A 67-year-old female presents to her primary care physician complaining of headaches in her left temple and scalp area, neck stiffness, occasional blurred vision, and pain in her jaw when chewing. The appropriate medical therapy is initiated, and a subsequent biopsy of the temporal artery reveals arteritis. Five months later, the patient returns to her physician with a complaint of weakness, leading to difficulty climbing stairs, rising from a chair, and combing her hair. The patient states that this weakness has worsened gradually over the last 2 months. She reports that her headaches, jaw pain, and visual disturbances have resolved. Physical examination is significant for 4/5 strength for both hip flexion/extension as well as shoulder flexion/extension/abduction. Initial laboratory work-up reveals ESR and creatine kinase levels within normal limits. Which of the following is the most likely diagnosis in this patient's current presentation?
Q922
A 68-year-old male visits his primary care physician after an episode of syncope during a tennis match. He reports exertional dyspnea with mild substernal chest pain. On physical exam a systolic crescendo-decrescendo murmur is heard best at the right 2nd intercostal space. This murmur was not heard at the patient's last appointment six months ago. Which of the following would most support a diagnosis of aortic stenosis?
Q923
A 43-year-old woman comes to the physician because of a 2-month history of chest pain. She describes the pain as intermittent and burning-like. She states that she has tried using proton pump inhibitors but has had no relief of her symptoms. She has had a 5-kg (11-lb) weight loss over the past 2 months. Her temperature is 36.7°C (98.1°F), pulse is 75/min, and blood pressure is 150/80 mm Hg. Examination shows tightness of the skin of the fingers; there are small nonhealing, nonpurulent ulcers over thickened skin on the fingertips. Fine inspiratory crackles are heard at both lung bases. There is mild tenderness to palpation of the epigastrium. Which of the following is most likely associated with her diagnosis?
Q924
A 23-year-old man presents with increasing neck pain for several months that does not improve with nonsteroidal anti-inflammatory drugs. The patient says he has had neck pain ever since he was involved in a motor vehicle accident 10 months ago. For the last 2 weeks, he says he has also noticed weakness and numbness in his hands and has difficulty gripping objects. Physical examination reveals a thermal injury that he says he got while holding a hot cup of coffee a week ago when he could not feel the warmth of the coffee mug. Strength is 4/5 bilaterally during elbow flexion and extension and wrist extension. He also has exaggerated deep tendon reflexes bilaterally and decreased sensation symmetrically on the dorsal and ventral surface of both forearms and hands. Which of the following additional findings would you expect to find in this patient?
Q925
A 62-year-old woman presents to the office because she has noticed yellowish bumps and patches on her elbows and knees that seem to come and go. Recently she noticed the same yellow bumps on her eyelids. She is a new patient and reports that she is otherwise healthy but did not have insurance until recently so she has not been to the doctor in over 8 years. Past medical history is significant for occasional headaches that she treats with aspirin. She used to smoke a pack a day for the last 20 years but recently quit. Her father died of a heart attack at the age of 55 years and her mother had a stroke at 64 and lives in a nursing home. Her blood pressure is 135/87 mm Hg, the heart rate is 95/min, the respiratory rate is 12/min, and the temperature is 37.0°C (98.6°F). On physical exam, she has multiple tan-yellow, firm papules on her knees and elbows. The papules around her eyes are smaller and soft. You discuss the likely cause of the bumps and explain that you will need to order additional tests. What test should you perform?
Q926
A 55-year-old black male otherwise healthy presents for a yearly physical. No significant past medical history. Current medications are a multivitamin and rosuvastatin 20 mg orally daily. Vitals are temperature 37°C (98.6°F), blood pressure 155/75 mm Hg, pulse 95/min, respirations 16/min, and oxygen saturation 99% on room air. On physical examination, the patient is alert and cooperative. The cardiac exam is significant for a high-pitched diastolic murmur loudest at the left sternal border. Peripheral pulses are bounding and prominent followed by a quick collapse on palpation. Lungs are clear to auscultation. The abdomen is soft and nontender. Chest X-ray is normal. ECG is significant for left axis deviation and broad bifid P-waves in lead II. Transthoracic echocardiography shows a bicuspid aortic valve, severe aortic regurgitation, left atrial enlargement and left ventricular dilatation and hypertrophy. Left ventricular ejection fraction is 45%. Which of the following is the best course of treatment for this patient?
