A 57-year-old man is sent to the emergency department by his primary care physician for hypertension. He was at a general health maintenance appointment when his blood pressure was found to be 180/115 mmHg; thus, prompting his primary doctor to send him to the emergency room. The patient is otherwise currently asymptomatic and states that he feels well. The patient has no other medical problems other than his hypertension and his labs that were drawn last week were within normal limits. His temperature is 98.3°F (36.8°C), blood pressure is 197/105 mmHg, pulse is 88/min, respirations are 14/min, and oxygen saturation is 99% on room air. Physical exam is unremarkable. Laboratory values are redrawn at this visit and shown below.
Hemoglobin: 15 g/dL
Hematocrit: 46%
Leukocyte count: 3,400/mm^3 with normal differential
Platelet count: 177,000/mm^3
Serum:
Na+: 139 mEq/L
Cl-: 102 mEq/L
K+: 4.0 mEq/L
HCO3-: 24 mEq/L
BUN: 29 mg/dL
Glucose: 139 mg/dL
Creatinine: 2.3 mg/dL
Ca2+: 10.2 mg/dL
Which of the following is the most likely diagnosis?
Q82
A 45-year-old man with type 1 diabetes mellitus comes to the physician for a health maintenance examination. He has a 10-month history of tingling of his feet at night and has had two recent falls. Three years ago, he underwent retinal laser photocoagulation in both eyes. Current medications include insulin and lisinopril, but he admits not adhering to his insulin regimen. He does not smoke or drink alcohol. His blood pressure is 130/85 mm Hg while sitting and 118/70 mm Hg while standing. Examination shows decreased sense of vibration and proprioception in his toes and ankles bilaterally. His serum hemoglobin A1C is 10.1%. Urine dipstick shows 2+ protein. Which of the following additional findings is most likely in this patient?
Q83
A 65-year-old man comes to the physician because of shortness of breath, chest pain, and a cough for 2 days. The pain is exacerbated by deep inspiration. He has a history of congestive heart failure, hypertension, type 2 diabetes mellitus, and hyperlipidemia. Current medications include metoprolol, lisinopril, spironolactone, metformin, and simvastatin. He has smoked half a pack of cigarettes daily for the past 25 years. His temperature is 38.5°C (101.3°F), pulse is 95/min, respirations are 18/min, and blood pressure is 120/84 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 93%. Examination shows dullness to percussion and an increased tactile fremitus in the right lower lung field. Auscultation over this area shows bronchial breath sounds and whispered pectoriloquy. The remainder of the examination shows no abnormalities. Which of the following is the most likely cause of these findings?
Q84
A 14-year-old male presents to his primary care physician with complaints of shortness of breath and easy fatigability when exercising for extended periods of time. He also reports that, when he exercises, his lower legs and feet turn a bluish-gray color. He cannot remember visiting a doctor since he was in elementary school. His vital signs are as follows: HR 72, BP 148/65, RR 14, and SpO2 97%. Which of the following murmurs and/or findings would be expected on auscultation of the precordium?
Q85
A 52-year-old man comes to the physician for a routine medical check-up. The patient feels well. He has hypertension, type 2 diabetes mellitus, and recurrent panic attacks. He had a myocardial infarction 3 years ago. He underwent a left inguinal hernia repair at the age of 25 years. A colonoscopy 2 years ago was normal. He works as a nurse at a local hospital. He is married and has two children. His father died of prostate cancer at the age of 70 years. He had smoked one pack of cigarettes daily for 25 years but quit following his myocardial infarction. He drinks one to two beers on the weekends. He has never used illicit drugs. Current medications include aspirin, atorvastatin, lisinopril, metoprolol, fluoxetine, metformin, and a multivitamin. He appears well-nourished. Temperature is 36.8°C (98.2°F), pulse is 70/min, and blood pressure is 125/75 mm Hg. Lungs are clear to auscultation. Cardiac examination shows a high-frequency, mid-to-late systolic murmur that is best heard at the apex. The abdomen is soft and nontender. The remainder of the physical examination shows no abnormalities. Which of the following is the most likely diagnosis?
