A 67-year-old man comes to the physician because of a 6-month history of increasing shortness of breath on exertion, dry cough, and fatigue. He has not had any fevers or night sweats. He worked in a glass manufacturing factory for 15 years and retired 2 years ago. Pulmonary examination shows diffuse crackles bilaterally. An x-ray of the chest shows well-defined calcification of the rims of hilar lymph nodes and scattered nodules in both upper lung fields. This patient is most likely to develop which of the following complications?
Q702
A 71-year-old man presents to the emergency department for shortness of breath. The patient was returning from a business trip to China, when he suddenly felt short of breath during the taxi ride home from the airport. The patient has a past medical history of poorly controlled diabetes mellitus and a 50 pack-year smoking history. The patient is non-compliant with his medications and is currently only taking ibuprofen. An initial ECG demonstrates sinus tachycardia. A chest radiograph is within normal limits. Laboratory values are notable for a creatinine of 2.4 mg/dL and a BUN of 32 mg/dL as compared to his baseline creatinine of 0.9 mg/dL. His temperature is 98.8°F (37.1°C), pulse is 122/min, blood pressure is 145/90 mmHg, respirations are 19/min, and oxygen saturation is 93% on room air. On physical exam, you note an older gentleman in distress. Cardiac exam is notable only for tachycardia. Pulmonary exam is notable for expiratory wheezes. Which of the following is the best confirmatory test for this patient?
Q703
A 77-year-old woman is brought to the physician for gradually increasing confusion and difficulty walking for the past 4 months. Her daughter is concerned because she has been forgetful and seems to be walking more slowly. She has been distracted during her weekly bridge games and her usual television shows. She has also had increasingly frequent episodes of urinary incontinence and now wears an adult diaper daily. She has hyperlipidemia and hypertension. Current medications include lisinopril and atorvastatin. Her temperature is 36.8°C (98.2°F), pulse is 84/min, respirations are 15/min, and blood pressure is 139/83 mmHg. She is confused and oriented only to person and place. She recalls 2 out of 3 words immediately and 1 out of 3 after five minutes. She has a broad-based gait and takes short steps. Sensation is intact and muscle strength is 5/5 throughout. Laboratory studies are within normal limits. Which of the following is the most likely diagnosis in this patient?
Q704
A 32-year-old woman comes to the physician because of a 6-week history of fatigue and weakness. Examination shows marked pallor of the conjunctivae. The spleen tip is palpated 2 cm below the left costal margin. Her hemoglobin concentration is 9.5 g/dL, serum lactate dehydrogenase concentration is 750 IU/L, and her serum haptoglobin is undetectable. A peripheral blood smear shows multiple spherocytes. When anti-IgG antibodies are added to a sample of the patient's blood, there is clumping of the red blood cells. Which of the following is the most likely predisposing factor for this patient's condition?
Q705
A 59-year-old woman comes to the emergency department because of a 2-day history of worsening fever, chills, malaise, productive cough, and difficulty breathing. Three days ago, she returned from a trip to South Africa. She has type 2 diabetes mellitus, hypertension, and varicose veins. Her current medications include metformin, lisinopril, and atorvastatin. Her temperature is 39.4°C (102.9°F), pulse is 102/minute, blood pressure is 94/68 mm Hg, and respirations are 31/minute. Pulse oximetry on 2 L of oxygen via nasal cannula shows an oxygen saturation of 91%. Examination reveals decreased breath sounds and dull percussion over the left lung base. The skin is very warm and well-perfused. The remainder of the examination shows no abnormalities. Laboratory studies show:
Hemoglobin 11.6 g/dL
Leukocyte count 15,400/mm3
platelet count 282,000/mm3
Serum
Na+ 144 mEq/L
Cl- 104 mEq/L
K+ 4.9 mEq/L
Creatinine 1.5 mg/dL
Blood and urine for cultures are obtained. Intravenous fluid resuscitation is begun. Which of the following is the next best step in management?
Q706
A 75-year-old woman presents to the physician with a complaint of a frequent need to void at nighttime, which has been disrupting her sleep. She notes embarrassingly that she is often unable to reach the bathroom in time, and experiences urinary leakage throughout the night as well as during the day. The patient undergoes urodynamic testing and a urinalysis is obtained which is normal. She is instructed by the physician to perform behavioral training to improve her bladder control. Which of the following is the most likely diagnosis contributing to this patient’s symptoms?
