A 27-year-old man from Southern California presents with progressive chest pain, non-productive cough, and shortness of breath for the past 24 hours. He denies any similar symptoms in the past. He denies any family history of cardiac disease, recent travel, or exposure to sick contacts. His temperature is 38.5°C (101.3°F), pulse is 105/min, blood pressure is 108/78 mm Hg, and the respiratory rate is 32/min. On physical examination, patient is cachectic and ill-appearing. Bilateral pleural friction rubs are present on pulmonary auscultation. Antecubital track marks are noted bilaterally. An echocardiogram is performed and results are shown below. Which of the following is the most likely diagnosis in this patient?
Q562
A 19-year-old man presents to the emergency department after 2 separate episodes of loss of consciousness. The first episode occurred 1 year ago while he was running in gym class. Witnesses reported clenching and shaking of both hands after he had fallen. On getting up quickly, he felt lightheaded, nauseated, and sweaty. He was given intravenous phenytoin because of concern that he may have had a seizure. His electroencephalogram was negative, and he was not started on long-term antiepileptics. One year later, a second episode of loss of consciousness occurred while playing dodgeball. He experienced a similar prodrome of lightheadedness and sweating. He has no history of seizures outside of these 2 episodes. Family history is non-contributory. He has a temperature of 37.0°C (98.6°F), a blood pressure of 110/72 mm Hg, and a pulse of 80/min. Physical examination is unremarkable. His 12-lead ECG shows normal sinus rhythm without any other abnormalities. Which of the following is the best next step in this patient?
Q563
A 35-year-old woman is brought to the emergency department for a severe, left-sided headache and neck pain that started 24 hours after she completed a half-marathon. Shortly after the headache started, she also had weakness of her right upper extremity and sudden loss of vision in her left eye, which both subsided on her way to the hospital. On arrival, she is alert and oriented to person, place, and time. Her temperature is 37.3°C (99.1°F), pulse is 77/min, respiratory rate is 20/min, and blood pressure is 160/90 mm Hg. Examination shows drooping of the left eyelid and a constricted left pupil. Visual acuity in both eyes is 20/20. There is no swelling of the optic discs. Muscle strength and deep tendon reflexes are normal bilaterally. A noncontrast CT scan of the head shows no abnormalities. Duplex ultrasonography of the neck shows absence of flow in the left internal carotid artery. Administration of which of the following is the most appropriate next step in management?
Q564
A 33-year-old Caucasian female presents to her primary care provider for pruritus and shortness of breath. Over the past year, she has experienced mild progressive diffuse pruritus. She also reports that her skin seems "hard" and that it has been harder to move her fingers freely. She initially attributed her symptoms to stress at work as a commercial pilot, but when her symptoms began impacting her ability to fly, she decided to seek treatment. She has a history of major depressive disorder and takes citalopram. She smokes 1 pack per day and drinks socially. Her temperature is 98.6°F (37°C), blood pressure is 148/88 mmHg, pulse is 83/min, and respirations are 21/min. On exam, she appears anxious with increased work of breathing. Dry rales are heard at her lung bases bilaterally. Her fingers appear shiny and do not have wrinkles on the skin folds. A normal S1 and S2 are heard on cardiac auscultation. This patient's condition is most strongly associated with which of the following antibodies?
Q565
A 22-year-old woman comes to the physician because of 1 week of progressive left anterior knee pain. The pain is worse after sitting for a prolonged period of time and while ascending stairs. She first noticed the pain the day after a basketball game. She has often taken painful blows to the side of the knees while playing basketball but does not recall this having happened in the last game. Four weeks ago, she was diagnosed with a chlamydial urinary tract infection and treated with azithromycin. She is sexually active with one male partner; they use condoms inconsistently. Her vital signs are within normal limits. She is 178 cm (5 ft 10 in) tall and weighs 62 kg (137 lb); BMI is 19.6 kg/m2. Physical examination shows tenderness over the left anterior knee that is exacerbated with anterior pressure to the patella when the knee is fully extended; there is no erythema or swelling. Which of the following is the most likely diagnosis?
Q566
A 30-year-old woman comes to the physician because of increased urinary frequency over the past month. She also reports having dry mouth and feeling thirsty all the time despite drinking several liters of water per day. She has not had any weight changes and her appetite is normal. She has a history of obsessive compulsive disorder treated with citalopram. She drinks 1–2 cans of beer per day. Her vital signs are within normal limits. Physical examination shows no abnormalities. Laboratory studies show:
Serum
Na+ 130 mEq/L
Glucose 110 mg/dL
Osmolality 265 mOsmol/kg
Urine
Osmolality 230 mOsmol/kg
The patient is asked to stop drinking water for 3 hours. Following water restriction, urine osmolality is measured every hour, whereas serum osmolality is measured every 2 hours. Repeated laboratory measurements show a serum osmolality of 280 mOsmol/kg and a urine osmolality of 650 mOsmol/kg. Which of the following is the most likely diagnosis?
