A 46-year-old woman comes to the physician for a follow-up examination. She had a blood pressure recording of 148/94 mm Hg on her previous visit one week ago. Her home blood pressure log shows readings of 151/97 and 146/92 mm Hg in the past week. She has no history of serious illness and takes no medications. She is 160 cm (5 ft 3 in) tall and weighs 52 kg (115 lb); BMI is 20 kg/m2. Her pulse is 88/min and blood pressure is 150/96 mm Hg. Cardiopulmonary examination is unremarkable. Abdominal examination shows no abnormalities. The extremities are well perfused with strong peripheral pulses. Serum concentrations of electrolytes, creatinine, lipids, TSH, and fasting glucose are within the reference range. A urinalysis is within normal limits. Which of the following is the most appropriate next step in management?
Q892
An 11-year-old girl presents with a 1-day history of frothy brown urine. She has no significant medical history and takes no medications. She reports that several of her classmates have been sick, and she notes that she had a very sore throat with a fever approx. 2 weeks ago. Her blood pressure is 146/94 mm Hg, heart rate is 74/min, and respiratory rate is 14/min. Laboratory analysis reveals elevated serum creatinine, hematuria with RBC casts, and elevated urine protein without frank proteinuria. Physical examination reveals a healthy-looking girl with no abdominal or costovertebral angle tenderness. Which of the following is the most likely diagnosis?
Q893
A 46-year-old woman comes to the physician for a routine health examination. She was last seen by a physician 3 years ago. She has been healthy aside from occasional mild flank pain. Her only medication is a multivitamin. Her blood pressure is 154/90 mm Hg. Physical examination shows no abnormalities. Serum studies show:
Sodium 141 mEq/L
Potassium 3.7 mEq/L
Calcium 11.3 mg/dL
Phosphorus 2.3 mg/dL
Urea nitrogen 15 mg/dL
Creatinine 0.9 mg/dL
Albumin 3.6 g/dL
Subsequent serum studies show a repeat calcium of 11.2 mg/dL, parathyroid hormone concentration of 890 pg/mL, and 25-hydroxyvitamin D of 48 ng/mL (N = 25–80). Her 24-hour urine calcium excretion is elevated. An abdominal ultrasound shows several small calculi in bilateral kidneys. Further testing shows normal bone mineral density. Which of the following is the most appropriate next step in management?
Q894
Four days after being admitted to the intensive care unit for acute substernal chest pain and dyspnea, an 80-year-old man is evaluated for hypotension. Coronary angiography on admission showed an occlusion in the left anterior descending artery, and a drug-eluting stent was placed successfully. The patient has a history of hypertension and type 2 diabetes mellitus. Current medications include aspirin, clopidogrel, metoprolol, lisinopril, and atorvastatin. His temperature is 37.2 °C (99 °F), pulse is 112/min, respirations are 21/min, and blood pressure is 72/50 mm Hg. Cardiac examination shows a normal S1 and S2 and a new harsh, holosystolic murmur heard best at the left sternal border. There is jugular venous distention and a right parasternal heave. The lungs are clear to auscultation. Pitting edema extends up to the knees bilaterally. An ECG shows Q waves in the inferior leads. Which of the following is the most likely cause of this patient’s hypotension?
Q895
A 73-year-old man with a 50-year history of type 2 diabetes and stage 3 chronic kidney disease presents to his primary care doctor for a scheduled follow-up and routine labs. He states that he has had no real change in his health except that he feels like he has had bouts of lightheadedness and almost passing out, which resolve with sitting down. The patient does not have a history of syncope or arrhythmia. On his labs, he is found to have a hemoglobin of 11.0 g/dL. His estimated glomerular filtration rate is determined to be 45 ml/min/1.73m^2. Testing of his stool is negative for blood. Additionally, a peripheral blood smear demonstrates normochromic cells. As a result, the patient is started on erythropoietin. Which of the following likely describes the anemia?
