Medications management perioperatively — MCQs

10 questions

A 52-year-old man comes to the physician for a routine health maintenance examination. He feels well. His blood pressure is 125/70 mm Hg. His glomerular filtration rate is calculated to be 105 mL/min/1.73 m2 and glucose clearance is calculated to be 103 mL/min. This patient is most likely being treated with which of the following agents?

A 59-year-old woman is scheduled to undergo a right hip total arthroplasty for severe hip osteoarthritis that has failed conservative management. She has never had surgery before. She has a history of major depressive disorder and takes sertraline daily and ibuprofen occasionally for pain. Her mother died of breast cancer and her father died from a myocardial infarction. She has a brother who had an adverse reaction following anesthesia, but she does not know details of the event. In the operating room, the anesthesiologist administers isoflurane and succinylcholine. Two minutes later, the patient develops hypercarbia and hypertonicity of her bilateral upper and lower extremities. Her temperature is 103.7°F (39.8°C), blood pressure is 155/95 mmHg, pulse is 115/min, and respirations are 20/min. A medication with which of the following mechanisms of action is most strongly indicated for this patient?

A 70-year-old male presents for an annual exam. His past medical history is notable for shortness of breath when he sleeps, and upon exertion. Recently he has experienced dyspnea and lower extremity edema that seems to be worsening. Both of these symptoms have resolved since he was started on several medications and instructed to weigh himself daily. Which of the following is most likely a component of his medical management?

A 30-year-old man with history of intravenous drug use and methamphetamine-associated chronic thromboembolic pulmonary hypertension (CTEPH) is brought to the emergency department by his girlfriend for worsening abdominal pain and fevers. The patient said the pain was initially around his umbilicus, but he is now experiencing intense tenderness near his groin. He was initially prescribed rivaroxaban, but due to insurance issues, he was switched to warfarin for management of CTEPH two weeks ago. His temperature is 102°F (38.9°C), blood pressure is 95/60 mmHg, pulse is 95/min, respirations are 22/min. He states that his blood pressure usually runs low. His physical exam is notable for an unremarkable cardiac exam, bibasilar crackles, and RLQ tenderness with rebound tenderness when the LLQ is palpated. Laboratory results are shown below: Hemoglobin: 11 g/dL Hematocrit: 35 % Leukocyte count: 16,000/mm^3 with normal differential Platelet count: 190,000/mm^3 Serum: Na+: 137 mEq/L Cl-: 100 mEq/L K+: 3.7 mEq/L HCO3-: 23 mEq/L BUN: 40 mg/dL Glucose: 110 mg/dL Creatinine: 0.8 mg/dL Ca2+: 9.1 mg/dL AST: 34 U/L ALT: 45 U/L International normalized ratio (INR): 6.2 Prothrombin time (PT): 40 seconds Partial thromboplastin time: 70 seconds Blood type: O Rhesus: Positive Antibody screen: Negative A clinical diagnosis is made and supported by the surgical consult team in lieu of imaging. The next operating room for an add-on procedure will not be available for another 5 hours. Appropriate medical therapy is initiated. What is the best next step for surgical optimization?

A 45-year-old woman presents to your office with a serum glucose of 250 mg/dL and you diagnose diabetes mellitus type II. You intend to prescribe the patient metformin, but you decide to order laboratory tests before proceeding. Which of the following basic metabolic panel values would serve as a contraindication to the use of metformin?

Immediately after undergoing a right total knee replacement, a 69-year-old woman has severe abdominal pain, non-bloody emesis, and confusion. She has a history of Hashimoto thyroiditis that is well-controlled with levothyroxine and hyperlipidemia that is controlled by diet. She underwent bunion removal surgery from her right foot 10 years ago. Her temperature is 39°C (102.2°F), pulse is 120/min, and blood pressure is 60/30 mm Hg. Abdominal examination shows a diffusely tender abdomen with normal bowel sounds. She is confused and oriented to person but not place or time. Laboratory studies are pending. Which of the following is the most appropriate next step in the management of this patient?

