A 53-year-old female presents with worsening shortness of breath with activity. Physical exam reveals a diastolic murmur with an opening snap. The patient’s medical history is significant for a left hip replacement 10 years ago, and she vaguely recalls an extended period of illness as a child described as several severe episodes of sore throat followed by rash, fever, and joint pains. Administration of which of the following treatments at that time would have been most effective in reducing her risk of developing cardiac disease?
Q762
A 63-year-old man presents to the emergency department because of progressive difficulty with breathing. He has a history of diabetes, hypertension, and chronic bronchitis. He has been receiving medications to moderate his conditions and reports being compliant with his schedule. He reports a recent difficulty with tackling simple chores in the house. He has not been able to walk for more than 1 block over the past few days. His persistent cough has also been worsening with more formation of sputum. During his diagnosis of bronchitis, about a year ago, he had a 40-pack-year smoking history. The patient is in evident distress and uses his accessory muscles to breathe. The vital signs include: temperature 38.6°C (101.5°F), blood pressure 120/85 mm Hg, pulse 100/min, respiratory rate 26/min, and oxygen (O2) saturation 87%. A decrease in breathing sounds with expiratory wheezes is heard on auscultation of the lungs. The arterial blood gas (ABG) analysis shows:
PCO2 60 mm Hg
PO2 45 mm Hg
pH 7.3
HCO3– 25 mEq/L
Which of the following is the most appropriate next step in the treatment?
Q763
A 66-year-old woman with hypertension comes to the physician because of crampy, dull abdominal pain and weight loss for 1 month. The pain is located in the epigastric region and typically occurs within the first hour after eating. She has had a 7-kg (15.4-lb) weight loss in the past month. She has smoked 1 pack of cigarettes daily for 20 years. Physical examination shows a scaphoid abdomen and diffuse tenderness to palpation. Laboratory studies including carbohydrate antigen 19-9 (CA 19-9), carcinoembryonic antigen (CEA), and lipase concentrations are within the reference range. Which of the following is the most likely cause of this patient's symptoms?
Q764
A 72-year-old man presents to his primary care physician for a wellness visit. He says that he has been experiencing episodes of chest pain and lightheadedness. Approximately 1 week ago he fell to the ground after abruptly getting up from the bed. Prior to the fall, he felt lightheaded and his vision began to get blurry. According to his wife, he was unconscious for about 5 seconds and then spontaneously recovered fully. He experiences a pressure-like discomfort in his chest and lightheadedness with exertion. At times, he also experiences shortness of breath when climbing the stairs. Medical history is significant for hypertension and hypercholesterolemia. He does not smoke cigarettes or drink alcohol. Cardiac auscultation demonstrates a systolic ejection murmur at the right upper border and a normal S1 and soft S2. Which of the following is most likely found in this patient?
Q765
A 57-year-old man presents to his family physician for a routine exam. He feels well and reports no new complaints since his visit last year. Last year, he had a colonoscopy which showed no polyps, a low dose chest computerized tomography (CT) scan that showed no masses, and routine labs which showed a fasting glucose of 93 mg/dL. He is relatively sedentary and has a body mass index (BMI) of 24 kg/m^2. He has a history of using methamphetamines, alcohol (4-5 drinks per day since age 30), and tobacco (1 pack per day since age 18), but he joined Alcoholics Anonymous and has been in recovery, not using any of these for the past 7 years. Which of the following is indicated at this time?
Q766
A 59-year-old man presents to his primary care physician with a 5-month history of breathing difficulties. He says that he has been experiencing exertional dyspnea that is accompanied by a nonproductive cough. His past medical history is significant for a solitary lung nodule that was removed surgically 10 years ago and found to be benign. He works as a coal miner, does not smoke, and drinks socially with friends. His family history is significant for autoimmune diseases. Physical exam reveals fine bibasilar inspiratory crackles in both lungs, and laboratory testing is negative for antinuclear antibody and rheumatoid factor. Which of the following is associated with the most likely cause of this patient's symptoms?
