A 37-year-old woman presents to her primary care physician for bilateral nipple discharge. The patient states that she has observed a milky discharge coming from her nipples for the past month. On review of systems, the patient states that she has felt fatigued lately and has experienced decreased libido. She also endorses headaches that typically resolve by the middle of the day and a 5 pound weight gain this past month. The patient has a past medical history of obesity, schizophrenia, and constipation. Her temperature is 99.5°F (37.5°C), blood pressure is 145/95 mmHg, pulse is 60/min, respirations are 15/min, and oxygen saturation is 98% on room air. On physical exam, you note an obese, fatigued-appearing woman. Dermatologic exam reveals fine, thin hair over her body. Cardiopulmonary exam is within normal limits. Neurological exam reveals cranial nerves II-XII as grossly intact. The patient exhibits 1+ sluggish reflexes. Which of the following is the most likely diagnosis?
Q652
A 41-year-old woman presents to the emergency room with chest pain. She has had progressive substernal chest pain accompanied by weakness and mild shortness of breath for the past 2 hours. Her past medical history is notable for poorly controlled systemic lupus erythematosus (SLE), Sjogren syndrome, and interstitial lung disease. She was hospitalized last year with pericarditis presumed to be from SLE. Her temperature is 98.6°F (37°C), blood pressure is 106/56 mmHg, pulse is 132/min, and respirations are 26/min. On exam, the skin overlying the internal jugular vein fills at 9 cm above the sternal angle and distant heart sounds are appreciated. There is no friction rub. She is given 1000cc of intravenous fluids with no appreciable change in her blood pressure. An electrocardiogram in this patient would most likely reveal which of the following findings?
Q653
A 57-year-old immigrant from Nigeria presents to the emergency department for sudden, severe pain and swelling in her lower extremity. She was at a rehabilitation hospital when her symptoms became apparent. The patient has a past medical history of obesity, diabetes, bipolar disorder, and tonic-clonic seizures. Her current medications include metformin, insulin, lisinopril, and valproic acid. The patient is a prominent IV drug and alcohol user who has presented to the ED many times for intoxication. On physical exam you note anasarca and asymmetric lower extremity swelling. Based on the results of a doppler ultrasound of her swollen lower extremity, heparin is started. The patient is then transferred to the general medicine floor for continued management. Laboratory studies are shown below.
Serum:
Na+: 137 mEq/L
K+: 5.5 mEq/L
Cl-: 100 mEq/L
HCO3-: 24 mEq/L
Urea nitrogen: 22 mg/dL
Ca2+: 5.7 mg/dL
Creatinine: 1.7 mg/dL
Glucose: 70 mg/dL
The patient's presentation includes generalized edema (anasarca) along with laboratory abnormalities. What is the most likely underlying diagnosis that explains her overall clinical presentation?
Q654
A 67-year-old man with hypertension comes to the physician because of a 5-month history of a facial rash. He occasionally feels burning or stinging over the affected area. His only medication is lisinopril. Physical examination shows the findings in the photograph. Which of the following is the most common trigger for exacerbation of this patient's skin condition?
Q655
A 62-year-old man comes to the physician because of increasing pain in his right leg for 2 months. The pain persists throughout the day and is not relieved by rest. He tried taking acetaminophen, but it provided no relief from his symptoms. There is no family history of serious illness. He does not smoke. He occasionally drinks a beer. Vital signs are within normal limits. On examination, the right tibia is bowing anteriorly; range of motion is limited by pain. An x-ray of the right leg shows a deformed tibia with multiple lesions of increased and decreased density and a thickened cortical bone. Laboratory studies show markedly elevated serum alkaline phosphatase and normal calcium and phosphate levels. This patient is most likely to develop which of the following complications?
Q656
A 67-year-old man with type 2 diabetes mellitus comes to the emergency department because of lightheadedness over the past 2 hours. He reports that he has had similar episodes of lightheadedness and palpitations over the past 3 days. His only medication is metformin. His pulse is 110/min and irregularly irregular. An ECG shows a variable R-R interval and absence of P waves. The patient undergoes transesophageal echocardiography. During the procedure, the tip of the ultrasound probe is angled posteriorly within the esophagus. This view is most helpful for evaluating which of the following conditions?