Q86
A 68-year-old man presents to his primary care physician for a routine checkup. He currently has no complaints. During routine blood work, he is found to have a slightly elevated calcium (10.4 mg/dL) and some findings of plasma cells in his peripheral blood smear (less than 10%). His physician orders a serum protein electrophoresis which demonstrates a slight increase in gamma protein that is found to be light chain predominate. What is the most likely complication for this patient as this disease progresses if left untreated?
Q87
A 67-year-old woman presents to her primary care physician because she has been feeling increasingly fatigued over the last month. She has noticed that she gets winded halfway through her favorite walk in the park even though she was able to complete the entire walk without difficulty for years. She recently moved to an old house and started a new Mediterranean diet. Her past medical history is significant for hypertension and osteoarthritis for which she underwent a right hip replacement 2 years ago. Physical exam reveals conjunctival pallor as well as splenomegaly. Labs are obtained and the results are shown below:
Hemoglobin: 9.7 g/dL (normal: 12-15.5 g/dL)
Mean corpuscular volume: 91 µm^3 (normal: 80-100 µm^3)
Direct Coombs test: positive
Indirect Coombs test: positive
Peripheral blood smear reveals spherical red blood cells. The disorder that is most likely responsible for this patient's symptoms should be treated in which of the following ways?
Q88
A 22-year-old woman comes to the physician for gradual worsening of her vision. Her father died at 40 years of age. She is 181 cm (5 ft 11 in) tall and weighs 69 kg (152 lb); BMI is 21 kg/m2. A standard vision test shows severe myopia. Genetic analysis shows an FBN1 gene mutation on chromosome 15. This patient is at greatest risk of mortality due to which of the following causes?
Q89
A 65-year-old male presents to the emergency department with a 2-day onset of right-lower quadrant and right flank pain. He also states that over this period of time he has felt dizzy, light-headed, and short of breath. He denies any recent trauma or potential inciting event. His vital signs are as follows: T 37.1 C, HR 118, BP 74/46, RR 18, SpO2 96%. Physical examination is significant for an irregularly irregular heart rhythm as well as bruising over the right flank. The patient's medical history is significant for atrial fibrillation, hypertension, and hyperlipidemia. His medication list includes atorvastatin, losartan, and coumadin. IV fluids are administered in the emergency department, resulting in an increase in blood pressure to 100/60 and decrease in heart rate to 98. Which of the following would be most useful to confirm this patient's diagnosis and guide future management?
Q90
A 27-year-old woman presents to her primary care physician for a wellness checkup. She states that she is currently doing well but is unable to engage in exercise secondary to her asthma. Her asthma is well-controlled at baseline, and her symptoms only arise when she is trying to exercise once a week at volleyball practice. She is currently only using an albuterol inhaler once a month. The patient’s physical exam is notable for good bilateral air movement without wheezing on pulmonary exam. Which of the following is the best next step in management?
Cardiology US Medical PG Practice Questions and MCQs
Question 81: A 57-year-old man is sent to the emergency department by his primary care physician for hypertension. He was at a general health maintenance appointment when his blood pressure was found to be 180/115 mmHg; thus, prompting his primary doctor to send him to the emergency room. The patient is otherwise currently asymptomatic and states that he feels well. The patient has no other medical problems other than his hypertension and his labs that were drawn last week were within normal limits. His temperature is 98.3°F (36.8°C), blood pressure is 197/105 mmHg, pulse is 88/min, respirations are 14/min, and oxygen saturation is 99% on room air. Physical exam is unremarkable. Laboratory values are redrawn at this visit and shown below.
Hemoglobin: 15 g/dL
Hematocrit: 46%
Leukocyte count: 3,400/mm^3 with normal differential
Platelet count: 177,000/mm^3
Serum:
Na+: 139 mEq/L
Cl-: 102 mEq/L
K+: 4.0 mEq/L
HCO3-: 24 mEq/L
BUN: 29 mg/dL
Glucose: 139 mg/dL
Creatinine: 2.3 mg/dL
Ca2+: 10.2 mg/dL
Which of the following is the most likely diagnosis?
