A 58-year-old woman presents to her primary care physician with complaints of an aching pain and stiffness in her neck, shoulders, and hips for the past several months. She reports difficulty in rising from a seated position as well as in raising her arms above her head. The patient also states that she has had fatigue and chronic fevers for the past month. Close and careful physical examination reveals normal muscle strength (despite some pain with testing and palpation), but limited range of motion of the neck, shoulders, and hips. There is no evidence in the history or physical examination of giant cell (temporal) arteritis. An initial work-up reveals a hemoglobin of 9 g/dL on a complete blood count. Further laboratory results are still pending. Which of the following results would be expected in the work-up of this patient's presenting condition?
Q642
A 23-year-old man is admitted to the intensive care unit with acute respiratory distress syndrome (ARDS) due to influenza A. He has no history of serious illness and does not smoke. An x-ray of the chest shows diffuse bilateral infiltrates. Two weeks later, his symptoms have improved. Pulmonary examination on discharge shows inspiratory crackles at both lung bases. This patient is most likely to develop which of the following long-term complications?
Q643
A 28-year-old woman presents with a 12-month history of headache, tinnitus, retrobulbar pain, and photopsias. She says the headaches are mild to moderate, intermittent, diffusely localized, and refractory to nonsteroidal anti-inflammatory drugs (NSAIDs). In addition, this past week, she began to have associated dizziness and photopsia with the headaches. Physical examination reveals a body temperature of 36.5°C (97.7°F), blood pressure of 140/80 mm Hg, and a respiratory rate of 13/min and regular. BMI is 29 kg/m2. Neurological examination is significant for peripheral visual field loss in the inferior nasal quadrant, diplopia, bilateral abducens nerve palsy, and papilledema. A T1/T2 MRI of the brain did not identify extra-axial or intra-axial masses or interstitial edema, and a lumbar puncture showed an opening pressure of 27 cm H2O, with a cerebrospinal fluid analysis within the normal range. Which of the following best describes the pathogenic mechanism underlying these findings?
Q644
A 79-year-old woman with type 2 diabetes mellitus and hypertension undergoes 99mTc cardiac scintigraphy for the evaluation of a 3-month history of retrosternal chest tightness on exertion. The patient's symptoms are reproduced following the administration of dipyridamole. A repeat ECG shows new ST depression and T wave inversion in leads V5 and V6. Which of the following is the most likely underlying mechanism of this patient's signs and symptoms during the procedure?
Q645
A 42-year-old woman with hypertension comes to the physician because of a 2-month history of persistent reddening of her face, daytime fatigue, and difficulty concentrating. She has fallen asleep multiple times during important meetings. Her only medication is lisinopril. She is 170 cm (5 ft 7 in) tall and weighs 88 kg (194 lb); BMI is 30 kg/m2. Her blood pressure is 145/85 mm Hg. Physical examination shows erythema of the face that is especially pronounced around the cheeks, nose, and ears. Serum glucose concentration is 120 mg/dL. Which of the following is the most likely cause of this patient's facial discoloration?
Q646
A 57-year-old woman presents to her physician’s office because she is coughing up blood. She says that she first observed a somewhat reddish sputum a few months ago. However, over the past couple of weeks, the amount of blood she coughs has significantly increased. She has been smoking for the past 30 years. She says that she smokes about 2 packs of cigarettes daily. She does not have fever, night sweats, weight loss, or chills. She reports progressive difficulty in breathing. On examination, her vital signs are stable. On auscultation of her chest, she has an expiratory wheeze. Oxygen saturation is 98%. Which of the following would be the next best step in the management of this patient?
Q647
A 46-year-old woman presents to her primary care physician for her annual examination. At her prior exam one year earlier, she had a Pap smear which was within normal limits. Which of the following health screenings is recommended for this patient?
Q648
A 72-year-old man presents to the emergency department after a fall. The patient was found lying down on the floor in his room in his retirement community. The patient has a past medical history of Alzheimer dementia and a prosthetic valve. His current medications include donepezil and warfarin. His temperature is 97.7°F (36.5°C), blood pressure is 85/50 mmHg, pulse is 160/min, respirations are 13/min, and oxygen saturation is 97% on room air. The patient is started on IV fluids and a type and screen is performed. Laboratory values are ordered as seen below.