Q657
A 44-year-old woman comes to the physician for the evaluation of a 1-month history of fatigue and difficulty swallowing. During this period, she has also had dry skin, thinning hair, and rounding of her face. She has type 1 diabetes mellitus and rheumatoid arthritis. Her father had a thyroidectomy for papillary thyroid cancer. The patient had smoked one pack of cigarettes daily for 20 years but quit 3 years ago. She drinks 2–3 glasses of wine daily. Her current medications include insulin, omeprazole, and daily ibuprofen. She appears well. Her temperature is 36.3°C (97.3°F), pulse is 62/min, and blood pressure is 102/76 mm Hg. Examination of the neck shows a painless, diffusely enlarged thyroid gland. Cardiopulmonary examination shows no abnormalities. Further evaluation is most likely to show which of the following?
Q658
A 47-year-old woman complains of weight gain and irregular menses for the past 2 years. She has gained 13 kg (28.6 lb) and feels that most of the weight gain is in her abdomen and face. She has type 2 diabetes and hypertension for 1 year, and they are difficult to control with medications. Vital signs include a temperature of 36.9°C (98.4°F), blood pressure of 160/100 mm Hg, and pulse of 95/min. The patient's late-night salivary cortisol is elevated. Morning plasma ACTH is high. Brain magnetic resonance imaging shows a 2 cm pituitary adenoma. Which of the following is the optimal therapy for this patient?
Q659
A 62-year-old man with a past medical history notable for hemochromatosis now presents for urgent care with complaints of increased thirst and urinary frequency. Physical examination is grossly unremarkable, although there is a bronze discoloration of his skin. His vital signs include: temperature 36.7°C (98.0°F), blood pressure 126/74 mm Hg, heart rate 74/min, and respiratory rate 14/min. Laboratory analysis reveals fasting blood glucose of 192 mg/dL and subsequently, HbA1c of 8.7. Given the following options, what is the definitive treatment for the patient's underlying disease?
Q660
A 50-year-old man presents with a complaint of pain and swelling of his right leg for the past 2 days. He remembers hitting his leg against a table 3 days earlier. Since then, the pain and swelling of the leg have gradually increased. His past medical history is significant for atopy and pulmonary tuberculosis. The patient reports a 20-pack-year smoking history and currently smokes 2 packs of cigarettes per day. His pulse is 98/min, respiratory rate is 15/min, temperature is 38.4°C (101.2°F), and blood pressure is 100/60 mm Hg. On physical examination, his right leg is visibly swollen up to the groin with moderate erythema and 2+ pitting edema. The peripheral pulses are 2+ in the right leg and there is no discomfort. There is no increased resistance or pain in the right calf in response to forced dorsiflexion of the right foot. Which of the following is the best next step in the management of this patient?
Cardiology US Medical PG Practice Questions and MCQs
Question 651: A 37-year-old woman presents to her primary care physician for bilateral nipple discharge. The patient states that she has observed a milky discharge coming from her nipples for the past month. On review of systems, the patient states that she has felt fatigued lately and has experienced decreased libido. She also endorses headaches that typically resolve by the middle of the day and a 5 pound weight gain this past month. The patient has a past medical history of obesity, schizophrenia, and constipation. Her temperature is 99.5°F (37.5°C), blood pressure is 145/95 mmHg, pulse is 60/min, respirations are 15/min, and oxygen saturation is 98% on room air. On physical exam, you note an obese, fatigued-appearing woman. Dermatologic exam reveals fine, thin hair over her body. Cardiopulmonary exam is within normal limits. Neurological exam reveals cranial nerves II-XII as grossly intact. The patient exhibits 1+ sluggish reflexes. Which of the following is the most likely diagnosis?
A. Dopamine blockade in the tuberoinfundibular pathway
B. Protein-secreting CNS mass
C. Normal pregnancy
D. Viral infection of the thyroid gland
E. Autoimmune destruction of the thyroid gland (Correct Answer)
Explanation: ***Autoimmune destruction of the thyroid gland***
- The patient's symptoms of **fatigue**, **weight gain**, **constipation**, **bradycardia** (pulse 60/min), and **sluggish reflexes** are classic signs of **hypothyroidism**.
- **Nipple discharge** can occur due to secondary **hyperprolactinemia** caused by increased TRH (thyrotropin-releasing hormone) from the hypothalamus in an attempt to stimulate the underactive thyroid. **Autoimmune destruction** (e.g., Hashimoto's thyroiditis) is the most common cause of hypothyroidism.