Q707
A 68-year old woman presents with recurring headaches and pain while combing her hair. Her past medical history is significant for hypertension, glaucoma and chronic deep vein thrombosis in her right leg. Current medication includes rivaroxaban, latanoprost, and benazepril. Her vitals include: blood pressure 130/82 mm Hg, pulse 74/min, respiratory rate 14/min, temperature 36.6℃ (97.9℉). Physical examination reveals neck stiffness and difficulty standing up due to pain in the lower limbs. Strength is 5 out of 5 in the upper and lower extremities bilaterally. Which of the following is the next best step in the management of this patient?
Q708
A 59-year-old woman comes to the physician because of a 1-year history of pain and stiffness in her fingers and knees. The stiffness lasts for about 10 minutes after she wakes up in the morning. She also reports that her knee pain is worse in the evening. She drinks one glass of wine daily. Her only medication is acetaminophen. She is 175 cm (5 ft 9 in) tall and weighs 102 kg (225 lb); BMI is 33 kg/m2. Physical examination shows firm nodules on the distal interphalangeal joints of the index, ring, and little fingers of both hands. Which of the following is the most likely diagnosis?
Q709
One day after undergoing total knee replacement for advanced degenerative osteoarthritis, a 66-year-old man has progressive lower abdominal pain. The surgery was performed under general anesthesia and the patient was temporarily catheterized for perioperative fluid balance. Several hours after the surgery, the patient began to have decreasing voiding volumes, nausea, and progressive, dull lower abdominal pain. He has Sjögren syndrome. He is sexually active with his wife and one other woman and uses condoms inconsistently. He does not smoke and drinks beer occasionally. Current medications include pilocarpine eye drops. He appears uncomfortable and is diaphoretic. His temperature is 37.3°C (99.1°F), pulse is 90/min, and blood pressure is 130/82 mm Hg. Abdominal examination shows a pelvic mass extending to the umbilicus. It is dull on percussion and diffusely tender to palpation. His hemoglobin concentration is 13.9 g/dL, leukocyte count is 9,000/mm3, a platelet count is 230,000/mm3. An attempt to recatheterize the patient transurethrally is unsuccessful. Which of the following is the most likely underlying cause of this patient's symptoms?
Q710
A 33-year-old man presents to the emergency department after an episode of syncope. He states that for the past month ever since starting a new job he has experienced an episode of syncope or near-syncope every morning while he is getting dressed. The patient states that he now gets dressed, shaves, and puts on his tie sitting down to avoid falling when he faints. He has never had this before and is concerned it is stress from his new job as he has been unemployed for the past 5 years. He is wondering if he can get a note for work since he was unable to head in today secondary to his presentation. The patient has no significant past medical history and is otherwise healthy. His temperature is 99.2°F (37.3°C), blood pressure is 122/83 mmHg, pulse is 92/min, respirations are 16/min, and oxygen saturation is 100% on room air. Cardiopulmonary and neurologic exams are within normal limits. An initial ECG and laboratory values are unremarkable as well. Which of the following is the most likely diagnosis?
Cardiology US Medical PG Practice Questions and MCQs
Question 701: A 67-year-old man comes to the physician because of a 6-month history of increasing shortness of breath on exertion, dry cough, and fatigue. He has not had any fevers or night sweats. He worked in a glass manufacturing factory for 15 years and retired 2 years ago. Pulmonary examination shows diffuse crackles bilaterally. An x-ray of the chest shows well-defined calcification of the rims of hilar lymph nodes and scattered nodules in both upper lung fields. This patient is most likely to develop which of the following complications?
A. Pneumocystis pneumonia
B. Pulmonary tuberculosis (Correct Answer)
C. Invasive aspergillosis
D. Malignant mesothelioma
E. Spontaneous pneumothorax
Explanation: ***Pulmonary tuberculosis***
* The description of **shortness of breath**, **dry cough**, and fatigue in a patient with a history of working in a **glass manufacturing factory** (exposing him to silica) with specific radiographic findings such as **egg-shell calcification of hilar lymph nodes** and scattered nodules in the upper lung fields is highly suggestive of **silicosis**.
* Patients with **silicosis** have an increased risk of developing **pulmonary tuberculosis** due to impaired macrophage function, leading to reduced clearance of *Mycobacterium tuberculosis*.
*Pneumocystis pneumonia*
* This infection primarily affects **immunocompromised individuals**, such as those with HIV/AIDS or those on immunosuppressive medications.
* There is no information in the vignette to suggest the patient is immunocompromised in a way that would predispose him to *Pneumocystis* pneumonia.
*Invasive aspergillosis*
* This is typically an opportunistic infection found in severely **immunocompromised patients** (e.g., those with hematologic malignancies, transplant recipients, or prolonged neutropenia) or those with pre-existing lung cavitations.
