A 40-year-old woman comes to the physician because of a small lump on the right side of her neck that she noticed while putting lotion on 1 week ago. She does not have any weight change, palpitations, or altered bowel habits. There is no family history of serious illness. Menses occur at regular 30-day intervals and lasts for 4 days. She appears well. Her temperature is 37°C (98.6° F), pulse is 88/min, and blood pressure is 116/74 mm Hg. Examination shows a small swelling on the right side of the neck that moves with swallowing. There is no lymphadenopathy. Ultrasound of the neck shows a 0.9-cm (0.35-in) right lobe thyroid mass with microcalcifications and irregular margins. Which of the following is the most appropriate next step in diagnosis?
Q872
A 77-year-old man is brought to his primary care physician by his daughter. She states that lately, his speech has been incoherent. It seemed to have started a few weeks ago and has been steadily worsening. He is otherwise well; however, she notes that she has had to start him on adult diapers. The patient has a past medical history of hypertension, hyperlipidemia, and type 2 diabetes mellitus. He has been smoking 1 pack of cigarettes per day for over 40 years. His temperature is 98.9°F (37.2°C), blood pressure is 167/108 mmHg, pulse is 83/min, respirations are 12/min, and oxygen saturation is 97% on room air. Physical exam reveals a confused elderly man who does not respond coherently to questions. Cardiac and pulmonary exam is within normal limits. Inspection of the patient's scalp reveals a healing laceration which the daughter claims occurred yesterday when he fell while walking. Gait testing is significant for the patient taking short steps with reduced cadence. Which of the following findings is most likely in this patient?
Q873
A 56-year-old woman is brought to the emergency department by her husband because of slurred speech and left facial droop for the past 30 minutes. During this period, she has also had numbness on the left side of her face. She has never had such an episode before. She has hypertension, hypercholesterolemia, and type 2 diabetes mellitus. Her father died of lung cancer 1 week ago. The patient has smoked one pack of cigarettes daily for 30 years. She drinks one glass of wine daily. Her current medications include metformin, sitagliptin, enalapril, and atorvastatin. She is 168 cm (5 ft 6 in) tall and weighs 86 kg (190 lb); BMI is 30.5 kg/m2. She is oriented to time, place, and person. Her temperature is 37°C (98.7°F), pulse is 97/min, and blood pressure is 140/90 mm Hg. Examination shows drooping of the left side of the face. Her speech is clear. Examination shows full muscle strength. Deep tendon reflexes are 2+ bilaterally. A finger-nose test and her gait are normal. Cardiopulmonary examination shows a right-sided carotid bruit. A complete blood count and serum concentrations of creatinine, glucose, and electrolytes are within the reference ranges. An ECG shows left ventricular hypertrophy. A noncontrast CT scan of the brain shows no abnormalities. On the way back from the CT scan, her presenting symptoms resolve. Which of the following is the most likely diagnosis?
Q874
A 71-year-old Caucasian male presents to your office with bloody diarrhea and epigastric pain that occurs 30 minutes after eating. He has lost 15 pounds in 1 month, which he attributes to fear that the pain will return following a meal. He has a history of hyperlipidemia and myocardial infarction. Physical exam and esophagogastroduodenoscopy are unremarkable. What is the most likely cause of this patient's pain?
Q875
A 24-year-old woman comes to the physician because of pain and swelling of her left leg over the past 24 hours. The pain is worse while walking and improves when resting. Seven months ago, she was diagnosed with a pulmonary embolism and was started on warfarin. Anticoagulant therapy was discontinued 1 month ago. Her sister has systemic lupus erythematosus. The patient does not smoke. She currently takes no medications. Her temperature is 37.8°C (100°F), pulse is 78/min, and blood pressure is 123/72 mm Hg. On physical examination, the left calf is diffusely erythematous, swollen, and tender. Dorsal flexion of the left foot elicits pain. Cardiopulmonary examination shows no abnormalities. On duplex ultrasonography, the left popliteal vein is not compressible. Laboratory studies show an elevated serum concentration of D-dimer and insensitivity to activated protein C. Further examination is most likely to show which of the following?
Q876
The rapid response team is called for a 74-year-old woman on an inpatient surgical floor for supraventricular tachycardia. The patient had surgery earlier in the day for operative management of a femur fracture. The patient has a history of hypertension, atherosclerosis, type 2 diabetes, and uterine cancer status post total abdominal hysterectomy 20 years prior. With carotid massage, valsalva maneuvers, and metoprolol, the patient breaks out of her supraventricular tachycardia. Thirty minutes later, the nurse notices a decline in the patient’s status. On exam, the patient has a temperature of 98.4°F (36.9°C), blood pressure of 102/74 mmHg, pulse of 86/min, and respirations are 14/min. The patient is now dysarthric with noticeable right upper extremity weakness of 2/5 in elbow flexion and extension. All other extremities demonstrate normal strength and sensation. Which of the following most likely contributed to this decline?