Q567
A 41-year-old woman comes to the physician because of a 3-month history of anxiety, difficulty falling asleep, heat intolerance, and a 6-kg (13.2-lb) weight loss. The patient's nephew, who is studying medicine, mentioned that her symptoms might be caused by a condition that is due to somatic activating mutations of the genes for the TSH receptor. Examination shows warm, moist skin and a 2-cm, nontender, subcutaneous mass on the anterior neck. Which of the following additional findings should most raise concern for a different underlying etiology of her symptoms?
Q568
A 65-year-old man comes to the physician because of double vision that began this morning. He has hypertension and type 2 diabetes mellitus. He has smoked two packs of cigarettes daily for 40 years. His current medications include lisinopril, metformin, and insulin. Physical examination shows the right eye is abducted and depressed with slight intorsion. Visual acuity is 20/20 in both eyes. Extraocular movements of the left eye are normal. Serum studies show a hemoglobin A1c of 11.5%. Which of the following additional findings is most likely in this patient?
Q569
Immediately after undergoing a right total knee replacement, a 69-year-old woman has severe abdominal pain, non-bloody emesis, and confusion. She has a history of Hashimoto thyroiditis that is well-controlled with levothyroxine and hyperlipidemia that is controlled by diet. She underwent bunion removal surgery from her right foot 10 years ago. Her temperature is 39°C (102.2°F), pulse is 120/min, and blood pressure is 60/30 mm Hg. Abdominal examination shows a diffusely tender abdomen with normal bowel sounds. She is confused and oriented to person but not place or time. Laboratory studies are pending. Which of the following is the most appropriate next step in the management of this patient?
Q570
A 62-year-old man comes to the physician because of painless swelling in his left foot for 4 months. The swelling was initially accompanied by redness, which has since resolved. He has not had fever or chills. He has a history of coronary artery disease, hyperlipidemia, and type 2 diabetes mellitus. He has had 3 sexual partners over the past year and uses condoms inconsistently. His mother had rheumatoid arthritis. Current medications include clopidogrel, aspirin, metoprolol, losartan, atorvastatin, and insulin. He is 180 cm (5 ft 11 in) tall and weighs 95 kg (209 lb); BMI is 29 kg/m2. Vital signs are within normal limits. Cardiovascular examination shows no abnormalities. Examination of the feet shows swelling of the left ankle with collapse of the midfoot arch and prominent malleoli. There is no redness or warmth. There is a small, dry ulcer on the left plantar surface of the 2nd metatarsal. Monofilament testing shows decreased sensation along both feet up to the shins bilaterally. His gait is normal. Which of the following is the most likely diagnosis?
Cardiology US Medical PG Practice Questions and MCQs
Question 561: A 27-year-old man from Southern California presents with progressive chest pain, non-productive cough, and shortness of breath for the past 24 hours. He denies any similar symptoms in the past. He denies any family history of cardiac disease, recent travel, or exposure to sick contacts. His temperature is 38.5°C (101.3°F), pulse is 105/min, blood pressure is 108/78 mm Hg, and the respiratory rate is 32/min. On physical examination, patient is cachectic and ill-appearing. Bilateral pleural friction rubs are present on pulmonary auscultation. Antecubital track marks are noted bilaterally. An echocardiogram is performed and results are shown below. Which of the following is the most likely diagnosis in this patient?
A. Infective endocarditis (Correct Answer)
B. Pulmonary embolism
C. Histoplasmosis
D. Hypertrophic cardiomyopathy
E. Tuberculosis
Explanation: ***Infective endocarditis***
- The patient's presentation with **fever, new chest pain, dyspnea, and bilateral pleural friction rubs** in the setting of **antecubital track marks** strongly suggests infective endocarditis with possible septic emboli to the lungs.
- The echocardiogram image shows a **vegetation (white arrow labeled 'veg')** on the tricuspid valve, which is characteristic of right-sided infective endocarditis often seen in **intravenous drug users**.
*Pulmonary embolism*
- While pulmonary embolism can cause **chest pain and shortness of breath**, it typically presents with sudden onset symptoms and is less likely to cause a **fever** to this degree or **pleural friction rubs** without an underlying infection.