* While lung pathology due to silicosis could potentially create an environment for fungal colonization, invasive aspergillosis is not the most common or direct complication.
*Malignant mesothelioma*
* **Malignant mesothelioma** is primarily associated with **asbestos exposure**, not silica exposure.
* The patient's history of working in a **glass manufacturing factory** indicates **silica exposure**, not asbestos.
*Spontaneous pneumothorax*
* While some types of interstitial lung disease, including advanced silicosis, can increase the risk of pneumothorax, it is not as classically or directly associated as tuberculosis.
* **Tuberculosis** reactivation is a well-established and significant complication of **silicosis** due to altered immune response.
Question 702: A 71-year-old man presents to the emergency department for shortness of breath. The patient was returning from a business trip to China, when he suddenly felt short of breath during the taxi ride home from the airport. The patient has a past medical history of poorly controlled diabetes mellitus and a 50 pack-year smoking history. The patient is non-compliant with his medications and is currently only taking ibuprofen. An initial ECG demonstrates sinus tachycardia. A chest radiograph is within normal limits. Laboratory values are notable for a creatinine of 2.4 mg/dL and a BUN of 32 mg/dL as compared to his baseline creatinine of 0.9 mg/dL. His temperature is 98.8°F (37.1°C), pulse is 122/min, blood pressure is 145/90 mmHg, respirations are 19/min, and oxygen saturation is 93% on room air. On physical exam, you note an older gentleman in distress. Cardiac exam is notable only for tachycardia. Pulmonary exam is notable for expiratory wheezes. Which of the following is the best confirmatory test for this patient?
A. Ventilation perfusion scan
B. Lower extremity ultrasound with Doppler
C. CT angiogram (Correct Answer)
D. Arterial blood gas
E. D-dimer
Explanation: ***CT angiogram***
- This patient presents with multiple risk factors for **pulmonary embolism (PE)**, including a recent long-haul flight and acute onset of dyspnea with tachycardia and hypoxemia. CT pulmonary angiography (CTPA) is the **gold standard confirmatory test** for PE, directly visualizing thrombi in the pulmonary arteries with high sensitivity (>90%) and specificity.
- While this patient has **acute kidney injury** (creatinine elevated from 0.9 to 2.4 mg/dL), raising concerns about contrast-induced nephropathy, the **high clinical probability of PE** (recent long flight, acute dyspnea, tachycardia, hypoxemia) makes urgent diagnosis critical. In hemodynamically stable patients with intermediate-to-high PE probability and renal insufficiency, CTPA with appropriate precautions (IV hydration, minimizing contrast dose, avoiding nephrotoxic agents) is still preferred as it provides the most definitive diagnosis.
- The patient's hemodynamic stability (BP 145/90) allows time for renal protective measures before contrast administration.
*Ventilation perfusion scan*
- A V/Q scan is an important **alternative** for diagnosing PE, particularly valuable in patients with severe renal insufficiency (CKD Stage 4-5) or contrast allergy where CTPA is truly contraindicated.
- However, in this patient with **expiratory wheezes** suggesting possible underlying obstructive lung disease (50 pack-year smoking history), a V/Q scan has higher likelihood of **indeterminate results** (intermediate probability), which would not confirm or exclude PE and might necessitate additional testing anyway.
- V/Q scans also have lower sensitivity than CTPA and require the patient to cooperate with breathing maneuvers, which may be difficult in an acutely dyspneic patient.
*Lower extremity ultrasound with Doppler*
- This test diagnoses **deep vein thrombosis (DVT)**, the most common source of PE. While a positive DVT in a patient with suspected PE would support treatment, a **negative study does not rule out PE** since the thrombus may have already completely embolized.
- This is a supportive test, not a confirmatory test for PE itself. The patient's symptoms require direct assessment of the pulmonary vasculature.
*Arterial blood gas*
- An ABG typically shows **hypoxemia and respiratory alkalosis** in PE due to V/Q mismatch and hyperventilation, but these findings are **non-specific** and occur in many cardiopulmonary conditions (pneumonia, asthma, COPD exacerbation, heart failure).
- ABG is a supportive tool that may guide oxygen therapy but does not confirm PE diagnosis.
*D-dimer*
- D-dimer has excellent **negative predictive value** and is useful to exclude PE in patients with **low clinical probability** (Wells score <2 or PERC rule negative).
- In this patient with **high clinical probability** of PE (recent long flight, acute symptoms, risk factors), D-dimer would almost certainly be elevated and thus **not helpful for confirmation**. Elevated D-dimer occurs in many conditions including infection, inflammation, malignancy, recent surgery, and advanced age, making it non-specific in this context.