*Dopamine blockade in the tuberoinfundibular pathway*
- This could lead to **hyperprolactinemia** and nipple discharge, especially if she is on **antipsychotic medications** for schizophrenia.
- However, it does not explain the other prominent symptoms of **hypothyroidism** such as fatigue, weight gain, constipation, and bradycardia.
*Protein-secreting CNS mass*
- A **prolactinoma** (a type of protein-secreting CNS mass) can cause **galactorrhea**, headaches, and decreased libido.
- However, it would not typically cause the systemic symptoms of **hypothyroidism** like constipation, weight gain, fatigue, and bradycardia.
*Normal pregnancy*
- **Pregnancy** can cause nipple discharge and fatigue, but vital signs indicate **bradycardia** (pulse of 60/min) rather than the typical tachycardia of pregnancy.
- There is no mention of missed periods or other classic signs of pregnancy; therefore, it is less likely given the full symptom constellation.
*Viral infection of the thyroid gland*
- A viral infection of the thyroid gland (e.g., **subacute thyroiditis**) can initially present with **hyperthyroidism** followed by a hypothyroid phase.
- However, the patient's symptoms are primarily hypothyroid from the onset, and the presentation does not suggest an acute inflammatory process typical of viral thyroiditis.
Question 652: A 41-year-old woman presents to the emergency room with chest pain. She has had progressive substernal chest pain accompanied by weakness and mild shortness of breath for the past 2 hours. Her past medical history is notable for poorly controlled systemic lupus erythematosus (SLE), Sjogren syndrome, and interstitial lung disease. She was hospitalized last year with pericarditis presumed to be from SLE. Her temperature is 98.6°F (37°C), blood pressure is 106/56 mmHg, pulse is 132/min, and respirations are 26/min. On exam, the skin overlying the internal jugular vein fills at 9 cm above the sternal angle and distant heart sounds are appreciated. There is no friction rub. She is given 1000cc of intravenous fluids with no appreciable change in her blood pressure. An electrocardiogram in this patient would most likely reveal which of the following findings?
A. Polymorphic P waves
B. ST elevations in leads II, III, and aVF
C. Peaked T waves
D. Wide QRS complexes with no P waves
E. Electrical alternans (Correct Answer)
Explanation: ***Electrical alternans***
- The patient's symptoms (chest pain, shortness of breath, **hypotension**, **tachycardia**, **elevated JVP**, and **distant heart sounds**) in the context of a history of **pericarditis** and **SLE** are highly suggestive of **cardiac tamponade.**
- **Electrical alternans**, characterized by alternating QRS complex heights due to the swinging motion of the heart in a large pericardial effusion, is a classic EKG finding for cardiac tamponade.
- This finding reflects the mechanical swinging of the heart within the pericardial fluid, causing beat-to-beat variation in QRS amplitude.
*Polymorphic P waves*
- **Polymorphic P waves** (multifocal atrial tachycardia) occur when there are at least three different P wave morphologies on the EKG, indicating multiple ectopic atrial foci.
- This is typically seen in patients with severe lung disease or other conditions causing increased atrial stretch, but it is not a direct consequence or typical finding of cardiac tamponade.
*ST elevations in leads II, III, and aVF*
- **ST elevations in leads II, III, and aVF** indicate an **inferior myocardial infarction**, which is caused by coronary artery occlusion.
- While chest pain is present, the patient's other signs (elevated JVP, distant heart sounds, hypotension not responding to fluids, history of pericarditis/SLE) point away from an acute MI and strongly towards cardiac tamponade.
*Peaked T waves*
- **Peaked T waves** are characteristic of **hyperkalemia**, a condition of excessively high potassium levels in the blood.
- While hyperkalemia can cause cardiac symptoms, it does not typically present with the specific hemodynamic compromise and physical exam findings (elevated JVP, distant heart sounds) described, which are classic for cardiac tamponade.
*Wide QRS complexes with no P waves*
- **Wide QRS complexes with no P waves** are characteristic of a **ventricular arrhythmia**, such as ventricular tachycardia or idioventricular rhythm.
- While the patient is hypotensive and tachycardic, the presenting symptoms and physical exam findings are not directly indicative of a primary ventricular arrhythmia, but rather suggest an extracardiac compression of the heart due to tamponade.