Q927
A 70-year-old man presented to the emergency department complaining of left-sided weakness for the past 5 hours. Past medical history is significant for a previous ischemic stroke involving the right posterior cerebral artery and left-sided homonymous hemianopia. He also has a history of type-II diabetes mellitus and hypertension. He takes an 81 mg aspirin, amlodipine, atorvastatin, and a vitamin supplement with calcium and vitamin D. A brain MRI reveals a small atrophic area of the left occipital lobe and a new acute infarct involving the territory of the right middle cerebral artery. Electrocardiogram (ECG) shows normal sinus rhythm. An echocardiogram reveals mild left ventricular hypertrophy with an ejection fraction of 55%. Doppler ultrasound of the carotid arteries reveals no significant narrowing. What is the next step in the management to prevent future risks of stroke?
Q928
A 45-year-old woman presents to the clinic for a routine examination. She has a chronic history of systemic lupus erythematosus, diagnosed at age 27. Medications include hydroxychloroquine and low-dose prednisone. She has had no recent flare-ups and is compliant with her medication. Anticardiolipin and anti-beta-2 glycoprotein-1 antibodies are negative, and she has had no history of thrombi or emboli. Physical examination is normal except for mild bilateral tenderness and swelling of the knees. Creatinine and GFR are normal. Which of the following is the next best step in management to monitor disease activity?
Q929
A 65-year-old man is brought to the emergency department by his wife because of progressive lethargy and confusion during the past 2 days. His wife reports that he has been complaining of nausea and increased urination for the past 5 days. He also developed a cough 1 week ago. He has a history of a cerebrovascular accident 3 years ago and was diagnosed with hypertension 10 years ago. Current medications include lisinopril and aspirin. His temperature is 38.5°C (101.3°F), pulse is 114/min, respirations are 15/min, and blood pressure is 108/75 mm Hg. He is somnolent and oriented only to person. Examination shows dry mucous membranes and decreased skin turgor. Crackles are heard at the left lung base. The remainder of the physical examination shows no abnormalities. Which of the following is the most appropriate next step in management?
Q930
A 25-year-old female presents with recent muscle weakness, fatigue, and constipation. Physical examination reveals a bradycardic patient with cool, dry skin. Which of the following lab values would be most likely to be present with this patient's presentation?
Cardiology US Medical PG Practice Questions and MCQs
Question 921: A 67-year-old female presents to her primary care physician complaining of headaches in her left temple and scalp area, neck stiffness, occasional blurred vision, and pain in her jaw when chewing. The appropriate medical therapy is initiated, and a subsequent biopsy of the temporal artery reveals arteritis. Five months later, the patient returns to her physician with a complaint of weakness, leading to difficulty climbing stairs, rising from a chair, and combing her hair. The patient states that this weakness has worsened gradually over the last 2 months. She reports that her headaches, jaw pain, and visual disturbances have resolved. Physical examination is significant for 4/5 strength for both hip flexion/extension as well as shoulder flexion/extension/abduction. Initial laboratory work-up reveals ESR and creatine kinase levels within normal limits. Which of the following is the most likely diagnosis in this patient's current presentation?
A. Polymyalgia rheumatica
B. Mononeuritis multiplex
C. Polymyositis
D. Drug-induced myopathy (Correct Answer)
E. Dermatomyositis
Explanation: ***Drug-induced myopathy***
* **Glucocorticoid-induced myopathy** is a common consequence of long-term steroid therapy, often used in conditions like **giant cell arteritis**.
* It typically presents with **proximal muscle weakness** (difficulty rising from a chair, climbing stairs, combing hair) and **normal creatine kinase (CK) levels**, differentiating it from inflammatory myopathies.
*Polymyalgia rheumatica*
* While often associated with **giant cell arteritis**, PMR primarily causes **pain and stiffness** in the shoulders, neck, and hips, rather than significant muscle weakness.
* Patients with PMR exhibit **elevated ESR**, which is normal in this case.
*Mononeuritis multiplex*
* This condition involves **damage to two or more peripheral nerves**, typically presenting with **asymmetric weakness** and sensory deficits in specific nerve distributions.