Question 703: A 77-year-old woman is brought to the physician for gradually increasing confusion and difficulty walking for the past 4 months. Her daughter is concerned because she has been forgetful and seems to be walking more slowly. She has been distracted during her weekly bridge games and her usual television shows. She has also had increasingly frequent episodes of urinary incontinence and now wears an adult diaper daily. She has hyperlipidemia and hypertension. Current medications include lisinopril and atorvastatin. Her temperature is 36.8°C (98.2°F), pulse is 84/min, respirations are 15/min, and blood pressure is 139/83 mmHg. She is confused and oriented only to person and place. She recalls 2 out of 3 words immediately and 1 out of 3 after five minutes. She has a broad-based gait and takes short steps. Sensation is intact and muscle strength is 5/5 throughout. Laboratory studies are within normal limits. Which of the following is the most likely diagnosis in this patient?
A. Pseudodementia
B. Normal pressure hydrocephalus (Correct Answer)
C. Creutzfeldt-Jakob disease
D. Frontotemporal dementia
E. Dementia with Lewy-bodies
Explanation: ***Normal pressure hydrocephalus***
- The constellation of **gradually increasing confusion**, an **ataxic gait** (broad-based, short steps), and **urinary incontinence** in an elderly patient is the classic triad of **normal pressure hydrocephalus (NPH)**.
- Lumbar puncture with temporary symptom improvement or **neuroimaging** showing ventriculomegaly without significant sulcal atrophy would further support this diagnosis.
*Pseudodementia*
- **Pseudodementia** is a cognitive impairment primarily caused by **depression**, characterized by rapid onset of symptoms and often a history of mood disturbances.
- The patient's progressive decline over 4 months and lack of overt depressive symptoms make this less likely.
*Creutzfeldt-Jakob disease*
- **Creutzfeldt-Jakob disease (CJD)** is a rapidly progressive and fatal neurodegenerative disorder characterized by a very fast decline in cognitive function, typically over months, along with **myoclonus**, ataxia, and other neurological signs.
- The slower, more subtle progression of symptoms and absence of myoclonus make CJD less likely.
*Frontotemporal dementia*
- **Frontotemporal dementia (FTD)** usually presents with prominent early changes in **personality, behavior**, or **language (aphasia)**, rather than the classic NPH triad.
- While confusion can occur, gait disturbance and incontinence are not typically primary or early features.
*Dementia with Lewy-bodies*
- **Dementia with Lewy bodies (DLB)** is characterized by **fluctuating cognition**, **recurrent visual hallucinations**, and **spontaneous parkinsonism**.
- While gait disturbance can occur (parkinsonism), the absence of hallucinations and significant cognitive fluctuations makes NPH a more fitting diagnosis for the specific triad presented.
Question 704: A 32-year-old woman comes to the physician because of a 6-week history of fatigue and weakness. Examination shows marked pallor of the conjunctivae. The spleen tip is palpated 2 cm below the left costal margin. Her hemoglobin concentration is 9.5 g/dL, serum lactate dehydrogenase concentration is 750 IU/L, and her serum haptoglobin is undetectable. A peripheral blood smear shows multiple spherocytes. When anti-IgG antibodies are added to a sample of the patient's blood, there is clumping of the red blood cells. Which of the following is the most likely predisposing factor for this patient's condition?
A. Bicuspid aortic valve
B. Epstein-Barr virus infection
C. Mycoplasma pneumoniae infection
D. Systemic lupus erythematosus (Correct Answer)
E. Hereditary spectrin defect
Explanation: ***Systemic lupus erythematosus***
- The patient's presentation with **fatigue, weakness, pallor, splenomegaly**, and laboratory findings of **hemolytic anemia** (low hemoglobin, elevated LDH, undetectable haptoglobin, spherocytes) along with a **positive direct antiglobulin test** (clumping with anti-IgG antibodies) is highly suggestive of **autoimmune hemolytic anemia (AIHA)**.
- **Systemic lupus erythematosus (SLE)** is a common cause of secondary AIHA, where the immune system mistakenly attacks red blood cells, leading to their destruction.
*Bicuspid aortic valve*
- A **bicuspid aortic valve** is a congenital heart defect that can lead to increased stress on red blood cells, but it typically causes **mechanical hemolysis**, not autoimmune hemolysis.
- Mechanical hemolysis would not explain the **positive direct antiglobulin test** and the presence of **spherocytes** as the hallmark of immune-mediated destruction.
*Epstein-Barr virus infection*
- **Epstein-Barr virus (EBV) infection** can cause various hematologic complications, including anemia, but it is more commonly associated with cold agglutinin disease (a type of AIHA where IgM antibodies are involved), not warm AIHA (IgG-mediated) with spherocytes.