Hemoglobin: 13 g/dL
Hematocrit: 39%
Leukocyte count: 5,500 cells/mm^3 with normal differential
Platelet count: 225,000/mm^3
INR: 2.5
AST: 10 U/L
ALT: 12 U/L
A chest radiograph and EKG are performed and are within normal limits. A full physical exam is within normal limits. The patient's vitals are repeated. His temperature is 99.5°F (37.5°C), blood pressure is 110/70 mmHg, pulse is 90/min, respirations are 10/min, and oxygen saturation is 98% on room air. Which of the following is the best next step in management?
Q649
A 59-year-old man with angina pectoris comes to the physician because of a 6-month history of shortness of breath on exertion that improves with rest. He has hypertension and hyperlipidemia. Current medications include aspirin, metoprolol, and nitroglycerine. Echocardiography shows left ventricular septal and apical hypokinesis. Cardiac catheterization shows 96% occlusion of the left anterior descending artery. The patient undergoes angioplasty and placement of a stent. The patient's shortness of breath subsequently resolves and follow-up echocardiography one week later shows normal regional contractile function. Which of the following is the most accurate explanation for the changes in echocardiography?
Q650
A 78-year-old man presents with fatigue and exertional dyspnea. The patient says that symptoms onset gradually 4 weeks ago and have not improved. He denies any history of anemia or nutritional deficiency. Past medical history is significant for ST-elevation myocardial infarction 6 months ago, status post coronary artery bypass graft, complicated by recurrent hemodynamically unstable ventricular tachycardia. Current medications are rosuvastatin, aspirin, and amiodarone. His blood pressure is 100/70 mm Hg, the pulse is 71/min, the temperature is 36.5°C (97.7°F), and the respiratory rate is 16/min. On physical examination, patient appears lethargic and tired. Skin is dry and coarse, and there is generalized pitting edema present. A complete blood count (CBC) and a peripheral blood smear show evidence of normochromic, normocytic anemia. Additional laboratory tests reveal decreased serum level of iron, decreased TIBC (total iron-binding capacity) and increased serum level of ferritin. Which of the following is the most likely etiology of the anemia in this patient?
Cardiology US Medical PG Practice Questions and MCQs
Question 641: A 58-year-old woman presents to her primary care physician with complaints of an aching pain and stiffness in her neck, shoulders, and hips for the past several months. She reports difficulty in rising from a seated position as well as in raising her arms above her head. The patient also states that she has had fatigue and chronic fevers for the past month. Close and careful physical examination reveals normal muscle strength (despite some pain with testing and palpation), but limited range of motion of the neck, shoulders, and hips. There is no evidence in the history or physical examination of giant cell (temporal) arteritis. An initial work-up reveals a hemoglobin of 9 g/dL on a complete blood count. Further laboratory results are still pending. Which of the following results would be expected in the work-up of this patient's presenting condition?
A. Normal erythrocyte sedimentation rate and normal serum creatinine kinase
B. Elevated serum C-reactive protein and normal erythrocyte sedimentation rate
C. Normal erythrocyte sedimentation rate and elevated serum creatine kinase
D. Elevated erythrocyte sedimentation rate and normal serum creatine kinase (Correct Answer)
E. Elevated erythrocyte sedimentation rate and elevated serum creatine kinase
Explanation: ***Elevated erythrocyte sedimentation rate and normal serum creatine kinase***
- **Polymyalgia Rheumatica (PMR)** is characterized by an **elevated erythrocyte sedimentation rate (ESR)** and/or **C-reactive protein (CRP)**, reflecting the underlying inflammatory process.
- **Creatine kinase (CK)** levels are typically **normal** in PMR, as the condition primarily involves inflammation of the synovium, bursae, and joint capsules, rather than direct muscle fiber damage.