Q896
A 72-year-old man presents to the physician with severe lower back pain and fatigue for 3 months. The pain increases with activity. He has no history of a serious illness. He takes ibuprofen for pain relief. He does not smoke. The blood pressure is 105/65 mm Hg, the pulse is 86/min, the respirations are 16/min, and the temperature is 36.7℃ (98.1℉). The conjunctivae are pale. Palpation over the 1st lumbar vertebra shows tenderness. The heart, lung, and abdominal examination shows no abnormalities. No lymphadenopathy is palpated. The results of the laboratory studies show:
Laboratory test
Hemoglobin 9 g/dL
Mean corpuscular volume 90 μm3
Leukocyte count 5,500/mm3 with a normal differential
Platelet count 350,000/mm3
Serum
Calcium 11.5 mg/dL
Albumin 3.8 g/dL
Urea nitrogen 54 mg/dL
Creatinine 2.5 mg/dL
Lumbosacral computed tomography (CT) scan shows a low-density lesion in the 1st lumbar vertebra and several similar lesions in the pelvic bones. Which of the following is the most likely diagnosis?
Q897
A 21-year-old woman presents with malaise, joint pains, and a rash that worsens with sun exposure. Examination reveals an erythematous facial rash with edema. Her complete blood count shows lymphocytopenia. In addition to the most likely diagnosis, which of the following disorders can also cause lymphocytopenia? I. HIV II. Autoimmune disorders III. Tuberculosis IV. Lymphoma V. Hypersplenism
Q898
A 62-year-old man is brought to the emergency department by his wife for high blood pressure readings at home. He is asymptomatic. He has a history of hypertension and hyperlipidemia for which he takes atenolol and atorvastatin, however, his wife reports that he recently ran out of atenolol and has not been able to refill it due to lack of health insurance. His temperature is 36.8°C (98.2°F), the pulse 65/min, the respiratory rate 22/min, and the blood pressure 201/139 mm Hg. He has no papilledema on fundoscopic examination. A CT scan shows no evidence of intracranial hemorrhage or ischemia. Of the following, what is the next best step?
Q899
A 65-year-old woman comes to clinic complaining of pain with chewing solid foods. She reports that she has been feeling unwell lately, with pains in her shoulders and hips, and she has lost five pounds in the past few months. Her vital signs are T 39C, RR 18 breaths/min, HR 95 bpm, BP 120/65 mmHg. When you ask her to stand from her chair to get on the exam table she moves stiffly but displays preserved proximal muscle strength. Another potential symptom or sign of this disease could be:
Q900
A 48-year-old woman presents to her primary care physician with the complaints of persistent fatigue, dizziness, and weight loss for the past 3 months. She has hypothyroidism for 15 years and takes thyroxine replacement. Her blood pressure is 90/60 mm Hg in a supine position and 65/40 mm Hg while sitting, temperature is 36.8°C (98.2°F) and pulse is 75/min. On physical examination, there is a mild increase in thyroid size, with a rubbery consistency. Her skin shows diffuse hyperpigmentation, more pronounced in the oral mucosa and palmar creases. The morning serum cortisol test is found to be 3 µg/dL. Which of the following is the best next step in this case?
Cardiology US Medical PG Practice Questions and MCQs
Question 891: A 46-year-old woman comes to the physician for a follow-up examination. She had a blood pressure recording of 148/94 mm Hg on her previous visit one week ago. Her home blood pressure log shows readings of 151/97 and 146/92 mm Hg in the past week. She has no history of serious illness and takes no medications. She is 160 cm (5 ft 3 in) tall and weighs 52 kg (115 lb); BMI is 20 kg/m2. Her pulse is 88/min and blood pressure is 150/96 mm Hg. Cardiopulmonary examination is unremarkable. Abdominal examination shows no abnormalities. The extremities are well perfused with strong peripheral pulses. Serum concentrations of electrolytes, creatinine, lipids, TSH, and fasting glucose are within the reference range. A urinalysis is within normal limits. Which of the following is the most appropriate next step in management?
A. Echocardiography
B. Renal ultrasonography
C. Polysomnography
D. Plasma renin activity
E. Electrocardiogram (Correct Answer)
Explanation: ***Electrocardiogram***
- An **electrocardiogram (ECG)** is essential for newly diagnosed hypertension to assess for **left ventricular hypertrophy (LVH)**, a common indicator of target-organ damage.
- Early detection of **LVH** can guide treatment intensity and is associated with increased cardiovascular risk.
*Echocardiography*
- While echocardiography can provide a more detailed assessment of **cardiac structure** and function, it is generally considered a second-line investigation for **LVH** after ECG in uncomplicated hypertension.
- ECG is a more cost-effective and readily available initial screening tool for **LVH**.