- While EBV can cause lymphoproliferation and autoimmune phenomena, it is not the most direct or common predisposing factor for this specific presentation of warm AIHA.
*Mycoplasma pneumoniae infection*
- **Mycoplasma pneumoniae infection** is a well-known cause of **cold agglutinin disease**, where **IgM antibodies** (specifically anti-I antibodies) cause clumping of red blood cells at lower temperatures.
- This patient's direct antiglobulin test is positive for **IgG antibodies**, indicating a warm AIHA, which is typically not caused by Mycoplasma.
*Hereditary spectrin defect*
- A **hereditary spectrin defect** is characteristic of **hereditary spherocytosis**, a genetic disorder causing red blood cell membrane abnormalities and spherocyte formation.
- While hereditary spherocytosis leads to spherocytes and hemolysis, it is associated with a **negative direct antiglobulin test** because the hemolysis is due to intrinsic red blood cell defects, not autoimmune processes.
Question 705: A 59-year-old woman comes to the emergency department because of a 2-day history of worsening fever, chills, malaise, productive cough, and difficulty breathing. Three days ago, she returned from a trip to South Africa. She has type 2 diabetes mellitus, hypertension, and varicose veins. Her current medications include metformin, lisinopril, and atorvastatin. Her temperature is 39.4°C (102.9°F), pulse is 102/minute, blood pressure is 94/68 mm Hg, and respirations are 31/minute. Pulse oximetry on 2 L of oxygen via nasal cannula shows an oxygen saturation of 91%. Examination reveals decreased breath sounds and dull percussion over the left lung base. The skin is very warm and well-perfused. The remainder of the examination shows no abnormalities. Laboratory studies show:
Hemoglobin 11.6 g/dL
Leukocyte count 15,400/mm3
platelet count 282,000/mm3
Serum
Na+ 144 mEq/L
Cl- 104 mEq/L
K+ 4.9 mEq/L
Creatinine 1.5 mg/dL
Blood and urine for cultures are obtained. Intravenous fluid resuscitation is begun. Which of the following is the next best step in management?
A. Erythromycin
B. Intravenous ceftriaxone and azithromycin (Correct Answer)
C. External cooling and intravenous acetaminophen
D. Intravenous vancomycin and ceftriaxone
E. CT of the chest with contrast
Explanation: ***Intravenous ceftriaxone and azithromycin***
* This patient presents with **severe community-acquired pneumonia (CAP)** meeting criteria for ICU-level care, including hypotension (94/68 mm Hg), hypoxemia requiring supplemental oxygen, tachypnea (31/min), and altered mental status indicators. The presentation meets multiple **severe CAP criteria** (CURB-65 score ≥3 or IDSA/ATS major criteria).
* **Intravenous ceftriaxone** (a third-generation cephalosporin) provides broad-spectrum coverage against common bacterial causes of CAP, including *Streptococcus pneumoniae* and *Haemophilus influenzae*. **Azithromycin** (a macrolide) is crucial to cover atypical pathogens like *Mycoplasma pneumoniae*, *Chlamydophila pneumoniae*, and *Legionella pneumoniae*.
* This combination represents the **standard empiric therapy for severe CAP** per IDSA/ATS guidelines. The patient's recent travel to South Africa and severe symptoms increase the likelihood of atypical pathogens or resistant strains, making dual therapy essential.
*Erythromycin*
* While erythromycin is a macrolide that covers atypical pathogens, its use is generally limited due to higher rates of gastrointestinal side effects and a less favorable dosing profile compared to newer macrolides like azithromycin. It does not provide adequate coverage for typical bacterial causes of CAP.
* In severe CAP with signs of sepsis, monotherapy with erythromycin would be insufficient and would not address the need for broad-spectrum coverage against both typical and atypical bacteria. Dual antibiotic therapy is required for severe cases.
*External cooling and intravenous acetaminophen*
* These interventions are appropriate for **fever reduction** but do not address the underlying severe infection (pneumonia with sepsis). While important for symptomatic relief, they are not the "next best step in management" for a life-threatening condition.
* Treating the infection with appropriate antibiotics is paramount to prevent further deterioration and organ damage. In severe sepsis from pneumonia, **source control through antimicrobial therapy takes precedence** over symptomatic fever management.
*Intravenous vancomycin and ceftriaxone*
* **Vancomycin** is primarily used to cover **methicillin-resistant *Staphylococcus aureus* (MRSA)**. While MRSA can cause severe pneumonia, there are no specific risk factors for MRSA in this patient (e.g., recent hospitalization, IV drug use, prior MRSA infection, severe influenza, cavitary lesions, hemoptysis).