- The presence of a **cardiac vegetation** on echocardiogram points away from an isolated pulmonary embolism as the primary diagnosis.
*Histoplasmosis*
- **Histoplasmosis** is a fungal infection that can cause pulmonary symptoms and fever, particularly in endemic areas (not typically Southern California).
- It does not typically present with **pleural friction rubs** or **cardiac vegetations**, which are key findings in this patient.
*Hypertrophic cardiomyopathy*
- **Hypertrophic cardiomyopathy** is a genetic heart condition causing thickening of the heart muscle, leading to symptoms like chest pain and shortness of breath, often exacerbated by exertion.
- It does not cause **fever, track marks, pleural friction rubs**, or **infectious vegetations** on heart valves.
*Tuberculosis*
- **Tuberculosis** can cause chronic cough, fever, and weight loss (patient is cachectic), but it usually has a more insidious onset than 24 hours and is less likely to cause **acute chest pain** and **pleural friction rubs** without specific findings like effusions or cavitary lesions.
- It does not explain the **cardiac vegetation** or the **antecubital track marks**, which are highly suggestive of intravenous drug use and associated endocarditis.
Question 562: A 19-year-old man presents to the emergency department after 2 separate episodes of loss of consciousness. The first episode occurred 1 year ago while he was running in gym class. Witnesses reported clenching and shaking of both hands after he had fallen. On getting up quickly, he felt lightheaded, nauseated, and sweaty. He was given intravenous phenytoin because of concern that he may have had a seizure. His electroencephalogram was negative, and he was not started on long-term antiepileptics. One year later, a second episode of loss of consciousness occurred while playing dodgeball. He experienced a similar prodrome of lightheadedness and sweating. He has no history of seizures outside of these 2 episodes. Family history is non-contributory. He has a temperature of 37.0°C (98.6°F), a blood pressure of 110/72 mm Hg, and a pulse of 80/min. Physical examination is unremarkable. His 12-lead ECG shows normal sinus rhythm without any other abnormalities. Which of the following is the best next step in this patient?
A. Head-up tilt-table test
B. Dix-Hallpike maneuver
C. 24-hour Holter monitoring
D. Head computerized tomography (CT)
E. Echocardiography (Correct Answer)
Explanation: ***Echocardiography***
- This patient presents with **exertional syncope** (occurring during running and dodgeball), which is a **red flag** for cardiac causes and requires urgent evaluation for structural heart disease.
- **Hypertrophic cardiomyopathy (HCM)** is the most common cause of sudden cardiac death in young athletes and classically presents with exertional syncope.
- **Echocardiography** is the best initial test to evaluate for structural abnormalities including HCM, arrhythmogenic right ventricular cardiomyopathy (ARVC), valvular disease, and other cardiac causes.
- While the patient has a prodrome suggestive of vasovagal syncope, **exertional triggers mandate ruling out life-threatening cardiac conditions first** before attributing symptoms to benign causes.
*Head-up tilt-table test*
- Tilt-table testing is the gold standard for diagnosing **vasovagal (neurocardiogenic) syncope**.
- It is most appropriate for **non-exertional syncope** with typical prodrome after cardiac causes have been excluded.
- In this case with **exertional syncope**, cardiac evaluation must take priority, making tilt-table testing premature at this stage.
*Dix-Hallpike maneuver*
- This maneuver diagnoses **benign paroxysmal positional vertigo (BPPV)**, which causes brief episodes of vertigo triggered by head position changes.
- BPPV does not cause **loss of consciousness** or **tonic-clonic movements**, making this inappropriate for this presentation.
*24-hour Holter monitoring*
- Holter monitoring can detect cardiac arrhythmias that may cause syncope.
- While potentially useful in the workup, **echocardiography should be performed first** to evaluate for structural heart disease in exertional syncope.
- Holter monitoring has relatively low yield unless symptoms occur during the monitoring period; an exercise stress test or event monitor may be more appropriate if initial structural evaluation is normal.
*Head computerized tomography (CT)*
- Head CT evaluates for structural intracranial pathology such as hemorrhage, mass lesions, or stroke.
- The patient's **normal EEG**, **clear exertional triggers**, and **typical vasovagal prodrome** make primary neurological causes unlikely.
- Seizures rarely occur exclusively during exercise, and the clinical picture is more consistent with syncope (with convulsive movements due to cerebral hypoperfusion) rather than primary seizure disorder.