Q767
A 75-year-old woman comes to the physician because of generalized weakness for 6 months. During this period, she has also had a 4-kg (8.8-lb) weight loss and frequent headaches. She has been avoiding eating solids because of severe jaw pain. She has hypertension and osteoporosis. She underwent a total left-sided knee arthroplasty 2 years ago because of osteoarthritis. The patient does not smoke or drink alcohol. Her current medications include enalapril, metoprolol, low-dose aspirin, and a multivitamin. She appears pale. Her temperature is 37.5°C (99.5°F), pulse is 82/min, and blood pressure is 135/80 mm Hg. Physical examination shows no abnormalities. Laboratory studies show:
Hemoglobin 10 g/dL
Mean corpuscular volume 87 μm3
Leukocyte count 8,500/mm3
Platelet count 450,000/mm3
Erythrocyte sedimentation rate 90 mm/h
Which of the following is the most appropriate next step in management?
Q768
A 47-year-old woman comes to her primary care doctor because of a new, pruritic rash. She was gardening in her yard two days ago and now has an eczematous papulovesicular rash on both ankles. You also note a single, 5 mm brown lesion with a slightly raised border on her left thigh. You prescribe a topical corticosteroid for contact dermatitis. Which of the following is the appropriate next step for the thigh lesion?
Q769
A 45-year-old woman presents to her physician with a four-month history of headache. Her headache is nonfocal but persistent throughout the day without any obvious trigger. She was told that it was a migraine but has never responded to sumatriptan, oxygen, or antiemetics. She takes amlodipine for hypertension. She does not smoke. She denies any recent weight loss or constitutional symptoms. Her temperature is 98°F (36.7°C), blood pressure is 180/100 mmHg, pulse is 70/min, and respirations are 15/min. She is obese with posterior cervical fat pads and central abdominal girth. Her neurological exam is unremarkable. In her initial laboratory workup, her fasting blood glucose level is 200 mg/dL. The following additional lab work is obtained and is as follows:
Serum:
Na+: 142 mEq/L
Cl-: 102 mEq/L
K+: 4.1 mEq/L
HCO3-: 24 mEq/L
BUN: 20 mg/dL
Glucose: 135 mg/dL
Creatinine: 1.3 mg/dL
Ca2+: 10.0 mg/dL
AST: 8 U/L
ALT: 8 U/L
24-hour urinary cortisol: 500 µg (reference range < 300 µg)
Serum cortisol: 25 µg/mL (reference range 5-23 µg/dL)
24-hour low dose dexamethasone suppression test: Not responsive
High dose dexamethasone suppression test: Responsive
Adrenocorticotropin-releasing hormone (ACTH): 20 pg/mL (5-15 pg/mL)
Imaging reveals a 0.5 cm calcified pulmonary nodule in the right middle lobe that has been present for 5 years but an otherwise unremarkable pituitary gland, mediastinum, and adrenal glands. What is the best next step in management?
Q770
A 23-year-old man presents to the emergency department brought in by police. He was found shouting at strangers in the middle of the street. The patient has no significant past medical history, and his only medications include a short course of prednisone recently prescribed for poison ivy exposure. His temperature is 77°F (25°C), blood pressure is 90/50 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air. The patient is only wearing underwear, and he is occasionally mumbling angrily about the government. He appears to be responding to internal stimuli, and it is difficult to obtain a history from him. Which of the following is the next best step in management?
Cardiology US Medical PG Practice Questions and MCQs
Question 761: A 53-year-old female presents with worsening shortness of breath with activity. Physical exam reveals a diastolic murmur with an opening snap. The patient’s medical history is significant for a left hip replacement 10 years ago, and she vaguely recalls an extended period of illness as a child described as several severe episodes of sore throat followed by rash, fever, and joint pains. Administration of which of the following treatments at that time would have been most effective in reducing her risk of developing cardiac disease?
A. Ciprofloxacin
B. Vancomycin
C. Penicillin (Correct Answer)
D. Acyclovir
E. Aspirin
Explanation: ***Penicillin***
- The patient's childhood history of recurrent sore throats, rash, fever, and joint pains is highly suggestive of **rheumatic fever**, a sequela of untreated **Group A Streptococcal (GAS) pharyngitis**.
- **Penicillin** is the most effective antibiotic for treating GAS pharyngitis and preventing subsequent rheumatic fever and its associated **valvular heart disease**, such as the **mitral stenosis** suggested by the diastolic murmur and opening snap.
*Ciprofloxacin*
- **Ciprofloxacin** is a fluoroquinolone antibiotic primarily used for gram-negative bacterial infections and some gram-positive infections, but it is **not the first-line treatment for GAS pharyngitis**.