* Adding vancomycin without specific indications for MRSA coverage would represent unnecessary broad-spectrum antibiotic use and could contribute to antibiotic resistance. The combination of **ceftriaxone and azithromycin is the standard empiric therapy** for severe CAP without MRSA risk factors.
*CT of the chest with contrast*
* A CT scan of the chest might be useful for further characterizing the pneumonia, identifying complications (e.g., empyema, abscess), or differentiating from other conditions **after initial stabilization**. However, in a patient with severe pneumonia, hypoxemia, and hypotension, the immediate priority is stabilization and initiation of empiric antibiotic therapy.
* Delaying life-saving antibiotic treatment to obtain a CT scan could worsen the patient's prognosis and violate the principle of **early appropriate antibiotics in sepsis** (ideally within 1 hour). Clinical diagnosis with chest X-ray is sufficient to initiate treatment, and further imaging can be obtained after stabilization if needed.
Question 706: A 75-year-old woman presents to the physician with a complaint of a frequent need to void at nighttime, which has been disrupting her sleep. She notes embarrassingly that she is often unable to reach the bathroom in time, and experiences urinary leakage throughout the night as well as during the day. The patient undergoes urodynamic testing and a urinalysis is obtained which is normal. She is instructed by the physician to perform behavioral training to improve her bladder control. Which of the following is the most likely diagnosis contributing to this patient’s symptoms?
A. Urinary tract infection
B. Stress incontinence
C. Urge incontinence (Correct Answer)
D. Overflow incontinence
E. Total incontinence
Explanation: ***Urge incontinence***
- The patient's symptoms of a **frequent need to void**, inability to reach the bathroom in time (urgency), and **nocturnal leakage** (nocturia with incontinence) are classic for urge incontinence.
- This condition is characterized by **detrusor overactivity**, leading to sudden, strong urges to urinate that are difficult to defer.
*Urinary tract infection*
- While UTIs can cause urgency and frequency, the patient's **normal urinalysis** rules out an active infection as the cause of her symptoms.
- UTIs typically present with dysuria, hematuria, or suprapubic pain, which are not mentioned.
*Stress incontinence*
- This type of incontinence is characterized by **involuntary urine leakage with increased intra-abdominal pressure**, such as coughing, sneezing, or laughing.
- The patient's description of sudden urges and inability to reach the bathroom in time does not align with stress incontinence.
*Overflow incontinence*
- This condition is due to **incomplete bladder emptying**, leading to a constantly full bladder and continuous leakage.
- It often presents with weak stream, hesitancy, and a feeling of incomplete voiding, which are not described here.
*Total incontinence*
- Total incontinence involves the **continuous and unpredictable leakage** of urine, day and night, without any discernible pattern.
- While the patient experiences significant leakage, her symptoms point more specifically to the urge component rather than a complete absence of bladder control.
Question 707: A 68-year old woman presents with recurring headaches and pain while combing her hair. Her past medical history is significant for hypertension, glaucoma and chronic deep vein thrombosis in her right leg. Current medication includes rivaroxaban, latanoprost, and benazepril. Her vitals include: blood pressure 130/82 mm Hg, pulse 74/min, respiratory rate 14/min, temperature 36.6℃ (97.9℉). Physical examination reveals neck stiffness and difficulty standing up due to pain in the lower limbs. Strength is 5 out of 5 in the upper and lower extremities bilaterally. Which of the following is the next best step in the management of this patient?
A. Erythrocyte sedimentation rate (Correct Answer)
B. CK-MB
C. Fundoscopic examination
D. Lumbar puncture
E. Temporal artery biopsy
Explanation: ***Erythrocyte sedimentation rate***
- The patient's symptoms of recurring headaches, pain while combing hair, and neck stiffness are highly suggestive of **giant cell arteritis (GCA)**, a vasculitis requiring prompt diagnosis.
- An elevated **erythrocyte sedimentation rate (ESR)** is a hallmark laboratory finding in GCA and is the most appropriate initial diagnostic test to support the clinical suspicion.
*CK-MB*
- **CK-MB** (creatine kinase-myocardial band) is a marker primarily used to diagnose myocardial injury, such as a heart attack.
- The patient's symptoms are not consistent with an acute cardiac event; therefore, CK-MB measurement would not be the next best step.
*Fundoscopic examination*
- While **fundoscopic examination** can reveal signs of vasculitis or optic nerve ischemia in GCA, it is not the primary diagnostic test and may not show abnormalities early in the disease.