* It is not characterized by the **symmetrical proximal weakness** seen in this patient.
*Polymyositis*
* This is an **inflammatory myopathy** characterized by **proximal muscle weakness** and **elevated creatine kinase (CK) levels**.
* The patient's **normal CK levels** and the history of steroid use make drug-induced myopathy more likely.
*Dermatomyositis*
* Similar to polymyositis, dermatomyositis is an **inflammatory myopathy** causing **proximal muscle weakness** and **elevated CK**.
* It is distinguished by characteristic **skin rashes** (e.g., heliotrope rash, Gottron papules), which are absent in this patient.
Question 922: A 68-year-old male visits his primary care physician after an episode of syncope during a tennis match. He reports exertional dyspnea with mild substernal chest pain. On physical exam a systolic crescendo-decrescendo murmur is heard best at the right 2nd intercostal space. This murmur was not heard at the patient's last appointment six months ago. Which of the following would most support a diagnosis of aortic stenosis?
A. Asymmetric ventricular hypertrophy
B. Murmur radiates to axilla
C. Murmur radiates to carotid arteries bilaterally (Correct Answer)
D. Double pulsation of the carotid pulse
E. Presence of S3
Explanation: ***Murmur radiates to carotid arteries bilaterally***
- The **systolic crescendo-decrescendo murmur** heard best at the right 2nd intercostal space, along with radiation to the carotid arteries, is a classic finding in **aortic stenosis**.
- This radiation pattern occurs because the turbulent blood flow through the narrowed aortic valve propagates into the great vessels of the neck.
*Asymmetric ventricular hypertrophy*
- **Asymmetric ventricular hypertrophy** (specifically of the interventricular septum) is characteristic of **hypertrophic obstructive cardiomyopathy (HOCM)**, not typically seen in aortic stenosis.
- While left ventricular hypertrophy can occur in aortic stenosis due to chronic pressure overload, it is usually concentric and symmetrical, rather than asymmetric.
*Murmur radiates to axilla*
- A murmur radiating to the **axilla** is a hallmark feature of **mitral regurgitation**, due to the regurgitant jet targeting this area.
- Aortic stenosis murmurs primarily radiate superiorly to the neck and sometimes to the apex, not the axilla.
*Double pulsation of the carotid pulse*
- A **double pulsation** (pulsus bisferiens) of the carotid pulse is often associated with **aortic regurgitation** complicating **hypertrophic cardiomyopathy** or **severe aortic stenosis** with significant regurgitation, resulting in a bifid pulse.
- While it can be present, it is not as specific a diagnostic indicator for pure aortic stenosis as the typical radiation pattern of the murmur.
*Presence of S3*
- The presence of an **S3 gallop** typically indicates **left ventricular failure** due to volume overload, commonly seen in conditions like dilated cardiomyopathy or severe mitral/aortic regurgitation.
- Although severe aortic stenosis can lead to heart failure, S3 is not a direct or specific finding for the *diagnosis* of aortic stenosis itself; it suggests a complication.
Question 923: A 43-year-old woman comes to the physician because of a 2-month history of chest pain. She describes the pain as intermittent and burning-like. She states that she has tried using proton pump inhibitors but has had no relief of her symptoms. She has had a 5-kg (11-lb) weight loss over the past 2 months. Her temperature is 36.7°C (98.1°F), pulse is 75/min, and blood pressure is 150/80 mm Hg. Examination shows tightness of the skin of the fingers; there are small nonhealing, nonpurulent ulcers over thickened skin on the fingertips. Fine inspiratory crackles are heard at both lung bases. There is mild tenderness to palpation of the epigastrium. Which of the following is most likely associated with her diagnosis?
A. Anti-Ro/SSA and anti-La/SSB antibodies
B. Anti-histone antibodies
C. Anti-topoisomerase antibodies (Correct Answer)
D. Anti-mitochondrial antibodies
E. c-ANCA
Explanation: ***Anti-topoisomerase antibodies***
- The patient's symptoms, including **skin tightening on fingers**, **non-healing fingertip ulcers**, and **inspiratory crackles (suggesting interstitial lung disease)**, are highly indicative of **systemic sclerosis (scleroderma)**, particularly the diffuse cutaneous form.