Question 563: A 35-year-old woman is brought to the emergency department for a severe, left-sided headache and neck pain that started 24 hours after she completed a half-marathon. Shortly after the headache started, she also had weakness of her right upper extremity and sudden loss of vision in her left eye, which both subsided on her way to the hospital. On arrival, she is alert and oriented to person, place, and time. Her temperature is 37.3°C (99.1°F), pulse is 77/min, respiratory rate is 20/min, and blood pressure is 160/90 mm Hg. Examination shows drooping of the left eyelid and a constricted left pupil. Visual acuity in both eyes is 20/20. There is no swelling of the optic discs. Muscle strength and deep tendon reflexes are normal bilaterally. A noncontrast CT scan of the head shows no abnormalities. Duplex ultrasonography of the neck shows absence of flow in the left internal carotid artery. Administration of which of the following is the most appropriate next step in management?
A. Alteplase
B. Sumatriptan
C. Mannitol
D. Heparin (Correct Answer)
E. Aspirin
Explanation: ***Heparin***
- The patient's presentation with headache, neck pain, Horner syndrome (left eyelid drooping and constricted pupil), transient right upper extremity weakness, and left eye vision loss following a half-marathon, along with imaging showing **absence of flow in the left internal carotid artery**, is highly suggestive of **carotid artery dissection**.
- **Anticoagulation with heparin** is an appropriate initial management option to prevent thromboembolic complications such as stroke, especially given the acute symptoms and confirmed dissection without signs of intracranial hemorrhage on CT.
- **Current guidelines** indicate that both anticoagulation (heparin/warfarin) and antiplatelet therapy (aspirin) are acceptable for carotid dissection, with **no definitive evidence showing superiority of one over the other**. Heparin may be preferred in acute settings with recent symptoms or when there are fluctuating/progressive neurological deficits.
*Aspirin*
- **Aspirin** is an **antiplatelet agent** that is also an acceptable treatment option for carotid artery dissection and is increasingly used as first-line therapy in many centers.
- While aspirin would be appropriate, in this acute presentation with recent transient neurological deficits (within 24 hours), some clinicians prefer **initial anticoagulation with heparin** to more aggressively prevent thrombus propagation and recurrent embolic events during the hyperacute phase.
- Either aspirin or heparin would be defensible choices; heparin is selected here given the very recent onset and transient focal deficits suggesting active thromboembolic risk.
*Alteplase*
- **Alteplase** is a **thrombolytic agent** used in acute ischemic stroke within a narrow time window (typically 3-4.5 hours from symptom onset).
- It is **contraindicated in arterial dissection** due to high risk of hemorrhage and extension of the dissection.
- The patient's symptoms are transient and have resolved, and there is no evidence of acute, disabling ischemic stroke that would warrant thrombolysis.
*Sumatriptan*
- **Sumatriptan** is a **triptan derivative** used for acute treatment of migraine headaches.
- While the patient has severe headache, the associated neurological deficits (Horner syndrome, transient weakness and vision loss) and confirmed **carotid dissection on imaging** indicate a serious vascular pathology rather than primary migraine.
- Sumatriptan is actually **contraindicated** in patients with cerebrovascular disease due to its vasoconstrictive effects.
*Mannitol*
- **Mannitol** is an **osmotic diuretic** used to reduce intracranial pressure in cases of cerebral edema or elevated intracranial pressure.
- The patient's noncontrast CT scan showed no abnormalities, indicating no signs of mass effect, hemorrhage, or cerebral edema, making mannitol unnecessary.
Question 564: A 33-year-old Caucasian female presents to her primary care provider for pruritus and shortness of breath. Over the past year, she has experienced mild progressive diffuse pruritus. She also reports that her skin seems "hard" and that it has been harder to move her fingers freely. She initially attributed her symptoms to stress at work as a commercial pilot, but when her symptoms began impacting her ability to fly, she decided to seek treatment. She has a history of major depressive disorder and takes citalopram. She smokes 1 pack per day and drinks socially. Her temperature is 98.6°F (37°C), blood pressure is 148/88 mmHg, pulse is 83/min, and respirations are 21/min. On exam, she appears anxious with increased work of breathing. Dry rales are heard at her lung bases bilaterally. Her fingers appear shiny and do not have wrinkles on the skin folds. A normal S1 and S2 are heard on cardiac auscultation. This patient's condition is most strongly associated with which of the following antibodies?
A. Anti-DNA topoisomerase I (Correct Answer)
B. Anti-double-stranded DNA
C. Anti-U1-ribonucleoprotein
D. Anti-SS-A
E. Anti-cyclic citrullinated peptide
Explanation: ***Anti-DNA topoisomerase I***
- The patient's symptoms of **pruritus**, **"hard" skin**, difficulty moving fingers, and **dry rales at lung bases** are highly suggestive of **systemic sclerosis (scleroderma)**, particularly the **diffuse cutaneous systemic sclerosis** type.