Q877
A 38-year-old man with a history of hypertension presents to his primary care physician for a headache and abdominal pain. His symptoms began approximately 1 week ago and have progressively worsened. He describes his headache as pressure-like and is mildly responsive to ibuprofen. His abdominal pain is located in the bilateral flank area. His hypertension is poorly managed with lifestyle modification and chlorthalidone. He had 1 urinary tract infection that was treated with ciprofloxacin approximately 6 months ago. He has a home blood pressure monitor, where his average readings are 155/95 mmHg. Family history is significant for his father expiring secondary to a myocardial infarction and his history was complicated by refractory hypertension and end-stage renal disease. His vital signs are significant for a blood pressure of 158/100 mmHg. Physical examination is notable for bilateral flank masses. Laboratory testing is significant for a creatinine of 3.1 mg/dL. Urinalysis is remarkable for hematuria and proteinuria. Which of the following will this patient most likely be at risk for developing?
Q878
A 50-year-old female teacher presents to the clinic with complaints of discoloration of the skin around the right ankle accompanied by itching. She began noticing it a month ago and the pruritus worsened over time. She also has some pain and swelling of the region every night, especially on days when she teaches late into the evening. Her past medical history is significant for diabetes mellitus type 2, for which she takes metformin. She lives with her husband and takes oral contraceptive pills. On examination, the physician observes hyperpigmentation of the medial aspect of her right ankle. The skin is dry, scaly, and edematous along with some superficial varicosities. Dorsiflexion of the foot is extremely painful. Peripheral pulses are equally palpable on both lower limbs. There is a small 2 cm ulcer noted near the medial malleolus with thickened neighboring skin and indurated edges. Laboratory studies show D-dimer of 1,000 µg/L and HbA1c of 9%. Doppler ultrasound of the lower extremity reveals an intramural thrombus in the popliteal vein. Which of the following is the most likely diagnosis in this patient?
Q879
A 19-year-old female student presents to her physician for overall fatigue. She is having a hard time concentrating while studying and feeling tired most of the time. She also has had constipation for more than 3 weeks and rectal bleeding on occasions. She notices she is getting colder and often needs to wear warmer clothes than usual for the same weather. On examination, a small nodule around the size of 1cm is palpated in the left thyroid lobule; the gland is nontender. There is no lymphadenopathy. Her vital signs are: blood pressure is 118/75 mm Hg, respirations are 17/min, pulse is 87/min, and temperature is 36.1°C (97.0°F). Which of the following is the best next step in the management of this patient?
Q880
A 36-year-old healthy man presents to his physician to discuss his concerns about developing heart disease. His father, grandfather, and older brother had heart problems, and he has become increasingly worried he might be at risk. He takes no medications and his past medical history is only significant for an appendectomy at 20 years ago. He is married happily with 2 young children and works as a hotel manager and exercises occasionally in the hotel gym. He drinks 3–5 alcoholic beverages per week but denies smoking and illicit drug use. Today his blood pressure is 146/96 mm Hg, pulse rate is 80/min, and respiratory rate is 16/min. He has a body mass index of 26.8 kg/m2. His physical examination is otherwise unremarkable. Laboratory tests show:
Laboratory test
Serum glucose (fasting) 88 mg/dL
Serum electrolytes
Sodium 142 mEq/L
Potassium 3.9 mEq/L
Chloride 101 mEq/L
Serum creatinine 0.8 mg/dl
Blood urea nitrogen 10 mg/dl
Cholesterol, total 350 mg/dL
HDL-cholesterol 40 mg/dL
LDL-cholesterol 280 mg/dL
Triglycerides 130 mg/dL
Besides appropriate medications for his cholesterol and a follow-up for his hypertension, which of the following supplements is thought to provide a protective cardiovascular effect?
Cardiology US Medical PG Practice Questions and MCQs
Question 871: A 40-year-old woman comes to the physician because of a small lump on the right side of her neck that she noticed while putting lotion on 1 week ago. She does not have any weight change, palpitations, or altered bowel habits. There is no family history of serious illness. Menses occur at regular 30-day intervals and lasts for 4 days. She appears well. Her temperature is 37°C (98.6° F), pulse is 88/min, and blood pressure is 116/74 mm Hg. Examination shows a small swelling on the right side of the neck that moves with swallowing. There is no lymphadenopathy. Ultrasound of the neck shows a 0.9-cm (0.35-in) right lobe thyroid mass with microcalcifications and irregular margins. Which of the following is the most appropriate next step in diagnosis?