- Its broad spectrum and potential side effects make it unsuitable for routine use in preventing rheumatic fever.
*Vancomycin*
- **Vancomycin** is a powerful antibiotic reserved for serious infections caused by gram-positive bacteria, particularly **MRSA** and **_Clostridioides difficile_**.
- While it has activity against GAS, it is **not appropriate for treating GAS pharyngitis** due to its reserved status for resistant infections, requirement for IV administration, and potential side effects, making it unsuitable for preventing rheumatic fever.
*Acyclovir*
- **Acyclovir** is an antiviral medication used to treat herpes simplex and varicella-zoster virus infections.
- It has **no antibacterial activity** and would be completely ineffective in treating GAS pharyngitis or preventing rheumatic heart disease.
*Aspirin*
- **Aspirin** is an anti-inflammatory and antiplatelet agent used to manage symptoms of rheumatic fever like **arthralgia** and fever, but it **does not treat the underlying streptococcal infection**.
- While it can alleviate some acute symptoms, it **does not prevent the development of permanent cardiac damage**.
Question 762: A 63-year-old man presents to the emergency department because of progressive difficulty with breathing. He has a history of diabetes, hypertension, and chronic bronchitis. He has been receiving medications to moderate his conditions and reports being compliant with his schedule. He reports a recent difficulty with tackling simple chores in the house. He has not been able to walk for more than 1 block over the past few days. His persistent cough has also been worsening with more formation of sputum. During his diagnosis of bronchitis, about a year ago, he had a 40-pack-year smoking history. The patient is in evident distress and uses his accessory muscles to breathe. The vital signs include: temperature 38.6°C (101.5°F), blood pressure 120/85 mm Hg, pulse 100/min, respiratory rate 26/min, and oxygen (O2) saturation 87%. A decrease in breathing sounds with expiratory wheezes is heard on auscultation of the lungs. The arterial blood gas (ABG) analysis shows:
PCO2 60 mm Hg
PO2 45 mm Hg
pH 7.3
HCO3– 25 mEq/L
Which of the following is the most appropriate next step in the treatment?
A. O2 supplementation (Correct Answer)
B. Aminophylline
C. Methylprednisolone
D. Albuterol
E. Levofloxacin
Explanation: ***O2 supplementation***
- The patient presents with **severe hypoxemia** (SpO2 87%, PO2 45 mm Hg), which is a life-threatening condition requiring immediate intervention. **Oxygen supplementation** is critical to improve tissue oxygenation and prevent organ damage.
- The patient's presentation is consistent with an acute exacerbation of COPD, likely triggered by infection, where *initial management focuses on correcting hypoxemia* and *relieving bronchospasm*.
- In COPD patients, **controlled oxygen therapy** is essential (target SpO2 88-92%) to avoid worsening CO2 retention, but with SpO2 of 87% and severe hypoxemia, oxygen remains the immediate priority.
*Aminophylline*
- Aminophylline is a **methylxanthine** with bronchodilatory effects, but its **narrow therapeutic index** and significant side effect profile (e.g., arrhythmias, seizures) make it a less favored first-line treatment for acute exacerbations of COPD.
- While it can be considered in severe cases unresponsive to other therapies, it is not the most appropriate immediate next step given the patient's critical hypoxemia, where oxygen is paramount.
*Methylprednisolone*
- **Corticosteroids** like methylprednisolone are important in reducing inflammation during COPD exacerbations and improving lung function.
- However, their full therapeutic effect takes hours to develop, and they do not immediately address the acute, life-threatening hypoxemia present in this patient.
*Albuterol*
- Albuterol is a **short-acting beta-agonist (SABA)**, which is crucial for *bronchodilation* in COPD exacerbations. It should be administered promptly to relieve airway obstruction.
- While essential in managing the exacerbation, addressing the *severe hypoxemia* with oxygen takes immediate precedence to prevent organ damage, as albuterol will not directly increase oxygen saturation to a safe level alone.
*Levofloxacin*
- **Antibiotics** like levofloxacin are indicated when there's evidence of a bacterial infection triggering the COPD exacerbation, as suggested by increased sputum purulence and fever.
- While important for treating the underlying infection, administering antibiotics does not immediately address the *acute respiratory distress* and *severe hypoxemia*, which are the most urgent concerns.
