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201
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A 62-year-old man presents to the emergency department with increased fatigue and changes in his vision. For the past month, he has felt abnormally tired and today noticed his vision is blurry. The patient also endorses increased sweating at night and new-onset headaches. He currently feels dizzy. The patient has a medical history of diabetes and hypertension. His current medications include insulin, metformin, and lisinopril. His temperature is 99.5°F (37.5°C), blood pressure is 157/98 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air. A cardiopulmonary exam is within normal limits. HEENT exam reveals non-tender posterior and anterior chain lymphadenopathy. Abdominal exam reveals splenomegaly and hepatomegaly. There are large, non-tender palpable lymph nodes in the patient's inguinal region. A neurological exam is notable for decreased sensation in the patient's hands and feet. He also complains of numbness and tingling pain in his extremities that has been persistent during this time. The dermatologic exam is notable for multiple bruises on his upper and lower extremities. Which of the following is most likely to be abnormal in this patient?
|
{
"A": "IgA and IgG",
"B": "Calcium",
"C": "T-cells",
"D": "IgM",
"E": ""
}
|
D
|
This patient is presenting with symptoms of hyperviscosity, fatigue, and organomegaly suggestive of a diagnosis of Waldenstrom macroglobulinemia (WM). WM is characterized by increased IgM production.
WM occurs secondary to a clonal B-cell that pathologically overproduces IgM. High levels of IgM can lead to symptoms of hyperviscosity including blurred vision, dizziness, headaches, and peripheral neuropathy. Organomegaly is a unique finding in WM and can present with hepatomegaly and splenomegaly. Other non-specific findings include fatigue, anemia, and lymphadenopathy. This disease can be diagnosed using protein electrophoresis, which would demonstrate a spike in the levels of IgM protein. Treatment can include plasmapheresis and rituximab.
Gertz et al. review the evidence regarding the diagnosis and treatment of patients with WM. They discuss how patients often present with organomegaly as well as symptoms of hyperviscosity. They recommend rituximab treatment in symptomatic patients.
Incorrect Answers:
Answers 1 & 2: Calcium and IgA/IgG can be elevated in multiple myeloma (MM). MM presents with fatigue, weight loss, bone pain (back pain in particular), and other non-specific findings. MM less commonly presents with symptoms of hyperviscosity and organomegaly and this phenomenon has been described primarily with the IgA subtype. This is a late phenomenon and would be unlikely without preceding symptoms of bone pain and weight loss as a substantial protein concentrations (>5 g/dL) are required for this phenomenon. Treatment is with systemic chemotherapeutic agents.
Answers 4 & 5: Natural killer cells and T-cells could be elevated in non-Hodgkin lymphoma which would present with fatigue, lymphadenopathy, and "B-symptoms" (e.g., night sweats and chills). It would not present with symptoms of hyperviscosity. Treatment is with multi-agent chemotherapy as well as possible local radiation therapy.
Bullet Summary:
Waldenstrom macroglobulinemia (hyper IgM syndrome) presents with symptoms of hyperviscosity, fatigue, and organomegaly.
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https://step2.medbullets.com/testview?qid=109769
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202
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A 37-year-old machinist presents to his primary care physician with eye problems. He has felt a mass in his eye that has persisted for the past month. The patient has a medical history of blepharitis treated with eye cleansing and squamous cell carcinoma of the skin treated with Mohs surgery. His temperature is 99.5°F (37.5°C), blood pressure is 157/102 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam is notable for a firm and rubbery nodule palpable inside the patient's left eyelid. Physical exam does not elicit any pain. Which of the following is the most likely diagnosis?
|
{
"A": "Chalazion",
"B": "Foreign body",
"C": "Hordeolum",
"D": "Meibomian cell carcinoma",
"E": ""
}
|
A
|
This patient presenting with a painless firm and rubbery nodule has symptoms that are suggestive of a chalazion.
Chalazion presents with a hard and painless eyelid nodule. This pathology occurs secondary to granulomatous inflammation of the Meibomian gland. The lesion can be treated with simple excision; however, recurrent lesions are concerning for Meibomian cell carcinoma. The most important differential diagnosis to consider in these patients is a hordeolum which presents with a firm and painful lid nodule (in contrast to painless). Treatment is with warm compresses followed by incision and curettage in refractory cases.
Li et al. review the evidence regarding the diagnosis and treatment of chalazion. They discuss how gland loss is a possible sequelae from this disorder. They recommend using warm compresses for symptomatic relief.
Incorrect Answers:
Answer B: Foreign body is a possible diagnosis given this patient's occupation as a machinist; however, this would typically present with pain over the patient's cornea with a sudden onset of symptoms. Treatment is with removal of the foreign body.
Answer C: Hordeolum presents with a hard and painful lid nodule in contrast to a hard and painless lid nodule. Treatment is with warm compresses and possible debridement in refractory cases.
Answer D: Ingrown eyelash follicle could present with a firm lid nodule; however, it would be located near the margin of the eyelid and would likely be inflamed and tender. Treatment is with warm compresses and possible debridement in refractory cases.
Answer E: Meibomian cell carcinoma is a possible diagnosis but is epidemiologically less common than a chalazion. This diagnosis would be more likely if the lesion was recurrent despite excision. Treatment is with wide excision of the lesion.
Bullet Summary:
Chalazion presents with a firm and painless eyelid nodule.
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https://step2.medbullets.com/testview?qid=109961
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203
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A 55-year-old male bodybuilder presents to the emergency department with weakness of his right arm. The patient states he has experienced these symptoms for a few weeks; however, today his hand felt so weak he dropped his cup of tea. The patient has a medical history of diabetes. He drinks 2-7 alcoholic drinks per day and has smoked 2 packs of cigarettes per day since he was 25. The patient uses anabolic steroids. He has lost 17 pounds since he last came to the emergency department 1 month ago. His temperature is 99.5°F (37.5°C), blood pressure is 177/108 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam reveals decreased sensation in the right arm and 2/5 strength in the right arm and 5/5 strength in in the left arm. The patient states that he is experiencing a dull aching and burning pain in his right arm during the exam. Symptoms are not changed with changes in head and neck position. Which of the following is the most likely diagnosis?
|
{
"A": "Apical lung tumor",
"B": "Brachial plexopathy",
"C": "Cerebral infarction",
"D": "Scalenus anticus syndrome",
"E": ""
}
|
A
|
This patient is presenting with unilateral upper extremity paresthesia and weakness suggestive of compression of the neurovascular structures of the upper extremity secondary to an apical lung tumor.
An apical lung tumor can compress the neurovascular structures in its proximity and cause pain, numbness, and weakness of the ipsilateral arm. A Horner syndrome can also be observed with compression of the sympathetic chain leading to ipsilateral miosis, ptosis, and anhidrosis in some cases. These malignancies typically occur in older male smokers and can be associated with symptoms such as fatigue, cough, and weight loss. Chest radiography will demonstrate an apical opacity and CT scan can confirm the size and location of the mass. Treatment is with chemotherapy and surgical excision of the tumor.
Davis and Knight review the evidence regarding the diagnosis and treatment of patients with apical lung tumors. They discuss how these tumors can be associated with brachial plexus injuries. They recommend surgical excision of these tumors if they are resectable.
Incorrect Answers:
Answer B: Brachial plexopathy could present with weakness and numbness of the ipsilateral arm but is a less likely diagnosis (and a diagnosis of exclusion). Treatment is with identification and surgical release of any underlying anatomic defects (such as compressive bands) and supportive therapy if none are found.
Answer C: Cerebral infarction (stroke) would present with sudden onset of acute neurological deficits. These would typically only affect one side of the body and would not necessarily be associated with a dull pain or numbness that is chronic. Treatment is with thrombolytics if patients meet criteria for acute therapy.
Answer D: Scalenus anticus syndrome occurs in bodybuilders or athletes with hypertrophied neck muscles that compress the brachial plexus. Symptoms are typically worsened by certain positions. Treatment is with physical therapy and surgical decompression in refractory cases.
Answer E: Subclavian steal syndrome presents with numbness, tingling, weakness in a limb, and CNS symptoms (vertigo, slurred speech, or stroke-like symptoms) that are worsened with activity and relieved with rest. Treatment is with vascular intervention to restore blood flow.
Bullet Summary:
Apical lung tumors can compress neurovascular structures in the upper extremity and cause pain, numbness, and tingling in the ipsilateral arm.
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https://step2.medbullets.com/testview?qid=109967
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204
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A 55-year-old man presents to the emergency department with chest pain and shortness of breath. He has a medical history of hypertension, diabetes, and obesity. His temperature is 98.6°F (37.0°C), blood pressure is 177/118 mmHg, pulse is 127/min, respirations are 11/min, and oxygen saturation is 98% on room air. An ECG is performed and notable for ST elevation in leads II, III, and aVF. The patient is treated appropriately and transferred to the medical floor. On the 2nd day of his hospitalization, the patient has abdominal pain. His serum lipase is 272 U/L and his creatinine is 1.6 mg/dL. A physical exam is notable for the finding in Figure A. He is requesting pain medication for his abdominal pain. Which of the following is the most likely underlying diagnosis?
|
{
"A": "Cholesterol embolism",
"B": "Heart failure and reinfarction",
"C": "Pancreatitis",
"D": "Renal failure",
"E": ""
}
|
A
|
This patient is presenting with abdominal pain and livedo reticularis after a catheterization procedure. These symptoms are suggestive of a cholesterol embolism.
A cholesterol embolism typically presents after any vascular procedure due to a dislodged cholesterol emboli. Symptoms include livedo reticularis, gastrointestinal problems such as mesenteric ischemia or pancreatitis, and acute kidney injury. Patients who have undergone cardiac catheterization should be monitored for the development of this complication. Treatment is centered around treating the current complications, often using supportive therapy as they self-resolve. In addition, patients should be treated carefully to prevent recurrent embolism.
Maningding and Kermani review the evidence regarding the presentation of vasculitis mimics. They discuss how cholesterol embolism can cause diverse systemic symptoms and livedo reticularis. They recommend carefully considering the history of each patient.
Figure/Illustration A is a clinical photograph demonstrating a netlike reticular bluish discoloration of the skin (red circle). These findings are consistent with livedo reticularis.
Incorrect Answers:
Answer B: Heart failure and reinfarction could present with renal failure but would likely present with other symptoms of heart failure as well (pulmonary crackles, edema, and jugular venous distension). Treatment of a repeat infarct involves catheterization and fluid overload involves volume optimization.
Answer C: Medication side effects could explain this patient's livedo reticularis, but the drugs that may cause this (certain antivirals and amantadine) would not have been given to this patient. These medications also typically do not cause abdominal pain.
Answer D: Pancreatitis presents with abdominal pain and an elevated lipase; however, it is not the underlying pathology for this patient's presentation but rather is a complication of the cholesterol embolism. Treatment of pancreatitis is with gastrointestinal rest and fluid support.
Answer E: Renal failure is another complication in this patient secondary to the cholesterol embolism as revealed by the elevated creatinine, but is not the underlying pathology. Treatment is with renal replacement therapy if renal function does not return promptly.
Bullet Summary:
Cholesterol embolism presents after a vascular procedure with livedo reticularis, gastrointestinal complications, and acute kidney injury.
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https://step2.medbullets.com/testview?qid=210075
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205
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A 39-year-old man presents to his doctor for a wellness checkup. He is concerned about a rash that does not seem to be improving. He was recently exposed to his grandfather who has vesicular lesions on his skin and is being treated. He has a family history of skin cancer, colon cancer, and ovarian cancer. The patient has a medical history of asthma and seasonal allergies. His temperature is 98.6°F (37.0°C), blood pressure is 137/98 mmHg, pulse is 90/min, respirations are 14/min, and oxygen saturation is 98% on room air. Physical exam reveals the finding in Figure A. Which of the following describes this patient's most likely diagnosis?
|
{
"A": "Benign capillary proliferation",
"B": "Edema of the epidermis",
"C": "Healthy dermatologic development",
"D": "Viral infection",
"E": ""
}
|
A
|
This patient who presents with red raised papules is presenting with a cherry angioma. These lesions are composed of benign capillary proliferations.
Cherry angiomas present with cherry red macules/papules that occur secondary to benign capillary and venule proliferation. The lesions are entirely benign and are cosmetic. These lesions are common in middle-aged adults. As the patient ages, more lesions will appear. In the absence of symptoms, observation and reassurance can be used for conservative management. They can be removed surgically if the patient desires.
Nazer et al. study the risk factors associated with the development of cherry angioma. They found that the use of clopidogrel and tamsulosin is associated with these lesions. They recommend ruling out underlying conditions.
Figure/Illustration A demonstrates cherry red macules/papules classically seen in patients with cherry angioma.
Incorrect Answers:
Answer B: Edema of the epidermis describes eczema or atopic dermatitis. This disease would present with pruritic, erythematous, and vesicular lesions. Topical creams and hygiene can be used for symptomatic management of these lesions.
Answer C: Healthy dermatologic development misses the diagnosis of a cherry angioma, which although benign, is a more accurate diagnosis for this case.
Answer D: Malignant blood vessel proliferation does not describe a cherry angioma which is benign and purely cosmetic. An angiosarcoma usually occurs in deep tissues and requires surgical excision.
Answer E: Viral infection describes herpes simplex virus which would present with vesicular lesions and neurogenic pain. These patients can be treated with valacyclovir as well as gabapentin for neuropathic pain.
Bullet Summary:
Cherry angiomas are benign capillary proliferations that appear as cherry red macules/papules.
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https://step2.medbullets.com/testview?qid=210076
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206
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A 23-year-old woman is admitted to the inpatient psychiatry unit after her boyfriend reported she was “acting funny and refusing to talk.” The patient’s boyfriend states that he came home from work and found the patient sitting up in bed staring at the wall. When he said her name or waved his hand in front of her, she did not respond. When he tried to move her, she would remain in whatever position she was placed. Her temperature is 99°F (37.2°C), blood pressure is 122/79 mmHg, pulse is 68/min, and respirations are 12/min with an oxygen saturation of 98% on room air. The patient is lying on the bed with her left arm raised and pointing at the ceiling. She resists any attempt to change her position. The patient remains mute and ignores any external stimuli. The patient’s medical history is significant for depression. She was recently switched from phenelzine to fluoxetine. Which of the following is the most appropriate initial therapy?
|
{
"A": "Benztropine",
"B": "Electroconvulsive therapy",
"C": "Haloperidol",
"D": "Lorazepam",
"E": ""
}
|
D
|
The patient has a history of depression and is presenting with decreased motor activity, waxy flexibility, lack of response to external stimuli, and mutism, suggesting the diagnosis of catatonia. Catatonia should initially be treated with benzodiazepines like lorazepam.
Catatonia is a state of psychomotor immobility and apathy that is associated with a mood disorder or psychosis. The diagnosis is made clinically by having at least 3 of the following symptoms: stupor (no psychomotor activity), negativism (no response to external stimuli), catalepsy (muscle rigidity in a position against gravity), waxy flexibility (maintaining positioning placed by the examiner), mutism, echolalia (mimicking speech), echopraxia (mimicking movements), stereotypy, grimacing, and non-purposeful agitation or mannerisms. Initial treatment involves benzodiazepines for symptomatic relief. If the patient is unresponsive to benzodiazepines, electroconvulsive therapy (ECT) can be used.
Francis reviews the evidence regarding the treatment of patients with catatonia. He discusses how benzodiazepines can be used with rapid improvement in symptoms. He recommends electroconvulsive therapy in refractory cases.
Incorrect Answers:
Answer A: Benztropine and IV diphenhydramine can be used to treat an acute dystonic reaction. Dystonic reactions present as involuntary spasms or sustained contractions of the face, neck, torso, pelvis, extremities, and larynx. Medications that block dopamine D2 receptors, such as neuroleptics and antiemetics, carry the greatest risk.
Answer B: Cyproheptadine is a serotonin antagonist that may be part of the treatment for serotonin syndrome. Serotonin syndrome may occur as a result of the simultaneous use of monoamine oxidase inhibitors (MAOIs), selective serotonin reuptake inhibitors (SSRIs), or serotonin-norepinephrine reuptake inhibitors (SNRIs). It presents with myoclonus, hyperthermia, flushing, tachycardia, and delirium.
Answer C: Electroconvulsive therapy is an effective treatment for catatonia but would be considered 2nd line to benzodiazepines for refractory cases.
Answer D: Haloperidol is an antipsychotic, which may worsen catatonia. It can cause neuroleptic malignant syndrome, which can mimic catatonia.