A. Pheochromocytoma
B. Cushing syndrome
C. Hypertension
D. Hypertensive emergency (Correct Answer)
E. Hypertensive urgency
Explanation: ***Hypertensive emergency***
- This patient presents with **severe hypertension** (BP 197/105 mmHg) accompanied by evidence of **acute end-organ damage**, specifically a new elevation in **creatinine to 2.3 mg/dL** and **BUN to 29 mg/dL**, suggestive of acute kidney injury.
- An asymptomatic presentation does not rule out hypertensive emergency; the key is the presence of **acute, severe elevation in blood pressure with new or worsening end-organ damage**.
*Pheochromocytoma*
- While it causes episodic or sustained hypertension, it typically presents with classic symptoms like **palpitations, headaches, and sweating**, which are absent in this patient.
- Diagnosis involves elevated plasma or urinary metanephrines, not just elevated BP with acute kidney injury.
*Cushing syndrome*
- Characterized by hypertension, but also includes other features like **central obesity, moon facies, striae, and muscle weakness**, none of which are described.
- Diagnosis is based on cortisol excess, confirmed by specific tests such as dexamethasone suppression tests.
*Hypertension*
- This is a general term for elevated blood pressure. While the patient certainly has hypertension, the presence of **acute end-organ damage (elevated creatinine/BUN)** elevates it beyond simple hypertension.
- The definition of hypertension alone does not encompass the acute, severe nature and organ damage seen here.
*Hypertensive urgency*
- Defined as **severe elevation in blood pressure without evidence of acute end-organ damage**.
- This patient has a new elevation in creatinine and BUN, indicating **acute kidney injury**, which constitutes end-organ damage, thus moving it beyond urgency to an emergency.
Question 82: A 45-year-old man with type 1 diabetes mellitus comes to the physician for a health maintenance examination. He has a 10-month history of tingling of his feet at night and has had two recent falls. Three years ago, he underwent retinal laser photocoagulation in both eyes. Current medications include insulin and lisinopril, but he admits not adhering to his insulin regimen. He does not smoke or drink alcohol. His blood pressure is 130/85 mm Hg while sitting and 118/70 mm Hg while standing. Examination shows decreased sense of vibration and proprioception in his toes and ankles bilaterally. His serum hemoglobin A1C is 10.1%. Urine dipstick shows 2+ protein. Which of the following additional findings is most likely in this patient?
A. Dilated pupils
B. Hyperreflexia
C. Increased lower esophageal sphincter pressure
D. Incomplete bladder emptying (Correct Answer)
E. Premature ejaculation
Explanation: ***Incomplete bladder emptying***
- This patient has signs of **diabetic neuropathy**, including peripheral neuropathy (tingling, sensory deficits) and likely **autonomic neuropathy** given the orthostatic hypotension. Autonomic neuropathy can affect the bladder, leading to **detrusor underactivity** and incomplete bladder emptying.
- **Poor glycemic control** (HbA1c 10.1%) significantly increases the risk and progression of both peripheral and autonomic neuropathies.
*Dilated pupils*
- Diabetic autonomic neuropathy can affect pupillary function, but typically causes **miosis** (constricted pupils) and **poor pupillary light reflex**, rather than dilation.
- Dilated pupils are more characteristic of other neurological conditions or medication side effects.
*Hyperreflexia*
- **Peripheral neuropathy** due to diabetes typically causes **hyporeflexia** or areflexia, especially in the lower extremities, due to damage to the peripheral nerves.
- Hyperreflexia suggests an upper motor neuron lesion, which is not indicated by the patient's symptoms or diabetes.
*Increased lower esophageal sphincter pressure*
- Diabetic autonomic neuropathy can affect the gastrointestinal tract, leading to conditions like **gastroparesis**, but it tends to cause **reduced lower esophageal sphincter (LES) pressure**, contributing to **gastroesophageal reflux**, rather than increased pressure.
- Increased LES pressure is typically seen in disorders like achalasia.
*Premature ejaculation*
- While diabetic neuropathy can cause **sexual dysfunction** in men, it more commonly leads to **erectile dysfunction** or **retrograde ejaculation** due to autonomic nerve damage.
- Premature ejaculation is less directly associated with diabetic autonomic neuropathy compared to other forms of sexual dysfunction.