A. Open biopsy
B. Fine-needle aspiration biopsy of the swelling (Correct Answer)
C. Thyroid-stimulating hormone level
D. CT of the neck
E. Thyroid scintigraphy
Explanation: ***Fine-needle aspiration biopsy of the swelling***
- The ultrasound shows **suspicious features** (microcalcifications and irregular margins) that are highly specific for **papillary thyroid carcinoma**.
- According to **ATA guidelines**, FNA is indicated for nodules with high-risk ultrasound features, regardless of size or TSH level.
- FNA is the **gold standard** for cytological diagnosis and can distinguish benign from malignant nodules with high accuracy.
- In this case with clear suspicious features, **FNA should not be delayed** for other tests like TSH.
*Thyroid-stimulating hormone level*
- While TSH is part of the **initial workup** for thyroid nodules, it should not delay FNA when suspicious ultrasound features are already present.
- The presence of microcalcifications and irregular margins makes a **"hot" (hyperfunctioning) nodule extremely unlikely**.
- TSH can be checked concurrently but should not be the rate-limiting step before FNA.
*CT of the neck*
- Not the **initial diagnostic choice** for evaluating a thyroid nodule.
- CT is reserved for assessing **extrathyroidal extension** and invasion after malignancy is suspected or confirmed on FNA.
- It provides unnecessary **radiation exposure** when ultrasound has already characterized the nodule.
*Open biopsy*
- This is an **invasive surgical procedure** that is not the first step in diagnosing a thyroid nodule.
- It is reserved for cases where FNA results are **nondiagnostic** after multiple attempts or when there is suspicion of lymphoma.
*Thyroid scintigraphy*
- Used to assess whether a nodule is **"hot" (hyperfunctioning) or "cold" (non-functioning)**.
- Hot nodules are rarely malignant, but the suspicious ultrasound features in this case make a hot nodule **highly unlikely**.
- Scintigraphy is **not indicated** when ultrasound already shows features suggestive of malignancy; FNA is the appropriate next step.
Question 872: A 77-year-old man is brought to his primary care physician by his daughter. She states that lately, his speech has been incoherent. It seemed to have started a few weeks ago and has been steadily worsening. He is otherwise well; however, she notes that she has had to start him on adult diapers. The patient has a past medical history of hypertension, hyperlipidemia, and type 2 diabetes mellitus. He has been smoking 1 pack of cigarettes per day for over 40 years. His temperature is 98.9°F (37.2°C), blood pressure is 167/108 mmHg, pulse is 83/min, respirations are 12/min, and oxygen saturation is 97% on room air. Physical exam reveals a confused elderly man who does not respond coherently to questions. Cardiac and pulmonary exam is within normal limits. Inspection of the patient's scalp reveals a healing laceration which the daughter claims occurred yesterday when he fell while walking. Gait testing is significant for the patient taking short steps with reduced cadence. Which of the following findings is most likely in this patient?
A. Dilated ventricles on MRI (Correct Answer)
B. Decreased dopamine synthesis in the substantia nigra on dopamine uptake scan
C. Severe atrophy of the cerebral cortex on MRI
D. White matter T2 hyperintensities of the cerebral cortex on MRI
E. Minor atrophy of the cerebral cortex on CT
Explanation: ***Dilated ventricles on MRI***
- The patient's symptoms of **incoherent speech**, **urinary incontinence**, and **gait disturbance (short steps, reduced cadence)**, developing over weeks in an elderly individual, are classic for **Normal Pressure Hydrocephalus (NPH)**.
- **NPH** is characterized by **ventriculomegaly (dilated ventricles)** with normal intracranial pressure, which can be visualized on MRI.
*Decreased dopamine synthesis in the substantia nigra on dopamine uptake scan*
- This finding is characteristic of **Parkinson's disease**, which primarily presents with **bradykinesia, rigidity, tremor, and gait instability**.
- While the patient has a gait disturbance, the prominent **incoherence and incontinence** over a short period are not typical for isolated Parkinson's disease.
*Severe atrophy of the cerebral cortex on MRI*
- **Severe cortical atrophy** is a hallmark of **Alzheimer's disease** and other neurodegenerative dementias.
- Although dementia can cause incoherence, prominent **gait disturbance and incontinence** developing over weeks are less characteristic of early to moderate Alzheimer's, which typically progresses over years.
*White matter T2 hyperintensities of the cerebral cortex on MRI*
- **White matter hyperintensities** are often seen in **vascular dementia** or due to chronic small vessel ischemic disease.
- While the patient has vascular risk factors, the triad of symptoms (gait, incontinence, cognitive decline) strongly points to NPH rather than solely vascular dementia.