Bullet Summary:
Catatonia can present in patients with a history of mood disorders and psychosis with symptoms of decreased motor activity, rigid posture, and mutism, and should be treated initially with a benzodiazepine.
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https://step2.medbullets.com/testview?qid=210373
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207
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A 15-year-old boy presents to his pediatrician after an appendectomy 1 week ago. The patient denies any abdominal pain, fevers, chills, nausea, vomiting, diarrhea, or constipation. He eats solids and drinks liquids without difficulty. He is back to playing basketball for his school team without any difficulty. His urine appears more amber than usual but he suspects dehydration. His temperature is 98.6°F (37°C), blood pressure is 110/70 mmHg, pulse is 76/min, and respirations are 15/min. His physical exam is unremarkable. The laparoscopic incision sites are all clean without erythema. The pediatrician orders a urinalysis, which is notable for the following. Urine: Epithelial cells: Scant Glucose: Negative Protein: 3+ WBC: 3/hpf Bacteria: None Leukocyte esterase: Negative Nitrites: Negative The patient is told to return in 3 days for a follow-up appointment; however, his urinalysis at that time is similar. Which of the following is the most appropriate next step in management?
|
{
"A": "CT scan abdomen and pelvis with contrast",
"B": "Renal biopsy",
"C": "Repeat urinalysis",
"D": "Urine dipstick in the morning and in the afternoon",
"E": ""
}
|
D
|
This patient is found to have proteinuria on urinalysis in the absence of clinical symptoms or signs of nephrotic syndrome. Given the likely diagnosis of transient proteinuria, the most appropriate next step is to repeat the urine dipstick in the morning and in the afternoon.
Transient proteinuria can be due to febrile illnesses, seizures, strenuous exercise, emotional stress, serious illnesses like heart failure, and abdominal surgery. A detailed workup is not needed if the clinical story is clear, but an orthostatic test can be completed. One way to do this is to assess the urine dipstick in the morning and in the afternoon. Another way requires the patient to collect urine at multiple times throughout the day. A diagnosis is confirmed if the morning sample is protein-free but the evening sample contains protein. In general, pediatric patients with orthostatic proteinuria should have under 1 gram of protein in a full 24 hours. Treatment is with reassurance because this condition usually resolves by itself.
Ingold and Bhatt review the evidence regarding the diagnosis and treatment of orthostatic proteinuria in patients. They discuss how this condition is benign and typically occurs in adolescents. They recommend reassurance and supportive treatment.
Incorrect Answers:
Answer A: A CT scan of the abdomen and pelvis with contrast could assess for any anatomic obstruction and a possible post-renal cause of kidney dysfunction. It would be more prudent to obtain basic labs and a timed urinalysis before exposing a pediatric patient to radiation.
Answer B: Renal biopsy is indicated if the patient's clinical presentation is concerning for a glomerular or tubulointerstitial etiology for proteinuria. Patients will have edema, hematuria, or dysuria.
Answer C: Repeat urinalysis will not change the presence of proteinuria. Generally, a patient who has proteinuria should have a repeat urinalysis performed to rule out transient proteinuria. If the repeat urinalysis demonstrates proteinuria (as in this patient), then the diagnosis is unlikely to be transient proteinuria, and further workup is needed.
Answer E: Urine electrolytes and creatinine will assess the kidney's ability to concentrate urine and assess the etiology of acute kidney injury. Patients will present with oliguria or anuria.
Bullet Summary:
Consistent proteinuria in a child should by evaluated by performing a urinalysis in the morning and in the afternoon to see if proteinuria comes on toward the end of the day.
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https://step2.medbullets.com/testview?qid=210475
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208
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A 32-year-old man presents to the emergency department for evaluation of headache. His symptoms started last night and have persisted. He occasionally has migraine headaches, but he has not had a headache like this in the past. He reports associated nausea, vomiting, fevers, and neck pain. He has a medical history of asthma. His temperature is 100.4°F (38.0°C), blood pressure is 110/60 mmHg, pulse is 95/min, respirations are 17/min, and oxygen saturation is 98% on room air. On physical exam, he appears uncomfortable. Neurologic exam reveals no focal deficits. There is pain with passive neck flexion. No edema or rashes are noted. Lungs are clear to auscultation bilaterally. Lumbar puncture is performed and CSF results are obtained as shown below. Cerebrospinal fluid (CSF): Cell count: 175/mm^3 RBCs: 0/mm^3 Cl-: 119 mEq/L Glucose: 49 mg/dL Pressure: 150 mmH2O Total protein: 55 mg/dL Based on these results, which of the following is the most appropriate treatment regimen for this patient?
|
{
"A": "Acyclovir",
"B": "Ceftriaxone and vancomycin",
"C": "Ceftriaxone, vancomycin and steroids",
"D": "Supportive care and monitoring",
"E": ""
}
|
D
|
This patient with headache, fever, and neck stiffness has a presentation and CSF studies consistent with a diagnosis of viral or aseptic meningitis. Supportive care is the most appropriate management strategy for patients with viral meningitis.
Aseptic (viral) meningitis presents similarly to bacterial meningitis with neck stiffness, photophobia, fever, malaise, and flu-like symptoms. Patients should be worked up and treated as if they have bacterial meningitis until proven otherwise. CSF findings in aseptic meningitis show an elevated cell count (though typically < 300/mm^3 in contrast to bacterial meningitis), a normal or elevated protein, and a normal glucose. CSF should be sent for Gram stain and culture to confirm the diagnosis and rule out bacterial meningitis. Once the diagnosis has been confirmed, management of viral meningitis consists of supportive care and monitoring for complications such as seizures, cerebral edema, or SIADH.
Kohil et. al review viral meningitis. They discuss the pathophysiology, clinical manifestation and diagnosis. They recommend that most patients with viral meningitis be treated with supportive care.
Incorrect Answers:
Answer A: Acyclovir would be appropriate for suspected HSV or varicella encephalitis or meningitis. This patient with no RBCs in the CSF and no changes in mental status is not likely to have infection with HSV or varicella.
Answer B: Amphotericin and 5-flucytosine followed by long-term fluconazole is the appropriate management of cryptococcal meningitis. Cryptococcal meningitis presents similarly to bacterial and viral meningitis, almost exclusively in immunocompromised patients.
Answer C: Ceftriaxone and vancomycin would be appropriate if bacterial meningitis was suspected. Steroids are generally added if a bacterial source is likely. However, this patient has a presentation that is less concerning for bacterial meningitis, and CSF studies that are more consistent with aseptic meningitis.
Answer D: Ceftriaxone, vancomycin and steroids are an appropriate initial regimen for bacterial meningitis. Dexamethasone reduces inflammatory injury while patients are being treated with antibiotics.
Bullet Summary:
Viral or aseptic meningitis is managed with supportive care and monitoring.
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https://step2.medbullets.com/testview?qid=210854
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209
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A 70-year-old woman is brought to the emergency department by ambulance. She was found on the floor of her apartment after her neighbor called 911. She is confused and is unable to provide any history, but complains of generalized pain. Her temperature is 99.2°F (37.3°C), blood pressure is 129/64 mmHg, pulse is 63/min, respirations are 13/min, and oxygen saturation is 99% on room air. Physical exam reveals, a confused, ill-appearing woman. Lungs are clear to auscultation bilaterally. An electrocardiogram is obtained as shown in Figure A. Dipstick urinalysis is notable for 4+ blood and dark colored urine. Which of the following is the most appropriate next step in management?
|
{
"A": "Albuterol and IV fluid resuscitation",
"B": "Calcium gluconate",
"C": "IV fluid resuscitation",
"D": "Sodium polystyrene sulfonate",
"E": ""
}
|
B
|
This patient with confusion, dark urine, and peaked T waves on electrocardiogram in the setting of a prolonged time spent down likely has developed rhabdomyolysis with associated hyperkalemia. For patients with suspected hyperkalemia and electrocardiogram changes, the most appropriate next step in management is treatment with calcium gluconate
Rhabdomyolysis occurs when muscle cells lyse and release their intracellular contents. This can occur secondary to intense athletics, seizures, stimulant drug use, or a prolonged period of immobility. Lysis of muscle cells leads to release of potassium, myoglobin, purines, and other intracellular contents. Release of large amounts of myoglobin can result in renal impairment and myoglobinuria. On dipstick urinalysis, myoglobin causes a positive result for blood. Renal impairment further increases the risk for development of hyperkalemia. On ECG, hyperkalemia manifests with a "peaked" appearance of T waves, especially in the precordial leads. As hyperkalemia worsens, electrocardiogram changes progress to loss of P waves, QRS complex widening, and eventual sine wave rhythm. For patients with suspected hyperkalemia and characteristic changes noted on the electrocardiogram, the most appropriate immediate step in management is treatment with intravenous calcium gluconate. Calcium gluconate acts to stabilize cardiac myocyte membranes and prevent development of life-threatening arrhythmias.
Gupta et. al review rhabdomyolysis. They discuss the pathophysiology, clinical manifestations and diagnosis. They further detail complications that may arise such as hyperkalemia, and discuss respective management strategies.
Figure A demonstrates an electrocardiogram with features characteristic of hyperkalemia. Note the peaked appearance of the T waves in the precordial leads.
Incorrect Answers:
Answer A: Albuterol and IV fluid resuscitation may eventually be appropriate. Albuterol (a beta agonist) will act to shift potassium to the intracellular compartment. This patient's electrocardiogram changes warrant immediate treatment with calcium gluconate in order to stabilize cardiac myocyte membranes.
Answer C: Insulin, glucose, and IV fluid resuscitation are indicated in this patient. Insulin acts to shift potassium to the intracellular compartment, and fluid resuscitation is warranted for the patient's likely renal impairment. Calcium gluconate is the more immediate priority to prevent development of arrhythmia.
Answer D: IV fluid resuscitation is indicated for this patient with likely renal impairment. However, calcium gluconate is the more immediate priority to address this patient's hyperkalemia and prevent development of arrhythmia.
Answer E: Sodium polystyrene is an oral potassium binder that increases GI excretion of potassium. It may be appropriate to treat mild hyperkalemia in some patients. It takes a prolonged amount of time to have any significant effect.
Bullet Summary:
For patients with suspected hyperkalemia and characteristic changes noted on ECG, the most appropriate immediate step in management is treatment with intravenous calcium gluconate.
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https://step2.medbullets.com/testview?qid=210867
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210
|
A 31-year-old man presents to the emergency department for fever, malaise, and cough. For the last week, his cough has been progressively worsening, and he has been noticing blood in his sputum. He denies any recent travel or sick contacts and infrequently smokes cigarettes. Approximately 5 weeks ago, he presented with similar symptoms and was found to have a right upper lobe lung infiltrate, a CD4 count of 40/mm^3, and an HIV viral load of 115,000 copies/mL. He was appropriately treated and discharged home. Four weeks after initiation of treatment, his CD4 count was over 400/mm^3 and HIV viral load was negligible. His temperature today is 102°F (38.9°C), blood pressure is 130/90 mmHg, pulse is 100/min, and respirations are 20/min. A radiograph of the chest demonstrates new nodules in the left upper lobe and hilar adenopathy. Which of the following is the most appropriate next step in management?
|
{
"A": "Continue current anti-retroviral treatment, antimicrobial, and anti-tuberculoid therapies",
"B": "Determine drug sensitivities against the patient’s pulmonary infection",
"C": "Discontinue antimicrobial treatment",
"D": "Obtain a D-dimer level",
"E": ""
}
|
A
|
This patient with recently diagnosed HIV and tuberculosis infection (upper lung lobe infiltrate) is presenting with worsening symptoms after being appropriately treated. Worsening of symptoms after initiation of these therapies is concerning for immune reconstitution inflammatory syndrome (IRIS), which is managed by continuing current combined antiretroviral medications, antibiotics for opportunistic infections and symptom management.
IRIS describes a paradoxical worsening of a patient's underlying infection after initiating antiretroviral therapy for patients with HIV. IRIS can also occur in HIV-uninfected patients with tuberculosis or leprosy who are started on antimycobacterial treatment. The pathogenesis of IRIS is unclear, but in patients with HIV, antiretroviral therapy increases the amount of CD4+ T-helper cells, which can lead to an exaggerated inflammatory response (e.g., increased cytokine release) towards the infection. Thus, there is a paradoxical worsening of the infection symptoms. When patients have a paradoxical worsening of their symptoms in the setting of starting their antiretroviral therapy, the therapy should be continued with symptomatic management (acetaminophen for fever).
Nelson et al review IRIS. They note it is seen in patients with HIV. They recommend antiretroviral therapy and antibiotics for bacterial infections.
Incorrect Answers:
Answer B: Determining drug sensitivities against the patient’s pulmonary infection would be of low diagnostic utility since IRIS best explains his current clinical presentation.
Answer C: Discontinuing antimicrobial treatment would not be appropriate since the patient has findings concerning for tuberculosis (upper lobe lung infiltrate), and lack of treatment can lead to progression of his infection.
Answer D: Obtaining a D-dimer level is only indicated in low-risk patients for pulmonary embolism by Wells criteria.
Answer E: Starting high-dose glucocorticoid treatment and discontinuing antiretroviral therapy would not be appropriate since discontinuing his antiretroviral therapy would not control his HIV infection, which would place him at greater risk of acquiring opportunistic infections. Corticosteroid use is part of symptom management as it decreases the inflammatory response.
Bullet Summary:
Immune reconstitution inflammatory syndrome (IRIS) can result in worsening of infectious symptoms and is managed by continuing antiviral therapy with symptomatic treatment.
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https://step2.medbullets.com/testview?qid=214791
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211
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A 44-year-old homeless man presents to the emergency department after being stabbed multiple times in the abdomen. The patient is intoxicated and is unable to offer further history. His temperature is 97.5°F (36.4°C), blood pressure is 92/52 mmHg, pulse is 145/min, respirations are 33/min, and oxygen saturation is 90% on room air. He is intubated to protect his airway, given 2 units of packed red blood cells, and sent to the operating room for an exploratory laparotomy. The patient is subsequently admitted to the intensive care unit. He is extubated the next day and appears well. His vitals are within normal limits. Physical exam reveals sparse hair that is falling out throughout the patient’s body. He has a rash by the corners of his mouth. The patient has multiple loose bowel movements and on day 6 the patient’s surgical wound does not appear to be healing. It is held together only by the sutures with minimal underlying healing. Which of the following is most likely deficient in this patient?
|
{
"A": "Thiamine",
"B": "Vitamin C",
"C": "Zinc",
"D": "Riboflavin",
"E": ""
}
|
C
|
This homeless patient who likely has poor nutritional status presents with angular cheilitis, sparse hair that is falling out, diarrhea, and poor wound healing, all of which are suggestive of zinc deficiency.
Zinc is involved in many physiologic processes and is an important mineral to include in the diet. Zinc deficiency is common in patients with poor nutritional status such as the homeless, individuals living in developing nations without access to food, and patients with eating disorders. Many malabsorptive conditions can cause zinc deficiency including steatorrhea and chronic pancreatitis. Zinc deficiency presents with impaired wound healing and impaired immune function. Other symptoms suggestive of zinc deficiency include xerosis, alopecia, stomatitis, oral ulceration, angular cheilitis, impaired vision (night blindness), impaired smell/taste, diarrhea, and anorexia. The treatment of zinc deficiency involves zinc supplementation and workup for any other nutritional deficiencies.
Nagata etc al. study the incidence of zinc deficiency among younger patients with anorexia nervosa. The authors find that men and women are both equally likely to have zinc deficiency when admitted. The authors recommend screening all patients with eating disorders for zinc deficiency.
Incorrect Answers:
Answer A: Riboflavin deficiency may present with angular cheilitis, stomatitis, and a non-specific rash. The treatment involves supplementing or consuming foods with riboflavin; however, it is rare in the developed world to be riboflavin deficient (due to fortified foods) and would not cause such significant wound healing issues as in this patient.
Answer B: Thiamine deficiency is common in alcoholics and can cause Wernicke-Korsakoff syndrome, which presents with ataxia, nystagmus, and ophthalmoplegia in addition to amnesia. The treatment involves the administration of high-dose thiamine.
Answer C: Vitamin C deficiency causes scurvy, which presents with easy fractures, bleeding gums or loose teeth, delayed wound healing, and perifollicular hemorrhages. It is common in the homeless and alcoholics. Treatment involves vitamin C replacement or a diet rich in fruits and vegetables.
Answer D: Vitamin D deficiency is common in the homeless, alcoholics, or those who suffer from steatorrhea (such as chronic pancreatitis or Crohn disease). It presents with weak, soft bones (osteomalacia/osteoporosis), and hypocalcemia which may present with paresthesias and tetany. Treatment involves replacement of vitamin D.