A 73-year-old man presents to the outpatient clinic complaining of chest pain with exertion. He states that resting for a few minutes usually resolves the chest pain. Currently, he takes 81 mg of aspirin daily. He has a blood pressure of 127/85 mm Hg and heart rate of 75/min. Physical examination reveals regular heart sounds and clear lung sounds bilateral. Which medication regimen below should be added?

A 26-year-old G1P0 woman at 32-weeks gestation presents for follow-up ultrasound. She was diagnosed with gestational diabetes during her second trimester, but admits to poor glucose control and non-adherence to insulin therapy. Fetal ultrasound reveals an asymmetric, enlarged interventricular septum, left ventricular outflow tract obstruction, and significantly reduced ejection fraction. Which of the following is the most appropriate step in management after delivery?

A 28-year-old male intern is currently on a trauma surgery service. After a busy overnight shift, the intern did not have enough time to prepare to present all of the patients on the team’s list. At morning rounds, the chief resident made a sarcastic comment that the intern “really put a lot of effort into preparing for rounds.” After rounds, while managing the floor with the third year medical student, the intern berates the student that she “needs to step up her game and do a better job helping with pre-rounding in the morning.” What type of ego defense is most relevant in this situation?

Q10

A 31 year-old-man presents to an urgent care clinic with symptoms of lower abdominal pain, bloating, bloody diarrhea, and fullness, all of which have become more frequent over the last 3 months. Rectal examination reveals a small amount of bright red blood. His vital signs include: temperature 36.7°C (98.0°F), blood pressure 126/74 mm Hg, heart rate 74/min, and respiratory rate 14/min. Colonoscopy is performed, showing extensive mucosal erythema, induration, and pseudopolyps extending from the rectum to the splenic flexure. Given the following options, what is the most appropriate treatment to induce remission in this patient?

Medications management perioperatively US Medical PG Practice Questions and MCQs

Question 1: A 52-year-old man comes to the physician for a routine health maintenance examination. He feels well. His blood pressure is 125/70 mm Hg. His glomerular filtration rate is calculated to be 105 mL/min/1.73 m2 and glucose clearance is calculated to be 103 mL/min. This patient is most likely being treated with which of the following agents?

A. Ifosfamide
B. Acarbose
C. Canagliflozin (Correct Answer)
D. Glipizide
E. Metformin

Explanation: ***Canagliflozin*** - The key finding is that **glucose clearance (103 mL/min) approximately equals GFR (105 mL/min)**, indicating nearly complete failure of glucose reabsorption. - **Canagliflozin** is an **SGLT2 inhibitor** that blocks the sodium-glucose cotransporter 2 in the proximal tubule, preventing glucose reabsorption. - This causes filtered glucose to be excreted in urine, resulting in **glucose clearance approaching GFR** - exactly what is seen in this patient. - SGLT2 inhibitors are increasingly used as first-line agents in Type 2 Diabetes, especially with cardiovascular or renal benefits. *Metformin* - **Metformin** is a biguanide that decreases hepatic gluconeogenesis and increases peripheral insulin sensitivity. - It does **NOT affect renal glucose handling** or glucose clearance, which would remain near zero in patients on metformin. - The elevated glucose clearance in this patient rules out metformin monotherapy. *Ifosfamide* - **Ifosfamide** is an alkylating chemotherapy agent used for cancer treatment, not diabetes management. - It can cause **Fanconi syndrome** (proximal tubule dysfunction) leading to glycosuria, but this would also cause decreased GFR, proteinuria, and electrolyte abnormalities. - This patient's normal GFR and otherwise normal presentation makes ifosfamide-induced toxicity unlikely. *Acarbose* - **Acarbose** is an alpha-glucosidase inhibitor that slows carbohydrate absorption in the intestine. - It works in the **GI tract**, not the kidneys, and does not affect glucose clearance. - It would not explain the elevated renal glucose excretion seen here. *Glipizide* - **Glipizide** is a sulfonylurea that stimulates pancreatic insulin release. - It does **NOT affect renal glucose handling** and would not cause elevated glucose clearance. - The patient's glucose clearance pattern is inconsistent with sulfonylurea therapy.