Question 83: A 65-year-old man comes to the physician because of shortness of breath, chest pain, and a cough for 2 days. The pain is exacerbated by deep inspiration. He has a history of congestive heart failure, hypertension, type 2 diabetes mellitus, and hyperlipidemia. Current medications include metoprolol, lisinopril, spironolactone, metformin, and simvastatin. He has smoked half a pack of cigarettes daily for the past 25 years. His temperature is 38.5°C (101.3°F), pulse is 95/min, respirations are 18/min, and blood pressure is 120/84 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 93%. Examination shows dullness to percussion and an increased tactile fremitus in the right lower lung field. Auscultation over this area shows bronchial breath sounds and whispered pectoriloquy. The remainder of the examination shows no abnormalities. Which of the following is the most likely cause of these findings?
A. Pleural fluid accumulation
B. Ruptured pulmonary blebs
C. Parenchymal consolidation (Correct Answer)
D. Alveolar transudate
E. Pulmonary infarction
Explanation: ***Parenchymal consolidation***
- The combination of **fever**, **cough**, **shortness of breath**, and pleuritic chest pain in a patient with risk factors like smoking, followed by examination findings of **dullness to percussion**, **increased tactile fremitus**, **bronchial breath sounds**, and **whispered pectoriloquy**, is highly indicative of **pneumonia** leading to **parenchymal consolidation**.
- **Consolidation** occurs when alveoli fill with inflammatory exudate (e.g., in pneumonia), increasing the density of lung tissue and enhancing sound transmission.
*Pleural fluid accumulation*
- **Pleural effusion** would typically present with **dullness to percussion** but would cause **decreased tactile fremitus** and **decreased or absent breath sounds** over the affected area, as fluid dampens sound transmission.
- While pleuritic pain can be present, the specific collection of physical exam findings points away from fluid accumulation.
*Ruptured pulmonary blebs*
- A **ruptured pulmonary bleb** can lead to **pneumothorax**, which would typically manifest with sudden chest pain, shortness of breath, and physical exam findings of **hyperresonance to percussion** and **decreased or absent breath sounds**.
- There would also be **decreased tactile fremitus**, which contradicts the patient's presentation.
*Alveolar transudate*
- **Alveolar transudate** (e.g., in **pulmonary edema** due to CHF exacerbation) would lead to widespread **crackles** or rales bilaterally, not localized dullness and increased tactile fremitus.
- While the patient has CHF, the localized findings are more suggestive of an infectious process.
*Pulmonary infarction*
- **Pulmonary infarction**, often due to **pulmonary embolism**, typically presents with sudden onset of pleuritic chest pain, dyspnea, and sometimes a cough with hemoptysis.
- While it can cause some localized findings on auscultation, it does not typically produce the classic consolidation signs like **increased tactile fremitus**, **bronchial breath sounds**, and **whispered pectoriloquy**.
Question 84: A 14-year-old male presents to his primary care physician with complaints of shortness of breath and easy fatigability when exercising for extended periods of time. He also reports that, when he exercises, his lower legs and feet turn a bluish-gray color. He cannot remember visiting a doctor since he was in elementary school. His vital signs are as follows: HR 72, BP 148/65, RR 14, and SpO2 97%. Which of the following murmurs and/or findings would be expected on auscultation of the precordium?
A. Continuous, machine-like murmur at the left infraclavicular area
B. Mid-systolic murmur loudest at the right second intercostal space, with radiation to the right neck
C. Right supraclavicular continuous murmur which disappears with pressure on the internal jugular vein
D. Left infraclavicular systolic ejection murmur with decreased blood pressure in the lower extremities (Correct Answer)
E. Holodiastolic murmur loudest at the apex, with an opening snap following the S2 heart sound
Explanation: ***Left infraclavicular systolic ejection murmur with decreased blood pressure in the lower extremities***
- The combination of **hypertension (BP 148/65 mmHg)**, **exercise-induced dyspnea and fatigability**, and **cyanosis of the lower extremities** (blue-gray color) strongly suggests **coarctation of the aorta**.