- **Anti-DNA topoisomerase I** (also known as **anti-Scl-70**) antibodies are strongly associated with **diffuse cutaneous systemic sclerosis** and are often linked to a higher risk of **interstitial lung disease**, correlating with the observed shortness of breath and dry rales.
*Anti-double-stranded DNA*
- **Anti-double-stranded DNA (anti-dsDNA)** antibodies are a hallmark of **systemic lupus erythematosus (SLE)**.
- While SLE can cause skin changes and shortness of breath (e.g., pleuritis, interstitial lung disease), the specific presentation of **"hard" skin** and **lack of wrinkles in skin folds** is much more indicative of scleroderma than SLE.
*Anti-U1-ribonucleoprotein*
- **Anti-U1-ribonucleoprotein (anti-U1-RNP)** antibodies are primarily associated with **mixed connective tissue disease (MCTD)**.
- MCTD can have overlapping features of systemic sclerosis, SLE, and polymyositis, but the predominant and severe **skin hardening** with **lung involvement** described points more directly to scleroderma.
*Anti-SS-A*
- **Anti-SS-A (Ro) antibodies** are primarily associated with **Sjögren's syndrome**, a chronic autoimmune disease affecting exocrine glands, leading to dry eyes and dry mouth.
- They can also be present in SLE and neonatal lupus, but are **not typically associated with the extensive skin hardening and significant lung fibrosis** seen in this patient.
*Anti-cyclic citrullinated peptide*
- **Anti-cyclic citrullinated peptide (anti-CCP)** antibodies are highly specific for **rheumatoid arthritis (RA)**.
- RA primarily causes **inflammatory arthritis** affecting synovial joints, and while it can have extra-articular manifestations, the patient's symptoms of diffuse skin hardening, pruritus, and specific lung findings do not fit the typical presentation of RA.
Question 565: A 22-year-old woman comes to the physician because of 1 week of progressive left anterior knee pain. The pain is worse after sitting for a prolonged period of time and while ascending stairs. She first noticed the pain the day after a basketball game. She has often taken painful blows to the side of the knees while playing basketball but does not recall this having happened in the last game. Four weeks ago, she was diagnosed with a chlamydial urinary tract infection and treated with azithromycin. She is sexually active with one male partner; they use condoms inconsistently. Her vital signs are within normal limits. She is 178 cm (5 ft 10 in) tall and weighs 62 kg (137 lb); BMI is 19.6 kg/m2. Physical examination shows tenderness over the left anterior knee that is exacerbated with anterior pressure to the patella when the knee is fully extended; there is no erythema or swelling. Which of the following is the most likely diagnosis?
A. Osgood-Schlatter disease
B. Patellofemoral pain syndrome (Correct Answer)
C. Patellar tendinitis
D. Medial collateral ligament injury
E. Anterior cruciate ligament injury
Explanation: **_Patellofemoral pain syndrome_**
- The patient's symptoms of **anterior knee pain worse with prolonged sitting and ascending stairs**, along with **tenderness over the anterior knee exacerbated by patellar pressure**, are classic for **patellofemoral pain syndrome (PFPS)**.
- PFPS is often triggered by changes in activity level, such as increased basketball playing, and is common in young, active individuals.
*Osgood-Schlatter disease*
- This condition typically presents with localized pain and swelling at the **tibial tubercle**, which is the insertion site of the patellar tendon.
- It is more common in **adolescent males** undergoing growth spurts and is caused by repetitive stress on the immature apophysis, which does not fit this patient's age or presentation.
*Patellar tendinitis*
- **Patellar tendinitis** (jumper's knee) causes pain directly over the **patellar tendon**, usually just below the patella, especially with jumping and running.
- While it can be related to athletic activity, the characteristic feature is **pain on palpation of the patellar tendon itself**, rather than just the anterior knee or patellar compression.
*Medial collateral ligament injury*
- An injury to the **medial collateral ligament (MCL)** typically presents with pain and tenderness along the **medial side of the knee**.
- It is usually caused by a direct valgus stress to the knee, and physical examination would reveal **pain with valgus stress testing**, which is not described.
*Anterior cruciate ligament injury*
- An **anterior cruciate ligament (ACL) injury** usually results from a mechanism involving **sudden twisting or hyperextension** of the knee and is often associated with a **'popping' sensation** and significant knee instability.
- The primary complaint is instability, and physical examination would show a **positive Lachman or anterior drawer test**, which is not consistent with the patient's symptoms.