*Renal ultrasonography*
- **Renal ultrasonography** would be indicated if there were suspicious findings suggesting **renal artery stenosis**, such as refractory hypertension, an abdominal bruit, or unexplained decline in renal function.
- Her normal **creatinine** and **urinalysis** do not suggest kidney disease as an etiology for her hypertension.
*Polysomnography*
- **Polysomnography** is used to diagnose **sleep apnea**, which can be a cause or exacerbating factor of hypertension.
- The patient has no symptoms suggestive of **sleep apnea**, such as snoring, daytime somnolence, or witnessed apneic episodes.
*Plasma renin activity*
- **Plasma renin activity** is part of the workup for secondary hypertension, specifically to diagnose **primary hyperaldosteronism** or **renal artery stenosis**.
- Given the patient's normal electrolytes and absence of other red flags, screening for these conditions is not indicated as a first step.
Question 892: An 11-year-old girl presents with a 1-day history of frothy brown urine. She has no significant medical history and takes no medications. She reports that several of her classmates have been sick, and she notes that she had a very sore throat with a fever approx. 2 weeks ago. Her blood pressure is 146/94 mm Hg, heart rate is 74/min, and respiratory rate is 14/min. Laboratory analysis reveals elevated serum creatinine, hematuria with RBC casts, and elevated urine protein without frank proteinuria. Physical examination reveals a healthy-looking girl with no abdominal or costovertebral angle tenderness. Which of the following is the most likely diagnosis?
A. Poststreptococcal glomerulonephritis (Correct Answer)
B. Membranoproliferative glomerulonephritis
C. Henoch-Schönlein purpura
D. Alport syndrome
E. Minimal change disease
Explanation: ***Poststreptococcal glomerulonephritis***
- The presentation of an 11-year-old girl with **frothy brown urine**, elevated blood pressure, hematuria with **RBC casts**, elevated serum creatinine, and a history of a **sore throat 2 weeks prior** is highly suggestive of **poststreptococcal glomerulonephritis (PSGN)**.
- PSGN typically presents 1-3 weeks after a **Group A Streptococcus infection** of the pharynx or skin, characterized by glomerular inflammation and subsequent renal dysfunction.
*Membranoproliferative glomerulonephritis*
- This condition is characterized by **thickening of the glomerular basement membrane** and mesangial proliferation, often leading to a more chronic course.
- While it can cause hematuria and proteinuria, the **acute onset following an infection** and the patient's specific age group make PSGN a more likely diagnosis.
*Henoch-Schönlein purpura*
- This is an **IgA vasculitis** characterized by a classic tetrad of symptoms: **palpable purpura**, arthralgia, abdominal pain, and renal disease.
- The absence of **skin rash** or joint symptoms makes this diagnosis less likely, despite the presence of renal involvement (hematuria/proteinuria).
*Alport syndrome*
- Alport syndrome is a **hereditary nephropathy** characterized by progressive sensorineural hearing loss, ocular abnormalities, and end-stage renal disease due to mutations in collagen IV.
- The acute, post-infectious presentation and absence of a family history or other systemic features make this an unlikely diagnosis.
*Minimal change disease*
- This condition is the most common cause of **nephrotic syndrome in children**, characterized by heavy proteinuria, hypoalbuminemia, edema, and hyperlipidemia.
- While it presents with frothy urine (due to heavy proteinuria), it typically **does not cause significant hematuria, RBC casts, or hypertension** in the acute phase, and the primary issue is protein loss, not glomerular inflammation with RBC casts.
Question 893: A 46-year-old woman comes to the physician for a routine health examination. She was last seen by a physician 3 years ago. She has been healthy aside from occasional mild flank pain. Her only medication is a multivitamin. Her blood pressure is 154/90 mm Hg. Physical examination shows no abnormalities. Serum studies show:
Sodium 141 mEq/L
Potassium 3.7 mEq/L
Calcium 11.3 mg/dL
Phosphorus 2.3 mg/dL
Urea nitrogen 15 mg/dL
Creatinine 0.9 mg/dL
Albumin 3.6 g/dL
Subsequent serum studies show a repeat calcium of 11.2 mg/dL, parathyroid hormone concentration of 890 pg/mL, and 25-hydroxyvitamin D of 48 ng/mL (N = 25–80). Her 24-hour urine calcium excretion is elevated. An abdominal ultrasound shows several small calculi in bilateral kidneys. Further testing shows normal bone mineral density. Which of the following is the most appropriate next step in management?