Question 2: A 59-year-old woman is scheduled to undergo a right hip total arthroplasty for severe hip osteoarthritis that has failed conservative management. She has never had surgery before. She has a history of major depressive disorder and takes sertraline daily and ibuprofen occasionally for pain. Her mother died of breast cancer and her father died from a myocardial infarction. She has a brother who had an adverse reaction following anesthesia, but she does not know details of the event. In the operating room, the anesthesiologist administers isoflurane and succinylcholine. Two minutes later, the patient develops hypercarbia and hypertonicity of her bilateral upper and lower extremities. Her temperature is 103.7°F (39.8°C), blood pressure is 155/95 mmHg, pulse is 115/min, and respirations are 20/min. A medication with which of the following mechanisms of action is most strongly indicated for this patient?

A. Muscarinic antagonist
B. Antihistamine
C. Ryanodine receptor antagonist (Correct Answer)
D. Cholinesterase inhibitor
E. Dopamine receptor agonist

Explanation: ***Ryanodine receptor antagonist*** - The patient's presentation with **hyperthermia**, **hypercarbia**, and **muscle rigidity** after exposure to isoflurane and succinylcholine is highly indicative of **malignant hyperthermia (MH)**. - **Dantrolene**, a **ryanodine receptor antagonist**, is the primary treatment for MH as it blocks the release of calcium from the sarcoplasmic reticulum, thereby reducing muscle contraction and heat production. *Muscarinic antagonist* - **Muscarinic antagonists** like atropine block the action of acetylcholine at muscarinic receptors and are used to treat **bradycardia** or reduce secretions. - They would not address the underlying pathophysiology of malignant hyperthermia, which involves uncontrolled calcium release from the sarcoplasmic reticulum. *Antihistamine* - **Antihistamines** block histamine receptors and are used to treat **allergic reactions** or reduce nausea and vomiting. - They have no role in the management of malignant hyperthermia, which is not an allergic response. *Cholinesterase inhibitor* - **Cholinesterase inhibitors** increase acetylcholine levels at the neuromuscular junction and are used to reverse **neuromuscular blockade** or treat **myasthenia gravis**. - Administering a cholinesterase inhibitor would likely intensify muscle contraction and rigidity, worsening the patient's condition in malignant hyperthermia. *Dopamine receptor agonist* - **Dopamine receptor agonists** are primarily used to treat **Parkinson's disease** or as **vasopressors** in critical care. - They have no direct therapeutic effect on the severe muscle rigidity and hypermetabolic state characteristic of malignant hyperthermia.

Question 3: A 70-year-old male presents for an annual exam. His past medical history is notable for shortness of breath when he sleeps, and upon exertion. Recently he has experienced dyspnea and lower extremity edema that seems to be worsening. Both of these symptoms have resolved since he was started on several medications and instructed to weigh himself daily. Which of the following is most likely a component of his medical management?

A. Lidocaine
B. Verapamil
C. Carvedilol (Correct Answer)
D. Aspirin
E. Ibutilide

Explanation: ***Carvedilol*** - The patient exhibits classic symptoms of **heart failure**, such as **dyspnea on exertion**, **orthopnea** (shortness of breath when he sleeps), and **lower extremity edema**. - **Beta-blockers** like carvedilol are essential for managing **chronic heart failure** by reducing myocardial oxygen demand and improving cardiac function. *Lidocaine* - **Lidocaine** is primarily an **antiarrhythmic drug** used for acute treatment of **ventricular arrhythmias**, not for chronic heart failure management. - It works by blocking sodium channels and has no direct benefit in addressing the underlying pathophysiology of heart failure. *Verapamil* - **Verapamil** is a **non-dihydropyridine calcium channel blocker** typically used for hypertension, angina, and supraventricular tachyarrhythmias. - It can have **negative inotropic effects**, which are generally contraindicated or used with extreme caution in patients with **systolic heart failure** due to its potential to worsen cardiac function. *Aspirin* - **Aspirin** is an **antiplatelet agent** used for primary or secondary prevention of **atherosclerotic cardiovascular disease** (e.g., in patients with coronary artery disease). - It does not directly manage the symptoms or pathophysiology of **heart failure** unless there is a coexisting ischemic etiology. *Ibutilide* - **Ibutilide** is an **antiarrhythmic drug** specifically used for the rapid conversion of **atrial flutter and atrial fibrillation** of recent onset to sinus rhythm. - It is not a medication used for the long-term management of **heart failure** symptoms described in the patient.