*Elevated erythrocyte sedimentation rate and elevated serum creatine kinase*
- While an **elevated ESR** is characteristic of PMR, an **elevated CK** would suggest a primary muscle disorder like **polymyositis** or **dermatomyositis**, which is not supported by the clinical picture of *normal muscle strength* despite pain.
- The patient's inability to raise arms and difficulty rising point to **tendon/bursal inflammation** not myonecrosis.
*Normal erythrocyte sedimentation rate and normal serum creatine kinase*
- A **normal ESR** would make the diagnosis of PMR highly unlikely, as it is a key diagnostic criterion and indicator of inflammation.
- While **normal CK** is consistent with PMR, the absence of an elevated ESR would lead away from an inflammatory condition.
*Elevated serum C-reactive protein and normal erythrocyte sedimentation rate*
- Although **elevated CRP** is common in PMR, a **normal ESR** would be unusual, as both markers of inflammation are typically elevated concurrently in this condition.
- The combination of *elevated CRP and normal ESR* could occur if the CRP response is very acute and the ESR is lagging, but in chronic PMR, both are usually high.
*Normal erythrocyte sedimentation rate and elevated serum creatine kinase*
- A **normal ESR** contradicts the inflammatory nature of PMR, which consistently shows elevated inflammatory markers.
- An **elevated CK** suggests muscle damage, which is not characteristic of PMR, where muscle strength is typically preserved despite pain and stiffness.
Question 642: A 23-year-old man is admitted to the intensive care unit with acute respiratory distress syndrome (ARDS) due to influenza A. He has no history of serious illness and does not smoke. An x-ray of the chest shows diffuse bilateral infiltrates. Two weeks later, his symptoms have improved. Pulmonary examination on discharge shows inspiratory crackles at both lung bases. This patient is most likely to develop which of the following long-term complications?
A. Panacinar emphysema
B. Asthma
C. Pulmonary embolism
D. Interstitial lung disease (Correct Answer)
E. Spontaneous pneumothorax
Explanation: ***Interstitial lung disease***
- Patients who recover from **acute respiratory distress syndrome (ARDS)**, especially severe cases like that induced by influenza A, often develop **pulmonary fibrosis** leading to interstitial lung disease.
- The presence of **inspiratory crackles at both lung bases** after recovery from ARDS strongly suggests residual fibrotic changes.
*Panacinar emphysema*
- This condition is typically associated with **alpha-1 antitrypsin deficiency** or long-term smoking history, neither of which is indicated in this patient.
- Emphysema involves destruction of alveoli, not typically a direct long-term consequence of ARDS.
*Asthma*
- Asthma is a chronic inflammatory airway disease characterized by **reversible airflow obstruction**, usually with a history of recurrent episodes, not necessarily a direct sequela of ARDS.
- This patient's previous lack of serious illness and the nature of ARDS recovery make new-onset asthma unlikely as a long-term complication.
*Pulmonary embolism*
- While ARDS patients are at increased risk of **venous thromboembolism** during the acute phase due to immobility and inflammation, it is an acute complication, not a typical long-term sequela.
- Long-term complications are more related to lung parenchymal damage rather than persistent embolic risk.
*Spontaneous pneumothorax*
- Although ARDS can be complicated by **barotrauma** and pneumothorax during mechanical ventilation, a spontaneous pneumothorax as a long-term complication after recovery is less common.
- It does not explain the persistent bilateral basal crackles.
Question 643: A 28-year-old woman presents with a 12-month history of headache, tinnitus, retrobulbar pain, and photopsias. She says the headaches are mild to moderate, intermittent, diffusely localized, and refractory to nonsteroidal anti-inflammatory drugs (NSAIDs). In addition, this past week, she began to have associated dizziness and photopsia with the headaches. Physical examination reveals a body temperature of 36.5°C (97.7°F), blood pressure of 140/80 mm Hg, and a respiratory rate of 13/min and regular. BMI is 29 kg/m2. Neurological examination is significant for peripheral visual field loss in the inferior nasal quadrant, diplopia, bilateral abducens nerve palsy, and papilledema. A T1/T2 MRI of the brain did not identify extra-axial or intra-axial masses or interstitial edema, and a lumbar puncture showed an opening pressure of 27 cm H2O, with a cerebrospinal fluid analysis within the normal range. Which of the following best describes the pathogenic mechanism underlying these findings?