- A **systolic ejection murmur** over the left infraclavicular area and **decreased blood pressure in the lower extremities** are classic auscultatory and physical findings in coarctation.
*Continuous, machine-like murmur at the left infraclavicular area*
- This description is characteristic of a **patent ductus arteriosus (PDA)**, which typically presents with a **continuous murmur** throughout systole and diastole.
- While PDA can cause pulmonary hypertension and heart failure, the specific finding of **differential cyanosis in the lower limbs** (indicating right-to-left shunting) is more indicative of coarctation with PDA, or severe coarctation alone, rather than an isolated PDA.
*Mid-systolic murmur loudest at the right second intercostal space, with radiation to the right neck*
- This murmur description is typical of **aortic stenosis**, particularly in adults.
- While aortic stenosis can cause exertional dyspnea and fatigue, it does not typically cause **differential cyanosis of the lower extremities** or the specific blood pressure discrepancy seen in coarctation.
*Right supraclavicular continuous murmur which disappears with pressure on the internal jugular vein*
- This describes a **venous hum**, a benign finding that is common in children and usually disappears with position changes or compression of the jugular vein.
- It is not associated with the patient's symptoms of **dyspnea, fatigue, or differential cyanosis**.
*Holodiastolic murmur loudest at the apex, with an opening snap following the S2 heart sound*
- This sign is indicative of **mitral stenosis**, an abnormality of the mitral valve that obstructs blood flow from the left atrium to the left ventricle.
- Mitral stenosis would not explain the **hypertension in the upper extremities** or the **cyanosis localized to the lower extremities**.
Question 85: A 52-year-old man comes to the physician for a routine medical check-up. The patient feels well. He has hypertension, type 2 diabetes mellitus, and recurrent panic attacks. He had a myocardial infarction 3 years ago. He underwent a left inguinal hernia repair at the age of 25 years. A colonoscopy 2 years ago was normal. He works as a nurse at a local hospital. He is married and has two children. His father died of prostate cancer at the age of 70 years. He had smoked one pack of cigarettes daily for 25 years but quit following his myocardial infarction. He drinks one to two beers on the weekends. He has never used illicit drugs. Current medications include aspirin, atorvastatin, lisinopril, metoprolol, fluoxetine, metformin, and a multivitamin. He appears well-nourished. Temperature is 36.8°C (98.2°F), pulse is 70/min, and blood pressure is 125/75 mm Hg. Lungs are clear to auscultation. Cardiac examination shows a high-frequency, mid-to-late systolic murmur that is best heard at the apex. The abdomen is soft and nontender. The remainder of the physical examination shows no abnormalities. Which of the following is the most likely diagnosis?
A. Pulmonary valve regurgitation
B. Mitral valve stenosis
C. Tricuspid valve stenosis
D. Mitral valve prolapse (Correct Answer)
E. Pulmonary valve stenosis
Explanation: ***Mitral valve prolapse***
- A **mid-to-late systolic murmur** heard best at the apex is the characteristic finding of mitral valve prolapse, often accompanied by a **mid-systolic click** (though not mentioned here).
- The **high-frequency** nature of the murmur is consistent with MVP.
- Important association: **Panic attacks/anxiety disorders** are strongly linked with MVP, likely due to underlying connective tissue abnormalities and autonomic dysfunction.
- This patient's history of recurrent panic attacks further supports the diagnosis.
*Pulmonary valve regurgitation*
- This typically causes a **diastolic murmur** (Graham Steell murmur), not a systolic murmur as described.
- It is usually heard best at the **left upper sternal border**, not at the apex.
*Mitral valve stenosis*
- Mitral stenosis presents with a **low-pitched diastolic rumble** (mid-diastolic murmur) and often an **opening snap**, not a systolic murmur.
- Most commonly caused by **rheumatic fever**.
- Heard best at the apex but timing is diastolic, not systolic.
*Tricuspid valve stenosis*
- Tricuspid stenosis produces a **diastolic murmur**, usually accentuated with inspiration (Carvallo's sign).
- Heard best at the **lower left sternal border**.
*Pulmonary valve stenosis*
- Presents with a **systolic ejection murmur** heard best at the **left upper sternal border** (pulmonic area), often with a preceding ejection click.