Question 653: A 57-year-old immigrant from Nigeria presents to the emergency department for sudden, severe pain and swelling in her lower extremity. She was at a rehabilitation hospital when her symptoms became apparent. The patient has a past medical history of obesity, diabetes, bipolar disorder, and tonic-clonic seizures. Her current medications include metformin, insulin, lisinopril, and valproic acid. The patient is a prominent IV drug and alcohol user who has presented to the ED many times for intoxication. On physical exam you note anasarca and asymmetric lower extremity swelling. Based on the results of a doppler ultrasound of her swollen lower extremity, heparin is started. The patient is then transferred to the general medicine floor for continued management. Laboratory studies are shown below.
Serum:
Na+: 137 mEq/L
K+: 5.5 mEq/L
Cl-: 100 mEq/L
HCO3-: 24 mEq/L
Urea nitrogen: 22 mg/dL
Ca2+: 5.7 mg/dL
Creatinine: 1.7 mg/dL
Glucose: 70 mg/dL
The patient's presentation includes generalized edema (anasarca) along with laboratory abnormalities. What is the most likely underlying diagnosis that explains her overall clinical presentation?
A. Liver failure
B. Nephrotic syndrome (Correct Answer)
C. Antithrombin III deficiency
D. Prothrombin gene mutation
E. Factor V Leiden
Explanation: ***Nephrotic syndrome***
- The patient presents with **anasarca** (generalized edema), **asymmetric lower extremity swelling**, and laboratory findings consistent with **nephrotic syndrome**.
- Classic features present: **anasarca** (from hypoalbuminemia and fluid retention), **hypercoagulable state** leading to DVT (loss of antithrombin III in urine), and **renal dysfunction** (elevated creatinine 1.7 mg/dL).
- The **hypocalcemia (5.7 mg/dL)** is explained by low albumin—total calcium appears low because ~40% of serum calcium is albumin-bound; ionized calcium is likely normal.
- Nephrotic syndrome is characterized by: heavy proteinuria (>3.5 g/day), hypoalbuminemia, hyperlipidemia, and edema—this patient's presentation fits this diagnosis.
- Risk factors include diabetes (diabetic nephropathy is a common cause of nephrotic syndrome in adults).
*Liver failure*
- Although **anasarca** and **edema** can occur in liver failure due to decreased albumin synthesis and portal hypertension, the laboratory values do not show typical signs of severe hepatic dysfunction (e.g., elevated transaminases, bilirubin, or prolonged INR).
- The **elevated creatinine** and **hypercoagulable state with DVT** point more towards a primary renal issue rather than liver failure.
- Liver failure typically causes **hypocoagulability**, not the hypercoagulability seen here.
*Antithrombin III deficiency*
- This is a **hereditary thrombophilia** that increases the risk of **venous thromboembolism**, which could explain the DVT.
- However, it does **not explain** the patient's **anasarca**, **hypocalcemia**, **elevated creatinine**, or generalized fluid retention.
- This would be a complication of nephrotic syndrome (acquired AT-III deficiency from urinary loss), not the primary diagnosis.
*Prothrombin gene mutation*
- This is another **genetic thrombophilia** (G20210A mutation) that increases the risk of **blood clots**.
- Similar to Antithrombin III deficiency, it accounts for DVT risk but **fails to explain** the widespread edema, electrolyte abnormalities, and renal dysfunction.
*Factor V Leiden*
- The **Factor V Leiden mutation** is the most common inherited cause of **thrombophilia**, predisposing individuals to venous thromboembolism.
- While relevant to explaining DVT in isolation, it does **not explain** the patient's severe generalized edema, hypocalcemia, or renal impairment—all of which are key to this clinical presentation.
Question 654: A 67-year-old man with hypertension comes to the physician because of a 5-month history of a facial rash. He occasionally feels burning or stinging over the affected area. His only medication is lisinopril. Physical examination shows the findings in the photograph. Which of the following is the most common trigger for exacerbation of this patient's skin condition?
A. Lisinopril therapy
B. Complement component 1q deficiency
C. Filaggrin gene mutation
D. Alcohol consumption (Correct Answer)
E. Cutibacterium colonization
Explanation: **Alcohol consumption**
- The image shows **rosacea**, characterized by facial erythema, papules, and pustules, with symptoms of burning or stinging.
- **Alcohol consumption** is one of the most common **triggers** that exacerbate rosacea, causing flushing and worsening of inflammation through vasodilation.
- Other common triggers include hot beverages, spicy foods, stress, sun exposure, and temperature extremes.
- Note: Triggers differ from predisposing factors (fair skin, Northern European ancestry, family history).