Question 4: A 30-year-old man with history of intravenous drug use and methamphetamine-associated chronic thromboembolic pulmonary hypertension (CTEPH) is brought to the emergency department by his girlfriend for worsening abdominal pain and fevers. The patient said the pain was initially around his umbilicus, but he is now experiencing intense tenderness near his groin. He was initially prescribed rivaroxaban, but due to insurance issues, he was switched to warfarin for management of CTEPH two weeks ago. His temperature is 102°F (38.9°C), blood pressure is 95/60 mmHg, pulse is 95/min, respirations are 22/min. He states that his blood pressure usually runs low. His physical exam is notable for an unremarkable cardiac exam, bibasilar crackles, and RLQ tenderness with rebound tenderness when the LLQ is palpated. Laboratory results are shown below: Hemoglobin: 11 g/dL Hematocrit: 35 % Leukocyte count: 16,000/mm^3 with normal differential Platelet count: 190,000/mm^3 Serum: Na+: 137 mEq/L Cl-: 100 mEq/L K+: 3.7 mEq/L HCO3-: 23 mEq/L BUN: 40 mg/dL Glucose: 110 mg/dL Creatinine: 0.8 mg/dL Ca2+: 9.1 mg/dL AST: 34 U/L ALT: 45 U/L International normalized ratio (INR): 6.2 Prothrombin time (PT): 40 seconds Partial thromboplastin time: 70 seconds Blood type: O Rhesus: Positive Antibody screen: Negative A clinical diagnosis is made and supported by the surgical consult team in lieu of imaging. The next operating room for an add-on procedure will not be available for another 5 hours. Appropriate medical therapy is initiated. What is the best next step for surgical optimization?

A. Fresh frozen plasma
B. Prothrombin complex concentrate (Correct Answer)
C. Protamine
D. Do nothing
E. Phytonadione

Explanation: ***Prothrombin complex concentrate*** - The patient has **warfarin over-anticoagulation (INR 6.2)** and requires **emergency surgery** for suspected appendicitis with peritonitis, necessitating rapid reversal of anticoagulation. - **Prothrombin complex concentrate (4-factor PCC)** contains concentrated factors II, VII, IX, and X (and proteins C & S), providing **rapid and complete reversal** of warfarin's anticoagulant effects within minutes, which is crucial in emergency surgical situations. - PCC is **preferred over FFP** per current guidelines (ACCP, AHA) for urgent warfarin reversal due to faster administration, smaller volume, and more predictable INR correction. - **Vitamin K should be administered concurrently** to provide sustained reversal (takes 12-24 hours), but PCC is essential for immediate correction before surgery. *Fresh frozen plasma* - While FFP contains all coagulation factors and can reverse warfarin, it requires **larger volumes (4-6 units)**, takes longer to thaw and administer, and is **less effective** in rapidly correcting INR to normal range compared to PCC. - Administering large volumes of FFP can lead to **volume overload** (especially concerning in CTEPH patients) and **transfusion-related complications**. - PCC is superior for urgent reversal in patients requiring emergency surgery. *Protamine* - **Protamine** is used to reverse the anticoagulant effects of **unfractionated heparin** (and partially reverses low molecular weight heparin), not warfarin. - It would have **no effect** on the patient's elevated INR due to warfarin use. - Note: The elevated PTT (70s) in this case may suggest concurrent heparin bridging therapy or other factor deficiency, but the primary issue requiring reversal is the critical warfarin over-anticoagulation. *Do nothing* - This patient has **surgical peritonitis** (appendicitis with peritoneal signs) and requires emergency surgery with an INR of 6.2, creating **high risk of surgical bleeding**. - Proceeding to surgery without reversing anticoagulation would result in **life-threatening hemorrhage**. - Delaying treatment would likely result in further **clinical deterioration** with possible perforation and sepsis. *Phytonadione* - **Phytonadione (Vitamin K)** reverses warfarin's effects by restoring hepatic synthesis of vitamin K-dependent clotting factors, but its onset of action is **slow (12-24 hours for full effect)**, making it unsuitable as the sole agent for immediate reversal in patients requiring emergent surgery. - While **Vitamin K should be administered** alongside PCC to provide sustained reversal, it is **not sufficient alone** for rapid correction in surgical emergencies.