A. Systemic hypertension
B. Increased cerebrospinal fluid production
C. Aqueductal stenosis
D. Arachnoid granulation adhesions
E. Elevated intracranial venous pressure (Correct Answer)
Explanation: ***Elevated intracranial venous pressure***
- The combination of **papilledema**, **abducens nerve palsy**, normal brain MRI, and normal CSF analysis with **elevated opening pressure** (27 cm H2O; normal <20-25 cm H2O) is classic for **idiopathic intracranial hypertension (IIH)**, also known as pseudotumor cerebri.
- The primary pathogenic mechanism in IIH is often thought to be impaired **CSF absorption** due to elevated **intracranial venous pressure**, particularly within the dural venous sinuses, which can be exacerbated by obesity.
*Systemic hypertension*
- While the patient has slightly elevated blood pressure (140/80 mmHg), **systemic hypertension** rarely directly causes **papilledema** or **abducens nerve palsy** without other signs of hypertensive encephalopathy or end-organ damage, which are not described.
- The elevated intracranial pressure is not directly explained by simply high systemic blood pressure, especially with normal brain imaging.
*Increased cerebrospinal production*
- **Increased CSF production** is a very rare cause of intracranial hypertension, typically associated with choroid plexus tumors.
- The normal CSF analysis and absence of a mass on MRI make this an unlikely primary mechanism.
*Aqueductal stenosis*
- **Aqueductal stenosis** would lead to **obstructive hydrocephalus**, characterized by ventricular enlargement on MRI, which was not observed in this patient.
- While it causes elevated ICP, the normal ventricular size rules out this specific structural obstruction.
*Arachnoid granulation adhesions*
- **Arachnoid granulation adhesions** could theoretically impair CSF absorption, leading to elevated intracranial pressure.
- However, direct evidence of such adhesions is not typically observed on routine MRI, and the underlying cause often relates to a more systemic issue affecting CSF outflow, such as the venous drainage problem described in the correct option.
Question 644: A 79-year-old woman with type 2 diabetes mellitus and hypertension undergoes 99mTc cardiac scintigraphy for the evaluation of a 3-month history of retrosternal chest tightness on exertion. The patient's symptoms are reproduced following the administration of dipyridamole. A repeat ECG shows new ST depression and T wave inversion in leads V5 and V6. Which of the following is the most likely underlying mechanism of this patient's signs and symptoms during the procedure?
A. Dilation of coronary vasculature
B. Ruptured cholesterol plaque within a coronary vessel
C. Increased myocardial oxygen demand
D. Reduced left ventricular preload
E. Coronary steal phenomenon (Correct Answer)
Explanation: ***Correct: Coronary steal phenomenon***
- **Dipyridamole** is a **coronary vasodilator** that preferentially dilates **healthy coronary arteries** with intact endothelium and normal vasodilatory capacity.
- In patients with **coronary artery stenosis**, the vessels distal to the stenosis are already maximally dilated at baseline due to autoregulation.
- When dipyridamole causes further vasodilation of healthy vessels, blood flow is redistributed **away from** the ischemic areas supplied by stenotic vessels toward the healthy myocardium—this is the **"steal" phenomenon**.
- The patient's **ST depression and T wave inversion** in V5-V6 indicate lateral wall ischemia due to this maldistribution of coronary blood flow, not from increased oxygen demand.
- This mechanism makes dipyridamole useful for **pharmacologic stress testing** in patients who cannot exercise, as it reveals flow-limiting coronary stenoses without increasing heart rate or contractility.
*Incorrect: Increased myocardial oxygen demand*
- This is the mechanism of **exercise stress testing** or **dobutamine stress testing**, which increase heart rate, contractility, and blood pressure.
- **Dipyridamole does NOT increase myocardial oxygen demand**—it is a pure vasodilator that does not have positive inotropic or chronotropic effects.