*Minor atrophy of the cerebral cortex on CT*
- **Minor cortical atrophy** is a common finding in normal aging and is not specific enough to explain the rapid onset and specific triad of symptoms seen in this patient.
- It would not account for the significant **ventricular enlargement** expected in NPH.
Question 873: A 56-year-old woman is brought to the emergency department by her husband because of slurred speech and left facial droop for the past 30 minutes. During this period, she has also had numbness on the left side of her face. She has never had such an episode before. She has hypertension, hypercholesterolemia, and type 2 diabetes mellitus. Her father died of lung cancer 1 week ago. The patient has smoked one pack of cigarettes daily for 30 years. She drinks one glass of wine daily. Her current medications include metformin, sitagliptin, enalapril, and atorvastatin. She is 168 cm (5 ft 6 in) tall and weighs 86 kg (190 lb); BMI is 30.5 kg/m2. She is oriented to time, place, and person. Her temperature is 37°C (98.7°F), pulse is 97/min, and blood pressure is 140/90 mm Hg. Examination shows drooping of the left side of the face. Her speech is clear. Examination shows full muscle strength. Deep tendon reflexes are 2+ bilaterally. A finger-nose test and her gait are normal. Cardiopulmonary examination shows a right-sided carotid bruit. A complete blood count and serum concentrations of creatinine, glucose, and electrolytes are within the reference ranges. An ECG shows left ventricular hypertrophy. A noncontrast CT scan of the brain shows no abnormalities. On the way back from the CT scan, her presenting symptoms resolve. Which of the following is the most likely diagnosis?
A. Partial seizure
B. Bell palsy
C. Conversion disorder
D. Transient ischemic attack (Correct Answer)
E. Multiple sclerosis
Explanation: ***Transient ischemic attack***
- The patient presents with **acute neurological deficits** (slurred speech, left facial droop, numbness) that **resolve spontaneously** within a short period (30 minutes), strongly suggesting a **transient ischemic attack (TIA)**.
- Her significant risk factors for cerebrovascular disease, including **hypertension, hypercholesterolemia, type 2 diabetes mellitus, smoking**, and a **carotid bruit**, further support this diagnosis.
*Partial seizure*
- While seizures can cause focal neurological symptoms, they typically involve **stereotyped, repetitive movements or sensations**, and often have a **postictal state** that is not described here.
- The patient's symptoms are more consistent with a **vascular event** given her risk profile and the nature of the transient deficit.
*Bell palsy*
- **Bell palsy** is an acute **peripheral facial nerve paralysis** affecting only the motor function of the face, leading to drooping that does **not resolve within minutes**.
- It would not typically cause **slurred speech** or **numbness** (sensory deficits), as seen in this patient.
*Conversion disorder*
- **Conversion disorder** involves neurological symptoms that are inconsistent with known neurological conditions and often arise in response to psychological stress, which might be suggested by her father's recent death.
- However, the patient's strong vascular risk factors and objective findings like a **carotid bruit** make a **physiological cause** (TIA) much more likely than a somatoform disorder.
*Multiple sclerosis*
- **Multiple sclerosis** is a **demyelinating disease** that causes neurological symptoms, but these are typically **episodic (relapsing-remitting)** and often involve **sensory, motor, visual, or balance problems** that **last days to weeks**, not minutes.
- MS symptoms rarely resolve as quickly as described and are less common in this age group for a new presentation.
Question 874: A 71-year-old Caucasian male presents to your office with bloody diarrhea and epigastric pain that occurs 30 minutes after eating. He has lost 15 pounds in 1 month, which he attributes to fear that the pain will return following a meal. He has a history of hyperlipidemia and myocardial infarction. Physical exam and esophagogastroduodenoscopy are unremarkable. What is the most likely cause of this patient's pain?
A. Peptic ulcer disease
B. Amyloid deposition
C. Diverticulosis
D. Atherosclerosis (Correct Answer)
E. Crohn's disease
Explanation: ***Atherosclerosis***
- This patient's history of **hyperlipidemia** and **myocardial infarction** indicates generalized atherosclerosis, which can lead to **chronic mesenteric ischemia** (also known as "intestinal angina").
- The classic presentation includes **postprandial abdominal pain** (occurring 30-60 minutes after eating) due to increased oxygen demand by the intestines that cannot be met by stenotic mesenteric arteries, along with **weight loss** due to "food fear" (sitophobia).
- The triad of postprandial pain, weight loss, and atherosclerotic risk factors is highly suggestive of this diagnosis.
*Peptic ulcer disease*
- While peptic ulcer disease can cause epigastric pain and bloody stools, it would be detected on **esophagogastroduodenoscopy (EGD)**, which was unremarkable in this patient.
- Gastric ulcers typically cause pain shortly after eating, while duodenal ulcers cause pain 2-3 hours after eating and are relieved by food.