Question 5: A 45-year-old woman presents to your office with a serum glucose of 250 mg/dL and you diagnose diabetes mellitus type II. You intend to prescribe the patient metformin, but you decide to order laboratory tests before proceeding. Which of the following basic metabolic panel values would serve as a contraindication to the use of metformin?

A. HCO3- > 30
B. Na+ > 140
C. K+ > 4.0
D. Glucose > 300
E. Creatinine > 2.0 (Correct Answer)

Explanation: ***Creatinine > 2.0*** - An elevated **serum creatinine** level indicating significant renal impairment is a contraindication to metformin use, as it markedly increases the risk of **lactic acidosis**. - **Metformin** is primarily excreted by the kidneys unchanged, and impaired renal function leads to drug accumulation and potential toxicity. - Traditional contraindication thresholds include serum creatinine >1.5 mg/dL in men or >1.4 mg/dL in women; a value **>2.0 mg/dL** clearly indicates significant renal dysfunction requiring avoidance of metformin. - Current guidelines emphasize using **eGFR** (contraindicated if <30 mL/min/1.73m²), but creatinine remains a key marker of renal function on basic metabolic panels. *HCO3- > 30* - An elevated **bicarbonate level** (HCO3-) above 30 mEq/L typically indicates **metabolic alkalosis**, which is not a direct contraindication for metformin. - While metabolic alkalosis should be investigated, it does not pose the specific risk of lactic acidosis associated with renal dysfunction and metformin use. *Na+ > 140* - A slightly elevated **sodium level** (Na+) above 140 mEq/L (normal: 135-145 mEq/L) is often associated with **dehydration** or other electrolyte imbalances and is not a contraindication for metformin. - While significant electrolyte imbalances should be addressed, mild hypernatremia does not directly increase the risk of metformin-induced lactic acidosis. *K+ > 4.0* - A potassium level of >4.0 mEq/L is within the **normal range** (typically 3.5-5.0 mEq/L) and is not a contraindication for metformin. - Significant hyperkalemia or hypokalemia would require evaluation and management, but a normal or slightly elevated potassium level does not preclude metformin use. *Glucose > 300* - While a blood **glucose level** >300 mg/dL indicates poorly controlled diabetes, this is actually an **indication** for initiating glucose-lowering therapy like metformin, not a contraindication. - Metformin's primary therapeutic purpose is to lower elevated glucose levels, and severe hyperglycemia itself does not increase the risk of metformin's specific adverse effects.

Question 6: Immediately after undergoing a right total knee replacement, a 69-year-old woman has severe abdominal pain, non-bloody emesis, and confusion. She has a history of Hashimoto thyroiditis that is well-controlled with levothyroxine and hyperlipidemia that is controlled by diet. She underwent bunion removal surgery from her right foot 10 years ago. Her temperature is 39°C (102.2°F), pulse is 120/min, and blood pressure is 60/30 mm Hg. Abdominal examination shows a diffusely tender abdomen with normal bowel sounds. She is confused and oriented to person but not place or time. Laboratory studies are pending. Which of the following is the most appropriate next step in the management of this patient?