Bullet Summary:
Zinc deficiency presents with poor wound healing, hair loss, infertility, diarrhea, anorexia, and impaired immune function.
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https://step2.medbullets.com/testview?qid=214943
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212
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A 51-year-old man presents to the emergency department complaining of fever and a cough with yellow-green sputum for the past 3 days. He denies any hemoptysis, facial pain, rhinorrhea, or night sweats. The patient reported similar symptoms 2 months ago. Chest radiograph performed at the time was notable for a right middle lobe consolidation. He was diagnosed with lobar pneumonia and completed a 7-day course of antibiotics with complete resolution of his symptoms. He has no other significant medical history and does not take any medications. He has smoked 1 pack of cigarettes a day for 35 years and drinks 3 beers per week. He is sexually active with his wife. His temperature is 101.7°F (38.7°C), blood pressure is 127/85, pulse is 102/min, and respirations are 22/min. Physical exam is notable for decreased breath sounds on the right side without wheezing and increased dullness to percussion on the right side. A chest radiograph is ordered and reveals a consolidation in the right middle lobe. Which of the following is the most appropriate next step in management?
|
{
"A": "Interferon-gamma release assay",
"B": "CT of the chest without contrast",
"C": "Barium swallow",
"D": "Serum immunoglobulin levels",
"E": ""
}
|
B
|
This patient's presentation with recurrent pneumonia in the same anatomical location is concerning for an anatomic abnormality. Given his history of heavy smoking, lung cancer should be ruled out with a chest CT with possible subsequent bronchoscopy for tissue biopsy.
Recurrent pneumonia can be classified either as those confined to 1 anatomical location of the lung or those involving different portions of the lung. If recurrent pneumonia is limited to a single region, the patient should be evaluated for an anatomic obstruction, such as a mass or mucous plug. Obstruction will hinder mucociliary clearance and allow for the proliferation of bacteria, leading to recurrent infections. The most concerning etiology of such an obstruction is a tumor causing external bronchial compression. Thus, patients should be screened with a chest CT to rule out lung cancer in these cases. If lesions are identified on CT, subsequent bronchoscopy or CT-guided biopsy may be warranted. Treatment may involve radiotherapy, chemoimmunotherapy, or surgery depending on the underlying malignancy. Other causes of recurrent pneumonia limited to an anatomical region include recurrent aspiration secondary to tracheoesophageal disorders or seizures.
Purysko et al. discuss the role of contrast enhancement in chest CTs. The authors find common indications for contrast-enhanced chest CTs include investigation for pulmonary embolism, pleural pathology, or hilar pathology. The authors recommend against the regular use of contrast enhancement in chest CTs outside of selected indications as they rarely provide additional diagnostic benefits while subjecting the patient to the risk of adverse effects with contrast agents.
Incorrect Answers:
Answer A: Barium swallow is often done to investigate anatomical abnormalities of the upper gastrointestinal tract such as tracheoesophageal fistula or Zenker diverticulum. These can increase the risk of aspiration and lead to recurrent pneumonia. In a patient with positive risk factors for cancer, chest CT to rule out malignancy would be the most appropriate next step.
Answer C: Human immunodeficiency virus (HIV) can cause secondary immunodeficiency, which can predispose patients to recurrent infections. These recurrent pneumonias would be expected to be in different regions of the lung and not anatomically confined.
Answer D: Interferon-gamma release assay can be used to diagnose tuberculosis (TB). Reactivation of TB will present clinically with fever, cough, hemoptysis, and night sweats. Chest radiography will commonly reveal an upper lobe infiltrate.
Answer E: Serum immunoglobulin levels would be an appropriate next step to diagnose primary immunodeficiencies such as common variable immunodeficiency or other antibody defects. This would present with multiple lung infections in different regions of the lung. Moreover, these patients would be expected to have other infections such as sinusitis, otitis, and gastrointestinal infections.
Bullet Summary:
Recurrent pneumonia in the same anatomical region should be worked up with a CT with subsequent bronchoscopy and biopsy to rule out malignancy.
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https://step2.medbullets.com/testview?qid=214961
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213
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A 27-year-old man presents to the emergency department with altered mental status. He was running a marathon but became confused halfway through the race. He arrives unable to coherently answer questions and is not sure where he is. He has a history of a seizure disorder. His temperature is 105°F (40.6°C), blood pressure is 116/68 mmHg, pulse is 167/min, respirations are 29/min, and oxygen saturation is 99% on room air. Physical exam reveals a confused man who is moving all 4 extremities and is protecting his airway. During the exam, he develops a tonic-clonic seizure, which lasts 1 minute and then terminates on its own. The patient is given intravenous fluids, and basic laboratory studies are drawn and pending. A urine dipstick is positive for red blood cells. Which of the following is most likely to be seen on laboratory testing?
|
{
"A": "Hyponatremia",
"B": "Hyperkalemia",
"C": "Hyperuricemia",
"D": "Hypocalcemia",
"E": ""
}
|
D
|
This patient is presenting after running a marathon with hyperthermia and altered mental status suggestive of heatstroke. In the setting of his recent exertion, tonic-clonic seizure, and urine dipstick positive for red blood cells, he is likely suffering from rhabdomyolysis, which most commonly causes hypocalcemia.
Rhabdomyolysis occurs when there is a breakdown of the muscle cells. It can occur with exertion (such as marathon running or weight lifting), seizures (from prolonged and intense contraction of the muscles), cocaine use, lightning strikes, electrical injuries, and crush injuries. Damage to muscle cells most commonly causes hypocalcemia from the deposition of calcium in necrotic muscle cells as well as calcium sequestration by the muscle sarcoplasmic reticulum. Symptoms of hypocalcemia include perioral numbness and tetany, altered mental status, and seizure. ECG manifestations of hypocalcemia include QT prolongation. There is no treatment needed for hypocalcemia in rhabdomyolysis unless it is severe or is causing symptoms such as seizure or ECG changes. The management of rhabdomyolysis involves aggressive IV fluid administration titrated to urine output in order to prevent myoglobin nephrotoxicity. Myoglobin causes the classic false-positive finding of red blood cells on urine dipstick given the cross-reactivity of myoglobin and hemoglobin on this test.
Giannoglou et al. review the pathophysiology and diagnosis of rhabdomyolysis. The authors find that hypocalcemia is the most common electrolyte derangement seen in rhabdomyolysis. The authors recommend carefully monitoring ionized calcium in patients with rhabdomyolysis.
Incorrect Answers:
Answer A: Hyperkalemia is a common electrolyte derangement that occurs in rhabdomyolysis and can cause life-threatening dysrhythmias. Initial ECG findings suggestive of hyperkalemia include peaked T waves and QRS widening. The management of hyperkalemia involves the administration of calcium chloride to stabilize cardiac membranes followed by insulin, albuterol, and bicarbonate. Severe/refractory hyperkalemia can be treated with dialysis, but this is usually not needed in rhabdomyolysis. Hyperkalemia is less common when compared to hypocalcemia in rhabdomyolysis and does not cause seizures.
Answer B: Hyperphosphatemia is common in rhabdomyolysis and occurs secondary to the release of phosphorus from damaged muscle cells. Hyperphosphatemia does not usually require treatment in rhabdomyolysis, though phosphate restriction and phosphate binders can be administered. Hyperphosphatemia can rarely lead to seizures, though this is uncommon.
Answer C: Hyperuricemia is possible in rhabdomyolysis, occurs secondary to the release of purines from injured muscle cells, and is worsened by acute kidney injury which is common in rhabdomyolysis. The treatment of hyperuricemia in rhabdomyolysis involves IV fluids, rasburicase, and allopurinol (which works slowly).
Answer E: Hyponatremia may occur after running a marathon where the individual sweats out sodium, chloride, and water but rehydrates with only water. While this is possible in this patient and his seizure could reflect a hyponatremic seizure (which usually would not spontaneously resolve and requires hypertonic saline), there is concrete evidence of rhabdomyolysis with the positive urine dipstick for red blood cells.
Bullet Summary:
Rhabdomyolysis can cause hyperkalemia, hyperphosphatemia, and hypocalcemia (the most common electrolyte disturbance).
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https://step2.medbullets.com/testview?qid=214967
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214
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A 17-year-old girl presents to the clinic reporting 7 months without a menstrual period. Menarche was at age 12 and she had regular periods up until 2 years ago. At that time, her periods became less regular until around 7 months ago when they ceased altogether. She is otherwise healthy, participates in multiple school sports teams, and has been training rigorously for upcoming competitions. She denies alcohol use, smoking, and recreational drugs. She is not sexually active and does not take oral contraceptives. Her temperature is 36.7°C (98°F), blood pressure is 121/80 mmHg, pulse is 62/min, respirations are 11/min, oxygen saturation is 100% on room air, and BMI is 20 kg/m^2. Her pelvic exam reveals an anteverted uterus, no adnexal masses, a normal-appearing cervix with no cervical motion tenderness, and normal vaginal anatomy. Which of the following is the most likely cause of this patient's amenorrhea?
|
{
"A": "Hypothyroidism",
"B": "Functional hypothalamic amenorrhea",
"C": "Anorexia nervosa",
"D": "Polycystic ovarian syndrome",
"E": ""
}
|
B
|
This patient presenting with secondary amenorrhea (defined as 6 or more consecutive months without menstruation in women who have passed menarche) and a history of rigorous exercise most likely has functional hypothalamic amenorrhea.
Functional hypothalamic amenorrhea is a condition in which relative caloric deficiency (whether through severe caloric restriction, increased energy expenditure, or increased stress) leads to functional disruption of the normal pulsatile release of gonadotropin-releasing hormone (GnRH). This in turn leads to decreased levels of follicle-stimulating hormone (FSH) and luteinizing hormone (LH), disruption to estrogen levels, and amenorrhea. A common associated clinical presentation is known as the "female athlete triad", which includes decreased calorie availability or increased energy expenditure through exercise, decreased bone mineral density due to a decrease in estrogen levels, and menstrual dysfunction. Treatment includes increasing caloric intake, behavioral therapy as needed, and possible estrogen replacement therapy.
Ackerman et al. reviews the role of estrogen replacement in improving bone mineral density in patients with functional hypothalamic amenorrhea. The authors find that spine and femoral neck bone mineral density z-scores significantly increased with estrogen replacement. The authors recommend the use of transdermal estradiol over 12 months in improving bone mineral density in patients with functional hypothalamic amenorrhea.
Incorrect Answers:
Answer A: Anorexia nervosa will often manifest with secondary amenorrhea in women. This patient has a normal BMI and no history of disordered eating. The mechanism of amenorrhea in the setting of anorexia nervosa relates to the same hypothalamic-pituitary-ovarian axis at play in functional hypothalamic amenorrhea wherein the state of energy deficiency from inadequate caloric intake disrupts normal pulsatile GnRH secretion, leading to decreased FSH, LH, estrogen levels, and subsequent amenorrhea.
Answer C: Hypothyroidism is a cause of secondary amenorrhea wherein abnormal thyroid function can lead to altered levels of sex hormone-binding protein, prolactin, and gonadotropin-releasing hormone, thus causing menstrual dysfunction. This patient does not present with other signs of hypothyroidism, such as fatigue, sensitivity to cold, dry skin, muscle weakness, weight gain, constipation, joint stiffness, or thinning hair.
Answer D: Polycystic ovary syndrome is a condition often associated with obesity in which hyperinsulinemia or insulin resistance is hypothesized to alter the hypothalamus feedback response, leading to the increased luteinizing hormone to follicle-stimulating hormone ratio, increased androgen levels, and decreased rate of follicular maturation leading to unruptured follicles. Patients will often present with amenorrhea or oligomenorrhea, hirsutism, acne, and decreased fertility.
Answer E: Pregnancy is a cause of secondary amenorrhea that is less likely in this patient given her lack of sexual history and other associated symptoms such as decreased appetite, nausea, and insomnia. A beta-human chorionic gonadotropin (beta-hCG) test should always be part of the workup for secondary amenorrhea.
Bullet Summary:
Functional hypothalamic amenorrhea is a condition in which caloric restriction, increased energy expenditure through exercise, and/or increased stress leads to a disrupted pulsatile secretion of gonadotropin-releasing hormone with the downstream effect of amenorrhea.
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https://step2.medbullets.com/testview?qid=214976
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215
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A 65-year-old man presents to his primary care physician for a routine appointment. He has no concerns. His past medical history is significant for human immunodeficiency virus (HIV) infection, diagnosed 15 years ago. The patient is intermittently compliant with his antiretroviral therapy (ART). His temperature is 99.0°F (37.2°C), blood pressure is 130/84 mmHg, pulse is 92/min, and respirations are 11/min. His most recent lab work showed a cluster of differentiation CD4 count of 150 cells/µL. He received a dose of the 13-valent pneumococcal vaccine and a dose of the 23-valent pneumococcal vaccine 15 years ago, as well as a second dose of the 23-valent pneumococcal vaccine 10 years ago. In addition to encouraging greater compliance with his ART, which of the following is indicated in this patient?
|
{
"A": "Azithromycin and pneumococcal vaccine",
"B": "Trimethoprim-sulfamethoxazole and varicella vaccine",
"C": "Trimethoprim-sulfamethoxazole and zoster vaccine",
"D": "Trimethoprim-sulfamethoxazole and pneumococcal vaccine",
"E": ""
}
|
D
|
This patient with HIV and a CD4 count of 150 cells/μL requires trimethoprim-sulfamethoxazole (TMP-SMX) prophylaxis and another dose of the 23-valent pneumococcal vaccine.
All HIV patients with a CD4 count < 200 cells/μL require TMP-SMX as prophylaxis against Pneumocystis jirovecci pneumonia. Patients with CD4 counts < 100 cells/μL also require TMP-SMX as prophylaxis against toxoplasmosis. HIV patients require a dose of the 23-valent pneumococcal vaccine at age 65. Patients should initially receive the 13-valent pneumococcal vaccine, followed by the 23-valent pneumococcal vaccine 8 weeks later, 5 years later, and at age 65. Compliance with ART is also critical in patients with HIV.
Kaplan et al. discuss recommendations for the prevention of opportunistic infections in HIV-infected adults. The authors find that daily prophylaxis with TMP-SMX is an appropriate regimen for the prevention of Pneumocystis pneumonia. The authors recommend dapsone, atovaquone, or pentamidine for patients that cannot receive TMP-SMX.
Incorrect Answers:
Answer A: Azithromycin is used as prophylaxis against Mycobacterium avium complex (MAC) in patients with a CD4 count < 50 cells/μL that has not been started on ART. Since this patient has a CD4 count of 150 cells/μL, azithromycin is not indicated at this time.
Answer B: Azithromycin is used as prophylaxis against Mycobacterium avium complex (MAC) in patients with a CD4 count < 50 cells/μL that has not been started on ART. This patient should not receive the zoster vaccine as it is a live vaccine and is contraindicated in immunocompromised patients.
Answer D: Although this patient does require TMP-SMX as prophylaxis against Pneumocystis pneumonia, he should not receive the varicella vaccine as it is a live vaccine and therefore contraindicated in immunocompromised patients.
Answer E: Although this patient does require TMP-SMX as prophylaxis against Pneumocystis pneumonia, he should not receive the zoster vaccine as it is a live vaccine and therefore contraindicated in immunocompromised patients.
Bullet Summary:
Patients with a CD4 count < 200 cells/μL require prophylaxis with TMP-SMX and all patients with HIV should receive a dose of the 23-valent pneumococcal vaccine at age 65.
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https://step2.medbullets.com/testview?qid=215026
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216
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A 59-year-old woman comes to the clinic due to a 3-month history of “always feeling the urge to urinate” as well as vaginal pruritis. She states that she has had involuntary loss of urine about 4 times each day over the past 3 months. It is not associated with coughing or sneezing. Menopause occurred at age 52. She has a history of chlamydial infection in her 20's and has had 3 urinary tract infections over the past year. The patient has not been sexually active with her husband due to pain with intercourse. She has no other significant medical history and does not take any medications. Her temperature is 98.6°F (37.0°C), blood pressure is 115/70 mmHg, pulse is 70/min, and respirations are 12/min. On physical examination, the vulvar skin is pale and atrophic with reduced elasticity and multiple areas of petechiae. The vaginal mucosa also has a loss of rugae and several areas of friable irritation. There is minimal clear vaginal discharge. Urinalysis is normal and fecal occult blood test is negative. Pelvic ultrasound reveals a small, retroverted uterus. Which of the following is the most appropriate next step in management?
|
{
"A": "Metronidazole",
"B": "Nitrofurantoin",
"C": "Vaginal moisturizers",
"D": "Topical clobetasol",
"E": ""
}
|
C
|
This postmenopausal patient is presenting with vulvovaginal dryness and irritation, dyspareunia, urinary incontinence, and recurrent urinary tract infections, likely due to genitourinary syndrome of menopause (GSM). The most appropriate initial treatment is symptomatic relief with vaginal moisturizers and lubricants.