- **Anti-topoisomerase I (anti-Scl-70) antibodies** are strongly associated with **diffuse systemic sclerosis** and are often found in patients with significant organ involvement, including pulmonary fibrosis.
*Anti-Ro/SSA and anti-La/SSB antibodies*
- These antibodies are typically associated with **Sjogren's syndrome**, an autoimmune disorder primarily affecting exocrine glands.
- While Sjogren's can present with dryness and joint pain, it does not typically cause **skin thickening**, **digital ulcers**, or the specific type of lung involvement seen here.
*Anti-histone antibodies*
- These are the hallmark antibodies for **drug-induced lupus**, which presents with symptoms similar to systemic lupus erythematosus (SLE) but resolves upon discontinuation of the causative drug.
- The patient's symptoms are not consistent with lupus, and there is no mention of drug exposure.
*Anti-mitochondrial antibodies*
- These antibodies are highly specific for **primary biliary cholangitis (PBC)**, a chronic liver disease affecting the bile ducts.
- While PBC can be associated with other autoimmune conditions, the primary symptoms presented in the patient (skin thickening, digital ulcers, pulmonary findings) are not characteristic of PBC.
*c-ANCA*
- **Cytoplasmic anti-neutrophil cytoplasmic antibodies (c-ANCA)** are primarily associated with **Granulomatosis with Polyangiitis (Wegener's)**, an autoimmune vasculitis affecting small- and medium-sized vessels.
- This condition presents with upper and lower respiratory tract involvement and glomerulonephritis, which differs from the patient's presentation of skin thickening and specific lung findings.
Question 924: A 23-year-old man presents with increasing neck pain for several months that does not improve with nonsteroidal anti-inflammatory drugs. The patient says he has had neck pain ever since he was involved in a motor vehicle accident 10 months ago. For the last 2 weeks, he says he has also noticed weakness and numbness in his hands and has difficulty gripping objects. Physical examination reveals a thermal injury that he says he got while holding a hot cup of coffee a week ago when he could not feel the warmth of the coffee mug. Strength is 4/5 bilaterally during elbow flexion and extension and wrist extension. He also has exaggerated deep tendon reflexes bilaterally and decreased sensation symmetrically on the dorsal and ventral surface of both forearms and hands. Which of the following additional findings would you expect to find in this patient?
A. A cavitation in the cervical spinal cord (Correct Answer)
B. Bilateral carpal tunnel syndrome
C. Fusion of cervical vertebrae
D. Cervical spinal epidural abscess
E. Hypoplasia of the cerebellar vermis
Explanation: ***A cavitation in the cervical spinal cord***
- The patient's symptoms of **chronic neck pain**, **weakness and numbness in the hands**, **loss of pain and temperature sensation** (thermal injury from hot coffee), and **exaggerated deep tendon reflexes** ("upper motor neuron signs") are classic for **syringomyelia**, which involves a cavitation (syrinx) within the spinal cord.
- The **motor vehicle accident (MVA) 10 months prior** could have led to a spinal cord injury, which is a common cause of secondary syringomyelia due to altered CSF flow.
*Bilateral carpal tunnel syndrome*
- While carpal tunnel syndrome causes **numbness and weakness in the hands**, it typically affects the **median nerve distribution** (thumb, index, middle, and radial half of ring finger) and does not explain the **thermal injury** due to loss of pain/temperature sensation or the **exaggerated deep tendon reflexes** (upper motor neuron signs).
- Carpal tunnel syndrome primarily presents with **lower motor neuron signs** in the affected nerve distribution, not generalized hyperreflexia.
*Fusion of cervical vertebrae*
- **Cervical vertebral fusion** (e.g., Klippel-Feil syndrome) can cause neck pain and restricted range of motion but does not typically explain the acute onset of **sensory deficits (loss of pain/temperature)**, **weakness**, and **hyperreflexia** seen in this patient.
- While some congenital fusions can predispose to spinal cord compression over time, the constellation of symptoms points more directly to a developing syrinx.
*Cervical spinal epidural abscess*
- An **epidural abscess** would likely present with more acute, severe, and rapidly progressive symptoms, including **fever**, **severe localized back/neck pain**, and signs of **infection**, none of which are mentioned here.