A. Begin cinacalcet therapy
B. Order serum protein electrophoresis
C. Perform percutaneous nephrolithotomy
D. Begin hydrochlorothiazide therapy
E. Refer to surgery for parathyroidectomy (Correct Answer)
Explanation: ***Refer to surgery for parathyroidectomy***
* This patient presents with **hypercalcemia**, **elevated PTH**, and **normal vitamin D levels**, indicating **primary hyperparathyroidism**. The presence of **kidney stones** and **hypertension** (though mild) are common complications and indications for surgery.
* Given her age (<50 years), symptomatic presentation (kidney stones, hypertension), and markedly elevated PTH, **parathyroidectomy** is the definitive treatment for primary hyperparathyroidism.
*Begin cinacalcet therapy*
* **Cinacalcet** is a calcimimetic that increases the sensitivity of the calcium-sensing receptor to extracellular calcium, thereby lowering PTH and calcium levels.
* It is primarily used for **secondary hyperparathyroidism** in chronic kidney disease or for **inoperable primary hyperparathyroidism**, neither of which applies here.
*Order serum protein electrophoresis*
* **Serum protein electrophoresis** is used to diagnose conditions like **multiple myeloma**, which can cause hypercalcemia due to osteolytic lesions.
* However, this patient's presentation with **elevated PTH** and normal albumin makes multiple myeloma less likely as the cause of her hypercalcemia.
*Perform percutaneous nephrolithotomy*
* **Percutaneous nephrolithotomy** is an invasive procedure used to remove large or complex kidney stones.
* While the patient has kidney stones, addressing the **underlying cause (primary hyperparathyroidism)** through parathyroidectomy is the priority to prevent recurrence and other complications, rather than just treating the stones symptomatically.
*Begin hydrochlorothiazide therapy*
* **Hydrochlorothiazide** can be used to reduce urinary calcium excretion and prevent calcium stone formation in patients with idiopathic hypercalciuria.
* However, in patients with **primary hyperparathyroidism**, thiazide diuretics can **worsen hypercalcemia** by increasing renal calcium reabsorption, making it contraindicated in this setting.
Question 894: Four days after being admitted to the intensive care unit for acute substernal chest pain and dyspnea, an 80-year-old man is evaluated for hypotension. Coronary angiography on admission showed an occlusion in the left anterior descending artery, and a drug-eluting stent was placed successfully. The patient has a history of hypertension and type 2 diabetes mellitus. Current medications include aspirin, clopidogrel, metoprolol, lisinopril, and atorvastatin. His temperature is 37.2 °C (99 °F), pulse is 112/min, respirations are 21/min, and blood pressure is 72/50 mm Hg. Cardiac examination shows a normal S1 and S2 and a new harsh, holosystolic murmur heard best at the left sternal border. There is jugular venous distention and a right parasternal heave. The lungs are clear to auscultation. Pitting edema extends up to the knees bilaterally. An ECG shows Q waves in the inferior leads. Which of the following is the most likely cause of this patient’s hypotension?
A. Post-infarction fibrinous pericarditis
B. Ascending aortic dissection rupture
C. Interventricular septum rupture (Correct Answer)
D. Left ventricular free wall rupture
E. Left ventricular aneurysm rupture
Explanation: ***Interventricular septum rupture***
- A **harsh, holosystolic murmur** heard best at the **left sternal border** 4 days after an **acute MI (LAD occlusion with stenting)** is highly suggestive of interventricular septum rupture.
- VSR typically occurs **3-5 days post-MI** when myocardial necrosis weakens the septum, and can occur with both anterior and inferior infarctions.
- The rupture creates a **left-to-right shunt**, leading to **hypotension** (decreased systemic cardiac output), **JVD** and **right parasternal heave** (RV volume overload), and biventricular failure.
- The holosystolic murmur at the left sternal border with a palpable thrill is pathognomonic for VSR.
*Post-infarction fibrinous pericarditis*
- This would typically present with a **pericardial friction rub** and potentially pleuritic chest pain, not a holosystolic murmur.
- While it can cause pericardial effusion and tamponade leading to hypotension, the specific murmur described points away from this diagnosis.
*Ascending aortic dissection rupture*
- This would present with **sudden, severe tearing chest pain** radiating to the back and often a new **aortic regurgitation murmur** (diastolic, not systolic).