Question 566: A 30-year-old woman comes to the physician because of increased urinary frequency over the past month. She also reports having dry mouth and feeling thirsty all the time despite drinking several liters of water per day. She has not had any weight changes and her appetite is normal. She has a history of obsessive compulsive disorder treated with citalopram. She drinks 1–2 cans of beer per day. Her vital signs are within normal limits. Physical examination shows no abnormalities. Laboratory studies show:
Serum
Na+ 130 mEq/L
Glucose 110 mg/dL
Osmolality 265 mOsmol/kg
Urine
Osmolality 230 mOsmol/kg
The patient is asked to stop drinking water for 3 hours. Following water restriction, urine osmolality is measured every hour, whereas serum osmolality is measured every 2 hours. Repeated laboratory measurements show a serum osmolality of 280 mOsmol/kg and a urine osmolality of 650 mOsmol/kg. Which of the following is the most likely diagnosis?
A. Diabetes mellitus
B. Central diabetes insipidus
C. Primary polydipsia (Correct Answer)
D. Cerebral salt wasting
E. Nephrogenic diabetes insipidus
Explanation: ***Primary polydipsia***
- The patient's initial **hyponatremia** (Na+ 130 mEq/L) and low serum osmolality (265 mOsmol/kg) with **inappropriately dilute urine** (urine osmolality 230 mOsmol/kg) in the context of excessive water intake (several liters per day) is characteristic of primary polydipsia.
- The ability to concentrate urine significantly after water restriction (urine osmolality increasing to 650 mOsmol/kg) indicates that the **kidneys can respond to ADH** and that ADH secretion is intact, ruling out diabetes insipidus.
*Diabetes mellitus*
- This condition is characterized by **elevated blood glucose levels**, which are absent in this patient (glucose 110 mg/dL is normal).
- While diabetes mellitus causes polyuria and polydipsia, the specific laboratory findings (normal glucose and ability to concentrate urine after water restriction) are inconsistent with this diagnosis.
*Central diabetes insipidus*
- Patients with central DI would have **initially dilute urine** and would **not be able to concentrate urine** significantly in response to water restriction alone.
- The patient's urine osmolality significantly increased (from 230 to 650 mOsmol/kg) after water restriction, indicating intact ADH secretion and kidney responsiveness.
*Cerebral salt wasting*
- This condition typically presents with **hyponatremia** and **dehydration**, often following brain injury or neurosurgery.
- Patients usually have elevated urinary sodium excretion and clinical signs of volume depletion (hypotension, tachycardia), which are not present in this case.
*Nephrogenic diabetes insipidus*
- In nephrogenic DI, the **kidneys do not respond to ADH**, meaning urine osmolality would remain dilute even after water restriction and exogenous ADH administration.
- The patient's ability to achieve concentrated urine (650 mOsmol/kg) after water restriction rules out this diagnosis.
Question 567: A 41-year-old woman comes to the physician because of a 3-month history of anxiety, difficulty falling asleep, heat intolerance, and a 6-kg (13.2-lb) weight loss. The patient's nephew, who is studying medicine, mentioned that her symptoms might be caused by a condition that is due to somatic activating mutations of the genes for the TSH receptor. Examination shows warm, moist skin and a 2-cm, nontender, subcutaneous mass on the anterior neck. Which of the following additional findings should most raise concern for a different underlying etiology of her symptoms?
A. Atrial fibrillation
B. Hyperreflexia
C. Nonpitting edema (Correct Answer)
D. Fine tremor
E. Lid lag
Explanation: ***Nonpitting edema***
- Nonpitting edema, often referred to as **myxedema**, is a classic sign of **hypothyroidism**, not hyperthyroidism.
- The patient's symptoms (anxiety, insomnia, heat intolerance, weight loss) are indicative of **hyperthyroidism**, making myxedema an inconsistent finding that suggests a different underlying etiology.
*Atrial fibrillation*
- **Atrial fibrillation** is a common cardiovascular manifestation of **hyperthyroidism** due to the direct effects of thyroid hormones on the heart.
- Its presence would support, rather than contradict, the suspected diagnosis of hyperthyroidism.
*Hyperreflexia*
- **Hyperreflexia** is a neurological finding often associated with the hypermetabolic state of **hyperthyroidism**.
- Increased thyroid hormone levels can enhance neural excitability, making hyperreflexia an expected finding.
*Fine tremor*
- A **fine tremor** is a common and characteristic symptom of **hyperthyroidism**, resulting from increased adrenergic activity.
- This finding would be consistent with the patient's other symptoms of thyroid overactivity.