Question 763: A 66-year-old woman with hypertension comes to the physician because of crampy, dull abdominal pain and weight loss for 1 month. The pain is located in the epigastric region and typically occurs within the first hour after eating. She has had a 7-kg (15.4-lb) weight loss in the past month. She has smoked 1 pack of cigarettes daily for 20 years. Physical examination shows a scaphoid abdomen and diffuse tenderness to palpation. Laboratory studies including carbohydrate antigen 19-9 (CA 19-9), carcinoembryonic antigen (CEA), and lipase concentrations are within the reference range. Which of the following is the most likely cause of this patient's symptoms?
A. Focal wall thickening in the colon
B. Narrowing of the celiac artery (Correct Answer)
C. Decreased motility of gastric smooth muscle
D. Embolus in the superior mesenteric artery
E. Malignant mass at the head of the pancreas
Explanation: ***Narrowing of the celiac artery***
- This presentation, with postprandial epigastric pain, weight loss, and a history of hypertension and smoking, is highly suggestive of **chronic mesenteric ischemia**, often caused by **atherosclerotic narrowing** of the celiac or mesenteric arteries.
- The pain occurring consistently within an hour of eating is known as "intestinal angina," as the increased metabolic demand of digestion is unmet by the compromised blood supply.
*Focal wall thickening in the colon*
- This finding would more likely point to conditions such as **diverticulitis**, **inflammatory bowel disease**, or **colorectal cancer**.
- While these can cause abdominal pain and weight loss, the classic postprandial timing of the pain in the epigastric region is not typical.
*Decreased motility of gastric smooth muscle*
- This condition, known as **gastroparesis**, primarily causes symptoms like nausea, vomiting, early satiety, and bloating.
- While weight loss can occur, the prominent **crampy, dull epigastric pain** that consistently appears after eating is not typical of gastroparesis.
*Embolus in the superior mesenteric artery*
- An **acute arterial embolus** typically causes sudden onset, severe, diffuse abdominal pain with signs of acute abdomen or shock, often leading to rapid bowel ischemia and infarction.
- This patient's symptoms are chronic (lasting 1 month) and progressive, inconsistent with an acute embolic event.
*Malignant mass at the head of the pancreas*
- Pancreatic cancer often causes **epigastric pain**, **weight loss**, and sometimes **jaundice** if it obstructs the bile duct.
- However, the absence of elevated CA 19-9 and the very specific postprandial nature of the pain point away from pancreatic cancer as the *most likely* cause, although it remains a differential for epigastric pain and weight loss.
Question 764: A 72-year-old man presents to his primary care physician for a wellness visit. He says that he has been experiencing episodes of chest pain and lightheadedness. Approximately 1 week ago he fell to the ground after abruptly getting up from the bed. Prior to the fall, he felt lightheaded and his vision began to get blurry. According to his wife, he was unconscious for about 5 seconds and then spontaneously recovered fully. He experiences a pressure-like discomfort in his chest and lightheadedness with exertion. At times, he also experiences shortness of breath when climbing the stairs. Medical history is significant for hypertension and hypercholesterolemia. He does not smoke cigarettes or drink alcohol. Cardiac auscultation demonstrates a systolic ejection murmur at the right upper border and a normal S1 and soft S2. Which of the following is most likely found in this patient?
A. Pulsus paradoxus
B. Decreased murmur intensity with squatting
C. Bicuspid aortic valve
D. High bounding pulses
E. Increased blood flow velocity through the aortic valve (Correct Answer)
Explanation: ***Increased blood flow velocity through the aortic valve***
- The patient's symptoms of **chest pain**, **lightheadedness (syncope)**, and **shortness of breath (dyspnea)** with exertion, along with a **systolic ejection murmur** at the right upper sternal border, are classic for **aortic stenosis**.
- In aortic stenosis, the narrowed aortic valve orifice causes a significant increase in the **velocity of blood flow** through the valve to maintain cardiac output, which can be detected by Doppler echocardiography.
*Pulsus paradoxus*
- This is a decrease in systolic blood pressure by more than 10 mmHg during inspiration, typically associated with conditions like **cardiac tamponade** or **severe asthma/COPD**, not aortic stenosis.
- It results from increased right ventricular filling and bowing of the interventricular septum into the left ventricle during inspiration, impairing left ventricular filling.