- It would be part of a more extensive workup once GCA is suspected and initial lab tests are supportive.
*Lumbar puncture*
- A **lumbar puncture** is used to analyze cerebrospinal fluid, typically to diagnose conditions like meningitis, encephalitis, or subarachnoid hemorrhage.
- The patient's symptoms do not point towards these neurological emergencies, making a lumbar puncture an inappropriate initial step.
*Temporal artery biopsy*
- A **temporal artery biopsy** is the gold standard for confirming the diagnosis of giant cell arteritis.
- However, it is an invasive procedure and is typically performed *after* initial laboratory tests, such as ESR, support the clinical suspicion, and often after the initiation of empiric steroid treatment.
Question 708: A 59-year-old woman comes to the physician because of a 1-year history of pain and stiffness in her fingers and knees. The stiffness lasts for about 10 minutes after she wakes up in the morning. She also reports that her knee pain is worse in the evening. She drinks one glass of wine daily. Her only medication is acetaminophen. She is 175 cm (5 ft 9 in) tall and weighs 102 kg (225 lb); BMI is 33 kg/m2. Physical examination shows firm nodules on the distal interphalangeal joints of the index, ring, and little fingers of both hands. Which of the following is the most likely diagnosis?
A. Septic arthritis
B. Pseudogout
C. Gout
D. Rheumatoid arthritis
E. Osteoarthritis (Correct Answer)
Explanation: ***Osteoarthritis***
* The patient's age (59 years), obesity (BMI 33 kg/m2), short duration of morning stiffness (10 minutes), evening worsening of knee pain, and the presence of **firm nodules on the distal interphalangeal joints** (Heberden's nodes) are classic signs of **osteoarthritis**.
* This condition is a common **degenerative joint disease** associated with wear and tear, often affecting weight-bearing joints and small joints of the hands.
*Septic arthritis*
* **Septic arthritis** typically presents with an acutely painful, hot, and swollen joint, often with systemic symptoms like fever and chills, which are absent here.
* The chronic, progressive nature of the patient's symptoms and the presence of bony nodules point away from an infectious cause.
*Pseudogout*
* **Pseudogout**, or calcium pyrophosphate deposition disease, involves the deposition of calcium pyrophosphate crystals, leading to episodes of acute, painful arthritis, often in larger joints like the knee.
* While it can affect the knee, the insidious onset, chronic pain, and specific hand nodules seen in this case are not typical features of pseudogout.
*Gout*
* **Gout** is characterized by sudden, severe attacks of pain, redness, and swelling, often affecting a single joint (commonly the great toe) due to **uric acid crystal deposition**.
* The patient's chronic pain pattern, multiple joint involvement (fingers and knees), and the description of firm nodules (not tophi) make gout less likely.
*Rheumatoid arthritis*
* **Rheumatoid arthritis** typically presents with morning stiffness lasting longer than 30 minutes, symmetrical polyarthritis, and often affects the **proximal interphalangeal (PIP)** and **metacarpophalangeal (MCP) joints** of the hands, sparing the DIP joints.
* The patient's short morning stiffness, DIP joint involvement, and the absence of systemic inflammatory signs argue against rheumatoid arthritis.
Question 709: One day after undergoing total knee replacement for advanced degenerative osteoarthritis, a 66-year-old man has progressive lower abdominal pain. The surgery was performed under general anesthesia and the patient was temporarily catheterized for perioperative fluid balance. Several hours after the surgery, the patient began to have decreasing voiding volumes, nausea, and progressive, dull lower abdominal pain. He has Sjögren syndrome. He is sexually active with his wife and one other woman and uses condoms inconsistently. He does not smoke and drinks beer occasionally. Current medications include pilocarpine eye drops. He appears uncomfortable and is diaphoretic. His temperature is 37.3°C (99.1°F), pulse is 90/min, and blood pressure is 130/82 mm Hg. Abdominal examination shows a pelvic mass extending to the umbilicus. It is dull on percussion and diffusely tender to palpation. His hemoglobin concentration is 13.9 g/dL, leukocyte count is 9,000/mm3, a platelet count is 230,000/mm3. An attempt to recatheterize the patient transurethrally is unsuccessful. Which of the following is the most likely underlying cause of this patient's symptoms?
A. Neurogenic bladder
B. Adverse effect of pilocarpine
C. Urethral stricture
D. Prostate cancer
E. Benign prostatic enlargement (Correct Answer)
Explanation: ***Benign prostatic enlargement***
- The patient's symptoms of **decreasing voiding volumes**, **lower abdominal pain**, and a **palpable bladder** after surgery are highly suggestive of **acute urinary retention**. The most common cause of acute urinary retention in older men is **benign prostatic hyperplasia (BPH)**, leading to bladder outlet obstruction.