- The ischemia induced by dipyridamole is due to **supply maldistribution** (steal), not increased demand.
- This distinction is clinically important: dipyridamole is chosen for patients who cannot exercise precisely because it avoids increasing cardiac workload.
*Incorrect: Ruptured cholesterol plaque within a coronary vessel*
- This describes the pathophysiology of **acute coronary syndrome (ACS)**, including unstable angina, NSTEMI, or STEMI.
- ACS typically presents with **sudden-onset chest pain at rest**, prolonged symptoms, and more dramatic ECG changes (ST elevation or deep T wave inversions).
- This patient has **chronic stable angina** with reproducible exertional symptoms over 3 months, and the ECG changes occurred during a controlled stress test—not consistent with acute plaque rupture.
*Incorrect: Dilation of coronary vasculature*
- While dipyridamole does cause **coronary vasodilation**, this is not itself the mechanism of ischemia—it's the **differential** vasodilation that causes the problem.
- The phrase "dilation of coronary vasculature" describes the drug's action but not the pathophysiologic consequence.
- The specific mechanism by which this vasodilation causes ischemia is the **coronary steal phenomenon**, making that the more precise and complete answer.
*Incorrect: Reduced left ventricular preload*
- Dipyridamole can cause mild systemic vasodilation and slight reduction in preload, but this is **not the mechanism of myocardial ischemia** in this case.
- Reduced preload typically causes symptoms of **hypotension** (lightheadedness, dizziness) rather than ischemic chest pain and ST-T wave changes.
- The **lateral wall ischemia** pattern (V5-V6) indicates regional myocardial oxygen supply-demand mismatch due to coronary artery disease, not a global reduction in preload.
Question 645: A 42-year-old woman with hypertension comes to the physician because of a 2-month history of persistent reddening of her face, daytime fatigue, and difficulty concentrating. She has fallen asleep multiple times during important meetings. Her only medication is lisinopril. She is 170 cm (5 ft 7 in) tall and weighs 88 kg (194 lb); BMI is 30 kg/m2. Her blood pressure is 145/85 mm Hg. Physical examination shows erythema of the face that is especially pronounced around the cheeks, nose, and ears. Serum glucose concentration is 120 mg/dL. Which of the following is the most likely cause of this patient's facial discoloration?
A. Antibody-mediated vasculopathy
B. Increased bradykinin production
C. Increased cortisol levels (Correct Answer)
D. Increased serotonin levels
E. Increased erythropoietin production
Explanation: ***Increased cortisol levels***
- The patient's **facial plethora (reddening)**, **obesity** (BMI 30 kg/m2), **hypertension**, and **elevated fasting glucose** (120 mg/dL) are classic features of **Cushing's syndrome**, caused by sustained high cortisol levels.
- Her symptoms of **fatigue** and **difficulty concentrating**, coupled with **daytime sleepiness**, are also common non-specific manifestations associated with chronic hypercortisolism.
*Antibody-mediated vasculopathy*
- This typically presents with **purpura**, **livedo reticularis**, or **ulcers**, not generalized facial reddening or plethora.
- Conditions like **vasculitis** often involve systemic symptoms such as fever, arthralgias, and myalgias, which are not described.
*Increased bradykinin production*
- **Bradykinin** can cause **angioedema**, a rapid swelling of the deep dermis and subcutaneous tissue, often involving the face, lips, or tongue.
- This is distinct from generalized facial reddening and would also present with episodes of sudden swelling rather than persistent reddening.
*Increased serotonin levels*
- Elevated **serotonin levels**, usually due to a **carcinoid tumor**, can cause **flushing episodes** that are typically paroxysmal and associated with diarrhea, bronchospasm, and valvular heart disease.
- The patient's facial reddening is described as persistent rather than paroxysmal, and other classic symptoms of carcinoid syndrome are absent.
*Increased erythropoietin production*
- High levels of **erythropoietin** lead to **polycythemia**, which can cause a **ruddy complexion** (plethora) due to an increase in red blood cell mass.