- The murmur described is a mid-to-late systolic murmur at the apex, not an ejection murmur at the LUSB.
Question 86: A 68-year-old man presents to his primary care physician for a routine checkup. He currently has no complaints. During routine blood work, he is found to have a slightly elevated calcium (10.4 mg/dL) and some findings of plasma cells in his peripheral blood smear (less than 10%). His physician orders a serum protein electrophoresis which demonstrates a slight increase in gamma protein that is found to be light chain predominate. What is the most likely complication for this patient as this disease progresses if left untreated?
A. Peripheral neuropathy
B. Hepatomegaly
C. Kidney damage (Correct Answer)
D. Raynaud's phenomenon
E. Splenomegaly
Explanation: ***Kidney damage***
- The patient's presentation with **elevated calcium**, **plasma cells** in the peripheral blood (though <10%), and an **M-spike** (light chain predominance) on serum protein electrophoresis strongly suggests **Multiple Myeloma** or a precursor condition.
- One of the most common and serious complications of multiple myeloma is **kidney damage** due to the deposition of **light chains** (Bence Jones proteins) in the renal tubules, leading to casts and renal failure, or hypercalcemia-induced nephropathy.
*Peripheral neuropathy*
- While peripheral neuropathy can occur in plasma cell dyscrasias, it is more characteristic of **POEMS syndrome** (Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal protein, Skin changes) or amyloidosis, which are not directly indicated here.
- It is not the most likely primary complication of early multiple myeloma.
*Hepatomegaly*
- **Hepatomegaly** is not a common or direct complication of multiple myeloma, although liver involvement can occur in rare cases or with extensive amyloidosis.
- The primary symptoms and lab findings provided do not point towards significant liver involvement.
*Raynaud's phenomenon*
- **Raynaud's phenomenon** is an episodic vasospastic disorder, often associated with connective tissue diseases or cryoglobulinemia.
- It is not a typical direct complication of multiple myeloma based on the given presentation.
*Splenomegaly*
- **Splenomegaly** is uncommon in multiple myeloma. It can be seen in other hematologic malignancies or storage diseases, but not as a characteristic feature of this patient's likely condition.
- The presented symptoms do not suggest splenic involvement.
Question 87: A 67-year-old woman presents to her primary care physician because she has been feeling increasingly fatigued over the last month. She has noticed that she gets winded halfway through her favorite walk in the park even though she was able to complete the entire walk without difficulty for years. She recently moved to an old house and started a new Mediterranean diet. Her past medical history is significant for hypertension and osteoarthritis for which she underwent a right hip replacement 2 years ago. Physical exam reveals conjunctival pallor as well as splenomegaly. Labs are obtained and the results are shown below:
Hemoglobin: 9.7 g/dL (normal: 12-15.5 g/dL)
Mean corpuscular volume: 91 µm^3 (normal: 80-100 µm^3)
Direct Coombs test: positive
Indirect Coombs test: positive
Peripheral blood smear reveals spherical red blood cells. The disorder that is most likely responsible for this patient's symptoms should be treated in which of the following ways?
A. Avoidance of fava beans
B. Chelation therapy
C. Glucocorticoid administration (Correct Answer)
D. Vitamin supplementation
E. Chronic blood transfusions
Explanation: ***Glucocorticoid administration***
- This patient presents with signs of **anemia** (fatigue, dyspnea, conjunctival pallor) along with **splenomegaly**, a **positive Direct Coombs test**, and **spherocytes** on peripheral smear, all highly suggestive of **warm autoimmune hemolytic anemia (AIHA)**.
- **Glucocorticoids** are the first-line treatment for warm AIHA, as they suppress the immune system and reduce IgG antibody production against red blood cells.
*Avoidance of fava beans*
- This intervention is relevant for individuals with **glucose-6-phosphate dehydrogenase (G6PD) deficiency**, which can cause hemolytic anemia upon exposure to oxidative stressors like fava beans.
- However, the patient's symptoms and lab results (especially the positive Coombs test) are not consistent with G6PD deficiency, which typically presents with **Heinz bodies** and an absence of a positive Direct Coombs test.