- The patient's presentation with a holosystolic murmur and recent MI points to a post-infarction mechanical complication.
*Left ventricular free wall rupture*
- This is catastrophic and typically presents with **sudden profound hypotension**, **electromechanical dissociation**, and rapid death.
- Patients usually do not survive long enough for examination findings like a new murmur to develop; they present with acute tamponade and cardiovascular collapse.
*Left ventricular aneurysm rupture*
- A true LV aneurysm is a **late complication** (weeks to months post-MI), not occurring at day 4.
- It would not typically cause a new, harsh holosystolic murmur indicative of an acute shunting process.
- Aneurysm rupture would present similarly to free wall rupture with tamponade.
Question 895: A 73-year-old man with a 50-year history of type 2 diabetes and stage 3 chronic kidney disease presents to his primary care doctor for a scheduled follow-up and routine labs. He states that he has had no real change in his health except that he feels like he has had bouts of lightheadedness and almost passing out, which resolve with sitting down. The patient does not have a history of syncope or arrhythmia. On his labs, he is found to have a hemoglobin of 11.0 g/dL. His estimated glomerular filtration rate is determined to be 45 ml/min/1.73m^2. Testing of his stool is negative for blood. Additionally, a peripheral blood smear demonstrates normochromic cells. As a result, the patient is started on erythropoietin. Which of the following likely describes the anemia?
A. Macrocytic anemia with megaloblasts
B. Microcytic anemia
C. Macrocytic anemia without megaloblasts
D. Normocytic anemia with increased reticulocyte count
E. Normocytic anemia with decreased reticulocyte count (Correct Answer)
Explanation: ***Normocytic anemia with decreased reticulocyte count***
- Chronic kidney disease often leads to **anemia of chronic disease**, which is typically **normocytic and normochromic** due to impaired erythropoietin production by the kidneys.
- A **decreased reticulocyte count** in this context indicates a blunted bone marrow response to the anemia, consistent with insufficient erythropoietin stimulation.
*Macrocytic anemia with megaloblasts*
- This is characteristic of **B12 or folate deficiency**, which would typically show **hypersegmented neutrophils** and megaloblasts on bone marrow smear, not specified here.
- The patient's **normochromic cells** on peripheral smear make macrocytic anemia with megaloblasts less likely.
*Microcytic anemia*
- **Iron deficiency anemia** or **thalassemia** typically present as microcytic anemia, characterized by small, pale red blood cells.
- The patient's **normochromic cells** on peripheral blood smear rule out microcytic anemia.
*Macrocytic anemia without megaloblasts*
- This can be seen in conditions like **alcoholism**, **liver disease**, or **hypothyroidism**, which are not indicated in this patient's presentation.
- The patient's clinical picture and laboratory findings point more directly to a different underlying cause of anemia.
*Normocytic anemia with increased reticulocyte count*
- An **increased reticulocyte count** would suggest a responsive bone marrow trying to compensate for red blood cell loss or destruction, such as in **hemolytic anemia** or acute bleeding.
- The patient's anemia is likely due to underproduction (as suggested by CKD and lack of bleeding), not increased destruction or loss.
Question 896: A 72-year-old man presents to the physician with severe lower back pain and fatigue for 3 months. The pain increases with activity. He has no history of a serious illness. He takes ibuprofen for pain relief. He does not smoke. The blood pressure is 105/65 mm Hg, the pulse is 86/min, the respirations are 16/min, and the temperature is 36.7℃ (98.1℉). The conjunctivae are pale. Palpation over the 1st lumbar vertebra shows tenderness. The heart, lung, and abdominal examination shows no abnormalities. No lymphadenopathy is palpated. The results of the laboratory studies show:
Laboratory test
Hemoglobin 9 g/dL
Mean corpuscular volume 90 μm3
Leukocyte count 5,500/mm3 with a normal differential
Platelet count 350,000/mm3
Serum
Calcium 11.5 mg/dL
Albumin 3.8 g/dL
Urea nitrogen 54 mg/dL
Creatinine 2.5 mg/dL
Lumbosacral computed tomography (CT) scan shows a low-density lesion in the 1st lumbar vertebra and several similar lesions in the pelvic bones. Which of the following is the most likely diagnosis?