- While plethora may be present, polycythemia would also typically present with other symptoms like headache, dizziness, and pruritus after bathing, and would commonly be associated with erythrocytosis on lab tests, which is not mentioned.
Question 646: A 57-year-old woman presents to her physician’s office because she is coughing up blood. She says that she first observed a somewhat reddish sputum a few months ago. However, over the past couple of weeks, the amount of blood she coughs has significantly increased. She has been smoking for the past 30 years. She says that she smokes about 2 packs of cigarettes daily. She does not have fever, night sweats, weight loss, or chills. She reports progressive difficulty in breathing. On examination, her vital signs are stable. On auscultation of her chest, she has an expiratory wheeze. Oxygen saturation is 98%. Which of the following would be the next best step in the management of this patient?
A. Bronchoscopy
B. CT scan
C. Oxygen supplementation
D. Endoscopy
E. Chest radiograph (Correct Answer)
Explanation: **Chest radiograph**
- A **chest radiograph** is the most appropriate initial diagnostic step in a patient with hemoptysis and a significant smoking history. It helps identify potential causes like lung cancer, pneumonia, or tuberculosis.
- Given the patient's long smoking history and progressive symptoms, a chest X-ray can quickly reveal suspicious lesions or infiltrates guiding further investigation.
*Bronchoscopy*
- While eventually likely needed, **bronchoscopy** is generally performed after initial imaging (like a chest X-ray) has identified a potential area of concern or if the X-ray is normal but suspicion for a bronchial lesion remains high.
- It allows for direct visualization of the airways and biopsies, but it's not the very first step in evaluating **stable hemoptysis**.
*CT scan*
- A **CT scan** of the chest provides more detailed imaging than a chest X-ray and is often the next step if the X-ray is abnormal or inconclusive.
- However, for initial assessment in a stable patient, a chest X-ray is typically performed first due to its lower cost, radiation exposure, and quick availability.
*Oxygen supplementation*
- The patient's **oxygen saturation is 98%**, indicating she is not in acute respiratory distress requiring immediate oxygen supplementation.
- Oxygen is a supportive measure, not a diagnostic step to determine the cause of **hemoptysis**.
*Endoscopy*
- **Endoscopy** (referring to upper gastrointestinal endoscopy) is used to investigate bleeding from the gastrointestinal tract, not the respiratory system.
- **Hemoptysis** is blood coughed up from the lungs, while **hematemesis** is vomiting blood from the GI tract.
Question 647: A 46-year-old woman presents to her primary care physician for her annual examination. At her prior exam one year earlier, she had a Pap smear which was within normal limits. Which of the following health screenings is recommended for this patient?
A. Colorectal screening (Correct Answer)
B. Blood glucose and/or HbA1c screening
C. Blood pressure at least once every 3 years
D. Yearly Pap smear
E. Bone mineral density screening
Explanation: ***Colorectal screening***
- **Colorectal cancer screening** is generally recommended to start at age **45 years** for individuals at average risk.
- This patient is 46 years old, making immediate colorectal screening appropriate based on current guidelines.
*Blood glucose and/or HbA1c screening*
- **Blood glucose or HbA1c screening** for diabetes is recommended starting at age **35 for all adults** or earlier if there are risk factors such as obesity or a family history of diabetes.
- While this patient is 46, this screening should have already been initiated, and it is not the *most* uniquely recommended screening for this specific age that might have been overlooked.
*Blood pressure at least once every 3 years*
- **Blood pressure screening** should be performed **at least annually** for adults aged 40 and older, or more frequently if there are risk factors.
- Screening only every 3 years is insufficient for a 46-year-old patient.
*Yearly Pap smear*
- **Pap smear frequency** has changed; for women aged 30-65 with normal results, screening is recommended every **3 years** with cytology alone, or every 5 years with high-risk HPV testing alone or co-testing.
- A yearly Pap smear is no longer typical practice for a woman with normal prior results and no specific risk factors.
*Bone mineral density screening*
- **Bone mineral density (BMD) screening** for osteoporosis is typically recommended for women starting at age **65 years** or earlier if they have significant risk factors.