*Decreased murmur intensity with squatting*
- Squatting increases **venous return** and **systemic vascular resistance**, which typically *increases* the intensity of murmurs associated with forward flow lesions like aortic stenosis.
- A *decrease* in murmur intensity with squatting is characteristic of **hypertrophic obstructive cardiomyopathy (HOCM)**, which becomes less obstructive with increased left ventricular filling.
*Bicuspid aortic valve*
- While a **bicuspid aortic valve** is a common *cause* of aortic stenosis, it is a congenital anomaly and not a *finding* directly observed in the physical exam or a physiological consequence in a 72-year-old presenting with acquired calcific aortic stenosis.
- The question asks for what is *most likely found* in this patient *given the current presentation*, not the underlying etiology in an elderly patient where calcific degeneration is more prevalent.
*High bounding pulses*
- **High bounding pulses** (e.g., **Corrigan's pulse**) are characteristic of **aortic regurgitation**, where there is a wide pulse pressure due to rapid runoff from the aorta.
- In aortic stenosis, the pulse is typically **parvus et tardus** (small and delayed) due to the obstruction to outflow.
Question 765: A 57-year-old man presents to his family physician for a routine exam. He feels well and reports no new complaints since his visit last year. Last year, he had a colonoscopy which showed no polyps, a low dose chest computerized tomography (CT) scan that showed no masses, and routine labs which showed a fasting glucose of 93 mg/dL. He is relatively sedentary and has a body mass index (BMI) of 24 kg/m^2. He has a history of using methamphetamines, alcohol (4-5 drinks per day since age 30), and tobacco (1 pack per day since age 18), but he joined Alcoholics Anonymous and has been in recovery, not using any of these for the past 7 years. Which of the following is indicated at this time?
A. Colonoscopy
B. Chest computerized tomography (CT) scan (Correct Answer)
C. Abdominal ultrasound
D. Chest radiograph
E. Fasting glucose
Explanation: ***Chest computerized tomography (CT) scan***
- This patient has a significant **smoking history** (1 pack per day since age 18 = **39 pack-years**) and is 57 years old, placing him in a high-risk group for **lung cancer**.
- Annual low-dose CT screening for lung cancer is recommended for individuals aged 50-80 with a 20 pack-year smoking history who currently smoke or have quit within the past 15 years.
- He meets all criteria: age 57, 39 pack-years, and quit only 7 years ago (within the 15-year window).
- Since he had screening **last year** with no masses, this year's visit represents the appropriate time for his **annual follow-up screening**.
*Colonoscopy*
- The patient had a colonoscopy last year with **no polyps**, suggesting he is at average risk for colorectal cancer.
- For individuals at average risk with normal findings, repeat screening colonoscopy is typically recommended every **10 years** (or every 5 years for flexible sigmoidoscopy), not annually.
*Abdominal ultrasound*
- One-time abdominal ultrasound screening for **abdominal aortic aneurysm (AAA)** is recommended for men aged 65-75 who have ever smoked.
- This patient is only 57 years old and does not yet meet the age criteria for AAA screening.
*Chest radiograph*
- While a chest radiograph can identify some lung abnormalities, a **low-dose CT scan** is far more sensitive and specific for detecting early-stage lung cancer in high-risk populations.
- Chest radiography is **not recommended** as a screening tool for lung cancer due to its lower sensitivity and lack of mortality benefit in trials.
*Fasting glucose*
- The patient had a **normal fasting glucose** of 93 mg/dL last year, and there are no new symptoms suggestive of diabetes.
- For asymptomatic adults with normal glucose, diabetes screening is typically repeated every **3 years**.
- Annual re-screening is not indicated without new risk factors or symptoms.
Question 766: A 59-year-old man presents to his primary care physician with a 5-month history of breathing difficulties. He says that he has been experiencing exertional dyspnea that is accompanied by a nonproductive cough. His past medical history is significant for a solitary lung nodule that was removed surgically 10 years ago and found to be benign. He works as a coal miner, does not smoke, and drinks socially with friends. His family history is significant for autoimmune diseases. Physical exam reveals fine bibasilar inspiratory crackles in both lungs, and laboratory testing is negative for antinuclear antibody and rheumatoid factor. Which of the following is associated with the most likely cause of this patient's symptoms?