- The normal EGD effectively rules out this diagnosis.
*Amyloid deposition*
- **Amyloidosis** can cause gastrointestinal symptoms like malabsorption and bleeding, but it is a rare systemic disorder that typically presents with other organ involvement (renal, cardiac, neurologic).
- It does not typically cause the classic postprandial pain pattern seen with mesenteric ischemia.
- The patient's strong atherosclerotic history points away from this diagnosis.
*Diverticulosis*
- **Diverticulosis** can cause painless bloody diarrhea (hematochezia), but it typically presents with **left lower quadrant pain** when complicated by diverticulitis, not epigastric pain.
- The pain is not characteristically related to meals and does not cause the "food fear" behavior seen in mesenteric ischemia.
*Crohn's disease*
- **Crohn's disease** is an inflammatory bowel disease that can cause bloody diarrhea, abdominal pain, and weight loss.
- However, the **postprandial epigastric pain occurring 30 minutes after eating** and the patient's strong history of **atherosclerotic disease** point more toward ischemic etiology rather than inflammatory bowel disease.
- Crohn's typically affects younger patients and would show signs of chronic inflammation.
Question 875: A 24-year-old woman comes to the physician because of pain and swelling of her left leg over the past 24 hours. The pain is worse while walking and improves when resting. Seven months ago, she was diagnosed with a pulmonary embolism and was started on warfarin. Anticoagulant therapy was discontinued 1 month ago. Her sister has systemic lupus erythematosus. The patient does not smoke. She currently takes no medications. Her temperature is 37.8°C (100°F), pulse is 78/min, and blood pressure is 123/72 mm Hg. On physical examination, the left calf is diffusely erythematous, swollen, and tender. Dorsal flexion of the left foot elicits pain. Cardiopulmonary examination shows no abnormalities. On duplex ultrasonography, the left popliteal vein is not compressible. Laboratory studies show an elevated serum concentration of D-dimer and insensitivity to activated protein C. Further examination is most likely to show which of the following?
A. Deficiency of protein C
B. Mutation of prothrombin
C. Elevated levels of homocysteine
D. Antiphospholipid antibodies
E. Mutation of coagulation factor V (Correct Answer)
Explanation: ***Mutation of coagulation factor V***
- The patient presents with symptoms and signs of **deep vein thrombosis (DVT)**, recurrent as she had a previous pulmonary embolism, and an elevated D-dimer.
- The specific finding of **insensitivity to activated protein C (APC)** is highly suggestive of a **Factor V Leiden mutation**, which is the most common inherited thrombophilia.
*Deficiency of protein C*
- A deficiency in **protein C** would lead to a hypercoagulable state due to reduced inactivation of factors Va and VIIIa.
- However, while it would cause a predisposition to thrombosis, it would not directly manifest as **insensitivity to activated protein C (APC)** but rather as reduced levels of protein C activity.
*Mutation of prothrombin*
- A **prothrombin gene mutation (G20210A)** leads to elevated prothrombin levels, increasing clotting risk.
- While it causes thrombosis, it does not explain the specific finding of **insensitivity to activated protein C**.
*Elevated levels of homocysteine*
- **Hyperhomocysteinemia** can result from genetic defects (e.g., MTHFR mutation) or nutritional deficiencies (e.g., B12, folate) and is a risk factor for thrombosis.
- This condition does not directly cause **insensitivity to activated protein C** and would be reflected by elevated homocysteine levels, not an APC resistance assay.
*Antiphospholipid antibodies*
- **Antiphospholipid syndrome** is an acquired thrombophilia featuring antibodies (e.g., lupus anticoagulant, anticardiolipin) that cause thrombosis. The patient's sister has SLE, which is associated with antiphospholipid syndrome.
- While it can cause recurrent thrombosis and may be suggested by her sister's SLE, it typically causes a **prolonged PTT** *in vitro* (due to lupus anticoagulant) and does not directly cause **insensitivity to activated protein C**; rather, it often involves a different mechanism of action on the clotting cascade.
Question 876: The rapid response team is called for a 74-year-old woman on an inpatient surgical floor for supraventricular tachycardia. The patient had surgery earlier in the day for operative management of a femur fracture. The patient has a history of hypertension, atherosclerosis, type 2 diabetes, and uterine cancer status post total abdominal hysterectomy 20 years prior. With carotid massage, valsalva maneuvers, and metoprolol, the patient breaks out of her supraventricular tachycardia. Thirty minutes later, the nurse notices a decline in the patient’s status. On exam, the patient has a temperature of 98.4°F (36.9°C), blood pressure of 102/74 mmHg, pulse of 86/min, and respirations are 14/min. The patient is now dysarthric with noticeable right upper extremity weakness of 2/5 in elbow flexion and extension. All other extremities demonstrate normal strength and sensation. Which of the following most likely contributed to this decline?