A. High-dose hydrocortisone
B. Exploratory laparotomy
C. CT angiogram of the abdomen
D. Noncontrast CT of the head
E. Intravenous isotonic saline infusion (Correct Answer)

Explanation: ***Intravenous isotonic saline infusion*** - The patient presents with **shock** (BP 60/30 mm Hg, pulse 120/min, confusion), which is immediately life-threatening and requires urgent intervention. - **IV fluid resuscitation** is the **first priority** in any shock state to restore intravascular volume, improve tissue perfusion, and stabilize hemodynamics. - While this patient has features concerning for **acute adrenal crisis** (Hashimoto thyroiditis with possible polyglandular autoimmune syndrome, post-surgical stress, fever, hypotension, confusion), **fluid resuscitation must be initiated immediately** before or concurrent with other therapies. - In practice, **high-dose hydrocortisone should be given simultaneously** with fluids, but restoring circulating volume is the foundational first step. *High-dose hydrocortisone* - This patient has **Hashimoto thyroiditis** and presents with shock after major surgery (a known precipitant), raising strong suspicion for **acute adrenal crisis**. - Patients with autoimmune thyroid disease can have concurrent **autoimmune adrenal insufficiency** (Schmidt syndrome/APS-2). - **Hydrocortisone is critical** and should be given immediately (typically 100 mg IV), but **not before addressing the shock state** with fluid resuscitation. - This would be the appropriate **second step** or given concurrently with fluids. *Exploratory laparotomy* - While the patient has **severe abdominal pain** and **diffuse tenderness**, the overall presentation (fever, hypotension, post-op state) suggests **medical shock** rather than a surgical emergency. - **Normal bowel sounds** make mechanical obstruction or perforation less likely. - Surgery is inappropriate until the patient is hemodynamically stabilized and a surgical cause is confirmed. *CT angiogram of the abdomen* - This could evaluate for **mesenteric ischemia**, but the patient is **too unstable** for imaging. - The clinical picture better fits **adrenal crisis** or **septic shock** rather than vascular catastrophe. - **Delaying resuscitation** for imaging in a patient with severe hypotension would be harmful. *Noncontrast CT of the head* - The patient's **confusion** is most likely due to **hypoperfusion** and **shock** rather than a primary intracranial process. - **Altered mental status** is a common manifestation of shock and adrenal crisis. - Cerebral perfusion depends on adequate systemic blood pressure, making **circulatory stabilization the priority**.

Question 7: A 73-year-old man presents to the outpatient clinic complaining of chest pain with exertion. He states that resting for a few minutes usually resolves the chest pain. Currently, he takes 81 mg of aspirin daily. He has a blood pressure of 127/85 mm Hg and heart rate of 75/min. Physical examination reveals regular heart sounds and clear lung sounds bilateral. Which medication regimen below should be added?

A. Metoprolol and a statin daily. Sublingual nitroglycerin as needed. (Correct Answer)
B. Clopidogrel and amlodipine daily. Sublingual nitroglycerin as needed.
C. Amlodipine and a statin daily. Sublingual nitroglycerin as needed.
D. Amlodipine daily. Sublingual nitroglycerin as needed.
E. Metoprolol and ranolazine daily. Sublingual nitroglycerin as needed.