- While it can cause neurological deficits, the subacute onset and specific sensory loss pattern are less typical for an abscess.
*Hypoplasia of the cerebellar vermis*
- **Cerebellar vermis hypoplasia** (e.g., Dandy-Walker malformation) primarily causes **ataxia**, **truncal instability**, and other **cerebellar signs**, often associated with hydrocephalus.
- It does not explain the **localized cervical pain**, **hand weakness/numbness**, **thermal sensory loss**, and **upper motor neuron signs** in the limbs presented in this case.
Question 925: A 62-year-old woman presents to the office because she has noticed yellowish bumps and patches on her elbows and knees that seem to come and go. Recently she noticed the same yellow bumps on her eyelids. She is a new patient and reports that she is otherwise healthy but did not have insurance until recently so she has not been to the doctor in over 8 years. Past medical history is significant for occasional headaches that she treats with aspirin. She used to smoke a pack a day for the last 20 years but recently quit. Her father died of a heart attack at the age of 55 years and her mother had a stroke at 64 and lives in a nursing home. Her blood pressure is 135/87 mm Hg, the heart rate is 95/min, the respiratory rate is 12/min, and the temperature is 37.0°C (98.6°F). On physical exam, she has multiple tan-yellow, firm papules on her knees and elbows. The papules around her eyes are smaller and soft. You discuss the likely cause of the bumps and explain that you will need to order additional tests. What test should you perform?
A. Biopsy
B. Lipid panel (Correct Answer)
C. Celiac panel
D. PET scan
E. Erythrocyte sedimentation rate (ESR)
Explanation: ***Lipid panel***
- The yellowish bumps on elbows and knees (**tuberous/eruptive xanthomas**) and eyelids (**xanthelasma**) are pathognomonic for **dyslipidemia** (hypercholesterolemia or hypertriglyceridemia)
- A **lipid panel** is the appropriate first-line test to measure total cholesterol, LDL, HDL, and triglycerides
- Given her strong family history of premature cardiovascular disease (father died at 55 from MI), smoking history, and 8 years without medical care, screening for dyslipidemia is critical
- Results will guide treatment decisions (statin therapy, lifestyle modifications)
*Biopsy*
- While biopsy could confirm lipid deposits histologically, it is unnecessarily invasive for classic xanthoma presentation
- Reserved for atypical lesions when diagnosis is uncertain after initial blood work
*Celiac panel*
- Tests for celiac disease (anti-tissue transglutaminase antibodies)
- No clinical indicators present (no diarrhea, malabsorption, weight loss, or GI symptoms)
*PET scan*
- Used primarily for cancer staging, neurological conditions, or cardiac viability assessment
- Not indicated for evaluation of cutaneous lipid deposits
- Expensive and exposes patient to unnecessary radiation
*Erythrocyte sedimentation rate (ESR)*
- Non-specific inflammatory marker for infections, autoimmune diseases, or malignancy
- Patient's presentation is characteristic of metabolic/lipid disorder, not inflammatory disease
- Would not provide diagnostic information for xanthomas
Question 926: A 55-year-old black male otherwise healthy presents for a yearly physical. No significant past medical history. Current medications are a multivitamin and rosuvastatin 20 mg orally daily. Vitals are temperature 37°C (98.6°F), blood pressure 155/75 mm Hg, pulse 95/min, respirations 16/min, and oxygen saturation 99% on room air. On physical examination, the patient is alert and cooperative. The cardiac exam is significant for a high-pitched diastolic murmur loudest at the left sternal border. Peripheral pulses are bounding and prominent followed by a quick collapse on palpation. Lungs are clear to auscultation. The abdomen is soft and nontender. Chest X-ray is normal. ECG is significant for left axis deviation and broad bifid P-waves in lead II. Transthoracic echocardiography shows a bicuspid aortic valve, severe aortic regurgitation, left atrial enlargement and left ventricular dilatation and hypertrophy. Left ventricular ejection fraction is 45%. Which of the following is the best course of treatment for this patient?