A. Long bone fracture
B. Diabetes
C. Hypertension
D. Malignancy
E. Atherosclerosis (Correct Answer)
Explanation: ***Atherosclerosis***
- The sudden onset of **right upper extremity weakness** and **dysarthria** after an episode of supraventricular tachycardia (SVT) strongly suggests an **ischemic stroke**. Atherosclerosis is the primary underlying condition that made this patient vulnerable to stroke.
- **Carotid massage** in patients with **carotid atherosclerosis** carries a risk of **dislodging atherosclerotic plaques**, leading to embolic stroke. The temporal relationship between the carotid massage and the onset of focal neurological deficits 30 minutes later is highly suspicious for an atheroembolic event.
- The patient's history of **hypertension** and **type 2 diabetes** are significant risk factors that accelerate the progression of atherosclerosis, increasing plaque burden and the likelihood of **atheroembolic events**.
*Long bone fracture*
- While a long bone fracture can lead to complications, such as **fat emboli**, these typically cause a triad of respiratory distress, neurological symptoms (altered mental status, not localized weakness), and a petechial rash.
- The neurological symptoms of a fat embolism are usually more global and diffuse, unlike the focal deficits observed here (dysarthria, right upper extremity weakness).
- Fat embolism syndrome typically develops **24-72 hours post-fracture**, not immediately after carotid massage.
*Diabetes*
- Diabetes is a significant risk factor for **atherosclerosis** and stroke, but it is not the direct cause of the acute neurological decline; rather, it contributes to the underlying vascular disease.
- While diabetes can cause neurological complications like **neuropathy**, it does not typically present as acute focal weakness and dysarthria in this manner.
*Hypertension*
- Hypertension is a major modifiable risk factor for both **atherosclerosis** and **ischemic stroke**, contributing to vascular damage and plaque formation over time.
- However, hypertension itself is not the immediate cause of the focal neurological deficits in this scenario; it primarily exacerbates the underlying atherosclerotic process that enables embolic events.
*Malignancy*
- Malignancy can increase the risk of prothrombotic states (**Trousseau's syndrome**) and lead to embolic events, potentially causing a stroke.
- However, the patient's uterine cancer was treated 20 years prior, and there is no indication of active malignancy or a hypercoagulable state specifically linked to cancer in this acute presentation.
Question 877: A 38-year-old man with a history of hypertension presents to his primary care physician for a headache and abdominal pain. His symptoms began approximately 1 week ago and have progressively worsened. He describes his headache as pressure-like and is mildly responsive to ibuprofen. His abdominal pain is located in the bilateral flank area. His hypertension is poorly managed with lifestyle modification and chlorthalidone. He had 1 urinary tract infection that was treated with ciprofloxacin approximately 6 months ago. He has a home blood pressure monitor, where his average readings are 155/95 mmHg. Family history is significant for his father expiring secondary to a myocardial infarction and his history was complicated by refractory hypertension and end-stage renal disease. His vital signs are significant for a blood pressure of 158/100 mmHg. Physical examination is notable for bilateral flank masses. Laboratory testing is significant for a creatinine of 3.1 mg/dL. Urinalysis is remarkable for hematuria and proteinuria. Which of the following will this patient most likely be at risk for developing?
A. Migraine headache
B. Neuroendocrine pancreatic tumor
C. Lymphangioleiomyomatosis
D. Intracranial aneurysm (Correct Answer)
E. Epilepsy
Explanation: ***Intracranial aneurysm***
- This patient's presentation with **poorly controlled hypertension**, family history of **refractory hypertension and ESRD**, and bilateral **flank masses** strongly suggests **autosomal dominant polycystic kidney disease (ADPKD)**.
- Patients with **ADPKD** have a significantly increased risk of developing **intracranial aneurysms**, which can rupture and cause subarachnoid hemorrhage, often presenting with a severe headache.
*Migraine headache*
- While headaches are a common symptom, the description of a **pressure-like headache** that is only mildly responsive to ibuprofen, combined with other systemic symptoms, is less typical for a migraine.
- The presence of findings highly suggestive of ADPKD points to a more specific and severe cause for the headache in this context.
*Neuroendocrine pancreatic tumor*
- **Pancreatic cysts** can occur in ADPKD, but the development of **neuroendocrine pancreatic tumors** is not a characteristic or common complication of this genetic disorder.
- The patient's symptoms are more consistent with renal manifestations and ADPKD-associated complications rather than a pancreatic tumor.