*Lid lag*
- **Lid lag** is an ocular sign of **hyperthyroidism**, caused by sympathetic overstimulation of the Müller's muscle in the eyelid.
- While not indicative of Graves' ophthalmopathy, it is a common finding in thyrotoxicosis and would be consistent with the patient's clinical picture.
Question 568: A 65-year-old man comes to the physician because of double vision that began this morning. He has hypertension and type 2 diabetes mellitus. He has smoked two packs of cigarettes daily for 40 years. His current medications include lisinopril, metformin, and insulin. Physical examination shows the right eye is abducted and depressed with slight intorsion. Visual acuity is 20/20 in both eyes. Extraocular movements of the left eye are normal. Serum studies show a hemoglobin A1c of 11.5%. Which of the following additional findings is most likely in this patient?
A. Absent direct light reaction on the right eye
B. Upper eyelid droop on the right eye (Correct Answer)
C. Absent consensual light reaction on the right eye
D. Loss of the right nasolabial fold
E. Loss of smell
Explanation: ***Upper eyelid droop on the right eye***
- The patient's presentation of a right eye that is **abducted and depressed** with risk factors of **poorly controlled diabetes** (HbA1c 11.5%) and **hypertension** strongly suggests an **ischemic oculomotor nerve (CN III) palsy**.
- In **ischemic CN III palsy** (microvascular, as seen in diabetes), the **motor fibers** are affected, causing **ptosis (upper eyelid droop)** and abnormal eye position (down and out).
- Crucially, the **parasympathetic fibers** (which control pupil constriction and run on the periphery of CN III) are typically **spared** in ischemic palsy because they have different blood supply and are located peripherally, making them more vulnerable to compressive lesions but resistant to ischemic injury.
- Therefore, **ptosis is expected** while pupils remain reactive to light.
*Absent direct light reaction on the right eye*
- An absent direct light reaction would indicate **pupillary involvement** from parasympathetic fiber dysfunction.
- This finding is characteristic of **compressive CN III palsy** (e.g., posterior communicating artery aneurysm), where external compression affects the peripheral parasympathetic fibers first.
- In this patient with **ischemic CN III palsy** due to diabetes, the pupil is typically **spared** (remains reactive), making this finding unlikely.
*Absent consensual light reaction on the right eye*
- This would also indicate **parasympathetic fiber involvement** and pupillary dysfunction.
- As with the direct light reaction, pupils are typically **spared in ischemic CN III palsy**, so this finding is unlikely in this diabetic patient.
- The "pupil-sparing" nature of diabetic CN III palsy is a key distinguishing feature from compressive causes.
*Loss of the right nasolabial fold*
- Loss of the nasolabial fold indicates **facial nerve (CN VII) palsy**, causing weakness of facial expression muscles.
- This is unrelated to the **oculomotor nerve dysfunction** described and would not explain the eye movement abnormalities.
*Loss of smell*
- Loss of smell (**anosmia**) indicates **olfactory nerve (CN I) dysfunction**.
- This is completely unrelated to the ocular motor findings and is not associated with CN III palsy.
Question 569: Immediately after undergoing a right total knee replacement, a 69-year-old woman has severe abdominal pain, non-bloody emesis, and confusion. She has a history of Hashimoto thyroiditis that is well-controlled with levothyroxine and hyperlipidemia that is controlled by diet. She underwent bunion removal surgery from her right foot 10 years ago. Her temperature is 39°C (102.2°F), pulse is 120/min, and blood pressure is 60/30 mm Hg. Abdominal examination shows a diffusely tender abdomen with normal bowel sounds. She is confused and oriented to person but not place or time. Laboratory studies are pending. Which of the following is the most appropriate next step in the management of this patient?
A. High-dose hydrocortisone
B. Exploratory laparotomy
C. CT angiogram of the abdomen
D. Noncontrast CT of the head
E. Intravenous isotonic saline infusion (Correct Answer)
Explanation: ***Intravenous isotonic saline infusion***
- The patient presents with **shock** (BP 60/30 mm Hg, pulse 120/min, confusion), which is immediately life-threatening and requires urgent intervention.
- **IV fluid resuscitation** is the **first priority** in any shock state to restore intravascular volume, improve tissue perfusion, and stabilize hemodynamics.
- While this patient has features concerning for **acute adrenal crisis** (Hashimoto thyroiditis with possible polyglandular autoimmune syndrome, post-surgical stress, fever, hypotension, confusion), **fluid resuscitation must be initiated immediately** before or concurrent with other therapies.
- In practice, **high-dose hydrocortisone should be given simultaneously** with fluids, but restoring circulating volume is the foundational first step.