Reduced estrogen levels after menopause lead to vulvovaginal atrophy by causing reduced blood flow and collagen content in vulvovaginal tissues. Patients typically have thin vulvar skin and loss of vaginal tissue pliability. The bladder and urethral epithelium may also atrophy leading to dysuria and urinary frequency. Atrophic tissue becomes thin, dry, and susceptible to injury. The first line of treatment is vaginal moisturizers and lubricants. If this does not improve symptoms, the next step in treatment is vaginal estrogen to help restore blood flow in vulvovaginal tissues. Finally, hormone replacement therapy is indicated if symptoms are refractory to all other modalities.
Bhupathiraju et al. studied the association between vaginal estrogen and chronic disease risk. The authors found no association between low-dose vaginal estrogen and cardiovascular disease, cancer, and hip fractures over an 18-year period. The authors recommended that low-dose vaginal estrogen can be used indefinitely without concomitant progestin therapy.
Incorrect Answers:
Answer A: Metronidazole is the treatment for trichomoniasis or bacterial vaginosis. While patients with trichomoniasis can present with cervical petechiae and punctate hemorrhages, they typically also have frothy green discharge (absent in this patient). While patients with bacterial vaginosis can also have vaginal discharge, the discharge is typically malodorous and symptoms of pruritis are generally absent.
Answer B: Nitrofurantoin is the treatment of choice for urinary tract infections. While this patient has increased urinary frequency and a history of recurrent urinary tract infections, her normal urinalysis makes the diagnosis of urinary tract infection unlikely.
Answer C: Topical clobetasol cream is the treatment for lichen sclerosis. While lichen sclerosis can present with pain with intercourse and vulvar pruritis, patients often have plaques that disrupt the normal vulvar architecture. Lichen sclerosis does not affect the vaginal tissues.
Answer D: Topical estrogen is the treatment of choice for cases of vulvovaginal atrophy resistant to treatment with vaginal moisturizers and lubricants. This patient should first be trialed on vaginal moisturizers and lubricants.
Bullet Summary:
Vulvovaginal atrophy is initially treated with vaginal moisturizers and lubricants.
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https://step2.medbullets.com/testview?qid=215032
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217
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A 31-year-old man presents to clinic for evaluation of a 3-year history of infertility. He has no significant medical history and takes no medications. He exercises twice a day, often with heavy weightlifting, and eats a high-protein diet. He reports occasional alcohol use and remote marijuana use. His temperature is 99.5°F (37.5°C), blood pressure is 148/90 mmHg, pulse is 84/min, and respirations are 15/min. He is sexually active with his wife and has no history of sexually transmitted infections. Physical exam reveals small testes and a receding hairline. He also has palpable tissue underneath his nipples bilaterally. His muscle tone is normal in his upper and lower extremities bilaterally. His laboratory values are below:
Serum:
Creatinine: 1.3 mg/dL
Glucose: 110 mg/dL
Total bilirubin: 0.8 mg/dL
Aspartate aminotransferase (AST, GOT): 410 U/L
Alanine aminotransferase (ALT, GPT): 275 U/L
Hemoglobin: 12 g/dL
Leukocyte count: 5,300/mm^3
Platelet count: 250,000/mm^3
Which of the following is the most likely cause of this patient’s infertility?
|
{
"A": "Klinefelter syndrome",
"B": "Cryptorchidism",
"C": "Anabolic steroid use",
"D": "Excess growth hormone use",
"E": ""
}
|
C
|
This patient with infertility is presenting with decreased testicular size, receding hairline, gynecomastia (palpable breast tissue), and transaminitis. This is most likely due to exogenous testosterone from anabolic (androgenic) steroid use.
Young people (especially athletes and heavy weightlifters) looking to improve their physical performance may rely on the use of anabolic steroids (testosterone, boldenone, and stanozolol). These steroids adversely impair endogenous testicular function, causing infertility secondary to decreased testicular size and sperm count. Furthermore, hepatic dysfunction and cardiac dysfunction can occur at high doses. Excess testosterone is converted to estradiol, leading to breast enlargement and signs of gynecomastia. Aggression and mood disturbances may also occur in patients with excessive anabolic steroid use. Finally, skin findings of anabolic steroid use include accelerated male pattern baldness and acne. Patients should be counseled on avoiding these agents.
Van Wagoner et al. study the chemical composition of products marketed as selective androgen receptor modulators (SARMs). The authors find that less than half of the analyzed products contained compounds in the amount listed on the label. The authors recommend that clinicians counsel athletes and bodybuilders that these products are often mislabeled, are not regulated, and have not been shown to be safe or effective.
Incorrect Answers:
Answer B: Cryptorchidism is the failure of testicular descent into the scrotum and typically manifests in infancy. While uncorrected cryptorchidism can be a cause of infertility, this is an unlikely diagnosis in a man with palpable testes. Furthermore, cryptorchidism would not explain this patient’s receding hairline or gynecomastia.
Answer C: Excess growth hormone use should be suspected because growth hormone can be taken exogenously to improve athletic performance and can present with hypertension. This typically also presents with hyperglycemia and enlarged hands and feet.
Answer D: Klinefelter syndrome is an inherited disorder that also presents with infertility, gynecomastia, and decreased testicular size. This disorder also causes mental impairment and would not explain the patient’s elevated aminotransferases.
Answer E: Myotonic dystrophy is a multi-system disorder that can also present with testicular atrophy, reduced fertility, and hair loss. Patients with myotonic dystrophy also have widespread muscular atrophy and weakness, as well as clinical features of myotonia (e.g., difficulty releasing a handshake).
Bullet Summary:
Anabolic steroid use in men can cause reduced fertility by suppressing endogenous testosterone activity, and presents with gynecomastia, testicular atrophy, accelerated male balding patterns, and hepatotoxicity.
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https://step2.medbullets.com/testview?qid=215034
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218
|
A 52-year-old man presents to the clinic with a left foot ulcer that he noticed 6 days ago. He has a history of obesity, hypertension, type 2 diabetes mellitus, and depression. His current medications include metformin, aspirin, rosuvastatin, lisinopril, and fluoxetine. He has a 25-pack-year smoking history and drinks 1 glass of wine a day. His temperature is 98.6°F (37.0°C), blood pressure is 115/70 mmHg, pulse is 70/min, and respirations are 12/min. On physical exam, he has a 1.2 x 1.7 cm ulcer on the plantar surface of his left metatarsal head. Which of the following tests will most appropriately assess this patient’s future risk of foot ulcers?
|
{
"A": "Knee reflex testing",
"B": "Monofilament testing",
"C": "Contrast-enhanced foot magnetic resonance imaging",
"D": "Ankle-brachial index",
"E": ""
}
|
B
|
This patient with a history of diabetes, hypertension, and obesity now presenting with a foot ulcer most likely has a diabetic foot ulcer. He should undergo monofilament testing to assess the subsequent risk of developing foot ulcers.
Diabetic neuropathy is the most common underlying cause of diabetic foot ulcers. The pathophysiology of diabetic foot ulcers is thought to be the loss of pain and pressure sensation, which leads to muscular imbalance and foot deformities. This subsequently decreases microcirculation and impairs the integrity of the skin, leading to the formation of foot ulcers. Diabetic foot ulcers, like other neuropathic ulcers, occur commonly under bony prominences in the foot. During monofilament testing, a 10-g monofilament is placed on the plantar surface of the foot at a right angle, and pressure is applied until the patient can no longer tolerate it or the filament buckles. Patients with diabetic neuropathy have a higher-pressure threshold due to loss of sensation, and this is a useful predictor of the severity of diabetic neuropathy and future foot ulcer formation. The management of diabetic neuropathy consists of tight glycemic control, weight loss, blood pressure control, exercise, preventing complications, and pain management with pharmacotherapy (serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, or gabapentinoid antiseizure medications).
Tesfaye et al. study the efficacy of various first-line medications for diabetic nephropathy including amitriptyline, duloxetine, pregabalin, or gabapentin. The authors found that there were no differences between any of the medications as monotherapy. The authors recommended adding combination pharmacotherapy for patients with painful diabetic neuropathy that do not respond to initial monotherapy.
Incorrect Answers:
Answer A: Ankle-brachial index is a calculation made in the assessment of peripheral arterial disease (PAD). While PAD can present with arterial ulcers, these are usually located at the tip of the toes and not the plantar surface. Furthermore, the ankle-brachial index does not accurately assess small vessel disease, which is associated with diabetic foot ulcers.
Answer B: Capillary refill time, when delayed, may suggest decreased limb perfusion. This is a nonspecific test, as decreased limb perfusion can be caused by peripheral arterial disease, volume depletion, or hypotension.
Answer C: Contrast-enhanced foot MRI is the most sensitive and specific test to identify soft tissue complications of acute osteomyelitis. This patient has no clinical features of osteomyelitis (fever, chills, or malaise, ulcer that probes to bone) and does not require imaging currently.
Answer D: Knee reflex testing is not useful in assessing diabetic neuropathy. While diabetic neuropathy can affect large nerve fibers in the lower extremities, it typically impairs ankle reflexes while sparing knee reflexes.
Bullet Summary:
Preventative measures for diabetic foot ulcers should focus on regular foot exams with monofilament testing to assess for diabetic neuropathy.
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https://step2.medbullets.com/testview?qid=215040
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219
|
A 4-year-old boy comes to the pediatrician with his mother with a 3-day history of cough and runny nose with decreased oral intake over the past 24 hours. His activity level has been normal and he has been attending school until this morning. He has no medical history or known allergies, but he has not received any of the recommended vaccines due to parental refusal. His temperature is 100.3°F (37.9°C), blood pressure is 98/62 mmHg, pulse is 85/min, respirations are 22/min, and oxygen saturation is 98% on room air. On examination, the child is fussy. Bilateral conjunctivae are injected, and there is redness on and around the tonsils. There is no lymphadenopathy. Faint rhonchi are heard at the lung bases bilaterally. Which of the following is the most appropriate next step in management?
|
{
"A": "Amoxicillin",
"B": "Obtain chest radiography and respiratory virus panel",
"C": "Supportive care with return precautions",
"D": "Administer antitoxin and toxoid vaccine",
"E": ""
}
|
C
|
This boy presenting with 3 days of progressive fever, rhinorrhea, cough, conjunctivitis, and tonsilar erythema most likely has viral pharyngitis. The appropriate treatment for this is supportive care with return precautions (instructing the mother to bring the child back to a physician if he becomes short of breath).
Viral pharyngitis in children is most often caused by adenovirus, though other viruses can cause the condition as well. The diagnosis is clinical, with a presentation of fever, rhinorrhea, conjunctivitis, sore throat, and cough. Features that can help distinguish viral pharyngitis from pneumonia include a lack of tachypnea, increased work of breathing, hypoxemia, or adventitial lung sounds. No additional testing or intervention is necessary. The illness is typically self-limited and resolves with supportive care.
Shapiro et al. study features predictive of group A streptococcal (GAS) pharyngitis in children. The authors found that among patients with features of viral illness, patients older than 11 years of age who did not have a fever, cervical lymphadenopathy, or tonsillar exudates were at the lowest risk for GAS. The authors recommend against testing low-risk children for GAS to avoid antibiotic treatment in patients merely colonized with GAS.
Incorrect Answers:
Answer A: Administering antitoxin and toxoid vaccine is the treatment for Corynebacterium diphtheriae infection. Although this child has not received his age-appropriate vaccinations, his presentation is not concerning for infection with diphtheria. C. diphtheriae infection presents with cervical lymphadenopathy and gray pseudomembranes on pharyngeal exam, neither of which this child has.
Answer B: Amoxicillin should be given in cases of group A streptococcal (GAS) pharyngitis. Before amoxicillin is prescribed, testing with Streptococcal rapid antigen detection testing should be performed. Additionally, rapid antigen detection testing is not indicated in this patient as she has a cough and does not have cervical lymphadenopathy, tonsillar exudates, or palatal petechiae. All of these findings are not typical of GAS pharyngitis.
Answer C: Influenza testing and oseltamivir are indicated if the child had myalgias or high fevers that would make influenza more likely and if he presented within 2 days of symptom onset. Oseltamivir is only approved for treating influenza in uncomplicated cases if started within this 2-day window from symptom onset. Exceptions to this 2-day guideline include adults greater than 65 years of age, pregnant women, residents of long-term care facilities, American Indians, persons with BMI greater than 40 kg/m^2, and those receiving immunosuppressive medications.
Answer D: Obtaining a chest radiograph and respiratory virus panel can be done when a lower respiratory infection such as bacterial pneumonia is expected. However, viral infections are much more common than bacterial pneumonia in this age group. Additionally, this patient is not tachypneic, does not have evidence of increased work of breathing, and is not hypoxemic, all of which make bacterial pneumonia less likely.
Bullet Summary:
Viral pharyngitis in children is a clinical diagnosis consisting of fever, rhinorrhea, conjunctivitis, cough, sore throat, and pharyngeal erythema, and is treated with supportive care.
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220
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A 2-month-old girl is brought to the pediatrician by her mother for a follow-up visit. The patient was born at 29 weeks gestation to a G1P1 mother. Her postnatal course was complicated by a prolonged neonatal intensive care unit stay for neonatal respiratory distress syndrome (NRDS). Since discharge from the hospital, her mother reports that the patient has been doing well without health problems. She has been gaining weight appropriately. Her temperature is 98.6°F (37.0°C), blood pressure is 80/50 mmHg, pulse is 120/min, and respirations are 25/min. The patient's mother asks the pediatrician about potentially delaying the 2-month vaccine doses due to the baby's medical history. Which of the following is the correct vaccination plan for this infant in terms of the vaccinations below?
- Diphtheria, Tetanus, and acellular Pertussis - DTaP
- Hepatitis A - HAV
- Hepatitis B - HBV
- Haemophilus influenzae type B conjugate - HiB
- Pneumococcal conjugate - PCV 13
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{
"A": "Delay all vaccines for 2 months due to the infant's history of NRDS",
"B": "Administer DTaP, HAV, HBV, HiB, PCV 13, poliovirus, and rotavirus vaccines",
"C": "Administer DTaP, HBV, HiB, PCV 13, poliovirus, and rotavirus vaccines",
"D": "Delay all vaccines for 2 months because the infant was born 2 months premature",
"E": ""
}
|
C
|
This 2-month-old girl has a history of prematurity (born at 29 weeks gestation) complicated by a NICU stay for NRDS but is healthy at this time. It is recommended that she receive all vaccines (DTaP, HBV, HiB, PCV 13, poliovirus, and rotavirus vaccines) as scheduled during this visit.
Premature infants can safely be vaccinated on the regular schedule against serious infections. A history of both prematurity and respiratory disease makes a patient more at risk for these serious infections, increasing the importance of vaccinations. The regular vaccine schedule recommends the following vaccines at 2 months of age: DTaP (inactivated), HBV (subunit), HiB (inactivated), PCV 13 (inactivated), poliovirus (inactivated), and rotavirus (live-attenuated). The first dose of the HBV (subunit) vaccine is still given during the first 24 hours of life unless the child is born with a birth weight of < 2000 grams (4 pounds 6 ounces).
Saari et al. discuss the recommendations of the American Academy of Pediatrics Committee on Infectious Diseases for the immunization of preterm infants. The authors find that preterm infants are less likely to receive recommended vaccines on time. The authors recommend also administering the influenza vaccine beginning at 6 months of age during the influenza season.
Incorrect Answers:
Answer A: Administering DTaP, HAV, HBV, HiB, PCV 13, poliovirus, and rotavirus vaccines is incorrect as this answer choice includes the vaccine for the hepatitis A virus. The first dose of this vaccine is given at 12-24 months of age.
Answer B: Administering DTaP, HBV, HiB, PCV 13, and poliovirus vaccines is incorrect as this answer choice is missing the rotavirus vaccine. Despite being premature and having a history of NRDS, live vaccines are safe to administer on schedule to this infant.
Answer D: Delaying all vaccines for 2 months due to the infant's history of NRDS is incorrect as while this child has a history of NRDS, she is currently healthy. It is safe to administer all vaccines on the regular schedule to this patient.
Answer E: Delaying all vaccines for 2 months because the infant was born 2 months premature is incorrect as it is not recommended that previously premature infants, with or without a perinatal complication such as NRDS, delay vaccines to account for the discrepancy between gestational and chronologic age.