*Lisinopril therapy*
- Lisinopril, an **ACE inhibitor**, can cause a cough and, rarely, angioedema or a maculopapular rash, but it is not typically associated with the facial rash pattern seen in rosacea.
- It does not directly cause or significantly worsen rosacea.
*Complement component 1q deficiency*
- Deficiency in complement component 1q is associated with certain **autoimmune diseases like lupus-like syndromes**, but it is not a known predisposing factor or trigger for rosacea.
- This condition typically presents with systemic symptoms and specific immunological findings, unrelated to this patient's presentation.
*Filaggrin gene mutation*
- **Filaggrin mutations** are strongly associated with **atopic dermatitis** (eczema) and ichthyosis vulgaris, affecting the skin barrier function.
- They are not a primary predisposing factor or trigger for rosacea, which involves vascular and inflammatory pathways.
*Cutibacterium colonization*
- While *Cutibacterium acnes* (formerly *Propionibacterium acnes*) plays a role in **acne vulgaris**, it is not a primary trigger or predisposing factor for rosacea.
- Rosacea pathophysiology involves Demodex mites and innate immune activation, not Cutibacterium.
Question 655: A 62-year-old man comes to the physician because of increasing pain in his right leg for 2 months. The pain persists throughout the day and is not relieved by rest. He tried taking acetaminophen, but it provided no relief from his symptoms. There is no family history of serious illness. He does not smoke. He occasionally drinks a beer. Vital signs are within normal limits. On examination, the right tibia is bowing anteriorly; range of motion is limited by pain. An x-ray of the right leg shows a deformed tibia with multiple lesions of increased and decreased density and a thickened cortical bone. Laboratory studies show markedly elevated serum alkaline phosphatase and normal calcium and phosphate levels. This patient is most likely to develop which of the following complications?
A. Osteosarcoma
B. Renal insufficiency
C. Impaired hearing
D. Pancytopenia
E. High-output cardiac failure (Correct Answer)
Explanation: ***High-output cardiac failure***
- The patient's presentation with **bone pain**, **tibia bowing**, mixed **lytic and blastic lesions** on X-ray, and markedly **elevated alkaline phosphatase** with normal calcium and phosphate is classic for **Paget's disease of bone**.
- **Paget's disease** involves increased bone turnover, leading to highly vascularized bone. This increased vascularity can create **arteriovenous shunts**, expanding the vascular bed and increasing cardiac output, eventually leading to **high-output cardiac failure**.
- While this complication is **rare** (<3% of cases) and typically occurs only in **extensive polyostotic disease** (>35% skeletal involvement), it is the **most characteristic cardiovascular complication** and represents the direct pathophysiologic consequence of increased bone vascularity.
*Osteosarcoma*
- While **osteosarcoma** is a serious complication of Paget's disease occurring in approximately **1% of cases**, it is also relatively rare.
- Among the listed options, high-output cardiac failure represents the more **direct vascular consequence** of Paget's disease pathophysiology, making it the intended answer for this question about disease mechanisms.
*Renal insufficiency*
- **Hypercalcemia** can lead to nephrocalcinosis and renal insufficiency, but this patient has **normal calcium levels**, making renal insufficiency due to calcium abnormalities unlikely.
- Immobilized Paget's patients can develop hypercalcemia and renal issues, but this is not typical in ambulatory patients.
*Impaired hearing*
- **Impaired hearing** can occur in Paget's disease when the **skull is affected** (in 30-50% of skull cases), leading to **compression of cranial nerve VIII** or ossicular involvement.
- However, this patient's presentation involves **long bone disease** (tibia), and the question focuses on systemic complications of increased bone vascularity rather than localized cranial involvement.
*Pancytopenia*
- **Pancytopenia** is not a typical complication of Paget's disease.
- While severe widespread disease can rarely lead to bone marrow compromise, this is not a recognized primary complication and would not be the most likely outcome.
Question 656: A 67-year-old man with type 2 diabetes mellitus comes to the emergency department because of lightheadedness over the past 2 hours. He reports that he has had similar episodes of lightheadedness and palpitations over the past 3 days. His only medication is metformin. His pulse is 110/min and irregularly irregular. An ECG shows a variable R-R interval and absence of P waves. The patient undergoes transesophageal echocardiography. During the procedure, the tip of the ultrasound probe is angled posteriorly within the esophagus. This view is most helpful for evaluating which of the following conditions?