A. Caplan's syndrome
B. Centrilobular emphysema
C. Restrictive lung physiology
D. Coal macules and fibrosis (Correct Answer)
E. Progressive massive fibrosis
Explanation: ***Coal macules and fibrosis*** (Keep the correct option at the top and the incorrect options in the order they are provided in the input)
- The patient's history of working for a **coal mining company**, combined with **dyspnea**, nonproductive cough, and **bibasilar inspiratory crackles**, is highly suggestive of **coal workers' pneumoconiosis (CWP)**.
- The initial stages of CWP are characterized by the formation of **coal macules (anthracosis)** and subsequent **fibrosis** in the lungs, leading to symptoms.
*Caplan's syndrome*
- This syndrome is a rare complication of coal workers' pneumoconiosis (or other pneumoconioses), characterized by the presence of **rheumatoid nodules** in the lungs.
- The patient's **negative rheumatoid factor** makes Caplan's syndrome less likely, as it is typically associated with rheumatoid arthritis.
*Centrilobular emphysema*
- **Centrilobular emphysema** is predominantly caused by **smoking** and affects the central portion of the lobule.
- The patient explicitly states he **does not smoke**, making this diagnosis unlikely.
*Restrictive lung physiology*
- While coal workers' pneumoconiosis *does* cause **restrictive lung physiology**, this option describes a physiological consequence rather than the underlying pathological cause.
- This answer defines the *type* of lung disease, but not the specific **etiology** as requested by the question.
*Progressive massive fibrosis*
- **Progressive massive fibrosis (PMF)** represents an advanced stage of coal workers' pneumoconiosis, characterized by large fibrotic masses in the lungs.
- While it's a possibility given the occupational exposure, the initial presentation of symptoms and findings are more consistent with the **earlier stages** of coal macule formation and fibrosis, which precedes PMF.
Question 767: A 75-year-old woman comes to the physician because of generalized weakness for 6 months. During this period, she has also had a 4-kg (8.8-lb) weight loss and frequent headaches. She has been avoiding eating solids because of severe jaw pain. She has hypertension and osteoporosis. She underwent a total left-sided knee arthroplasty 2 years ago because of osteoarthritis. The patient does not smoke or drink alcohol. Her current medications include enalapril, metoprolol, low-dose aspirin, and a multivitamin. She appears pale. Her temperature is 37.5°C (99.5°F), pulse is 82/min, and blood pressure is 135/80 mm Hg. Physical examination shows no abnormalities. Laboratory studies show:
Hemoglobin 10 g/dL
Mean corpuscular volume 87 μm3
Leukocyte count 8,500/mm3
Platelet count 450,000/mm3
Erythrocyte sedimentation rate 90 mm/h
Which of the following is the most appropriate next step in management?
A. Temporal artery biopsy only
B. Intravenous methylprednisolone only
C. Intravenous methylprednisolone and temporal artery biopsy
D. Oral prednisone and temporal artery biopsy (Correct Answer)
E. Oral prednisone only
Explanation: ***Oral prednisone and temporal artery biopsy***
- The patient's symptoms (generalized weakness, weight loss, headaches, **jaw claudication**) and elevated **ESR** are highly suggestive of **giant cell arteritis**. Prompt initiation of high-dose oral corticosteroids (prednisone) is crucial to prevent irreversible vision loss.
- A **temporal artery biopsy** is necessary to confirm the diagnosis, but treatment should not be delayed while awaiting the biopsy results.
*Temporal artery biopsy only*
- While a **temporal artery biopsy** is essential for diagnosis, delaying treatment until after the biopsy significantly increases the risk of permanent complications, particularly **vision loss**.
- **Giant cell arteritis** is a medical emergency requiring immediate corticosteroid therapy.
*Intravenous methylprednisolone only*
- **Intravenous methylprednisolone** is typically reserved for cases with **severe vision loss** or other critical ischemic complications, which are not described here.
- While treatment should be initiated immediately, an **oral corticosteroid** generally suffices for initial management in the absence of severe symptoms, and it still requires a follow-up **biopsy**.
*Intravenous methylprednisolone and temporal artery biopsy*
- As mentioned, **IV methylprednisolone** is usually for more severe, vision-threatening cases. For this patient's presentation, **oral prednisone** is the appropriate initial corticosteroid.
- While both elements are part of management, the *route* of corticosteroid administration is typically oral for uncomplicated cases.
*Oral prednisone only*
- Initiating **oral prednisone** is appropriate to prevent complications like vision loss, but a definitive diagnosis requires a **temporal artery biopsy**.