A. Outpatient management on nifedipine 45 mg orally daily
B. Reassurance and recommend long-term follow-up with outpatient cardiology for clinical surveillance with regular echocardiography
C. Outpatient management on enalapril 10 mg orally twice daily
D. Admit to hospital for aortic valve replacement (Correct Answer)
E. Administer dobutamine and nitroprusside
Explanation: ***Admit to hospital for aortic valve replacement***
- The patient presents with **severe aortic regurgitation** (AR) as evidenced by the high-pitched diastolic murmur, bounding peripheral pulses (Corrigan's pulse), and echocardiographic findings of **left atrial enlargement**, **left ventricular dilatation** and **hypertrophy**, and a **reduced left ventricular ejection fraction (LVEF) of 45%**.
- Current guidelines recommend **aortic valve replacement (AVR)** for patients with severe AR who are symptomatic or have evidence of **LV dysfunction (LVEF < 50%)**, even if asymptomatic.
*Outpatient management on nifedipine 45 mg orally daily*
- **Nifedipine**, a dihydropyridine calcium channel blocker, is primarily used for **hypertension** and **angina**.
- It is **not indicated** as a primary treatment for severe aortic regurgitation with LV dysfunction and would not address the underlying valve pathology.
*Reassurance and recommend long-term follow-up with outpatient cardiology for clinical surveillance with regular echocardiography*
- This approach is appropriate for **mild to moderate asymptomatic AR** with preserved LV function.
- Given the patient's **severe AR** and **depressed LVEF (45%)**, active intervention with AVR is necessary, not just surveillance.
*Outpatient management on enalapril 10 mg orally twice daily*
- **Enalapril**, an ACE inhibitor, is beneficial for patients with **hypertension** and **heart failure with reduced ejection fraction**.
- While it may help manage the patient's elevated blood pressure and provide afterload reduction, it does **not address the severe aortic regurgitation** and is not a substitute for valve replacement in this situation.
*Administer dobutamine and nitroprusside*
- **Dobutamine** is an inotropic agent used to increase cardiac contractility, typically in **acute decompensated heart failure** or **cardiogenic shock**.
- **Nitroprusside** is a potent vasodilator used in **hypertensive emergencies** or to reduce afterload in acute heart failure; neither is a long-term solution for severe AR with chronic LV dysfunction requiring valve replacement.
Question 927: A 70-year-old man presented to the emergency department complaining of left-sided weakness for the past 5 hours. Past medical history is significant for a previous ischemic stroke involving the right posterior cerebral artery and left-sided homonymous hemianopia. He also has a history of type-II diabetes mellitus and hypertension. He takes an 81 mg aspirin, amlodipine, atorvastatin, and a vitamin supplement with calcium and vitamin D. A brain MRI reveals a small atrophic area of the left occipital lobe and a new acute infarct involving the territory of the right middle cerebral artery. Electrocardiogram (ECG) shows normal sinus rhythm. An echocardiogram reveals mild left ventricular hypertrophy with an ejection fraction of 55%. Doppler ultrasound of the carotid arteries reveals no significant narrowing. What is the next step in the management to prevent future risks of stroke?
A. Add dipyridamole (Correct Answer)
B. Add warfarin
C. Administer tPA
D. Increase aspirin to 325 mg
E. Stop aspirin and start warfarin
Explanation: ***Add dipyridamole***
- This patient has experienced a **recurrent ischemic stroke while on aspirin monotherapy**, indicating aspirin failure for secondary prevention.
- **Dual antiplatelet therapy** with aspirin plus extended-release **dipyridamole** is a guideline-supported option for secondary prevention of non-cardioembolic ischemic stroke.
- The **ESPS-2 and ESPRIT trials** demonstrated that aspirin-dipyridamole combination reduces recurrent stroke risk compared to aspirin alone.
- **Note**: Current guidelines also support switching to clopidogrel or short-term dual therapy with aspirin-clopidogrel as alternative strategies, though clopidogrel is not offered as an option here.
*Add warfarin*
- **Warfarin** is an anticoagulant indicated for **cardioembolic stroke prevention**, particularly in patients with atrial fibrillation or other cardiac sources of embolism.
- This patient has **normal sinus rhythm on ECG**, **no atrial fibrillation**, and a preserved ejection fraction (55%) with only mild LVH on echocardiogram.