Bullet Summary:
Children born with a history of prematurity, with or without health complications in their early life secondary to their prematurity, should receive all recommended vaccines as scheduled.
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A 47-year-old woman presents to the clinic with 3 weeks of increased thirst and urination. She has a history of obesity, hypertension, and depression for which she takes losartan and sertraline. She has smoked 1 pack of cigarettes per day for 30 years. Her temperature is 99.5°F (37.5°C), blood pressure is 148/90 mmHg, pulse is 84/min, and respirations are 15/min. Physical exam is unremarkable, including no costovertebral or suprapubic tenderness to palpation. Laboratory studies are performed and show:
Serum:
Na+: 140 mEq/L
K+: 4.4 mEq/L
HCO3-: 21 mEq/L
Blood urea nitrogen (BUN): 38 mg/dL
Creatinine: 1.1 mg/dL
Glucose: 215 mg/dL
Which of the following is the most appropriate screening test for nephropathy in this patient?
|
{
"A": "Creatinine clearance",
"B": "Oral glucose tolerance test",
"C": "Urine albumin-to-creatinine ratio",
"D": "Hemoglobin A1c",
"E": ""
}
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C
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This patient with a history of obesity and hypertension presenting with polyuria and polydipsia in the setting of an elevated random blood glucose (> 200 mg/dL) likely has a new diagnosis of type 2 diabetes mellitus. The urine albumin-to-creatinine ratio is the most appropriate early test for diabetic nephropathy.
Early detection of diabetic nephropathy is key to management, as the complication eventually leads to overt kidney disease and renal failure. The diagnosis of diabetic nephropathy is based on > 30 mg/g of albuminuria for > 3 months. Patients with type 2 diabetes mellitus should be screened annually with a random urine albumin-to-creatinine ratio starting at diagnosis. Elevation of urine albumin warrants treatment with ACE inhibitors or angiotensin receptor blockers. Blood pressure control slows the progression of diabetic nephropathy. Patients with type 2 diabetes mellitus and diabetic nephropathy should be started on a sodium-glucose cotransporter 2 (SGLT2) inhibitor. Patients with persistent albuminuria despite both ACE/ARB and SGLT2 inhibitor therapy should be started on the nonsteroidal selective mineralocorticoid receptor antagonist (MRA) finerenone.
Bakris et al. study the efficacy of finerenone, a nonsteroidal selective MRA, in the treatment of patients with albuminuria in patients with chronic kidney disease (CKD) and type 2 diabetes. The authors found in a randomized control trial that finerenone reduced the incidence of a composite outcome of kidney failure. The authors recommend the use of finerenone in patients with persistent albuminuria despite optimal medical therapy to prevent risks of CKD progression and cardiovascular events.
Incorrect Answers:
Answer A: Creatinine clearance changes over the time course of diabetic nephropathy and can be normal or elevated (due to glomerular hyperfiltration) in early diabetic nephropathy. Therefore, it is an unreliable test for early diabetic nephropathy compared to the more sensitive urine albumin-to-creatinine ratio.
Answer B: Hemoglobin A1c is a test that reflects the average blood glucose over the past 2 to 3 months. While this test provides information on a patient's glycemic control, it does not directly assess the presence or extent of diabetic nephropathy.
Answer C: Oral glucose tolerance test is the test of choice for diagnosing gestational diabetes. It does not play a role in the detection of diabetic nephropathy.
Answer E: Urine protein dipstick is a useful test to detect proteinuria. This test is insensitive to low levels of albumin. Therefore, it is considered an inferior test to urine albumin-to-creatinine ratio in the diagnosis of diabetic nephropathy.
Bullet Summary:
Urine albumin-to-creatinine ratio testing is the most sensitive test to detect moderately elevated levels of urinary albumin excretion, a known byproduct of diabetic nephropathy.
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A 46-year-old farmer presents to the office for a follow-up visit. He was seen 4 days ago for a new lesion on his arm that had been present for 1 week prior to that visit. A photograph of the lesion is shown in Figure A. At that time, he was prescribed treatment for the lesion and instructed to follow up as necessary. Today, he reports that he became sunburned this morning within an hour of beginning his workday, despite wearing appropriate sunscreen. He has a medical history significant for type 2 diabetes mellitus that is controlled with metformin. He has no known medical allergies. He smokes 1 pack of cigarettes per day and denies alcohol or illicit drug use. His temperature is 98.6°F (37.0°C), blood pressure is 125/70 mmHg, pulse is 65/min, and respirations are 12/min. On exam, there is a blistering erythematous rash on the arms and shoulders. The previous skin lesion appears unchanged. Which of the following is the most likely explanation for the patient's new rash?
|
{
"A": "Allergic reaction to prescribed therapy",
"B": "Progression of disease and alternative therapy is indicated",
"C": "Progression of disease and surgical debridement is necessary",
"D": "Adverse effect of doxycycline",
"E": ""
}
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D
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This farmer has a cutaneous black eschar most consistent with cutaneous anthrax for which doxycycline is an appropriate treatment. A new blistering, erythematous rash after spending an hour outside that appears 4 days after starting treatment is consistent with a photosensitivity reaction, a known adverse effect of doxycycline.
Cutaneous anthrax is the most common form of infection caused by Bacillus anthracis. The infection is contracted during contact with infected livestock. The first-line treatment is doxycycline, ciprofloxacin, levofloxacin, or moxifloxacin. Progression to systemic anthrax would result in pulmonary (flu-like symptoms and hemoptysis) or gastrointestinal (nausea, vomiting, and dysentery) symptoms and would require treatment with clindamycin plus ciprofloxacin. Patients with meningitis due to anthrax require antibiotic therapy with ciprofloxacin plus meropenem plus linezolid. Additionally, antitoxins such as raxibacumab and adjunctive therapies such as glucocorticoids should be considered. In addition to photosensitivity, adverse effects of doxycycline include gastrointestinal upset (most common), teeth discoloration, and inhibition of bone growth in children. Doxycycline is teratogenic and should not be prescribed during pregnancy.
Migone et al. discuss the use of raxibacumab, a monoclonal antibody against a component of the anthrax toxin, in treating inhalational anthrax. The authors found that in monkeys, raxibacumab significantly increased survival after exposure to anthrax. The authors recommend the use of antitoxins such as raxibacumab in any patient suspected of having systemic anthrax.
Figure/Illustration A demonstrates the characteristic black eschar (blue circle) of cutaneous anthrax.
Incorrect Answers:
Answer A: Adverse effects of ciprofloxacin do not include photosensitivity, though it is an appropriate antibiotic choice for cutaneous anthrax treatment. Adverse effects of ciprofloxacin include gastrointestinal upset, risk of tendon rupture, and QT prolongation.
Answer C: Allergic reactions to prescribed therapy would be characterized by urticaria and wheals. In severe cases, anaphylaxis may be present.
Answer D: Progression of disease and alternative therapy is indicated does not fit this case. The patient's symptoms (blistering, erythematous rash) are not concerning for the progression of cutaneous anthrax to systemic disease, which would result in pulmonary or gastrointestinal symptoms. Alternative therapy for systemic anthrax is not indicated in this case.
Answer E: Progression of disease and surgical debridement is not indicated. The patient's symptoms (blistering, erythematous rash) are not concerning for the progression of cutaneous anthrax to systemic disease, which would result in pulmonary or gastrointestinal symptoms. Additionally, surgical debridement is not indicated for cutaneous anthrax.
Bullet Summary:
Cutaneous anthrax presents with a black eschar and is treated with antitoxin and either doxycycline or ciprofloxacin, the former of which can cause a photosensitivity reaction.
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A 24-year-old motorcyclist is involved in a head-on collision with a motor vehicle and suffers various traumatic injuries. She has no significant medical history, is up to date on all vaccinations, and her last tetanus shot was 3 years ago. On arrival, her temperature is 36.7°C (98°F), blood pressure is 82/63 mmHg, pulse is 120/min, respirations are 20/min, and oxygen saturation is 97% on 2L oxygen nasal cannula. On physical exam, there are extensive ecchymoses and abrasions along her left posterior ribs and left flank. A CT scan of the abdomen is obtained, which is shown in Figure A. After the appropriate surgical intervention is performed for the grade V splenic injury, which of the following is the most appropriate next step in management?
|
{
"A": "Insertion of a nasogastric tube",
"B": "Tetanus vaccination",
"C": "Insertion of a thoracostomy tube",
"D": "Vaccination against Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae",
"E": ""
}
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D
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This patient has an extensive splenic injury and hemodynamic instability requiring splenectomy, as evidenced by trauma to the left posterior ribs and left flank, low blood pressures with reflex tachycardia, and evidence of splenic rupture and hemoperitoneum on computed tomography imaging. Subsequently, this asplenic patient will require vaccination against encapsulated bacteria such as S. pneumoniae, N. meningitidis, and H. influenzae.
The capsules of encapsulated bacteria serve as an antiphagocytic virulence factor. To clear these bacteria, opsonization and subsequent clearance by the spleen must occur. In the setting of asplenia, opsonization capability is significantly decreased and thus asplenic patients are at high risk of severe infections by encapsulated bacteria. As such, asplenic patients require vaccination against the encapsulated bacteria S. pneumoniae, N. meningitidis, and H. influenza.
Patton et al. review recommendations for serogroup B meningococcal vaccination. The authors find that for patients aged 10 to 25 years old who are at increased risk for meningococcal disease (asplenic patients); 3 doses of the MenB-FHbp vaccine should be given. The authors recommend the administration of only 2 doses of the vaccine to patients that are not at elevated risk.
Figure/Illustration A depicts a traumatic splenic rupture with perisplenic hemoperitoneum (red circle).
Incorrect Answers:
Answer A: Insertion of a nasogastric tube would be appropriate in a patient with bowel obstruction or significant post-operative ileus. There is no evidence that this patient is experiencing obstruction or ileus, which typically presents with nausea, vomiting, abdominal pain, bloating, and lack of flatus or bowel movements.
Answer B: Insertion of a thoracostomy tube is not indicated in this patient as there is no evidence of pneumothorax or hemothorax. Patients with pneumothorax or hemothorax typically present with tachycardia, tachypnea, and decreased oxygen saturation. On exam, such patients may have decreased breath sounds. Ultrasonography may also reveal the absence of lung sliding.
Answer C: Prophylactic intravenous antibiotics are not indicated in the immediate post-operative period for asplenic adults. However, daily oral antibiotic prophylaxis is indicated in asplenic patients with a history of another concurrent immunocompromising condition or a history of severe infection due to an encapsulated organism.
Answer D: Tetanus vaccination is indicated every 10 years in patients who have previously received 3 doses of the tetanus vaccine and have clean or minor wounds. In patients with more extensive wounds who have previously received 3 doses of tetanus vaccine, re-vaccination is only necessary if their last tetanus vaccine was 5 or more years ago. This patient has extensive abrasions but is up to date on all vaccines and last received a tetanus vaccine 3 years ago, so a re-vaccination during this time is not indicated.
Bullet Summary:
Asplenic patients are at increased risk of severe infection by encapsulated bacteria; thus patients that undergo splenic removal require vaccination against Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae within 14 days of the procedure.
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A 65-year-old man presents to the emergency department with anxiety and intermittent palpitations. He began feeling the palpitations 3 days ago while eating dinner. He denies chest pain, shortness of breath, or loss of consciousness. He has a history of hypertension, major depressive disorder, Raynaud disease, and chronic obstructive pulmonary disease (COPD) on 2 liters of oxygen at home. Current medications include lisinopril, inhaled umeclidinium-vilanterol, and as-needed albuterol. He drinks 4 beers a day and has smoked 1 pack of cigarettes a day for 40 years. His temperature is 98.9° F (37.2° C), blood pressure is 130/85 mmHg, pulse is 125/min, and respirations are 16/min. Physical exam is notable for an irregular pulse and scattered end-expiratory wheezes. An echocardiogram performed 1 month ago showed a left ventricular ejection fraction of 60-65%. The patient requires 3 liters of oxygen today. An ECG is performed as seen in Figure A. Which of the following is the most appropriate treatment for the patient’s tachycardia?
|
{
"A": "Amiodarone",
"B": "Digoxin",
"C": "Verapamil",
"D": "Metoprolol",
"E": ""
}
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C
|
This patient’s new-onset palpitations, irregularly irregular pulse, and absent p-waves on ECG are consistent with atrial fibrillation. In hemodynamically stable patients with a relative contraindication to β-blockers (COPD on home oxygen with increasing oxygen need), rate control with a non-dihydropyridine calcium channel blocker such as verapamil is preferred.
Atrial fibrillation can present with palpitations, lightheadedness, or shortness of breath. ECG findings will be an irregularly irregular rhythm and absent P waves with an erratic baseline as shown in Illustration A. Treatment is centered on rate control. First-line agents for rate control include β1 selective blockers (metoprolol and esmolol) and non-dihydropyridine calcium channel blockers (verapamil and diltiazem). In patients with COPD, non-selective β-blockers (propranolol, timolol, and sotalol) can worsen bronchoconstriction by activating β2-adrenoreceptors. Other relative contraindications to β-blockers include Raynaud disease and depression (increased risk of fatigue and sexual dysfunction). In patients with relative contraindications to β-blockers, non-dihydropyridine calcium channel blockers are the preferred initial treatment option.
Van Gelder et al. studied lenient (resting heart rate < 110 beats per minute) versus strict rate control (resting heart rate < 80 beats per minute) in patients with atrial fibrillation in a randomized control trial. The authors found that there was no difference in the primary composite outcome of death from cardiovascular causes, hospitalization for heart failure, stroke, bleeding, and life-threatening arrhythmias between the 2 groups. The authors recommend a lenient rate control strategy in patients with atrial fibrillation.
Figure/Illustration A is an ECG lacking P waves (red arrows) and irregularly irregular RR intervals (red/blue lines), which are classic findings in atrial fibrillation.
Incorrect Answers:
Answer A: Amiodarone is an antiarrhythmic that can be used in patients to convert atrial fibrillation to sinus rhythm. It is often suitable to use in patients with depressed left ventricular function. Amiodarone has multiple multi-system adverse effects including pulmonary toxicity, and it is not used as a first-line agent.
Answer B: Clopidogrel is an antiplatelet agent that can be used to reduce the risk of thrombosis. Although patients with atrial fibrillation are at increased risk of stroke, the preferred anticoagulation agents are warfarin or direct oral anticoagulants (apixaban).
Answer C: Digoxin can be used as a rate control agent in atrial fibrillation as it directly suppresses atrioventricular nodal conduction. Due to its narrow therapeutic window and risk of toxicity, it is used as second-line therapy when first-line agents fail.
Answer D: Metoprolol is a β-blocker that is a first-line agent for rate control in atrial fibrillation. In patients with contraindications to β-blockers, non-dihydropyridine calcium channel blockers are the treatment of choice. This patient has COPD with increasing oxygen needs making calcium channel blockers possibly a better choice.
Bullet Summary:
In hemodynamically stable patients with atrial fibrillation and relative contraindications to β-blockers, non-dihydropyridine calcium channel blockers are the treatment of choice.
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225
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A 26-year-old woman presents to the clinic with diarrhea, bloating, flatulence, and abdominal cramps. These symptoms have been going on for 2 months. She has lost 6 pounds (2.7 kg) over these 2 months. Her medical history is significant for mild intermittent asthma for which she uses an albuterol inhaler as needed. She is sexually active with 1 male partner. She recently returned from South India following a mission trip for 6 weeks. Her temperature is 98.6°F (37.0°C), blood pressure is 105/70 mmHg, pulse is 95/min, and respirations are 14/min. On examination, the patient’s skin is pale. Labs are obtained and show the following results:
Leukocyte count: 4,500/mm^3
Hemoglobin: 10.5 g/dL
Platelets: 110,000/mm^3
Mean corpuscular volume (MCV): 116 µm^3
Reticulocyte count: 0.5%
A biopsy of the small bowel reveals blunting of villi and a mixed infiltration of lymphocytes, plasma cells, and eosinophils. Which of the following is the most likely diagnosis?
|
{
"A": "Celiac disease",
"B": "Crohn disease",
"C": "Whipple disease",
"D": "Tropical sprue",
"E": ""
}
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D
|
The patient is presenting with chronic diarrhea, weight loss, megaloblastic anemia (low hemoglobin and elevated MCV), and a biopsy showing blunted villi and mixed infiltrate following significant travel to South India. This is consistent with tropical sprue.