- Without a biopsy, long-term corticosteroid therapy without histologic confirmation could lead to unnecessary side effects or mask an alternative diagnosis.
Question 768: A 47-year-old woman comes to her primary care doctor because of a new, pruritic rash. She was gardening in her yard two days ago and now has an eczematous papulovesicular rash on both ankles. You also note a single, 5 mm brown lesion with a slightly raised border on her left thigh. You prescribe a topical corticosteroid for contact dermatitis. Which of the following is the appropriate next step for the thigh lesion?
A. Further questioning (Correct Answer)
B. Full thickness biopsy
C. Simple shave biopsy
D. Reassurance
E. Topical corticosteroid
Explanation: ***Further questioning***
- **Obtaining a thorough history** about the brown lesion is crucial to assess for features suspicious for melanoma or other skin cancers (**A**symmetry, **B**order irregularity, **C**olor variation, **D**iameter >6mm, **E**volving).
- This step helps determine the urgency and type of subsequent diagnostic procedures, such as whether a biopsy is immediately needed and if so, what kind.
*Full thickness biopsy*
- A full-thickness biopsy, also known as an **excisional biopsy**, is generally reserved for lesions highly suspicious for melanoma where complete removal and accurate staging are desired.
- Performing an invasive procedure without first gathering more information about the lesion's history and characteristics is premature.
*Simple shave biopsy*
- A shave biopsy samples only the superficial layers of the skin and is appropriate for lesions that are primarily epidermal and raised, such as **seborrheic keratoses** or **basal cell carcinomas** not suspected of deep invasion.
- It is generally **contraindicated for pigmented lesions suspicious for melanoma**, as it may interfere with accurate staging if the lesion is malignant.
*Reassurance*
- Reassurance is inappropriate given the description of a **new, pigmented lesion with a slightly raised border**, which could indicate a potential malignancy.
- All suspicious skin lesions warrant further investigation to rule out serious conditions.
*Topical corticosteroid*
- Topical corticosteroids are used to treat inflammatory skin conditions like eczema or contact dermatitis, which is the diagnosis for the patient's ankle rash.
- Applying a corticosteroid to a **pigmented lesion of unknown etiology** is incorrect and potentially harmful, as it would not address a neoplastic process and could mask symptoms.
Question 769: A 45-year-old woman presents to her physician with a four-month history of headache. Her headache is nonfocal but persistent throughout the day without any obvious trigger. She was told that it was a migraine but has never responded to sumatriptan, oxygen, or antiemetics. She takes amlodipine for hypertension. She does not smoke. She denies any recent weight loss or constitutional symptoms. Her temperature is 98°F (36.7°C), blood pressure is 180/100 mmHg, pulse is 70/min, and respirations are 15/min. She is obese with posterior cervical fat pads and central abdominal girth. Her neurological exam is unremarkable. In her initial laboratory workup, her fasting blood glucose level is 200 mg/dL. The following additional lab work is obtained and is as follows:
Serum:
Na+: 142 mEq/L
Cl-: 102 mEq/L
K+: 4.1 mEq/L
HCO3-: 24 mEq/L
BUN: 20 mg/dL
Glucose: 135 mg/dL
Creatinine: 1.3 mg/dL
Ca2+: 10.0 mg/dL
AST: 8 U/L
ALT: 8 U/L
24-hour urinary cortisol: 500 µg (reference range < 300 µg)
Serum cortisol: 25 µg/mL (reference range 5-23 µg/dL)
24-hour low dose dexamethasone suppression test: Not responsive
High dose dexamethasone suppression test: Responsive
Adrenocorticotropin-releasing hormone (ACTH): 20 pg/mL (5-15 pg/mL)
Imaging reveals a 0.5 cm calcified pulmonary nodule in the right middle lobe that has been present for 5 years but an otherwise unremarkable pituitary gland, mediastinum, and adrenal glands. What is the best next step in management?
A. Pituitary resection
B. CT-guided biopsy of the pulmonary nodule
C. Inferior petrosal sinus sampling (Correct Answer)
D. Pulmonary nodule resection
E. Repeat high dose dexamethasone suppression test
Explanation: ***Inferior petrosal sinus sampling***
- The patient exhibits clear signs of **Cushing's syndrome** (hypertension, obesity with central fat distribution, hyperglycemia, elevated cortisol, lack of suppression with low-dose dexamethasone).