A. Waldenstrom’s macroglobulinemia
B. Multiple myeloma (Correct Answer)
C. Small-cell lung carcinoma
D. Secondary hyperparathyroidism
E. Metastatic prostatic cancer
Explanation: ***Multiple myeloma***
- The patient presents with classic symptoms and lab findings, including **anemia** (Hb 9 g/dL), **hypercalcemia** (11.5 mg/dL), **acute kidney injury** (creatinine 2.5 mg/dL, BUN 54 mg/dL), and **bone lesions** (low-density lesions in vertebrae and pelvic bones), collectively known as the **CRAB criteria**.
- This constellation of findings is highly suggestive of multiple myeloma, a **plasma cell malignancy** that produces M-proteins, leading to organ damage and characteristic skeletal destruction.
*Waldenstrom’s macroglobulinemia*
- This condition is also a **B-cell lymphoma** characterized by IgM paraproteinemia, leading to hyperviscosity syndrome and lymphadenopathy.
- However, it typically does not cause **lytic bone lesions** or **hypercalcemia**, which are prominent features in this case.
*Small-cell lung carcinoma*
- While it can metastasize to bone and cause paraneoplastic syndromes like SIADH (hyponatremia) or hypercalcemia (rarely), it does not typically present with widespread **radiolucent bone lesions** as described.
- The patient has no history of smoking or respiratory symptoms, making this less likely.
*Secondary hyperparathyroidism*
- This condition is caused by **chronic kidney disease** leading to low calcium or vitamin D levels, resulting in elevated PTH.
- It would present with **low or normal calcium** (not hypercalcemia) and elevated PTH levels, and bone lesions would be due to osteitis fibrosa cystica, which is distinct from the lytic lesions seen here.
*Metastatic prostatic cancer*
- Prostate cancer typically causes **osteoblastic (sclerotic) bone lesions**, appearing as increased density on imaging, rather than the low-density, **lytic lesions** described in the CT scan.
- While it can cause back pain and bone metastases, the nature of the bone lesions is inconsistent with prostatic cancer.
Question 897: A 21-year-old woman presents with malaise, joint pains, and a rash that worsens with sun exposure. Examination reveals an erythematous facial rash with edema. Her complete blood count shows lymphocytopenia. In addition to the most likely diagnosis, which of the following disorders can also cause lymphocytopenia? I. HIV II. Autoimmune disorders III. Tuberculosis IV. Lymphoma V. Hypersplenism
A. I, II, IV, V (Correct Answer)
B. III, V
C. I, II, III
D. III, IV
E. I, III, V
Explanation: ***I, II, IV, V***
- The patient's symptoms (malar rash, photosensitivity, joint pains, malaise, lymphocytopenia) are highly suggestive of **Systemic Lupus Erythematosus (SLE)**, an **autoimmune disorder** (II).
- **HIV (I)** directly destroys CD4+ T lymphocytes, causing profound lymphocytopenia.
- **Autoimmune disorders (II)** like SLE, rheumatoid arthritis, and Sjögren's syndrome cause lymphocytopenia via antibody-mediated destruction.
- **Lymphoma (IV)** causes lymphocytopenia through bone marrow infiltration, increased consumption, or sequestration.
- **Hypersplenism (V)** causes sequestration and destruction of lymphocytes along with other blood cells.
- While disseminated tuberculosis can occasionally cause lymphocytopenia, **chronic tuberculosis typically causes lymphocytosis**, making it a less reliable answer.
*III, V*
- This option is incomplete as it correctly identifies hypersplenism but omits HIV, autoimmune disorders, and lymphoma, which are more consistent causes of lymphocytopenia.
- **Tuberculosis (III)** in its chronic form typically causes **lymphocytosis**, not lymphocytopenia, though severe disseminated disease may cause lymphocytopenia.
*I, II, III*
- While HIV and autoimmune disorders are correct, including **tuberculosis (III)** is problematic as chronic TB typically causes **lymphocytosis**, not lymphocytopenia.
- This option omits lymphoma and hypersplenism, both important causes.
*III, IV*
- **Tuberculosis (III)** in chronic form typically causes **lymphocytosis** rather than lymphocytopenia, making it an unreliable choice.
- Although **lymphoma (IV)** is correct, this option excludes HIV, autoimmune disorders, and hypersplenism.