Tropical sprue is characterized by chronic diarrhea that occurs after travel to an endemic area. It is thought to be due to a bacterial overgrowth/infection that then damages the intestinal mucosa. Endemic areas include the Caribbean, Southeast Asia, and South India. Patients present with chronic diarrhea, abdominal discomfort/cramps, progressive weight loss, and clinical features of malabsorption. Patients with tropical sprue can develop megaloblastic anemia (low hemoglobin and elevated MCV) from a deficiency in folate and vitamin B12 absorption. A small bowel biopsy would show blunting of the villi and infiltration of lymphocytes, plasma cells, and eosinophils. Microorganisms may also be seen. Treatment is an oral tetracycline and folic acid for 3-6 months.
McCarroll et al. study the relationship between infectious gastroenteritis and tropical sprue. In a case-control study, the authors found that prior infectious gastroenteritis increased the risk of tropical sprue. The authors recommend treatment of suspected tropical sprue with oral folic acid replacement.
Incorrect Answers:
Answer A: Celiac disease can present similarly to tropical sprue with chronic diarrhea, abdominal pain, and weight loss. A small intestine biopsy can similarly show villous atrophy and a lymphocytic infiltrate, as well as crypt hyperplasia. Celiac disease is an immune response to gluten, while symptoms of tropical sprue are not diet-associated. The development of symptoms following significant travel (lasting at least several weeks) to an endemic country should raise suspicion for tropical sprue.
Answer B: Crohn disease presents with chronic diarrhea, abdominal pain, weight loss, skip lesions anywhere from mouth to anus, extraintestinal manifestations, and signs of malabsorption. A biopsy will show transmural inflammation with noncaseating granulomas, giant cells, and aggregates of lymphocytes in the lamina propria.
Answer C: Giardia is a parasite that is endemic in the tropics and North American mountain regions. Patients present with foul-smelling diarrhea, excessive gas, and nausea. Diagnosis can be confirmed with a stool analysis or immunoassay. Though a biopsy is normally not indicated, it would show mild lymphocytic infiltration and Giardia trophozoites on the intestinal surface.
Answer E: Whipple disease is caused by the bacteria Tropheryma whipplei. Patients present with diarrhea, abdominal pain, and signs of malabsorption. Extraintestinal symptoms such as arthritis are common. A biopsy of the small intestine would show Periodic acid-Schiff (PAS)-positive foamy macrophages in the lamina propria.
Bullet Summary:
Tropical sprue presents with diarrhea, abdominal cramping, weight loss, megaloblastic anemia due to malabsorption, and a small bowel biopsy showing villi blunting following travel to an endemic area such as South Asia or the Caribbean.
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A 25-year-old man is brought to the emergency department by paramedics for altered mental status. He was found lying down at a bus stop unresponsive. On arrival, the patient has slurred speech and is somnolent. Further is unable to be elicited. His temperature is 98.0°F (36.7°C), blood pressure is 130/80 mmHg, pulse is 80/min, and respirations are 12/min with a saturation of 97% on room air. Physical exam reveals a sleeping man with miotic pupils. The patient is easily arousable to voice and sternal rub but falls asleep rapidly. He has decreased bowel sounds. He is able to state his name and knows that he is at the hospital and has an otherwise normal neurologic exam. Which of the following is the most appropriate management?
|
{
"A": "Atropine",
"B": "Flumazenil",
"C": "Observation",
"D": "Naloxone",
"E": ""
}
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C
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This patient's presentation with altered mental status, pinpoint pupils, and decreased bowel sounds is most consistent with an opioid overdose. Given his stable respiratory status and oxygen saturation without notable bradypnea, observation alone until the patient is clinically sober is the most appropriate management.
Opioids are commonly used to treat painful conditions but have the potential to become drugs of abuse. Opioid overdose presents with bradypnea, somnolence, decreased bowel sounds, and pinpoint pupils. Any patient who is not protecting their airway, failing to oxygenate, or failing to ventilate should immediately be given naloxone which rapidly reverses the effect of opioids. However, this precipitates withdrawal which is unpleasant for patients and leads to nausea, vomiting, agitation, and diaphoresis among other findings. For this reason, patients who have overdosed on opioids and are stable can be observed until clinically sober.
Dietze et al. studied the effect of intranasal versus intramuscular naloxone for opioid overdose in a randomized control trial. The authors found that patients who received intranasal naloxone needed a second dose of naloxone more frequently compared to patients who received intramuscular naloxone. The authors recommend further study of optimal dosing and concentration of intranasal naloxone to respond to opioid overdoses outside of the hospital.
Incorrect Answers:
Answer A: Atropine is an appropriate treatment for a cholinergic toxidrome. This would manifest with bronchorrhea, bronchospasm, bradycardia, urinary incontinence, diarrhea, and drooling. Atropine should be administered until respiratory symptoms improve; large doses may be required.
Answer B: Disulfiram inhibits the enzyme acetaldehyde dehydrogenase causing severe nausea, vomiting, and a very ill feeling when a patient drinks alcohol from the accumulation of byproducts. This drug is a second-line agent used to reduce drinking in chronic alcohol use disorder but has no indication in managing acute alcohol intoxication as it is a preventive medication.
Answer C: Flumazenil is the reversal agent for benzodiazepines. Its use has fallen out of favor as it can precipitate seizures in chronic benzodiazepine users. Any patient with a suspected benzodiazepine overdose who is protecting their airway should be observed until clinically sober as there is no need to rapidly reverse them and possibly cause seizures.
Answer D: Naloxone is the antidote of choice in opioid overdose in patients who are not adequately oxygenating, ventilating, or protecting their airway. It is not indicated in opioid overdose in a clinically stable patient as the patient can merely be observed without the unpleasant side effects of immediate withdrawal from naloxone (including vomiting which in some cases could lead to aspiration). This patient is oxygenating well, protecting his airway, and does not have profound bradypnea.
Bullet Summary:
Opioid overdose presents with somnolence, pinpoint pupils, decreased bowel sounds, and bradypnea; stable patients who are adequately breathing and protecting their airway require only observation until clinically sober.
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A 27-year-old man presents to the emergency department after a bar fight. He was punched in the eye and is having pain and blurry vision. The patient is otherwise healthy and does not take any medications. His temperature is 98.1°F (36.7°C), blood pressure is 132/84 mmHg, pulse is 103/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam is notable for conjunctival injection of the patient’s left eye as shown in Figure A. Visual acuity reveals 20/20 vision in his right eye and 20/40 vision in his left. His left pupil is sluggish to constrict when compared to the right. A fluorescein stain is unremarkable and tonometry reveals a pressure of 45 mmHg in the left eye. Which of the following is the most appropriate next step in management?
|
{
"A": "Lateral canthotomy",
"B": "Cyclopentolate",
"C": "Topical timolol and pilocarpine",
"D": "Orbital ultrasound",
"E": ""
}
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A
|
This patient is presenting after blunt trauma to the eye with eye pain, blurry vision, conjunctival injection, a sluggish pupil, and elevated intraocular pressure (> 20 mmHg) suggesting a diagnosis of a retrobulbar hematoma/hemorrhage causing orbital compartment syndrome. The most important initial step in management is a lateral canthotomy to alleviate retrobulbar pressure.
A retrobulbar hematoma (or hemorrhage) occurs after blunt trauma to the eye. Presenting symptoms may include eye pain, photophobia, proptosis (an eye that appears to be anteriorly displaced), decreased visual acuity, and conjunctival injection. It is important to perform a thorough exam including a slit lamp exam and a fluorescein stain to rule out other traumatic injuries such as a globe rupture. Tonometry can be used to assess for increased intraocular pressure. A pressure > 20 mmHg suggests a diagnosis of orbital compartment syndrome, a vision-threatening condition. Immediate management with a lateral canthotomy is indicated in order to relieve pressure on the optic nerve and retina and save the patient’s vision. Further management may require drainage of the hematoma in the operating room.
Burkat et al. review the technique for performing a lateral canthotomy to relieve pressure in retrobulbar hematoma. The authors first excise the skin and orbicularis muscle at the lateral canthal angle in a horizontal direction for approximately 10 mm. The authors then recommend performing an inferior cantholysis by incising the inferior crus (a thick fibrous band connecting the lateral lower eyelid to the orbital rim) near the orbital rim.
Figure A demonstrates proptosis on physical exam which raises concern for a retrobulbar hematoma that is likely increasing orbital compartment pressure.
Incorrect Answers:
Answer A: CT scan of the head and facial bones would be appropriate if there was a concern for facial fracture. It would delay necessary and vision-saving interventions to perform a CT scan in the setting of orbital compartment syndrome. However, cross-sectional imaging may be performed after the pressure is relieved.
Answer B: Cyclopentolate is a cycloplegic that can be used to reduce pain in traumatic iritis. This typically presents after blunt trauma to the eye with erythema, photophobia, blurry vision, and cell/flare in the anterior chamber on slit lamp exam. A sluggish pupil may also be seen; however, increased intraocular pressure would not be seen in this condition.
Answer D: Orbital ultrasound could be used for diagnoses such as a retinal detachment which presents with flashes of light, floaters, and visual field loss like a “curtain coming down over the eye.” An ultrasound would demonstrate the detached retina in the back of the eye. Management involves elevating the head of the bed and surgical reattachment.
Answer E: Topical timolol and pilocarpine in addition to brimonidine, acetazolamide, and possible iridotomy would be the appropriate management of acute closed-angle glaucoma which presents with a rock-hard eye, blurry vision, a mid-dilated and fixed pupil, as well as a headache. This diagnosis can be supported by elevated intraocular pressure on tonometry. This is unlikely for this patient in the context of trauma.
Bullet Summary:
A retroorbital hematoma can cause orbital compartment syndrome which requires immediate treatment with a lateral canthotomy.
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A 50-year-old man presents to the emergency department with chest pain. He states that the pain is dull in quality, started 30 minutes ago, has been gradually worsening, and is worse with exertion. He also endorses some shortness of breath. He also believes the pain is worse when leaning back and improved when leaning forward. His wife noticed he fainted after the pain started but regained consciousness shortly after. He has a medical history of diabetes and hypertension for which he is on metformin and losartan. His temperature is 99.2°F (37.3°C), blood pressure is 130/87 mmHg, pulse is 99/min, respirations are 22/min, and oxygen saturation is 100% on room air. Physical exam reveals an overweight man. A normal S1 and S2 are auscultated with clear breath sounds. An ECG is performed as seen in Figure A. Which of the following is the most likely diagnosis?
|
{
"A": "Hypertrophic obstructive cardiomyopathy",
"B": "Hypokalemia",
"C": "Myocardial infarction",
"D": "Hyperkalemia",
"E": ""
}
|
C
|
This patient is presenting with chest pain and an ECG demonstrating hyperacute T waves (leads V2-V6) which is an early finding concerning for a myocardial infarction.
A myocardial infarction occurs when an atherosclerotic plaque ruptures causing occlusion of a coronary artery. Patients classically present with chest pain, dyspnea, and diaphoresis. Atypical manifestations of an acute myocardial infarction may include abdominal pain, nausea, reflux symptoms, and dizziness. The most important initial step in management is to administer aspirin as it lowers mortality and carries minimal risk. An ECG should then be performed. Classically, an ST-elevation myocardial infarction (STEMI) will demonstrate ST elevations in a vascular distribution. However, the progression to a STEMI is usually stepwise and may present with ST depressions, hyperacute T waves, pseudonormalization of the ST segment (a normal ST segment after a depression as it elevates), ST elevations, and finally tombstoning (a concave down wave that looks like a tombstone). If a STEMI is suspected after an ECG is performed, the patient should be started on a second antiplatelet agent (e.g., ticagrelor), heparin, and sent immediately to the cardiac catheterization laboratory.
Nable et al. review the typical electrophysiologic changes found in STEMI. The authors note that T-wave inversions and ST-segment depression can before, during, or after the STEMI event. The authors recommend obtaining serial ECGs in patients with suspected STEMI.
Figure/Illustration A demonstrates hyperacute T waves (blue arrows) that are only occurring in a vascular distribution (V2-V6).
Incorrect Answers:
Answer A: Hyperkalemia can present with peaked T waves; however, peaked T waves would be demonstrated in all leads. Other findings of hyperkalemia can include QRS widening. Immediate management of hyperkalemia with ECG changes should include calcium administration followed by drugs that shift potassium intracellularly such as insulin, albuterol, or sodium bicarbonate. Further management may include diuresis and/or dialysis.
Answer B: Hypertrophic obstructive cardiomyopathy may demonstrate increased voltages throughout the ECG, in particular, in leads V2-V6 with deep Q waves in the septal leads. It may present with syncope upon exertion in a young patient (and in rare cases, sudden cardiac death). Ultrasound would show hypertrophy and left ventricular outflow tract obstruction. Management involves staying hydrated, avoiding strenuous activities, and beta blockers.
Answer C: Hypokalemia can present initially on ECG with U waves and may progress to cardiac dysrhythmias. Repletion with potassium is the preferred treatment, and the magnesium level should be checked as low magnesium can lead to potassium wasting in the kidneys.
Answer E: Pericarditis presents with chest pain worse by laying back and relieved by leaning forward. ECG may demonstrate diffuse ST elevations with PR depressions, and echocardiography may demonstrate a pericardial effusion. Management involves the administration of ibuprofen or colchicine and steroids in refractory cases. However, these therapies should not be used after myocardial infarction.
Bullet Summary:
Hyperacute T waves are an early finding that is concerning for myocardial infarction.
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A 59-year-old man presents to his primary care physician for abdominal pain and foul-smelling diarrhea that has persisted for the past 2 years. The patient has a medical history of alcoholism and has been admitted to the hospital multiple times for withdrawal, abdominal pain, and traumatic injuries from his drinking. The patient states that his last drink was more than 1 year ago. His temperature is 99.3°F (37.4°C), blood pressure is 115/78 mmHg, pulse is 78/min, respirations are 15/min, and oxygen saturation is 99% on room air. Physical exam reveals a non-tender, non-distended abdomen. Laboratory studies are notable for a serum calcium of 7.0 mg/dL. A computed tomography (CT) scan of the abdomen is performed as seen in Figure A. A Sudan Black stain of the patient’s stool is positive. Which of the following is the most appropriate treatment for the underlying cause of this patient’s diarrhea?
|
{
"A": "Pantoprazole",
"B": "Oral rehydration",
"C": "Ciprofloxacin",
"D": "Loperamide",
"E": ""
}
|
A
|
This patient with a history of alcoholism is presenting with steatorrhea (foul-smelling diarrhea that stains with Sudan Black, a stain that detects fat in the stool), hypocalcemia, and findings suggestive of chronic pancreatitis on CT scan (inflammatory changes and calcification). His steatorrhea can be improved with the administration of proton pump inhibitors such as pantoprazole.
Chronic pancreatitis is a sequela that occurs after repeated bouts of acute pancreatitis. It can occur secondary to alcoholism or gallstones, and it may present with chronic abdominal pain, hypocalcemia, and signs of malnutrition and weight loss. Malnutrition and weight loss occur secondary to the pancreas’ inability to produce pancreatic enzymes which leads to poor nutrient absorption. Lack of lipase can lead to fat wasting in the stool, steatorrhea, and fat-soluble vitamin deficiency (A, D, E, and K). The management of chronic pancreatitis is the cessation of the underlying cause, pancreatic enzyme replacement, and the administration of proton pump inhibitors. Proton pump inhibitors help with steatorrhea by increasing the pH as low pH inactivates pancreatic enzymes.
Singh et al. review the diagnosis and management of chronic pancreatitis. The authors find that the diagnosis can be secured by typical findings on CT or magnetic resonance imaging (MRI) including pancreatic calcifications, ductal dilatation, and pancreatic atrophy. The authors recommend the use of endoscopic ultrasound in securing the diagnosis in patients with equivocal imaging findings and a high index of suspicion, such as patients with repeated episodes of acute pancreatitis.
Figure/Illustration A is a CT scan of the abdomen demonstrating calcifications and chronic inflammatory injury (red arrows) suggesting a diagnosis of chronic pancreatitis.
Incorrect Answers:
Answer A: Ciprofloxacin or ceftriaxone is the appropriate management of infectious diarrhea from a bacterial organism. This usually presents with fever, as well as bloody or purulent diarrhea. In general, young and healthy patients who are able to hydrate themselves should not be given antibiotics, even for infectious diarrhea. Elderly patients, immunosuppressed patients, or patients with symptoms that do not improve spontaneously should be managed with a stool culture and antibiotics.
Answer B: Loperamide is an anti-diarrheal agent that could be used for irritable bowel syndrome to decrease bowel motility and improve symptoms of diarrhea. Loperamide and other antidiarrheals should never be used for infectious causes of diarrhea as they will delay the fecal shedding of the organism or virus and could prolong symptoms.