A. Myxoma in the left atrium
B. Thrombus in the left pulmonary artery
C. Thrombus in the left ventricular apex
D. Tumor in the right main bronchus
E. Aneurysm of the descending aorta (Correct Answer)
Explanation: ***Aneurysm of the descending aorta***
- When the TEE probe is angled **posteriorly within the esophagus**, it optimally visualizes structures directly posterior to the esophagus, particularly the **descending thoracic aorta**.
- The descending aorta runs parallel and immediately posterior to the esophagus, making this the ideal view for evaluating **aortic aneurysms, dissections, and atherosclerotic disease** of the descending aorta.
- Note: This patient's symptoms (lightheadedness, palpitations) are due to **atrial fibrillation** (irregularly irregular rhythm, absent P waves). The TEE is likely being performed for stroke risk evaluation, but this question tests knowledge of TEE probe positioning and anatomical visualization.
*Myxoma in the left atrium*
- The left atrium is best visualized using **mid-esophageal views** (especially the 4-chamber view at 0-20 degrees), not a posteriorly angled view.
- While TEE is excellent for detecting left atrial myxomas and is commonly performed in AFib patients to evaluate for left atrial appendage thrombus, the posterior angle is not optimal for this structure.
*Thrombus in the left pulmonary artery*
- The pulmonary arteries are located **anterior** to the esophagus, making them poorly visualized with a posteriorly angled probe.
- Pulmonary artery evaluation requires **anterior or superior angulation** of the TEE probe, or CT pulmonary angiography is preferred for pulmonary embolism diagnosis.
*Thrombus in the left ventricular apex*
- The left ventricular apex is best visualized using **transgastric views** (probe in stomach looking upward), not posterior esophageal views.
- LV apex thrombus evaluation requires short-axis and 2-chamber transgastric views at 0-90 degrees.
*Tumor in the right main bronchus*
- The bronchi are **anterior** to the esophagus and are not adequately visualized with TEE, regardless of probe angle.
- TEE is designed for cardiac and great vessel evaluation, not airway pathology; bronchoscopy or CT chest would be appropriate for bronchial tumors.
Question 657: A 44-year-old woman comes to the physician for the evaluation of a 1-month history of fatigue and difficulty swallowing. During this period, she has also had dry skin, thinning hair, and rounding of her face. She has type 1 diabetes mellitus and rheumatoid arthritis. Her father had a thyroidectomy for papillary thyroid cancer. The patient had smoked one pack of cigarettes daily for 20 years but quit 3 years ago. She drinks 2–3 glasses of wine daily. Her current medications include insulin, omeprazole, and daily ibuprofen. She appears well. Her temperature is 36.3°C (97.3°F), pulse is 62/min, and blood pressure is 102/76 mm Hg. Examination of the neck shows a painless, diffusely enlarged thyroid gland. Cardiopulmonary examination shows no abnormalities. Further evaluation is most likely to show which of the following?
A. Positive thyroid peroxidase antibodies and thyroglobulin antibodies in serum (Correct Answer)
B. Diffusely increased uptake on a radioactive iodine scan
C. Increased uptake on radioactive iodine scan in discrete 1-cm area
D. Large irregular nuclei, nuclear grooves, and Psammoma bodies on thyroid biopsy
E. Positive immunohistochemical stain for calcitonin on thyroid biopsy
Explanation: ***Positive thyroid peroxidase antibodies and thyroglobulin antibodies in serum***
- The patient's symptoms (fatigue, dry skin, thinning hair, rounded face, bradycardia) are classic for **hypothyroidism**.
- The presence of **Type 1 diabetes mellitus** and **rheumatoid arthritis** suggests an underlying autoimmune diathesis, making **Hashimoto thyroiditis** (autoimmune hypothyroidism) highly likely, which is characterized by positive thyroid peroxidase (TPO) and thyroglobulin antibodies.
*Diffusely increased uptake on a radioactive iodine scan*
- **Diffusely increased uptake** on a radioactive iodine scan is characteristic of **hyperthyroidism**, such as in **Graves' disease**, which contradicts the patient's hypothyroid symptoms.
- In Hashimoto thyroiditis, especially in the hypothyroid phase, uptake is typically **reduced or normal**, not diffusely increased.
*Increased uptake on radioactive iodine scan in discrete 1-cm area*
- **Increased uptake in a discrete area** (a 'hot nodule') suggests a **toxic adenoma** or a multinodular goiter, which are causes of hyperthyroidism, not hypothyroidism.