*I, III, V*
- **HIV (I)** and **hypersplenism (V)** are valid causes, but **tuberculosis (III)** is inconsistent as chronic TB typically causes lymphocytosis.
- This option incorrectly includes tuberculosis while omitting autoimmune disorders and lymphoma.
Question 898: A 62-year-old man is brought to the emergency department by his wife for high blood pressure readings at home. He is asymptomatic. He has a history of hypertension and hyperlipidemia for which he takes atenolol and atorvastatin, however, his wife reports that he recently ran out of atenolol and has not been able to refill it due to lack of health insurance. His temperature is 36.8°C (98.2°F), the pulse 65/min, the respiratory rate 22/min, and the blood pressure 201/139 mm Hg. He has no papilledema on fundoscopic examination. A CT scan shows no evidence of intracranial hemorrhage or ischemia. Of the following, what is the next best step?
A. Start or restart low-dose medication to reduce blood pressure gradually over the next 24–48 hours (Correct Answer)
B. Admit him to the ICU and start intravenous medication to reduce blood pressure by 25% in the first 4 hours
C. Start high-dose medication to bring his blood pressure to under 140/90 within 24 hours
D. Admit him to the ICU and start intravenous medication to reduce blood pressure by 10% in the first hour
E. Start or restart low-dose medication to reduce blood pressure rapidly over the next 24–48 hours
Explanation: ***Start or restart low-dose medication to reduce blood pressure gradually over the next 24–48 hours***
- This patient presents with **severe asymptomatic hypertension** (hypertensive urgency), indicated by a blood pressure of **201/139 mm Hg** without signs of **acute end-organ damage** (no papilledema, no focal neurological deficits).
- The goal in hypertensive urgency is a gradual reduction in blood pressure over 24-48 hours using oral medications to prevent **hypoperfusion** of vital organs, especially given the rapid withdrawal of his **beta-blocker (atenolol)**.
*Admit him to the ICU and start intravenous medication to reduce blood pressure by 25% in the first 4 hours*
- This approach is reserved for **hypertensive emergencies**, where there is evidence of **acute end-organ damage** (e.g., papilledema, acute kidney injury, encephalopathy, myocardial ischemia).
- The patient is **asymptomatic** with no signs of end-organ damage, making aggressive intravenous therapy inappropriate and potentially harmful due to the risk of **ischemia** from rapid BP reduction.
*Start high-dose medication to bring his blood pressure to under 140/90 within 24 hours*
- While target blood pressure is generally <140/90 mm Hg, aiming for such a rapid, specific reduction with high-dose medication in asymptomatic hypertension can cause **hypoperfusion** and potentially **cerebral ischemia**.
- The goal for hypertensive urgency is a more modest and gradual reduction to about 160/100 mmHg over 24-48 hours, followed by a slower reduction to target levels.
*Admit him to the ICU and start intravenous medication to reduce blood pressure by 10% in the first hour*
- This is also an intervention typically considered for **hypertensive emergencies**, especially in specific scenarios like **aortic dissection** or **intracranial hemorrhage**, where rapid, controlled BP lowering is critical.
- For **asymptomatic hypertension**, such a rapid reduction, even if less aggressive than 25%, is still too fast and carries risks without the immediate benefit of preventing acute organ damage.
*Start or restart low-dose medication to reduce blood pressure rapidly over the next 24–48 hours*
- While low-dose medication is appropriate, the term "rapidly" is concerning, as **rapid reductions** in blood pressure for asymptomatic hypertensive urgency can lead to **ischemia**, particularly in the brain, heart, or kidneys.
- The reduction should be **gradual** to allow for autoregulation and avoid complications, distinguishing it from this option's emphasis on speed.
Question 899: A 65-year-old woman comes to clinic complaining of pain with chewing solid foods. She reports that she has been feeling unwell lately, with pains in her shoulders and hips, and she has lost five pounds in the past few months. Her vital signs are T 39C, RR 18 breaths/min, HR 95 bpm, BP 120/65 mmHg. When you ask her to stand from her chair to get on the exam table she moves stiffly but displays preserved proximal muscle strength. Another potential symptom or sign of this disease could be:
A. Blindness (Correct Answer)
B. Violaceous rash across the eyelids
C. Thickened, tight skin on the fingers
D. Hemoptysis
E. Easily sunburned on face and hands
Explanation: ***Blindness***
- This patient presents with symptoms highly suggestive of **giant cell arteritis (GCA)**, including **jaw claudication (pain with chewing)**, **proximal muscle pain (polymyalgia rheumatica-like symptoms)**, **low-grade fever**, and **weight loss**.