Answer C: Oral rehydration is recommended for any patient with diarrhea and signs of volume depletion and is preferred to IV fluids as the integrity of the gut is protected. This patient’s diarrhea is likely caused by his chronic pancreatitis; thus, oral rehydration may be indicated but does not address the underlying cause of this patient’s diarrhea.
Answer E: Rifaximin is an antibiotic that targets gut flora and can decrease enteric flora and treat conditions such as small bowel bacterial overgrowth. Small bowel bacterial overgrowth presents in patients with conditions such as diabetic gastroparesis or scleroderma secondary to decreased bowel motility causing bacterial overgrowth and profuse diarrhea. Treating the underlying cause in addition to rifaximin will eliminate the excess bacteria.
Bullet Summary:
Proton pump inhibitors should be given in patients with persistent diarrhea in the setting of chronic pancreatitis to prevent the inactivation of pancreatic enzymes.
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A 43-year-old man presents to the emergency department with bright red blood in his stool this morning. He noticed this yesterday as well, but it was much scanter. The patient is otherwise healthy. He was celebrating his birthday last night and admits having "too much to drink" and vomited profusely overnight. He currently feels well and is not nauseous. He has no other significant medical history and does not take any medications. His temperature is 99.2°F (37.3°C), blood pressure is 110/75 mmHg, pulse is 82/min, respirations are 16/min, and oxygen saturation is 100% on room air. Physical exam reveals a nontender abdomen with normal bowel sounds. Rectal exam reveals grossly bloody stool. Laboratory studies are ordered as shown below.
Hemoglobin: 12 g/dL
Hematocrit: 36%
Leukocyte count: 5,500/mm^3 with normal differential
Platelet count: 179,000/mm^3
Which of the following is the most likely cause of this patient's symptoms?
|
{
"A": "Erosion into a gastric vessel",
"B": "Submucosal esophageal tear",
"C": "Vascular malformation",
"D": "Malignancy",
"E": ""
}
|
C
|
This patient is presenting with bright red blood per rectum with a non-tender abdomen. Of the answer choices given, angiodysplasia is the most likely to cause such profuse and sudden bleeding.
Angiodysplasia is a vascular malformation found in the gastrointestinal (GI) tract, most commonly in the colon. The exposed vessels can bleed, leading to bright red blood per rectum. The diagnosis can be confirmed with colonoscopy. Ablation can be performed to stop the bleeding. Any patient who is unstable or anemic with a hemoglobin < 7.0 g/dL requires a transfusion with blood products. Angiodysplasia is a common cause of bright red blood per rectum but is not more common than diverticulosis.
Garcia-Compeon et al. review the presentation and treatment of gastrointestinal angiodysplasia. The authors note that angiodysplasias are the cause of many "occult" GI bleeds not visualized on upper endoscopy or colonoscopy. The authors recommend the use of capsule endoscopy in occult GI bleeds to identify angiodysplasias as a potential source.
Incorrect Answers:
Answer A: Erosion into a gastric vessel is the pathophysiology of a bleeding gastric vessel secondary to peptic ulcer disease. This usually presents with melena (black tarry stools) rather than bright red blood per rectum. Only in cases of extremely brisk upper GI bleeding would patients present with bright red blood per rectum. Treatment involves treating Helicobacter pylori infection if present, proton pump inhibitors, and sucralfate. Endoscopy is needed to confirm and treat the bleeding vessel.
Answer B: Inflammation and infection of colonic outpouching is the pathophysiology of diverticulitis which presents with a history of constipation with a fever and left lower quadrant abdominal pain. Management involves a computed tomography (CT) scan of the abdomen/pelvis and administration of antibiotics (such as ciprofloxacin and metronidazole or ceftriaxone and metronidazole). Diverticulosis presents with bright red blood and is possible in this patient, but it does not involve inflammation or infection, which defines diverticulitis.
Answer C: Malignancy or colon cancer can present with bright red blood per rectum, malaise, weight loss, and microcytic anemia. While it is possible in this patient, his age, lack of risk factors for colon cancer, and the sudden onset of his symptoms make this diagnosis less likely.
Answer D: Submucosal esophageal (Mallory-Weiss) tear presents after profuse vomiting (as in this patient) with bloody vomitus. Treatment is supportive and involves antiemetics.
Bullet Summary:
Angiodysplasia is a vascular malformation that presents with bright red blood per rectum.
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A 56-year-old man presents from prison with 1 month of subjective fevers, chills, cough, and night sweats. He noticed a gradual weight loss over the past year despite no changes to his diet or physical activity. He has never smoked cigarettes but does have a history of opiate use prior to incarceration. He does not take any medications. His temperature is 100.8°F (38.2°C), blood pressure is 142/88 mmHg, pulse is 78/min, and respirations are 12/min. Physical exam reveals a thin, ill-appearing man. Pulmonary auscultation reveals faint, inspiratory crackles in the right upper lobe. His chest radiograph is shown in Figure A. Which of the following is the most appropriate next step in management?
|
{
"A": "Vancomycin",
"B": "Ampicillin-sulbactam",
"C": "Rifampin, isoniazid, pyrazinamide, and ethambutol (RIPE) therapy",
"D": "Itraconazole",
"E": ""
}
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C
|
This patient likely has active tuberculosis (TB), as evidenced by his symptoms (fever, night sweats, cough, and weight loss), inmate status, and apical cavitary lesion on chest radiograph. He should be treated with RIPE therapy.
An active TB infection should be suspected in patients with a febrile illness, cough, night sweats, and weight loss along with epidemiological risk factors for TB infection. Risk factors include residence in or previous visits to endemic regions, work in hospitals or nursing homes, imprisonment, and immunosuppression. Treatment typically requires 2 phases: an intensive phase involving 2 months of rifampin, isoniazid, pyrazinamide, and ethambutol (RIPE) therapy and a continuation phase involving 4 additional months of just isoniazid and rifampin. Vitamin B6 (pyridoxine) should be taken with isoniazid to prevent peripheral neuropathy. Rifampin, isoniazid, and pyrazinamide use should be monitored for hepatotoxicity. Ethambutol can cause optic neuropathy.
Conradie et al. discuss the use of a bedaquiline-pretomanid-linezolid (BPal) regimen in the treatment of extensively drug-resistant tuberculosis. The authors find that most patients treated with BPal have a favorable outcome (no treatment failure or disease relapse) after 6 months. The authors recommend the use of this regimen in highly drug resistant TB.
Figure/Illustration A demonstrates a right upper lobe cavitating lesion (arrow) that resulted in extensive necrosis and fibrosis. These lesions are usually localized to the upper regions of the lung due to favorable oxygen concentrations in the apex.
Incorrect Answers:
Answer A: Ampicillin-sulbactam can be used as empiric treatment for a lung abscess to cover anaerobic pathogens and facultative anaerobic streptococci. A lung abscess is associated with aspiration risk factors (such as alcohol use) or poor dentition.
Answer B: Biopsy may be indicated for a solitary cavitary nodule that is suggestive of malignancy. In this case, the patient's inmate status, along with his fever, night sweats, and cough are more suggestive of an infectious rather than malignant etiology.
Answer C: Itraconazole can be used to treat chronic pulmonary aspergillosis. These patients typically have prior or current lung disease such as chronic obstructive pulmonary disease or tuberculosis. The classic air crescent sign may be seen on imaging in a patient with an aspergilloma, a form of pulmonary aspergillosis in which a fungal ball develops within an existing cavitary lesion.
Answer D: Vancomycin can be used to treat a lung abscess due to methicillin-resistant Staphylococcus aureus. S. aureus pneumonia classically presents as a secondary infection that follows an influenza infection.
Bullet Summary:
Active tuberculosis infection should be treated with rifampin, isoniazid, pyrazinamide, and ethambutol (RIPE) therapy.
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A 68-year-old man presents for evaluation by a neurologist for an involuntary hand tremor that started approximately 3 months ago. The shaking improves when he reaches for objects but returns when he is not using his hand. His temperature is 98.6°F (37.0°C), blood pressure is 115/70 mmHg, pulse is 70/min, and respirations are 12/min. His left hand exhibits a 4-6 Hz tremor when resting on his lap. The tremor extinguishes with voluntary movement. In addition, his left upper extremity has increased tone with passive range of motion. Which of the following is the most likely diagnosis?
|
{
"A": "Cerebellar stroke",
"B": "Essential tremor",
"C": "Lacunar stroke",
"D": "Parkinson disease",
"E": ""
}
|
D
|
This patient who presents with a low amplitude, 4-6 Hz resting tremor that resolves with voluntary movement and associated rigidity most likely has Parkinson disease.
Parkinson disease is caused by degeneration of dopaminergic neurons in the substantia nigra pars compacta of the basal ganglia. This neurodegenerative process leads to movement abnormalities such as bradykinesia, “cogwheel” muscle rigidity (intermittently increased muscle tone with passive range of motion), shuffling gait, postural instability, and a resting tremor sometimes referred to as “pill-rolling” in quality. Parkinson disease usually presents with unilateral symptoms and subsequently progresses to bilateral involvement. First-line treatment involves dopaminergic drugs such as carbidopa-levodopa. Antimuscarinic agents can also be used for symptom control.
Zhong et al. review the role of the cerebellum in tremor in Parkinson disease. The authors find that the cerebellum may modulate tremor amplitude via cerebello-thalamo-cortical circuits. The authors recommend further study of the cerebellum as an alternative therapeutic target in Parkinson patients with dopamine-resistant tremors.
Incorrect Answers:
Answer A: Cerebellar stroke can manifest as an intention tremor, which presents as an oscillatory tremor that increases in amplitude at the endpoint of visually goal-directed movement. Intention tremors are best exhibited in the finger-nose-finger test in which the patient repeatedly touches their nose and then extends their arm to touch the examiner's finger. Patients would also have more severe symptoms including ataxia, nausea, vomiting, and nystagmus.
Answer B: Essential tremor is a condition that is often familial and presents as a high frequency (4-9 Hz) tremor that occurs with sustained posture and is worsened with movement. Treatment includes propranolol and primidone.
Answer C: Huntington disease is an autosomal dominant trinucleotide repeat disorder that leads to neurodegeneration of the caudate and putamen. Chorea is a hallmark movement abnormality associated with Huntington disease and presents with spontaneous, jerking, purposeless involuntary movements.
Answer D: Lacunar stroke can result in ischemia to the subthalamic nucleus and produce hemiballismus. This presents as spontaneous unilateral explosive movements of an upper extremity and occasionally the ipsilateral lower extremity. Other motor deficits are also expected when there is a lacunar infarct.
Bullet Summary:
Resting tremor is a hallmark of Parkinson disease and presents with low amplitude, 4-6 Hz oscillatory rhythmic movements that temporarily extinguish with voluntary movement.
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A 55-year-old woman presents to the primary care clinic for her annual visit. She has no complaints and is asymptomatic. She has a history of hypertension, hyperlipidemia, and diabetes. Her medications are lisinopril, amlodipine, atorvastatin, and metformin. There is no family history of malignancy. She is a non-smoker and drinks 3-4 standard drinks per week. Her temperature is 98.2°F (36.8°C), blood pressure is 142/84 mmHg, pulse is 82/min, and respirations are 16/min. On physical exam, a solid, immobile neck mass is palpated inferior to the cricoid cartilage to the left of midline. An ultrasound is obtained and shows a 1.2 cm hypoechoic mass with microcalcifications. Serum thyroid-stimulating hormone (TSH) concentration is 7.2 µU/mL. Which of the following is the most appropriate next step in management?
|
{
"A": "Propylthiouracil",
"B": "Fine needle aspiration",
"C": "Radioiodine ablation",
"D": "Surgical removal of the mass",
"E": ""
}
|
B
|
This patient’s presentation with an asymptomatic thyroid nodule with suspicious ultrasound features (≥ 1 cm hypoechoic mass with microcalcifications) and elevated TSH is concerning for thyroid malignancy. The most appropriate next step in management is a fine needle aspiration (FNA).
The first step in the diagnostic work-up of a thyroid nodule, which can be found incidentally in asymptomatic individuals or in the presence of obstructive or vocal symptoms, includes an ultrasound and measurement of serum TSH levels. If TSH is normal or elevated, this suggests a hypofunctioning (“cold”) nodule, which increases the risk of cancer. These nodules should undergo FNA if suspicious sonographic findings are present. Suspicious sonographic findings include irregular margins, microcalcifications, taller-than-wide shape, and rim calcifications in nodules ≥ 1 cm in diameter. If TSH is low, then thyroid scintigraphy (radioiodine scan) should be performed to confirm whether the nodule is hyperfunctioning (“hot”). Hyperfunctioning nodules are rarely cancerous, so these patients can often avoid FNA. Hyperfunctioning nodules such as toxic adenomas which cause overt hyperthyroid symptoms may warrant further treatment with radioiodine, surgery, or anti-thyroid medications.
Durante et al. review the epidemiology and diagnostic approach to thyroid nodules. The authors find that nodules with suspicious sonographic patterns such as solid composition, hypoechogenicity, irregular margins, and microcalcifications should undergo cytological evaluation. The authors recommend molecular testing only in cases in which cytology is indeterminate.
Incorrect Answers:
Answer B: Propylthiouracil is a thionamide that inhibits thyroid peroxidase, thus preventing thyroid hormone synthesis. It can be used for the symptomatic control of hyperthyroidism in toxic adenomas prior to definitive surgical resection. It is not indicated for the treatment of a hypofunctioning nodule.
Answer C: Radioiodine ablation can be used in the treatment of a toxic adenoma, which would take up the radioactive iodine. It is not indicated for the treatment of a hypofunctioning nodule, which would not exhibit radioiodine uptake.
Answer D: Surgical removal of the mass is a treatment option for a malignant thyroid nodule. Although a hypofunctioning nodule is more likely to be malignant, an FNA should be performed first to confirm the diagnosis.
Answer E: Thyroid scintigraphy is used for thyroid nodules with low TSH, which increases the probability of a hyperfunctioning nodule. Confirmation of a hyperfunctioning nodule can help prevent further invasive diagnostic work-up because hyperfunctioning nodules are unlikely to be malignant. Thyroid scintigraphy would not be appropriate in this patient with an elevated TSH.
Bullet Summary:
The next step in management for a thyroid nodule with suspicious sonographic features and an elevated TSH is fine needle aspiration.
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A 19-year-old man presents to his primary care physician. He is asymptomatic and has no acute complaints, has no medical problems, and takes no medications. He was born in the United States but moved to El Salvador at age 11 and has only recently moved back to the United States in the past year. He was up to date on his vaccinations prior to his move to El Salvador. He last received a diphtheria, tetanus, and acellular pertussis (DTaP) vaccine 14 years ago at age 5, the second dose of a meningococcal vaccine 3 years ago, and an influenza vaccine 2 months ago. The patient’s temperature is 98.2°F (36.8°C), blood pressure is 120/76 mmHg, pulse is 82/min, and respirations are 16/min. There are no rashes noted on physical exam. Which of the following vaccine regimens is indicated in this patient?
|
{
"A": "Tetanus, diphtheria, acellular pertussis, and influenza",
"B": "Tetanus and diphtheria",
"C": "Influenza",
"D": "Tetanus, diphtheria, and acellular pertussis",
"E": ""
}
|
D
|
This patient has recently moved back to the United States after living in another country for several years and is behind on his tetanus, diphtheria, and pertussis vaccine series. The tetanus, diphtheria, and acellular pertussis (Tdap) vaccine is indicated at least once in adults who have not previously received Tdap.
The standard vaccination schedule for tetanus, diphtheria, and pertussis includes a 5-dose childhood vaccine series consisting of DTaP at ages 2 months, 4 months, 6 months, 15-18 months, and 4-6 years. The first booster dose then consists of Tdap at age 11-12, with a tetanus and diphtheria (Td) vaccine every 10 years afterwards. In adults who have not previously received Tdap, a single Tdap dose should be administered regardless of time interval since the last dose of Td. Subsequent Td booster doses should then be given at 10-year intervals. Contraindications to Tdap include prior anaphylaxis after a tetanus, diphtheria, or pertussis vaccine or a history of seizures or encephalopathy within 7 days of receiving a previous pertussis-containing vaccine.
Kerr et al. studied the risk of major birth defects after administering the Tdap vaccine in pregnant patients. The authors found no increase in the risk of malformations in the offspring of pregnant patients that received the Tdap vaccine. The authors recommend the administration of Tdap during pregnancy.
Incorrect Answers:
Answer A: Influenza is incorrect because the influenza vaccine is recommended only once per flu season. This patient already received the flu vaccine during this flu season, so the influenza vaccine is not indicated.