- This finding would also contradict the patient's clinical presentation of hypothyroidism.
*Large irregular nuclei, nuclear grooves, and Psammoma bodies on thyroid biopsy*
- These are classic cytologic features seen in **papillary thyroid carcinoma**, not Hashimoto thyroiditis.
- While the patient's father had papillary thyroid cancer, her clinical presentation is strongly indicative of hypothyroidism, and her diffusely enlarged, painless gland is more consistent with Hashimoto's than a focal malignant lesion showing these specific cytological features.
*Positive immunohistochemical stain for calcitonin on thyroid biopsy*
- A positive immunohistochemical stain for **calcitonin** is diagnostic for **medullary thyroid carcinoma**.
- This is a neuroendocrine tumor and does not typically present with the generalized hypothyroid symptoms described in the patient.
Question 658: A 47-year-old woman complains of weight gain and irregular menses for the past 2 years. She has gained 13 kg (28.6 lb) and feels that most of the weight gain is in her abdomen and face. She has type 2 diabetes and hypertension for 1 year, and they are difficult to control with medications. Vital signs include a temperature of 36.9°C (98.4°F), blood pressure of 160/100 mm Hg, and pulse of 95/min. The patient's late-night salivary cortisol is elevated. Morning plasma ACTH is high. Brain magnetic resonance imaging shows a 2 cm pituitary adenoma. Which of the following is the optimal therapy for this patient?
A. Unilateral adrenalectomy
B. Bilateral adrenalectomy
C. Pituitary radiotherapy
D. Medical therapy
E. Transsphenoidal pituitary adenomectomy (Correct Answer)
Explanation: ***Transsphenoidal pituitary adenomectomy***
- This patient presents with **Cushing's disease**, characterized by **elevated late-night salivary cortisol** and **high morning plasma ACTH**, coupled with a **pituitary adenoma** on MRI. **Transsphenoidal pituitary adenomectomy** is the first-line and most effective treatment for Cushing's disease, offering the highest chance of remission by directly removing the adenoma.
- Successful surgical removal of the tumor can quickly normalize **ACTH** and **cortisol** levels, leading to significant improvement in symptoms like **weight gain**, **hypertension**, **diabetes**, and **menstrual irregularities**.
*Unilateral adrenalectomy*
- This procedure treats **adrenal adenomas** causing Cushing's syndrome (primary adrenal hypercortisolism), which is characterized by **low or undetectable ACTH levels**. This patient has **high ACTH**, indicating a pituitary source.
- Performing a unilateral adrenalectomy in this case would not address the underlying **pituitary tumor** and would not cure Cushing's disease.
*Bilateral adrenalectomy*
- This is a treatment for severe, refractory Cushing's disease, or as a palliative measure, when **pituitary surgery** has failed or is contraindicated.
- While it effectively removes the source of **cortisol**, it leads to **adrenal insufficiency**, requiring lifelong corticosteroid replacement, and carries the risk of **Nelson's Syndrome** (rapid pituitary tumor growth due to loss of negative feedback).
*Pituitary radiotherapy*
- **Pituitary radiotherapy** is a secondary treatment option, typically used when **transsphenoidal surgery** fails to achieve remission, or if there is residual tumor.
- It has a slower onset of action (months to years) compared to surgery, and the patient's severe symptoms require more immediate control.
*Medical therapy*
- **Medical therapies** (e.g., **ketoconazole**, **mifepristone**, **pasireotide**) are often used as bridging therapy before surgery, when surgery is contraindicated, or for patients with persistent disease after surgery.
- They help control **hypercortisolism** but do not cure the underlying **pituitary adenoma**, making **surgical removal** the preferred definitive treatment.
Question 659: A 62-year-old man with a past medical history notable for hemochromatosis now presents for urgent care with complaints of increased thirst and urinary frequency. Physical examination is grossly unremarkable, although there is a bronze discoloration of his skin. His vital signs include: temperature 36.7°C (98.0°F), blood pressure 126/74 mm Hg, heart rate 74/min, and respiratory rate 14/min. Laboratory analysis reveals fasting blood glucose of 192 mg/dL and subsequently, HbA1c of 8.7. Given the following options, what is the definitive treatment for the patient's underlying disease?