*Lymphangioleiomyomatosis*
- **Lymphangioleiomyomatosis (LAM)** is a rare lung disease characterized by abnormal smooth muscle cell proliferation, primarily affecting women.
- It is often associated with **tuberous sclerosis complex (TSC)**, not ADPKD, and the patient's symptoms point to kidney disease rather than lung pathology.
*Epilepsy*
- Although **seizures** can occur in patients with **ADPKD** due to complications like uremia or intracerebral hemorrhage, **epilepsy** (a chronic neurological disorder characterized by recurrent unprovoked seizures) is not a direct or primary consequence of the disease itself.
- The patient's current symptoms do not directly indicate a diagnosis of epilepsy.
Question 878: A 50-year-old female teacher presents to the clinic with complaints of discoloration of the skin around the right ankle accompanied by itching. She began noticing it a month ago and the pruritus worsened over time. She also has some pain and swelling of the region every night, especially on days when she teaches late into the evening. Her past medical history is significant for diabetes mellitus type 2, for which she takes metformin. She lives with her husband and takes oral contraceptive pills. On examination, the physician observes hyperpigmentation of the medial aspect of her right ankle. The skin is dry, scaly, and edematous along with some superficial varicosities. Dorsiflexion of the foot is extremely painful. Peripheral pulses are equally palpable on both lower limbs. There is a small 2 cm ulcer noted near the medial malleolus with thickened neighboring skin and indurated edges. Laboratory studies show D-dimer of 1,000 µg/L and HbA1c of 9%. Doppler ultrasound of the lower extremity reveals an intramural thrombus in the popliteal vein. Which of the following is the most likely diagnosis in this patient?
A. Basal cell carcinoma
B. Atopic dermatitis
C. Stasis dermatitis (Correct Answer)
D. Cellulitis
E. Diabetic foot
Explanation: ***Stasis dermatitis***
- The patient's presentation with **discoloration (hyperpigmentation)**, **itching (pruritus)**, **edema**, and a **venous ulcer** on the medial aspect of the ankle, along with **superficial varicosities** and a **popliteal vein thrombus**, are classic signs of **stasis dermatitis** due to **chronic venous insufficiency**.
- Contributing factors like prolonged standing (teacher), **oral contraceptive use**, and diabetes (though less directly involved than venous issues for this specific diagnosis) increase the risk for venous stasis and associated dermatological changes.
*Basal cell carcinoma*
- Typically presents as a **pearly nodule** with **rolled borders** and **telangiectasias**, often on sun-exposed areas.
- While an ulcer can occur, the widespread discoloration, edema, itching, and association with venous issues are not characteristic of basal cell carcinoma.
*Atopic dermatitis*
- Characterized by **eczematous lesions** (red, itchy, dry skin) often in flexural areas like the antecubital or popliteal fossae, with a history of allergies or asthma.
- It does not present with hyperpigmentation, edema, or ulcers specifically associated with venous insufficiency.
*Cellulitis*
- Presents as an **acute bacterial infection** of the skin, characterized by **rapidly spreading redness**, **warmth**, **swelling**, and **pain**, often with fever and systemic symptoms.
- While there is pain and swelling, the chronic nature, hyperpigmentation, itching, and presence of varicosities and a venous ulcer point away from an acute infection like cellulitis.
*Diabetic foot*
- Characterized by **neuropathy** (loss of sensation), **peripheral arterial disease**, and **infection**, leading to **puncture wounds** or **ischemic ulcers** often on pressure points of the foot.
- While the patient has diabetes, the ulcer's location (medial malleolus), hyperpigmentation, edema, and clear evidence of venous thrombosis make **stasis dermatitis** a more fitting diagnosis than a typical diabetic foot ulcer.
Question 879: A 19-year-old female student presents to her physician for overall fatigue. She is having a hard time concentrating while studying and feeling tired most of the time. She also has had constipation for more than 3 weeks and rectal bleeding on occasions. She notices she is getting colder and often needs to wear warmer clothes than usual for the same weather. On examination, a small nodule around the size of 1cm is palpated in the left thyroid lobule; the gland is nontender. There is no lymphadenopathy. Her vital signs are: blood pressure is 118/75 mm Hg, respirations are 17/min, pulse is 87/min, and temperature is 36.1°C (97.0°F). Which of the following is the best next step in the management of this patient?
A. Combination T4 and T3 therapy
B. Radionuclide thyroid scan
C. Serum T3 levels
D. Thyroid ultrasound (Correct Answer)
E. Serum calcitonin levels
Explanation: ***Thyroid ultrasound***
- A **thyroid ultrasound** is the most appropriate initial imaging step when a **thyroid nodule** is palpable, and the patient also exhibits symptoms suggestive of **hypothyroidism** (fatigue, constipation, cold intolerance).