*High-dose hydrocortisone*
- This patient has **Hashimoto thyroiditis** and presents with shock after major surgery (a known precipitant), raising strong suspicion for **acute adrenal crisis**.
- Patients with autoimmune thyroid disease can have concurrent **autoimmune adrenal insufficiency** (Schmidt syndrome/APS-2).
- **Hydrocortisone is critical** and should be given immediately (typically 100 mg IV), but **not before addressing the shock state** with fluid resuscitation.
- This would be the appropriate **second step** or given concurrently with fluids.
*Exploratory laparotomy*
- While the patient has **severe abdominal pain** and **diffuse tenderness**, the overall presentation (fever, hypotension, post-op state) suggests **medical shock** rather than a surgical emergency.
- **Normal bowel sounds** make mechanical obstruction or perforation less likely.
- Surgery is inappropriate until the patient is hemodynamically stabilized and a surgical cause is confirmed.
*CT angiogram of the abdomen*
- This could evaluate for **mesenteric ischemia**, but the patient is **too unstable** for imaging.
- The clinical picture better fits **adrenal crisis** or **septic shock** rather than vascular catastrophe.
- **Delaying resuscitation** for imaging in a patient with severe hypotension would be harmful.
*Noncontrast CT of the head*
- The patient's **confusion** is most likely due to **hypoperfusion** and **shock** rather than a primary intracranial process.
- **Altered mental status** is a common manifestation of shock and adrenal crisis.
- Cerebral perfusion depends on adequate systemic blood pressure, making **circulatory stabilization the priority**.
Question 570: A 62-year-old man comes to the physician because of painless swelling in his left foot for 4 months. The swelling was initially accompanied by redness, which has since resolved. He has not had fever or chills. He has a history of coronary artery disease, hyperlipidemia, and type 2 diabetes mellitus. He has had 3 sexual partners over the past year and uses condoms inconsistently. His mother had rheumatoid arthritis. Current medications include clopidogrel, aspirin, metoprolol, losartan, atorvastatin, and insulin. He is 180 cm (5 ft 11 in) tall and weighs 95 kg (209 lb); BMI is 29 kg/m2. Vital signs are within normal limits. Cardiovascular examination shows no abnormalities. Examination of the feet shows swelling of the left ankle with collapse of the midfoot arch and prominent malleoli. There is no redness or warmth. There is a small, dry ulcer on the left plantar surface of the 2nd metatarsal. Monofilament testing shows decreased sensation along both feet up to the shins bilaterally. His gait is normal. Which of the following is the most likely diagnosis?
A. Diabetic arthropathy (Correct Answer)
B. Rheumatoid arthritis
C. Tertiary syphilis
D. Calcium pyrophosphate arthropathy
E. Reactive arthritis
Explanation: ***Diabetic arthropathy***
- This patient's long-standing **diabetes mellitus** and presence of **peripheral neuropathy** (decreased sensation on monofilament testing) strongly predispose him to **Charcot arthropathy**, a form of diabetic arthropathy.
- The classic presentation includes painless swelling, **collapse of the midfoot arch** (rocker-bottom foot), prominent malleoli, and sometimes a **plantar ulcer**, all of which are present in this patient.
*Rheumatoid arthritis*
- Rheumatoid arthritis typically presents with **bilateral, symmetrical polyarthritis**, usually affecting smaller joints of the hands and feet, and often has morning stiffness. This patient has unilateral foot swelling.
- While his mother had RA, his presentation with painless swelling, neuropathy, and specific foot deformities points away from typical RA.
*Tertiary syphilis*
- Tertiary syphilis can cause **Charcot joints (neuroarthropathy)**, similar to diabetes, but the patient's presentation is more consistent with diabetic complications given his medical history.
- Although the patient has a history of inconsistent condom use, there are no other symptoms suggestive of syphilis such as **tabes dorsalis** or **gummas**.
*Calcium pyrophosphate arthropathy*
- This condition (pseudogout) is caused by the deposition of **calcium pyrophosphate crystals** in joints and typically presents with acute, painful inflammation.
- The patient's swelling has been painless and chronic, and imaging would be needed to confirm crystal deposition, which is not suggested by the clinical picture.
*Reactive arthritis*
- Reactive arthritis typically presents as an **acute inflammatory oligoarthritis** often following a genitourinary or gastrointestinal infection, and is usually painful.
- While the patient has a history of inconsistent condom use, there are no symptoms of a preceding infection (e.g., urethritis, conjunctivitis, diarrhea) and the chronic, painless nature of the swelling is inconsistent with reactive arthritis.