- This patient is 46 years old and has no mentioned risk factors, so BMD screening is not routinely indicated at this age.
Question 648: A 72-year-old man presents to the emergency department after a fall. The patient was found lying down on the floor in his room in his retirement community. The patient has a past medical history of Alzheimer dementia and a prosthetic valve. His current medications include donepezil and warfarin. His temperature is 97.7°F (36.5°C), blood pressure is 85/50 mmHg, pulse is 160/min, respirations are 13/min, and oxygen saturation is 97% on room air. The patient is started on IV fluids and a type and screen is performed. Laboratory values are ordered as seen below.
Hemoglobin: 13 g/dL
Hematocrit: 39%
Leukocyte count: 5,500 cells/mm^3 with normal differential
Platelet count: 225,000/mm^3
INR: 2.5
AST: 10 U/L
ALT: 12 U/L
A chest radiograph and EKG are performed and are within normal limits. A full physical exam is within normal limits. The patient's vitals are repeated. His temperature is 99.5°F (37.5°C), blood pressure is 110/70 mmHg, pulse is 90/min, respirations are 10/min, and oxygen saturation is 98% on room air. Which of the following is the best next step in management?
A. CT scan (Correct Answer)
B. Urgent blood transfusion
C. Fresh frozen plasma
D. Exploratory laparoscopy
E. Exploratory laparotomy
Explanation: ***CT scan***
- A patient with a **prosthetic valve** on **warfarin** and a fall is at high risk for **intracranial hemorrhage**, even without focal neurological deficits.
- While initial vitals improved after IV fluids, the mechanism of injury (fall) and medication profile warrant a **CT scan** of the head to rule out serious internal injury, especially given the history of dementia which might mask symptoms.
*Urgent blood transfusion*
- The patient's **hemoglobin (13 g/dL)** and **hematocrit (39%)** are within normal limits, indicating no acute need for blood transfusion due to hemorrhage.
- Transfusions are typically reserved for patients with significant blood loss or severe symptomatic anemia.
*Fresh frozen plasma*
- The patient's **INR of 2.5** is within the therapeutic range for a patient with a prosthetic valve on warfarin.
- There is no evidence of active bleeding or supratherapeutic anticoagulation that would necessitate the administration of **fresh frozen plasma (FFP)** to reverse anticoagulation.
*Exploratory laparoscopy*
- There are no clinical signs or symptoms, such as abdominal pain, distension, or evidence of intra-abdominal bleeding (e.g., declining hemoglobin, peritoneal signs), to suggest an indication for an **exploratory laparoscopy**.
- The patient's physical exam was described as normal.
*Exploratory laparotomy*
- Similar to laparoscopy, there is no clinical evidence of acute abdominal injury or hemorrhage, which would necessitate an **exploratory laparotomy**.
- This invasive procedure is reserved for cases with strong suspicion of significant intra-abdominal pathology or trauma.
Question 649: A 59-year-old man with angina pectoris comes to the physician because of a 6-month history of shortness of breath on exertion that improves with rest. He has hypertension and hyperlipidemia. Current medications include aspirin, metoprolol, and nitroglycerine. Echocardiography shows left ventricular septal and apical hypokinesis. Cardiac catheterization shows 96% occlusion of the left anterior descending artery. The patient undergoes angioplasty and placement of a stent. The patient's shortness of breath subsequently resolves and follow-up echocardiography one week later shows normal regional contractile function. Which of the following is the most accurate explanation for the changes in echocardiography?
A. Myocardial scarring
B. Unstable angina pectoris
C. Stress cardiomyopathy
D. Hibernating myocardium (Correct Answer)
E. Cardiac remodeling
Explanation: ***Hibernating myocardium***
- This refers to chronically **ischemic but viable myocardium** that shows reduced contractility at rest due to persistent hypoperfusion, which improves or normalizes after revascularization.
- The resolution of symptoms and normalization of regional contractile function after stent placement in this patient with chronic angina and a highly occluded LAD artery is highly consistent with this phenomenon.