Explanation: ***Metoprolol and a statin daily. Sublingual nitroglycerin as needed.*** - This patient presents with symptoms consistent with **stable angina** (**chest pain with exertion, relieved by rest**). The recommended medical therapy includes **antiplatelet agents** (aspirin, already prescribed), **beta-blockers** (metoprolol) for symptom control and improved survival post-MI, and **high-intensity statins** for lipid management and plaque stabilization. **Sublingual nitroglycerin** is crucial for acute symptom relief. - Beta-blockers like metoprolol decrease myocardial **oxygen demand** by reducing heart rate and contractility, effectively treating angina. Statins are essential for **atherosclerosis management**. *Clopidogrel and amlodipine daily. Sublingual nitroglycerin as needed.* - While clopidogrel is an **antiplatelet agent**, aspirin is typically the first-line choice for stable angina unless there's an intolerance or compelling reason for dual antiplatelet therapy (e.g., recent stent placement), which is not indicated here. - Amlodipine, a **calcium channel blocker**, can be used for angina but is usually a second-line agent if beta-blockers are contraindicated or insufficient; it doesn't offer the mortality benefit seen with beta-blockers post-MI. *Amlodipine and a statin daily. Sublingual nitroglycerin as needed.* - This regimen includes a **statin** and sublingual nitroglycerin, which are appropriate. However, it uses amlodipine instead of a beta-blocker, which is generally the preferred initial therapy for angina due to its benefits in reducing myocardial oxygen demand and improving outcomes, especially in patients with a history of MI or heart failure. - Beta-blockers provide superior **mortality reduction benefits** in patients with coronary artery disease compared to calcium channel blockers. *Amlodipine daily. Sublingual nitroglycerin as needed.* - This option misses two critical components of comprehensive treatment for stable angina: a **statin** for lipid management and plaque stabilization, and a **beta-blocker** for primary symptom control and long-term cardiac protection. - Relying solely on amlodipine and sublingual nitroglycerin would leave the patient incompletely treated for their underlying **coronary artery disease**. *Metoprolol and ranolazine daily. Sublingual nitroglycerin as needed.* - This option lacks a **statin**, which is a cornerstone of therapy for stable angina to manage atherosclerosis. - While metoprolol is appropriate and ranolazine can be used as an add-on therapy for refractory angina, it's not typically a first-line agent and doesn't replace the need for a statin.

Question 8: A 26-year-old G1P0 woman at 32-weeks gestation presents for follow-up ultrasound. She was diagnosed with gestational diabetes during her second trimester, but admits to poor glucose control and non-adherence to insulin therapy. Fetal ultrasound reveals an asymmetric, enlarged interventricular septum, left ventricular outflow tract obstruction, and significantly reduced ejection fraction. Which of the following is the most appropriate step in management after delivery?

A. Medical management (Correct Answer)
B. Cardiac catheterization
C. Cardiac magnetic resonance imaging
D. Chest radiograph
E. Immediate surgical intervention

Explanation: ***Medical management*** - Asymmetric interventricular septal hypertrophy in infants of diabetic mothers is a transient phenomenon, primarily managed with **beta-blockers** to improve ventricular outflow. - The condition typically **resolves spontaneously** within weeks to months as the infant's heart adapts to the extra-uterine environment and insulin levels normalize. *Cardiac catheterization* - This is an **invasive procedure** used primarily for diagnostic purposes or for certain interventional treatments, not typically the first-line for transient septal hypertrophy. - It would carry unnecessary risks for an infant with a condition that is likely to resolve with medical management. *Cardiac magnetic resonance imaging* - While it provides detailed anatomical and functional information, **CMR is not usually indicated** for initial management of this specific condition in neonates. - An echocardiogram has already provided sufficient diagnostic information to guide initial therapy. *Chest radiograph* - A chest radiograph provides information about **lung fields and heart size/shape**, but it offers very limited detail regarding specific cardiac structural abnormalities or function. - It would not be helpful for characterizing the interventricular septum or ventricular outflow tract. *Immediate surgical intervention* - **Surgical myectomy** is reserved for severe, persistent left ventricular outflow tract obstruction that is *unresponsive* to maximal medical therapy and is causing significant symptoms or hemodynamic compromise. - Given the transient nature of the condition associated with maternal diabetes, immediate surgery would be premature and overly aggressive.

Question 9: A 28-year-old male intern is currently on a trauma surgery service. After a busy overnight shift, the intern did not have enough time to prepare to present all of the patients on the team’s list. At morning rounds, the chief resident made a sarcastic comment that the intern “really put a lot of effort into preparing for rounds.” After rounds, while managing the floor with the third year medical student, the intern berates the student that she “needs to step up her game and do a better job helping with pre-rounding in the morning.” What type of ego defense is most relevant in this situation?

