A 76-year-old man comes to the emergency department because of an episode of seeing jagged edges followed by loss of central vision in his right eye. The episode occurred 6 hours ago and lasted approximately 5 minutes. The patient has no pain. He has a 3-month history of intermittent blurriness out of his right eye and reports a 10-minute episode of slurred speech and left-sided facial droop that occurred 2 months ago. He has hypercholesterolemia, stable angina pectoris, hypertension, and a 5-year history of type 2 diabetes mellitus. Medications include glyburide, atorvastatin, labetalol, isosorbide, lisinopril, and aspirin. He feels well. He is oriented to person, place, and time. His temperature is 37°C (98.6°F), pulse is 76/min, respirations are 12/min, and blood pressure is 154/78 mm Hg. The extremities are well perfused with strong peripheral pulses. Ophthalmologic examination shows visual acuity of 20/30 in the left eye and 20/40 in the right eye. Visual fields are normal. Fundoscopic examination shows two pale spots along the supratemporal and inferotemporal arcade. Neurologic examination shows no focal findings. Cardiopulmonary examination shows systolic rumbling at the right carotid artery. The remainder of the examination shows no abnormalities. An ECG shows normal sinus rhythm with no evidence of ischemia. Which of the following is the most appropriate next step in management?
A. Echocardiography
B. Fluorescein angiography
C. Temporal artery biopsy
D. Reassurance and follow-up
E. Carotid duplex ultrasonography (Correct Answer)
Explanation: ***Carotid duplex ultrasonography***
- The patient's presentation with **transient monocular vision loss** (**amaurosis fugax**), transient ischemic attack (TIA) symptoms (**slurred speech, facial droop**), and a **carotid bruit** strongly suggests carotid artery stenosis as the source of emboli.
- **Carotid duplex ultrasonography** is the gold standard initial non-invasive imaging test to assess for **carotid artery stenosis** in symptomatic patients.
*Echocardiography*
- While echocardiography can identify cardiac sources of emboli (e.g., atrial fibrillation, valvular vegetations, PFO), the presence of a **carotid bruit** and prior TIA symptoms points more directly to carotid disease as the cause of transient visual and neurological deficits.
- This would be a reasonable next step if carotid studies were negative or if there were strong cardiac risk factors without carotid ones.
*Fluorescein angiography*
- **Fluorescein angiography** is used to evaluate the retinal circulation and can identify areas of ischemia or neovascularization, but it is not the primary diagnostic tool for determining the **etiology of amaurosis fugax** in a patient with a carotid bruit.
- It would be considered if a primary retinal vascular disease, rather than embolic phenomenon, were suspected.
*Temporal artery biopsy*
- **Temporal artery biopsy** is used to diagnose **giant cell arteritis (temporal arteritis)**, which can cause amaurosis fugax.
- However, this patient lacks typical symptoms of giant cell arteritis such as headache, jaw claudication, scalp tenderness, or an elevated ESR/CRP, making it less likely given the prominent carotid bruit and other embolic symptoms.
*Reassurance and follow-up*
- Given the patient's history of multiple transient ischemic events (amaurosis fugax, TIA) and clear signs of potential atherosclerotic disease (**carotid bruit**, multiple cardiovascular risk factors), **reassurance alone is inappropriate**.
- These are warning signs of impending stroke, and prompt investigation and management are crucial to prevent further, potentially permanent, neurological damage.
Question 450: A 69-year-old man is scheduled to undergo radical retropubic prostatectomy for prostate cancer in 2 weeks. He had a myocardial infarction at the age of 54 years. He has a history of GERD, unstable angina, hyperlipidemia, and severe osteoarthritis in the left hip. He is unable to climb up stairs or walk fast because of pain in his left hip. He had smoked one pack of cigarettes daily for 30 years but quit 25 years ago. He drinks one glass of wine daily. Current medications include aspirin, metoprolol, lisinopril, rosuvastatin, omeprazole, and ibuprofen as needed. His temperature is 36.4°C (97.5°F), pulse is 90/min, and blood pressure is 136/88 mm Hg. Physical examination shows no abnormalities. A 12-lead ECG shows Q waves and inverted T waves in leads II, III, and aVF. His B-type natriuretic protein is 84 pg/mL (N < 125). Which of the following is the most appropriate next step in management to assess this patient's perioperative cardiac risk?
A. No further testing
B. 24-hour ambulatory ECG monitoring
C. Radionuclide myocardial perfusion imaging (Correct Answer)
D. Treadmill stress test
E. Resting echocardiography
Explanation: ***Radionuclide myocardial perfusion imaging***
- This patient requires **perioperative cardiac risk assessment** before intermediate-risk surgery (radical prostatectomy).
- Key factors include: history of **myocardial infarction**, current cardiac risk factors, and **inability to exercise** due to severe osteoarthritis.
- Since he cannot perform exercise stress testing, **pharmacologic stress testing** with radionuclide myocardial perfusion imaging (using agents like adenosine, dipyridamole, or regadenoson) is the most appropriate test to assess for **inducible myocardial ischemia**.
- This provides functional assessment of coronary perfusion under pharmacologic stress, helping guide perioperative risk stratification and management.
- *Note: The presence of unstable angina would typically require cardiac stabilization first; this question focuses on selecting the appropriate stress test modality for a patient unable to exercise.*
*No further testing*
- This patient has significant cardiac risk factors including **prior MI**, ongoing cardiac medications, and ECG changes suggesting old infarction.
- Proceeding directly to surgery without functional cardiac assessment would be **inappropriate** given his risk profile and the intermediate-risk nature of the planned surgery.
*24-hour ambulatory ECG monitoring*
- Holter monitoring detects arrhythmias and silent ischemic episodes but does not provide **functional capacity assessment** or evaluation of inducible ischemia under stress conditions.
- It is not the primary tool for **perioperative cardiac risk stratification** before major surgery.
*Treadmill stress test*
- The patient's **severe osteoarthritis** prevents him from climbing stairs or walking fast, making him unable to achieve adequate exercise workload for a treadmill stress test.
- This functional limitation makes **exercise stress testing contraindicated**; pharmacologic stress testing is required instead.
*Resting echocardiography*
- Resting echocardiography assesses **baseline left ventricular function**, wall motion abnormalities from prior infarction, and valvular disease.
- While useful for structural assessment, it does **not evaluate for exercise-induced or stress-induced ischemia**, which is critical for perioperative risk assessment in patients with coronary artery disease.
- His normal BNP (84 pg/mL) suggests adequate baseline ventricular function, making functional ischemia assessment more relevant than structural evaluation alone.