- **Amaurosis fugax (transient monocular vision loss)** or **permanent blindness** due to **ischemic optic neuropathy** is a feared complication of untreated GCA, caused by inflammation of the **ophthalmic artery**.
*Violaceous rash across the eyelids*
- A **heliotrope rash** (violaceous discoloration of the eyelids) is characteristic of **dermatomyositis**, which is not supported by the patient's other symptoms.
- While dermatomyositis can cause muscle weakness, it typically presents with **proximal muscle weakness** rather than the pain and stiffness described.
*Thickened, tight skin on the fingers*
- **Sclerodactyly (thickened, tight skin on the fingers)** is a hallmark of **scleroderma (systemic sclerosis)**, which is not indicated by the patient's symptoms.
- Scleroderma often involves **Raynaud's phenomenon**, **esophageal dysmotility**, and **pulmonary fibrosis**.
*Hemoptysis*
- **Hemoptysis (coughing up blood)** is not a typical symptom of giant cell arteritis.
- It could be a symptom of various respiratory or systemic conditions, such as **pulmonary embolism**, **bronchiectasis**, or **granulomatosis with polyangiitis (GPA)**, none of which fit the overall clinical picture.
*Easily sunburned on face and hands*
- **Photosensitivity** (being easily sunburned) is a common symptom of **systemic lupus erythematosus (SLE)**, which is not suggested by the patient's primary complaints.
- SLE presents with a wide range of symptoms including **arthritis**, **malar rash**, and **nephritis**.
Question 900: A 48-year-old woman presents to her primary care physician with the complaints of persistent fatigue, dizziness, and weight loss for the past 3 months. She has hypothyroidism for 15 years and takes thyroxine replacement. Her blood pressure is 90/60 mm Hg in a supine position and 65/40 mm Hg while sitting, temperature is 36.8°C (98.2°F) and pulse is 75/min. On physical examination, there is a mild increase in thyroid size, with a rubbery consistency. Her skin shows diffuse hyperpigmentation, more pronounced in the oral mucosa and palmar creases. The morning serum cortisol test is found to be 3 µg/dL. Which of the following is the best next step in this case?
A. Serum adrenocorticotropic hormone (ACTH)
B. Plasma aldosterone
C. 21-hydroxylase antibodies
D. Adrenal imaging
E. Adrenocorticotropic hormone (ACTH) stimulation test (Correct Answer)
Explanation: ***Adrenocorticotropic hormone (ACTH) stimulation test***
- The patient's symptoms (fatigue, dizziness, weight loss, orthostatic hypotension, hyperpigmentation) and a very low morning cortisol level (3 µg/dL) are highly suggestive of **adrenal insufficiency**.
- An **ACTH stimulation test** (cosyntropin test) is the gold standard for officially diagnosing adrenal insufficiency by measuring the adrenal glands' response to synthetic ACTH.
*Serum adrenocorticotropic hormone (ACTH)*
- While measuring **ACTH levels** is crucial to differentiate between primary and secondary adrenal insufficiency, it should be done after confirming adrenal insufficiency with an ACTH stimulation test.
- A high ACTH level in conjunction with low cortisol confirms **primary adrenal insufficiency**, whereas a low ACTH indicates **secondary adrenal insufficiency**.
*Plasma aldosterone*
- **Aldosterone measurements** are useful in evaluating primary adrenal insufficiency, as it can be affected in this condition (leading to salt wasting).
- However, the primary concern is cortisol deficiency, and confirming adrenal insufficiency takes precedence for immediate management and diagnosis.
*21-hydroxylase antibodies*
- **21-hydroxylase antibodies** are markers for **autoimmune adrenal insufficiency**, which is the most common cause of primary adrenal insufficiency.
- While relevant for etiology, this test is performed after the diagnosis of adrenal insufficiency has been established by the ACTH stimulation test.
*Adrenal imaging*
- **Adrenal imaging** (e.g., CT or MRI) is typically performed to investigate the cause of adrenal insufficiency, especially after biochemical confirmation.
- It helps in identifying adrenal masses, atrophy, or hemorrhage, but it is not the initial diagnostic step for functional assessment.