A. Projection
B. Denial
C. Passive aggression
D. Reaction formation
E. Displacement (Correct Answer)

Explanation: ***Displacement*** - **Displacement** occurs when a person redirects an impulse, usually aggression, from a threatening or unacceptable target to a safer, less threatening one. The intern, unable to confront the chief resident, redirects their frustration onto the medical student. - The intern's anger and frustration stemmed from the chief resident's sarcastic comment, and instead of addressing the chief resident, the intern inappropriately vented these feelings towards the medical student. *Projection* - **Projection** involves attributing one's own unacceptable thoughts or feelings to another person. For example, if the intern felt lazy but accused the medical student of being lazy, that would be projection. - The intern is not attributing their own feelings of inadequacy to the student; rather, they are expressing directed anger that originated elsewhere. *Denial* - **Denial** is refusing to accept reality or fact, acting as if a painful event, thought, or feeling did not exist. The intern is aware of the situation and their feelings, not denying them. - The intern is actively acknowledging the criticism (by being upset) and reacting to it, rather than ignoring or disbelieving the situation. *Passive aggression* - **Passive aggression** is expressing negative feelings indirectly instead of openly addressing them. The intern's berating of the medical student is a direct, albeit misdirected, expression of aggression. - While there is aggression, it's not "passive"; the intern directly confronts and criticizes the student, even if the underlying cause of frustration is external. *Reaction formation* - **Reaction formation** converts an unacceptable impulse into its opposite. For example, if the intern secretly disliked the chief resident but praised them excessively, that would be reaction formation. - The intern is expressing anger, not masking an unacceptable impulse by acting in an opposite, overly positive, or agreeable manner.

Question 10: A 31 year-old-man presents to an urgent care clinic with symptoms of lower abdominal pain, bloating, bloody diarrhea, and fullness, all of which have become more frequent over the last 3 months. Rectal examination reveals a small amount of bright red blood. His vital signs include: temperature 36.7°C (98.0°F), blood pressure 126/74 mm Hg, heart rate 74/min, and respiratory rate 14/min. Colonoscopy is performed, showing extensive mucosal erythema, induration, and pseudopolyps extending from the rectum to the splenic flexure. Given the following options, what is the most appropriate treatment to induce remission in this patient?

A. Azathioprine
B. Mesalamine
C. Total proctocolectomy
D. Sulfasalazine
E. Systemic corticosteroids (Correct Answer)

Explanation: ***Systemic corticosteroids*** - The patient presents with classic symptoms of an acute **ulcerative colitis flare**, including bloody diarrhea, abdominal pain, and colonoscopy findings of extensive inflammation from the rectum to the splenic flexure (consistent with **left-sided colitis**). - **Systemic corticosteroids** such as prednisone or methylprednisolone are the **most appropriate treatment to induce remission** during active flares of moderate to severe ulcerative colitis due to their potent **anti-inflammatory effects** and rapid onset of action. - This patient has moderate to severe disease based on extent and symptom severity, warranting systemic corticosteroids rather than topical or aminosalicylate therapy alone. *Azathioprine* - **Azathioprine** is an **immunomodulator** used for maintaining remission in inflammatory bowel disease, not for acute flare treatment. - Its onset of action is slow (weeks to months), making it unsuitable for immediate symptom control in an acute flare. *Mesalamine* - **Mesalamine** (an aminosalicylate) is a **first-line therapy** for inducing and maintaining remission in **mild to moderate** ulcerative colitis, particularly for proctitis or left-sided colitis. - However, for extensive disease with significant symptoms as seen in this patient, **systemic corticosteroids** are preferred due to greater potency and more rapid induction of remission in moderate to severe flares. *Total proctocolectomy* - **Total proctocolectomy** is a surgical procedure that provides a **definitive cure** for ulcerative colitis by removing the entire colon and rectum. - However, surgery is reserved for cases of **refractory disease** (failure of medical therapy), severe complications (e.g., toxic megacolon, perforation, severe hemorrhage), or high risk of dysplasia/cancer. - This patient is presenting with an acute flare and should be managed medically first; surgery is not the initial treatment approach. *Sulfasalazine* - **Sulfasalazine** is an aminosalicylate similar to mesalamine, used for inducing and maintaining remission in mild to moderate ulcerative colitis. - While effective for mild disease, systemic corticosteroids are preferred for moderate to severe acute flares due to their stronger and more rapid anti-inflammatory action when the disease is extensive and symptomatic.

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