A. Metformin
B. Deferoxamine
C. Basal and bolus insulin
D. Recurrent phlebotomy (Correct Answer)
E. Basal insulin
Explanation: ***Recurrent phlebotomy***
- This patient has signs and symptoms of **hemochromatosis** (bronze skin, history of hemochromatosis) and **diabetes mellitus** (polydipsia, polyuria, elevated fasting glucose, elevated HbA1c).
- **Recurrent phlebotomy** is the definitive treatment for hemochromatosis as it removes excess iron from the body by drawing blood.
*Metformin*
- Metformin is a common initial treatment for **Type 2 Diabetes Mellitus**, but it does not address the underlying iron overload from hemochromatosis.
- While it could help manage the diabetes, it is not the **definitive treatment** for the patient's primary underlying disease process.
*Deferoxamine*
- **Deferoxamine** is an iron chelating agent used to treat iron overload, usually when phlebotomy is contraindicated or ineffective.
- While effective, **phlebotomy is generally preferred** as the first-line and most definitive treatment for hereditary hemochromatosis.
*Basal and bolus insulin*
- This is a treatment for **diabetes mellitus**, especially when oral medications are insufficient or in cases of severe insulin deficiency.
- Like metformin, it manages the diabetic symptoms but does not address the **iron overload** that is the root cause of the diabetes in this hemochromatosis patient.
*Basal insulin*
- **Basal insulin** provides a continuous insulin supply to manage fasting glucose levels in diabetic patients.
- This treatment addresses the **diabetes symptoms** but not the underlying hemochromatosis.
Question 660: A 50-year-old man presents with a complaint of pain and swelling of his right leg for the past 2 days. He remembers hitting his leg against a table 3 days earlier. Since then, the pain and swelling of the leg have gradually increased. His past medical history is significant for atopy and pulmonary tuberculosis. The patient reports a 20-pack-year smoking history and currently smokes 2 packs of cigarettes per day. His pulse is 98/min, respiratory rate is 15/min, temperature is 38.4°C (101.2°F), and blood pressure is 100/60 mm Hg. On physical examination, his right leg is visibly swollen up to the groin with moderate erythema and 2+ pitting edema. The peripheral pulses are 2+ in the right leg and there is no discomfort. There is no increased resistance or pain in the right calf in response to forced dorsiflexion of the right foot. Which of the following is the best next step in the management of this patient?
A. Ultrasound of the right leg (Correct Answer)
B. Outpatient management with furosemide
C. Reassurance and supportive treatment
D. D-dimer level
E. CT pulmonary angiography
Explanation: ***Ultrasound of the right leg***
- The patient presents with unilateral **pain, swelling, erythema**, and **pitting edema** of the right leg extending to the groin, which are classic signs of a **deep vein thrombosis (DVT)**.
- The absence of a positive Homan's sign (no pain with dorsiflexion) does not rule out DVT, as this sign has poor sensitivity and specificity.
- Given the high clinical suspicion based on presentation and risk factors (heavy smoking, recent trauma), an **ultrasound of the right leg** is the most appropriate initial diagnostic step to confirm or rule out DVT, as it is non-invasive, highly accurate, and readily available.
*Outpatient management with furosemide*
- **Furosemide** is a diuretic primarily used to treat fluid retention associated with conditions like heart failure or kidney disease.
- Prescribing a diuretic without a definitive diagnosis would be inappropriate and could mask underlying pathology, especially for a condition like DVT that requires anticoagulation, not diuresis.
*Reassurance and supportive treatment*
- Reassurance is inappropriate given the patient's symptoms (unilateral leg swelling, erythema, pitting edema, and pain), which strongly suggest a potentially serious condition such as DVT.
- Delaying diagnosis and treatment could lead to severe complications, including **pulmonary embolism**.
*D-dimer level*
- A **D-dimer test** can be useful in ruling out DVT in patients with a low pretest probability, but it has low specificity in patients with moderate to high probability.
- Given the patient's significant physical findings and risk factors, a positive D-dimer would still necessitate an ultrasound, making direct imaging more efficient. A negative D-dimer in this high-probability setting would be less reliable.
*CT pulmonary angiography*
- **CT pulmonary angiography (CTPA)** is the gold standard for diagnosing **pulmonary embolism (PE)**.
- While DVT can lead to PE, there are no specific signs or symptoms of PE (e.g., dyspnea, pleuritic chest pain, hemoptysis, hypoxia) mentioned in the patient's presentation that would warrant CTPA as the *initial* step before evaluating the leg.