- This imaging modality helps characterize the nodule's size, composition (solid vs. cystic), vascularity, and features suspicious for **malignancy**, guiding subsequent management.
*Combination T4 and T3 therapy*
- This therapy is used for treating **hypothyroidism** but should only be initiated after thyroid function is confirmed via blood tests, and the nature of the nodule is assessed.
- Starting hormone replacement without further investigation of the nodule could mask or delay the diagnosis of a **thyroid malignancy**.
*Radionuclide thyroid scan*
- A **radionuclide thyroid scan** is primarily used to assess the functional status of a nodule (hot vs. cold), which is typically done after initial characterization by ultrasound and TSH level measurement.
- It is not the first-line investigation for an incidentally found nodule, especially with symptoms suggesting possible hypothyroidism.
*Serum T3 levels*
- While thyroid function tests are necessary, **serum TSH** (Thyroid Stimulating Hormone) is the most sensitive initial test for evaluating thyroid function, not T3.
- **Low T3 levels** might be seen in severe hypothyroidism, but TSH is usually the first to deviate and is a more reliable screening tool.
*Serum calcitonin levels*
- **Serum calcitonin** is a tumor marker for **medullary thyroid carcinoma (MTC)**.
- While it can be measured when MTC is suspected, it is not a routine initial test for a palpable thyroid nodule and would typically be considered after other investigations suggest malignancy.
Question 880: A 36-year-old healthy man presents to his physician to discuss his concerns about developing heart disease. His father, grandfather, and older brother had heart problems, and he has become increasingly worried he might be at risk. He takes no medications and his past medical history is only significant for an appendectomy at 20 years ago. He is married happily with 2 young children and works as a hotel manager and exercises occasionally in the hotel gym. He drinks 3–5 alcoholic beverages per week but denies smoking and illicit drug use. Today his blood pressure is 146/96 mm Hg, pulse rate is 80/min, and respiratory rate is 16/min. He has a body mass index of 26.8 kg/m2. His physical examination is otherwise unremarkable. Laboratory tests show:
Laboratory test
Serum glucose (fasting) 88 mg/dL
Serum electrolytes
Sodium 142 mEq/L
Potassium 3.9 mEq/L
Chloride 101 mEq/L
Serum creatinine 0.8 mg/dl
Blood urea nitrogen 10 mg/dl
Cholesterol, total 350 mg/dL
HDL-cholesterol 40 mg/dL
LDL-cholesterol 280 mg/dL
Triglycerides 130 mg/dL
Besides appropriate medications for his cholesterol and a follow-up for his hypertension, which of the following supplements is thought to provide a protective cardiovascular effect?
A. Folic acid (Correct Answer)
B. Thiamine
C. Vitamin K
D. Vitamin B12
E. Vitamin E
Explanation: ***Folic acid***
- Folic acid (Vitamin B9) is involved in the metabolism of **homocysteine**, and elevated homocysteine levels are associated with increased cardiovascular risk.
- **Historically**, it was hypothesized that lowering homocysteine with folic acid would reduce cardiovascular events.
- However, **large randomized controlled trials (HOPE-2, NORVIT, VISP) have failed to demonstrate cardiovascular benefit** from folic acid supplementation despite successfully lowering homocysteine levels.
- Among the options listed, folic acid was the supplement most **historically thought** to provide cardiovascular protection, though current evidence does not support routine supplementation for this purpose.
- **Current guidelines do NOT recommend** folic acid supplementation for cardiovascular disease prevention in the general population.
*Thiamine*
- **Thiamine** (Vitamin B1) is crucial for carbohydrate metabolism and nerve function.
- Thiamine deficiency can lead to **beriberi** (including wet beriberi with cardiac manifestations), but supplementation in individuals without deficiency provides **no cardiovascular protection**.
*Vitamin K*
- **Vitamin K** is essential for blood clotting and bone metabolism, and may play a role in preventing vascular calcification.
- However, there is **insufficient evidence** to recommend vitamin K supplementation for cardiovascular protection in clinical practice.
*Vitamin B12*
- **Vitamin B12** is important for nerve function, red blood cell formation, and homocysteine metabolism.
- Like folic acid, B12 was studied for cardiovascular protection through homocysteine reduction, but **clinical trials failed to show benefit**.
- Routine B12 supplementation for cardiovascular protection in individuals with normal B12 levels is **not recommended**.
*Vitamin E*
- **Vitamin E** is an antioxidant that was extensively studied for cardiovascular protection in the 1990s-2000s.
- **Large clinical trials (HOPE, GISSI) conclusively showed NO cardiovascular benefit** from vitamin E supplementation, and some studies suggested potential harm at high doses.
- Vitamin E supplementation for cardiovascular disease prevention is **not recommended**.