- The elevated ACTH and suppression with high-dose dexamethasone point towards **Cushing's disease** (pituitary ACTH overproduction). However, with an unremarkable pituitary MRI, **inferior petrosal sinus sampling (IPSS)** is crucial to differentiate ectopic ACTH production (e.g., from a bronchial carcinoid, lung nodule) from pituitary disease.
*Pituitary resection*
- This is a treatment for **Cushing's disease** (pituitary adenoma), but it should only be performed after definitive localization of the ACTH-producing tumor.
- Since the pituitary gland appears unremarkable on imaging and the patient has a lung nodule, **IPSS** is needed to confirm the source of ACTH overexpression before surgery.
*CT-guided biopsy of the pulmonary nodule*
- While the patient has a calcified pulmonary nodule, it has been stable for 5 years and calcified, suggesting it is likely **benign**.
- Without evidence that this nodule is the source of **ectopic ACTH production** (which IPSS would help determine), a biopsy is premature and may not yield a definitive answer for the Cushing's presentation.
*Pulmonary nodule resection*
- Resection is a treatment for **ectopic ACTH-producing tumors**, typically **carcinoid tumors** in the lung.
- However, the nodule is calcified and stable, making it unlikely to be the cause of Cushing's syndrome, and further, the diagnosis of ectopic ACTH needs to be confirmed with **IPSS** before considering such an invasive procedure.
*Repeat high dose dexamethasone suppression test*
- The results already indicate responsiveness to the high-dose dexamethasone suppression test, suggesting a **pituitary source** of ACTH.
- Repeating the test would not add more diagnostic value and would only delay the necessary localization studies like **IPSS** or imaging.
Question 770: A 23-year-old man presents to the emergency department brought in by police. He was found shouting at strangers in the middle of the street. The patient has no significant past medical history, and his only medications include a short course of prednisone recently prescribed for poison ivy exposure. His temperature is 77°F (25°C), blood pressure is 90/50 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air. The patient is only wearing underwear, and he is occasionally mumbling angrily about the government. He appears to be responding to internal stimuli, and it is difficult to obtain a history from him. Which of the following is the next best step in management?
A. Haloperidol IM
B. Warmed IV normal saline and warm blankets (Correct Answer)
C. Lorazepam and discontinue steroids
D. Warm air recirculator
E. Risperidone and warm blankets
Explanation: ***Warmed IV normal saline and warm blankets***
- The patient's core body temperature of **77°F (25°C)** indicates severe **hypothermia**. The immediate priority is to rewarm the patient to prevent further physiological compromise.
- **Warmed IV normal saline** and **warm blankets** are essential interventions for **passive external rewarming** and **active core rewarming**, helping to gradually increase the patient's body temperature and stabilize hemodynamic status.
*Haloperidol IM*
- While the patient exhibits agitation and psychotic-like symptoms, addressing severe **hypothermia** is the immediate life-saving priority. Administering an antipsychotic without first stabilizing core temperature could be dangerous.
- Furthermore, **haloperidol** can have sedative effects that might mask the neurological signs of worsening hypothermia or other underlying conditions.
*Lorazepam and discontinue steroids*
- The patient's altered mental status and agitation are likely due to **hypothermia**, not necessarily an adverse effect of **prednisone** or an isolated psychiatric emergency requiring benzodiazepines.
- Discontinuing **steroids** abruptly can lead to **adrenal insufficiency**, which could further complicate the patient's critical condition, especially in the context of stress from severe hypothermia.
*Warm air recirculator*
- A **warm air recirculator** (e.g., forced-air warming blanket) is a form of **active external rewarming**. While beneficial, it is often used in conjunction with or after initiating **active core rewarming** with warmed IV fluids in cases of severe hypothermia.
- Relying solely on external rewarming might not be sufficient to rapidly correct **severe hypothermia** (core temperature < 28°C) and address associated **hemodynamic instability**.
*Risperidone and warm blankets*
- Similar to haloperidol, **risperidone** is an antipsychotic used for agitation and psychosis. However, the patient's primary and life-threatening issue is severe **hypothermia**.
- While **warm blankets** are appropriate for rewarming, addressing the underlying cause of the patient's presentation (hypothermia) takes precedence over immediate pharmacological management of psychiatric symptoms.