- The stroke mechanism appears to be **non-cardioembolic** (likely atherothrombotic or small vessel disease), making anticoagulation with warfarin inappropriate.
*Administer tPA*
- **Tissue plasminogen activator (tPA)** is an **acute thrombolytic therapy** for ischemic stroke, effective only within a narrow therapeutic window.
- The standard window is **3-4.5 hours from symptom onset** in eligible patients.
- This patient presented **5 hours after symptom onset**, placing him beyond the approved time window for tPA administration.
*Increase aspirin to 325 mg*
- There is **no evidence** that higher-dose aspirin (325 mg) is superior to low-dose aspirin (81 mg) for long-term secondary stroke prevention.
- The **2021 AHA/ASA Guidelines** recommend aspirin doses of 50-325 mg daily, with lower doses (75-100 mg) preferred due to similar efficacy and better GI tolerability.
- For patients with recurrent stroke on aspirin, **switching to or adding another antiplatelet agent** is more appropriate than simply increasing the aspirin dose.
*Stop aspirin and start warfarin*
- Switching to warfarin is **inappropriate** in this non-cardioembolic stroke context, as there is no identified cardiac source requiring anticoagulation.
- This approach would **increase bleeding risk** without providing superior stroke prevention compared to appropriate antiplatelet therapy.
- Warfarin is reserved for cardioembolic stroke prevention (e.g., atrial fibrillation, mechanical heart valves, left ventricular thrombus).
Question 928: A 45-year-old woman presents to the clinic for a routine examination. She has a chronic history of systemic lupus erythematosus, diagnosed at age 27. Medications include hydroxychloroquine and low-dose prednisone. She has had no recent flare-ups and is compliant with her medication. Anticardiolipin and anti-beta-2 glycoprotein-1 antibodies are negative, and she has had no history of thrombi or emboli. Physical examination is normal except for mild bilateral tenderness and swelling of the knees. Creatinine and GFR are normal. Which of the following is the next best step in management to monitor disease activity?
A. Anti-Smith antibody levels
B. Anti-dsDNA antibody levels (Correct Answer)
C. Urinalysis and renal biopsy
D. Reduce dosage and taper off hydroxychloroquine
E. Arthrocentesis and synovial fluid analysis
Explanation: ***Anti-dsDNA antibody levels***
- **Anti-dsDNA antibodies** correlate well with **disease activity** in SLE, especially with **lupus nephritis**, making them a useful marker for monitoring.
- While her GFR is normal now, monitoring these antibodies can help detect early changes or increased risk of renal involvement.
*Anti-Smith antibody levels*
- **Anti-Smith antibodies** are highly specific for SLE but do not typically fluctuate with disease activity, so they are not useful for monitoring.
- They are primarily used for diagnosis rather than follow-up.
*Urinalysis and renal biopsy*
- A **renal biopsy** is an invasive procedure and is not indicated at this time given her normal creatinine and GFR, and reported absence of recent flare-ups.
- While **urinalysis** is important for monitoring, it is not the *next best step* to broadly assess systemic disease activity, and the question asks for monitoring disease activity, not just kidney function.
*Reduce dosage and taper off hydroxychloroquine*
- **Hydroxychloroquine** is a cornerstone of SLE management, even in quiescent disease, to prevent flares and organ damage.
- Reducing its dosage without evidence of sustained remission or adverse effects is generally not recommended and could lead to a flare.
*Arthrocentesis and synovial fluid analysis*
- **Arthrocentesis** is a diagnostic procedure to identify the cause of joint effusion but is not a routine measure to monitor overall SLE disease activity.
- Her mild knee tenderness and swelling could be part of her chronic SLE and does not automatically warrant an invasive joint procedure as the primary next step for overall disease monitoring.
Question 929: A 65-year-old man is brought to the emergency department by his wife because of progressive lethargy and confusion during the past 2 days. His wife reports that he has been complaining of nausea and increased urination for the past 5 days. He also developed a cough 1 week ago. He has a history of a cerebrovascular accident 3 years ago and was diagnosed with hypertension 10 years ago. Current medications include lisinopril and aspirin. His temperature is 38.5°C (101.3°F), pulse is 114/min, respirations are 15/min, and blood pressure is 108/75 mm Hg. He is somnolent and oriented only to person. Examination shows dry mucous membranes and decreased skin turgor. Crackles are heard at the left lung base. The remainder of the physical examination shows no abnormalities. Which of the following is the most appropriate next step in management?