*Chelation therapy*
- **Chelation therapy** is used to remove excess heavy metals from the body, most commonly in cases of **iron overload (hemochromatosis)** or **lead poisoning**.
- There is no indication of heavy metal toxicity or iron overload in this patient's presentation; direct evidence of autoimmune hemolytic anemia points away from this treatment.
*Vitamin supplementation*
- **Vitamin supplementation**, particularly with **iron, folate, or vitamin B12**, is appropriate for **nutritional deficiencies** causing anemia.
- While vitamin deficiencies can cause anemia, the presence of spherocytes, splenomegaly, and a positive Coombs test strongly indicate an autoimmune etiology for hemolysis, not a nutritional deficiency.
*Chronic blood transfusions*
- While **blood transfusions** might be necessary for patients with severe, symptomatic anemia in AIHA, they are typically a supportive measure rather than a primary treatment.
- The focus is on treating the underlying autoimmune process to prevent further red blood cell destruction, making chronic transfusions an inappropriate initial or sole treatment strategy for AIHA.
Question 88: A 22-year-old woman comes to the physician for gradual worsening of her vision. Her father died at 40 years of age. She is 181 cm (5 ft 11 in) tall and weighs 69 kg (152 lb); BMI is 21 kg/m2. A standard vision test shows severe myopia. Genetic analysis shows an FBN1 gene mutation on chromosome 15. This patient is at greatest risk of mortality due to which of the following causes?
A. Eccentric ventricular hypertrophy
B. Obstruction of the superior vena cava lumen
C. Increased pressure in the pulmonary arteries
D. Intimal tear of the aortic root (Correct Answer)
E. Supraventricular tachyarrhythmia
Explanation: ***Intimal tear of the aortic root***
- This patient presents with features highly suggestive of **Marfan syndrome**: tall stature, severe myopia, and an **FBN1 gene mutation**.
- The most common cause of mortality in Marfan syndrome is **aortic dissection** or rupture, which typically begins with an intimal tear in the aortic root due to defective connective tissue.
*Eccentric ventricular hypertrophy*
- While Marfan syndrome can lead to **aortic regurgitation** and subsequent eccentric hypertrophy, it is not the primary cause of sudden mortality.
- The direct threat comes from the **integrity of the aortic wall**, not the secondary hypertrophy.
*Obstruction of the superior vena cava lumen*
- **Superior vena cava (SVC) syndrome** is usually caused by external compression from tumors or thrombosis, not directly associated with Marfan syndrome's primary pathology.
- There is no clinical information in the vignette to suggest SVC obstruction.
*Increased pressure in the pulmonary arteries*
- **Pulmonary hypertension** can be a complication of various cardiac conditions, but it is not the most direct or common life-threatening cardiovascular manifestation of Marfan syndrome.
- The primary vascular risk in Marfan syndrome involves the **systemic aorta**.
*Supraventricular tachyarrhythmia*
- While arrhythmias can occur in Marfan syndrome, they are generally **less life-threatening** than aortic dissection or rupture.
- The FBN1 gene mutation primarily affects connective tissue strength, particularly in the vasculature, making aortic complications the gravest risk.
Question 89: A 65-year-old male presents to the emergency department with a 2-day onset of right-lower quadrant and right flank pain. He also states that over this period of time he has felt dizzy, light-headed, and short of breath. He denies any recent trauma or potential inciting event. His vital signs are as follows: T 37.1 C, HR 118, BP 74/46, RR 18, SpO2 96%. Physical examination is significant for an irregularly irregular heart rhythm as well as bruising over the right flank. The patient's medical history is significant for atrial fibrillation, hypertension, and hyperlipidemia. His medication list includes atorvastatin, losartan, and coumadin. IV fluids are administered in the emergency department, resulting in an increase in blood pressure to 100/60 and decrease in heart rate to 98. Which of the following would be most useful to confirm this patient's diagnosis and guide future management?