*Myocardial scarring*
- **Myocardial scarring** represents irreversible damage and fibrosis, typically resulting from a myocardial infarction (heart attack).
- Scarred tissue does not regain contractile function even after revascularization; the observed improvement in contractility rules out this explanation.
*Unstable angina pectoris*
- **Unstable angina** is characterized by new-onset angina, crescendo angina, or angina at rest, indicating an acute coronary syndrome.
- While the patient had angina, the prompt and complete resolution of contractile dysfunction post-revascularization points to a chronic ischemic state rather than an acute, potentially irreversible event or a transient episode of unstable angina that would not cause such persistent functional changes.
*Stress cardiomyopathy*
- Also known as **Takotsubo cardiomyopathy**, this condition involves transient left ventricular dysfunction, often triggered by severe emotional or physical stress, mimicking a myocardial infarction.
- It typically resolves spontaneously over weeks or months and is not caused by fixed coronary artery occlusion that improves with revascularization via stenting.
*Cardiac remodeling*
- **Cardiac remodeling** refers to changes in the size, shape, and function of the heart in response to chronic stress, such as hypertension or chronic ischemia.
- While the patient's long-standing hypertension and hyperlipidemia could lead to some remodeling, the rapid and complete improvement in regional contractility specifically after LAD revascularization best explains the phenomenon as hibernating myocardium, a specific type of physiological adaptation, rather than general remodeling.
Question 650: A 78-year-old man presents with fatigue and exertional dyspnea. The patient says that symptoms onset gradually 4 weeks ago and have not improved. He denies any history of anemia or nutritional deficiency. Past medical history is significant for ST-elevation myocardial infarction 6 months ago, status post coronary artery bypass graft, complicated by recurrent hemodynamically unstable ventricular tachycardia. Current medications are rosuvastatin, aspirin, and amiodarone. His blood pressure is 100/70 mm Hg, the pulse is 71/min, the temperature is 36.5°C (97.7°F), and the respiratory rate is 16/min. On physical examination, patient appears lethargic and tired. Skin is dry and coarse, and there is generalized pitting edema present. A complete blood count (CBC) and a peripheral blood smear show evidence of normochromic, normocytic anemia. Additional laboratory tests reveal decreased serum level of iron, decreased TIBC (total iron-binding capacity) and increased serum level of ferritin. Which of the following is the most likely etiology of the anemia in this patient?
A. Iron deficiency anemia
B. Thalassemia
C. Pernicious anemia
D. Anemia of chronic disease (Correct Answer)
E. Hemolytic anemia
Explanation: ***Anemia of chronic disease***
- The patient's history of **ST-elevation myocardial infarction** and **ventricular tachycardia**, combined with his current medications and symptoms, points to an underlying chronic inflammatory state.
- Lab findings of **normochromic, normocytic anemia**, **decreased serum iron**, **decreased total iron-binding capacity (TIBC)**, and **increased ferritin** are classic for anemia of chronic disease.
*Iron deficiency anemia*
- This condition is characterized by **decreased serum iron**, **increased TIBC**, and **decreased ferritin**, which is inconsistent with this patient's labs.
- The patient denies any history of anemia or nutritional deficiency, and no sources of blood loss are mentioned despite the use of **aspirin**.
*Thalassemia*
- Thalassemia typically presents with **microcytic, hypochromic anemia**, which contradicts the patient's **normocytic, normochromic anemia**.
- It is a genetic disorder usually identified earlier in life, unlike this patient's gradual onset of symptoms in old age.
*Pernicious anemia*
- Pernicious anemia is a type of **macrocytic anemia** (due to B12 deficiency), which is inconsistent with the patient's **normocytic anemia**.
- It would typically involve **neurological symptoms** and **megaloblastic changes** on a peripheral smear, none of which are reported.
*Hemolytic anemia*
- Hemolytic anemia is characterized by evidence of **red blood cell destruction**, such as elevated reticulocyte count, increased LDH, decreased haptoglobin, and increased indirect bilirubin, none of which are mentioned.
- The patient's history and lab findings are not typical for a primary hemolytic process.