A. Chest x-ray
B. Broad-spectrum antibiotics
C. Arterial blood gas analysis
D. Blood glucose measurement (Correct Answer)
E. Serum calcium measurement
Explanation: ***Blood glucose measurement***
- The patient's symptoms of **lethargy, confusion, nausea, increased urination, and dehydration** are highly suggestive of **hyperglycemia**, possibly diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS), especially in the setting of a recent infection (cough, fever).
- Rapid determination of blood glucose levels is crucial for immediate diagnosis and initiation of appropriate treatment, which can be life-saving.
*Chest x-ray*
- While crackles at the lung base suggest **pneumonia**, a chest x-ray would confirm the diagnosis but is not the most immediate next step given the patient's severe neurological symptoms and signs of metabolic derangement.
- Addressing the metabolic emergency (hyperglycemia) takes precedence for initial stabilization.
*Broad-spectrum antibiotics*
- The patient has signs of infection (cough, fever, crackles) and potential sepsis, making antibiotics important, but **uncontrolled hyperglycemia can mimic or worsen sepsis** and needs immediate attention.
- Antibiotics should be considered after initial assessment and stabilization of immediate life threats, and often after obtaining cultures.
*Arterial blood gas analysis*
- An ABG would be useful to assess **acid-base status** in suspected DKA or lactic acidosis, but it is a more invasive and time-consuming test than a point-of-care blood glucose measurement.
- Determining blood glucose will guide the urgency and interpretation of an ABG.
*Serum calcium measurement*
- While hypercalcemia can cause lethargy and confusion, the patient's symptoms of **polyuria** and **nausea** are also prominent in diabetic emergencies, and his past medical history does not strongly suggest hypercalcemia.
- Blood glucose measurement is a more targeted and urgent test given the full constellation of symptoms.
Question 930: A 25-year-old female presents with recent muscle weakness, fatigue, and constipation. Physical examination reveals a bradycardic patient with cool, dry skin. Which of the following lab values would be most likely to be present with this patient's presentation?
A. Hypocalcemia
B. Elevated serum CK
C. Activating TSH-receptor immunoglobulins
D. Elevated serum calcitonin
E. Elevated serum TSH (Correct Answer)
Explanation: ***Elevated serum TSH***
- This patient presents with classic signs and symptoms of **primary hypothyroidism**: muscle weakness, fatigue, constipation, bradycardia, and cool, dry skin.
- **Elevated TSH** is the hallmark laboratory finding in primary hypothyroidism, occurring in virtually all cases as the pituitary attempts to stimulate the underactive thyroid gland.
- This is the **most likely** lab abnormality to be present and is the first-line diagnostic test for suspected hypothyroidism.
*Elevated serum CK*
- While **creatine kinase (CK)** can be elevated in hypothyroid myopathy due to muscle breakdown, this occurs in only 30-50% of hypothyroid patients.
- It is a **secondary consequence** rather than a primary diagnostic finding, making it less likely to be present than elevated TSH.
- CK elevation would not be the first test ordered in a patient with suspected hypothyroidism.
*Activating TSH-receptor immunoglobulins*
- These antibodies are characteristic of **Graves' disease**, which causes **hyperthyroidism**, not the hypothyroid symptoms presented.
- The patient's **bradycardia**, **cool/dry skin**, and **constipation** are inconsistent with hyperthyroidism, which typically presents with tachycardia, warm/moist skin, and diarrhea.
*Hypocalcemia*
- While muscle weakness can occur with **hypocalcemia**, the constellation of findings including **fatigue**, **constipation**, **bradycardia**, and **cool, dry skin** do not point to a primary calcium disorder.
- Hypocalcemia typically presents with perioral numbness, paresthesias, tetany, and positive Chvostek's/Trousseau's signs.
*Elevated serum calcitonin*
- An elevated **calcitonin** level is primarily associated with **medullary thyroid carcinoma**.
- This condition does not explain the patient's constellation of symptoms, particularly the generalized hypothyroid signs and does not cause TSH-mediated thyroid dysfunction.