A. Magnetic resonance angiography
B. Ultrasound of the right flank
C. Radiographs of the abdomen and pelvis
D. CT abdomen/pelvis (Correct Answer)
E. MRI abdomen/pelvis
Explanation: ***CT abdomen/pelvis***
- The patient's presentation with **flank pain**, **hypotension**, and **bruising over the flank (Grey Turner's sign)** in the context of anticoagulation points strongly to a **retroperitoneal hemorrhage**. A CT scan is the **gold standard** for diagnosing retroperitoneal hemorrhage, quantifying its size, and identifying any underlying cause or source of bleeding.
- CT provides **rapid, detailed imaging** of soft tissues, organs, and vascular structures in the abdomen and pelvis, making it crucial for confirming the diagnosis and guiding management in an acutely unstable patient.
*Magnetic resonance angiography*
- While MRA provides detailed vascular imaging, it is less readily available in an emergency setting and takes longer to perform than CT, which could delay critical interventions for an unstable patient.
- Its primary role is in evaluating vascular pathology, but a general CT scan is usually performed first to identify the source of bleeding and overall hemorrhage.
*Ultrasound of the right flank*
- Ultrasound can identify fluid collections and some soft tissue abnormalities but has **limited penetration and resolution** for deep retroperitoneal structures and active bleeding.
- It is not sensitive enough to accurately diagnose and characterize a significant retroperitoneal hemorrhage or identify a specific bleeding source in an emergent setting.
*Radiographs of the abdomen and pelvis*
- Radiographs provide very **limited information** about soft tissue pathology like hemorrhage and are primarily useful for skeletal abnormalities or detecting free air.
- They would not be able to visualize or diagnose a retroperitoneal hematoma or its source.
*MRI abdomen/pelvis*
- MRI offers excellent soft tissue contrast, but it is **time-consuming**, expensive, and often less accessible in an emergency setting, delaying diagnosis and management in a hemodynamically unstable patient.
- Patients with metallic implants or claustrophobia may not be able to undergo an MRI, and it's generally reserved for more stable patients or specific diagnostic questions not amenable to CT.
Question 90: A 27-year-old woman presents to her primary care physician for a wellness checkup. She states that she is currently doing well but is unable to engage in exercise secondary to her asthma. Her asthma is well-controlled at baseline, and her symptoms only arise when she is trying to exercise once a week at volleyball practice. She is currently only using an albuterol inhaler once a month. The patient’s physical exam is notable for good bilateral air movement without wheezing on pulmonary exam. Which of the following is the best next step in management?
A. Add inhaled fluticasone to her asthma regimen
B. Recommend cessation of athletic endeavors
C. Add oral prednisone to her asthma regimen
D. Recommend she use her albuterol inhaler prior to exercise (Correct Answer)
E. Add montelukast to her asthma regimen
Explanation: ***Recommend she use her albuterol inhaler prior to exercise***
- This patient presents with **exercise-induced bronchoconstriction (EIB)**, as her asthma symptoms are exclusively triggered by exercise.
- The most appropriate initial management for EIB is to use a **short-acting beta-agonist (SABA)** like albuterol 15-30 minutes before exercise.
*Add inhaled fluticasone to her asthma regimen*
- This option is used for **persistent asthma** that is not well-controlled with SABA alone, indicated by more frequent daily or nocturnal symptoms.
- The patient's asthma is well-controlled at baseline, only using albuterol once a month, suggesting that she does not require a daily inhaled corticosteroid at this time.
*Add oral prednisone to her asthma regimen*
- Oral prednisone is a **systemic corticosteroid** reserved for acute asthma exacerbations or severe, difficult-to-control asthma.
- The patient's symptoms are mild and intermittent, occurring only with exercise, and thus do not warrant systemic corticosteroids.
*Recommend cessation of athletic endeavors*
- This is an **unnecessary and restrictive** recommendation, as EIB can typically be well-managed with appropriate medication, allowing patients to participate in sports.
- Limiting physical activity can have negative impacts on a patient's overall health and well-being.
*Add montelukast to her asthma regimen*
- **Montelukast**, a leukotriene receptor antagonist, can be used as an alternative or add-on therapy for persistent asthma, or sometimes for EIB.
- However, the **first-line treatment** for preventing EIB symptoms is a SABA like albuterol, and montelukast is a less effective initial choice than pre-exercise SABA for this specific presentation.