- The **failed attempt to recatheterize** transurethrally further points to a mechanical obstruction at the level of the bladder neck or urethra, which is consistent with an enlarged prostate.
*Neurogenic bladder*
- While neurogenic bladder can cause urinary retention, it typically presents with a history of neurological deficits or risk factors (e.g., spinal cord injury, diabetes, multiple sclerosis), which are not mentioned here.
- The **acute onset** post-surgery and the **failed catheterization** strongly favor a mechanical obstruction over a purely neurogenic cause.
*Adverse effect of pilocarpine*
- Pilocarpine is a **muscarinic agonist** used to treat dry mouth/eyes from Sjögren syndrome and can increase bladder contractility, potentially *improving* urination, not causing retention.
- Its side effects generally include increased salivation, sweating, and gastrointestinal upset, not urinary retention.
*Urethral stricture*
- A urethral stricture could explain the resistance to catheterization and urinary retention but is less common acutely after simple catheterization for surgery, unless there was prior urethral trauma or infection.
- The presence of a **pelvic mass** (distended bladder) and the patient's age make BPH a more common and likely cause of obstruction.
*Prostate cancer*
- Prostate cancer can cause bladder outlet obstruction, but it typically presents more insidiously with urinary symptoms, and acute urinary retention as a sole initial presentation is less common than with BPH.
- While possible, the acute onset post-surgery in an elderly male without other symptoms (e.g., bone pain, weight loss) makes **benign prostatic enlargement** a more probable and immediate cause of obstruction.
Question 710: A 33-year-old man presents to the emergency department after an episode of syncope. He states that for the past month ever since starting a new job he has experienced an episode of syncope or near-syncope every morning while he is getting dressed. The patient states that he now gets dressed, shaves, and puts on his tie sitting down to avoid falling when he faints. He has never had this before and is concerned it is stress from his new job as he has been unemployed for the past 5 years. He is wondering if he can get a note for work since he was unable to head in today secondary to his presentation. The patient has no significant past medical history and is otherwise healthy. His temperature is 99.2°F (37.3°C), blood pressure is 122/83 mmHg, pulse is 92/min, respirations are 16/min, and oxygen saturation is 100% on room air. Cardiopulmonary and neurologic exams are within normal limits. An initial ECG and laboratory values are unremarkable as well. Which of the following is the most likely diagnosis?
A. Malingering
B. Hypertrophic obstructive cardiomyopathy
C. Aortic stenosis
D. Carotid hypersensitivity syndrome (Correct Answer)
E. Anxiety
Explanation: ***Carotid hypersensitivity syndrome***
- This patient's symptoms of recurrent syncope/near-syncope during activities like **shaving or putting on a tie**, which involve pressure on the neck where the **carotid sinus** is located, are classic for carotid sinus hypersensitivity.
- The maneuvers he is taking to avoid falling (getting dressed, shaving, and putting on his tie while sitting down) further support this diagnosis, as they show an adaptive behavior to a precise, reproducible trigger.
*Malingering*
- While the patient's request for a work note might raise some suspicion, there are **clear, physiologically plausible triggers** for his syncope, and his adaptive behavior suggests a genuine effort to cope with real symptoms rather than feigning illness for external gain.
- Malingering would typically involve less specific or consistent symptoms, and often a more overt attempt to obtain a specific outcome (e.g., disability benefits) without the accompanying adaptive behaviors seen here.
*Hypertrophic obstructive cardiomyopathy*
- This condition can cause exertional syncope due to outflow tract obstruction, but it's less likely to present with syncope triggered by distinct neck maneuvers like **shaving or tying a tie**.
- An initial **ECG and physical exam** would likely show abnormalities (e.g., prominent S waves in V1-V3, left ventricular hypertrophy, murmur) which are absent in this case.
*Aortic stenosis*
- Syncope in aortic stenosis is typically **exertional** and caused by reduced cerebral perfusion during physical activity, not by specific neck movements.
- Aortic stenosis would also likely present with a **characteristic systolic ejection murmur** and ECG changes that were not noted in this otherwise healthy patient, and is less common in a 33-year-old without other risk factors.
*Anxiety*
- While anxiety can cause symptoms like lightheadedness or hyperventilation leading to near-syncope, it typically does not cause **true syncope with loss of consciousness** with such a consistent and specific trigger (neck compression).
- The regular daily occurrence tied to specific actions and the body's physiological response points away from anxiety as the primary cause for the syncope itself, although anxiety about the events could be secondary.