Answer B: Tetanus and diphtheria only are incorrect because the Td vaccine booster is indicated every 10 years in adults who have already received a prior dose of Tdap. In adults who have never received a previous Tdap dose, Tdap is indicated unless contraindications exist.
Answer C: Tetanus, diphtheria, acellular pertussis, and influenza are incorrect because influenza vaccine is not indicated in this patient. This patient has already received a dose of the influenza vaccine during this flu season.
Answer E: Tetanus, diphtheria, and influenza are incorrect because neither the Td nor influenza vaccines are indicated in this patient. The Td vaccine is indicated every 10 years in adults who have already received a prior dose of Tdap. The influenza vaccine is only indicated once per flu season.
Bullet Summary:
The tetanus, diphtheria, and acellular pertussis (Tdap) vaccine is usually administered to adolescents at age 11-12 and is indicated at least once in adults who have not previously received Tdap.
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A 24-year-old man presents to the emergency room after a motor vehicle collision. He was the driver in a head-on collision and was not wearing a seatbelt. The patient is acutely intoxicated and is attempting to attack the nurses. Soon after presentation, he is sedated, paralyzed, and intubated. His medical history is unknown. His temperature is 97.6°F (36.4°C), blood pressure is 74/34 mmHg, pulse is 180/min, respirations are 32/min, and oxygen saturation is 98% on room air. Physical exam is notable for jugular venous distension. An electrocardiogram (ECG) is performed as seen in Figure A. Which of the following is the most appropriate next step in management?
|
{
"A": "Needle thoracostomy",
"B": "Pericardial window",
"C": "Tube thoracostomy",
"D": "Pericardiocentesis",
"E": ""
}
|
D
|
This patient is presenting after trauma with hypotension, tachycardia, jugular venous distension, and electrical alternans on ECG, which is concerning for cardiac tamponade. The most important initial step in management is pericardiocentesis.
Cardiac tamponade can occur after trauma, infections, or malignancy. It can occur if there is an accumulation of fluid in the pericardial sac with inadequate time for the pericardial sac to stretch and for the heart to adapt to the compression that causes diastolic dysfunction. Patients will present with hypotension, tachycardia, jugular venous distension, muffled heart sounds, and pulsus paradoxus (blood pressure drop > 10 mmHg with inspiration). The diagnosis can be supported with ultrasonography (in the clinical setting a point of care ultrasound will often be performed first); however, the initial step in management is a pericardiocentesis which will stabilize the patient. Subsequent management requires the placement of a pericardial drain or window, as well as treatment of the underlying cause.
Prabhakar et al. discuss pericardial decompression syndrome, an infrequent complication of pericardiocentesis. The authors find that pericardial decompression syndrome presents with paradoxical hemodynamic instability and/or pulmonary edema following pericardiocentesis, especially in patients with underlying myocardial dysfunction. The authors recommend careful monitoring of patients after pericardiocentesis for the development of this complication.
Figure/Illustration A is an ECG demonstrating electrical alternans. Note the alternating large QRS complexes (blue arrows) and small QRS complexes (green arrows) which are suggestive of the heart swinging in a fluid-filled pericardium.
Incorrect Answers:
Answers 1 & 5: Needle thoracostomy followed by tube thoracostomy is the appropriate management of a tension pneumothorax. A tension pneumothorax would also present with hypotension, tachycardia, and jugular venous distension; however, it would not present with muffled heart sounds and electrical alternans on ECG. On exam, there would be an absence of unilateral breath sounds and the presence of tracheal deviation.
Answer B: Packed red blood cells are appropriate management of a hypotensive and tachycardic trauma patient when it is suspected that their unstable vitals are secondary to hemorrhage. In this patient, there is conclusive evidence (jugular venous distension and electrical alternans) that this patient has cardiac tamponade.
Answer C: Pericardial window is the appropriate long-term treatment of recurrent pericardial effusions as it allows for a permanent conduit for the drainage of fluid. An acutely unstable patient should first be stabilized with a pericardiocentesis before going to the operating room for this procedure.
Bullet Summary:
The most important initial step in the management of cardiac tamponade in a hemodynamically unstable patient is pericardiocentesis.
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A 3-year-old girl is brought to the office for a routine well-child appointment. She was delivered preterm at 35 weeks, and her medical history is significant for several ear infections over the last year. Her older brother has been diagnosed with attention-deficit hyperactivity disorder (ADHD), but the rest of her family history is otherwise unremarkable. The patient has become more withdrawn lately and has sometimes been ignoring her parents when asked to perform tasks at home. This seems to have worsened over the last 8 weeks. Otherwise, the patient is energetic and started preschool 3 months ago. Her temperature is 98.6°F (37°C), blood pressure is 98/62 mmHg, pulse is 97/min, and respirations are 26/min. The patient successfully draws a square and can stand on 1 foot. Her language skills are unchanged from her appointment 6 months ago. Her neurological examination is normal, and she is at the 50th percentile for height and weight. She seems distracted during the interview and responds only intermittently to the physician’s directions. Which of the following is the most appropriate next step in management?
|
{
"A": "Refer to genetic testing",
"B": "Speech and language assessment",
"C": "Audiometry testing",
"D": "Parent and teacher ADHD rating scales",
"E": ""
}
|
C
|
This patient who presents with trouble following directions, inconsistent response to the physician's questions, and lack of progression in her language skills may have an acquired hearing impairment. The patient should undergo audiometry testing.
Hearing impairment in children can be genetic or acquired. In a patient with a history of recurrent ear infections, conductive hearing loss is the most common underlying cause of hearing impairment. Hearing impairment can often present similarly to behavioral or persistent developmental disorders. In a child with poor language skills, social skills, and self-isolation, hearing loss should be ruled out first before considering other diagnoses. Undetected hearing loss can progress with poor academic performance, personal-social maladjustment, and emotional difficulties as children progress through critical development stages. The treatment for hearing loss is the restoration of hearing through hearing aids, cochlear implants, and other supportive measures.
Dammeyer et al. studied the impact of childhood hearing loss on family life. They found that children with additional disabilities were more likely to be ignored by parents. They recommend understanding family dynamics in order to better support patients and families.
Incorrect Answers
Answer B: Autism spectrum screening questionnaire is useful in the diagnosis of autism spectrum disorder in children presenting with social isolation and poor communication skills. Autism spectrum disorder often presents with repetitive behaviors and fixed interests, which are absent in this child. Hearing loss should be ruled out first before pursuing this diagnosis. Treatment of autism spectrum disorders is early intervention and counseling.
Answer C: Parent and teacher ADHD rating scales should be obtained to aid in the diagnosis of attention-deficit hyperactivity disorder (ADHD). While children with ADHD often appear inattentive and impulsive in multiple domains, poor language development, and social isolation are not features of ADHD. This patient should first undergo an audiometry test. ADHD can be treated with stimulants such as methylphenidate.
Answer D: Referral for genetic testing is an incorrect first step in the management of this patient. While delayed language can be seen with several genetic conditions, there are usually signs of other global motor, cognitive, and social delays. Additional genetic testing can be pursued if the patient’s audiometry testing results are normal.
Answer E: Referral for speech and language assessment is an incorrect first step. A formal assessment should be obtained in the diagnosis of communication and language disorders. However, this should only be done after ruling out hearing loss. Therefore audiometric testing should be performed first.
Bullet Summary:
Children with a history of recurrent ear infections presenting with signs of social or language development delays should be evaluated for hearing impairment with an audiometry test.
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237
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A 15-year-old girl presents to the clinic due to concern that she may be pregnant. She had unprotected sexual intercourse earlier that morning and requests emergency contraception. She has had regular menses since menarche, and her last menstrual period ended 8 days ago. She has no significant medical history. Her temperature is 98.6°F (37°C), blood pressure is 114/71 mmHg, pulse is 81/min, and respirations are 12/min. A physical exam is unremarkable. A urine pregnancy test is negative. The patient asks for an emergency contraceptive pill and would prefer that her parents not be notified about her visit. In most states, which of the following is the most appropriate next step in the management for this patient?
|
{
"A": "Prescribe misoprostol pill",
"B": "Prescribe levonorgestrel pill",
"C": "Obtain parental consent before providing emergency contraception",
"D": "Prescribe high-dose oral contraceptives",
"E": ""
}
|
B
|
This patient with recent unprotected intercourse and a negative pregnancy test is a candidate for postcoital emergency contraception. She should receive the levonorgestrel or ulipristal pill, which in most states does not require parental consent.
Patients with a positive pregnancy test are not candidates for emergency contraception because implantation has already occurred, but patients with recent unprotected intercourse but a negative pregnancy test should receive the levonorgestrel pill (plan B) or ulipristal pill. These pills should be administered as soon as possible after intercourse. This is because the efficacy of the pills decrease after 72-120 hours post-intercourse. The high doses of progestin in these pills delay ovulation by blocking the LH surge, thereby preventing pregnancy. In most states, adolescents can receive emergency contraception without parental consent or notification.
Batur et al. present the current options available for emergency contraception. They discuss how ulipristal acetate tends to be more efficacious compared to levonorgestrel when used more than 72 hours post-coitally. They recommend that all providers who treat young women be familiar with the options and indications for emergency contraception.
Incorrect Answers:
Answer A: It is inappropriate to not administer emergency contraception despite the patient being under 18 years old. Adolescent patients at risk of pregnancy after unprotected intercourse who request emergency contraception should be presented with viable options.
Answer B: Obtaining parental consent before providing emergency contraception is an incorrect choice in most states. Most states allow adolescents to receive confidential care for contraception and pregnancy without parental involvement, consent, or notification.
Answer C: Prescribing high-dose oral contraceptives can be done in special circumstances to delay ovulation by patients taking multiple pills at once. However, combination oral contraceptives are less commonly used for post-coital contraception as they have significant side effects at high doses and are less effective than levonorgestrel pills.
Answer E: In patients with a positive pregnancy test (after implantation has occurred), misoprostol can be used for pregnancy termination by stimulating myometrial contractions. It does not prevent pregnancy. The use of drugs to terminate pregnancy varies significantly from state to state.
Bullet Summary:
Adolescents seeking emergency contraception may do so without parental consent or involvement in most states.
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A 67-year-old man presents to the emergency room reporting sudden-onset abdominal and back pain that began 3 hours ago. He was eating dinner when he started feeling severe pain in his abdomen that made him lose his appetite. He denies any diarrhea or hematochezia and says the pain is not affected by movement. He has a history of hypertension, hyperlipidemia, and depression. He currently takes amlodipine and atorvastatin and is compliant with his medications. He has a 45-pack-year smoking history, but he does not drink alcohol or use any illicit drugs. His temperature is 98.6°F (37°C), his blood pressure is 110/64 mmHg, pulse is 97/min, and respirations are 15/min. Physical exam is notable for diffuse abdominal tenderness without rigidity or guarding. During evaluation, the patient becomes diaphoretic and pale and reports that he feels fatigued. Repeat blood pressure is 87/50 and pulse is 127. Intravenous fluid boluses are administered. Which of the following is the most likely diagnosis?
|
{
"A": "Ischemic colitis",
"B": "Ruptured abdominal aortic aneurysm",
"C": "Aortic dissection",
"D": "Acute pancreatitis",
"E": ""
}
|
B
|
This patient who presents with sudden-onset abdominal pain, hemodynamic instability (symptomatic hypotension with tachycardia), and significant history of hypertension and smoking most likely has a ruptured abdominal aortic aneurysm (AAA).
Abdominal aortic aneurysms are dilations in the vessel wall that can predispose to rupture. Risk factors for AAA include advanced age (> 60 years), smoking history, male sex, and history of atherosclerosis. AAA can be asymptomatic or mildly symptomatic until it markedly expands or ruptures, leading to abdominal pain, back pain, or flank pain. The evaluation of suspected AAA depends on the hemodynamic stability of the patient and prior knowledge (or lack thereof) of the existence of an AAA. A hemodynamically unstable patient with a known history of AAA should be assumed to have a ruptured AAA and undergo surgical intervention without further workup (though bedside ultrasound can support the diagnosis). In an unstable patient without a known history, a bedside ultrasound to confirm the diagnosis should precede surgical intervention. In a hemodynamically stable patient with or without a known AAA history, an abdominal CTA is appropriate.
Sakalihasan et al. present a review of the presentation and treatment of abdominal aortic aneurysms. They discuss how patients are often asymptomatic until catastrophic rupture occurs. They recommend immediate surgical repair of the aneurysm during ruptures to prevent death.
Incorrect Answers
Answer A: Acute pancreatitis also presents with abdominal pain and can present with hemodynamic instability in severe cases of hemorrhagic conversion of pancreatitis. This is a rare entity and is less likely in this patient. Treatment is immediate transcatheter arterial embolization for unstable patients with hemorrhagic pancreatitis.
Answer B: Aortic dissection has similar risk factors to AAA (history of hypertension, advanced age) and also presents with acute onset back pain. Dissection normally occurs in the setting of hypertension. This diagnosis is possible but less likely in this man with a history of smoking.
Answer C: Ischemic colitis can also present with abdominal pain in a patient with risk factors for atherosclerotic disease. It is associated with hematochezia and diarrhea and is unlikely to cause the level of hypotension in this patient. Treatment is with restoration of blood flow to the ischemic bowel segment or resection if this is not possible. Management is usually centered on medical optimization.
Answer D: Perforated viscus is a surgical emergency that can also present acutely with hemodynamic instability and severe abdominal pain. However, signs of peritoneal irritation are usually present (guarding, rigidity). Treatment is with immediate surgical exploration and repair or resection.
Bullet Summary:
Patients with new-onset back and abdominal pain and a positive smoking history that progresses to hemodynamic instability should be suspected of having a ruptured abdominal aortic aneurysm.
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A 48-year-old man presents to the emergency room with a 2-hour history of severe abdominal pain, nausea, and vomiting. He states that he has not passed gas or had a bowel movement in 4 days and his pain has worsened and become constant over the past 2 hours. His only medical history includes an appendectomy that he underwent as a child, and he takes no daily medications. His temperature is 38.5°C (101.3°F), blood pressure is 92/60 mmHg, pulse is 138/min, and respirations are 25/min. His pulse oximetry is 99% on room air.There are no cardiopulmonary abnormalities on auscultation. His abdomen is distended and tender in all quadrants, with guarding and rebound present. He also has increased bowel sounds throughout. Laboratory results are as follows:
Hemoglobin: 11 g/dL
Leukocyte count: 16,500/mm^3 with normal differential
Platelets: 250,000/mm^3
Serum:
Creatinine: 1.0 mg/dL
Glucose: 95 mg/dL
Lipase: 45 U/L
Total bilirubin: 0.8 mg/dL
Alkaline phosphatase: 74 U/L
Aspartate aminotransferase (AST, GOT): 32 U/L
Alanine aminotransferase (ALT, GPT): 45 U/L
Lactate: 7.0 mmol/L
Which of the following is the most appropriate next step in management?
|
{
"A": "Supportive care, NPO, and intravenous fluids",
"B": "Urgent surgical intervention",
"C": "Nasogastric tube placement",
"D": "CT angiography of the abdomen and pelvis",
"E": ""
}
|
B
|
This patient with abdominal pain, vomiting, and obstipation is now hemodynamically unstable with fever, leukocytosis, rising lactate, and worsening pain. He most likely has a complicated small-bowel obstruction (SBO) and should undergo immediate surgical intervention.
SBO occurs when the normal progression of intraluminal contents in the intestines is interrupted, with most cases stemming from mechanical blockages. A history of abdominal surgery is a risk factor for SBO due to the formation of adhesions. Patients with SBO can typically be managed conservatively including nasogastric tube suction (if discomfort and active vomiting), bowel rest, and intravenous fluid resuscitation. However, patients with findings of a complicated SBO (changes in abdominal pain, fever, leukocytosis, guarding, and hemodynamic instability) require emergent surgical intervention. Delay in abdominal exploration may lead to necrosis, perforation, infection and a significant risk of mortality.
Bower et al. review small bowel obstruction. They note the need for operative intervention only in those who fail conservative management. They recommend nonoperative management for most cases of small bowel obstruction.
Incorrect Answers:
Answer A: Broad-spectrum antibiotics and serial abdominal radiographs alone would not be appropriate for this patient with a deteriorating clinical picture (hemodynamically unstable, worsening abdominal pain, fever, leukocytosis, high lactate). Antibiotics are not indicated in patients with uncomplicated SBO but may be useful in reducing infection risk in patients with complicated SBO. This patient should undergo emergent abdominal exploration in addition to receiving broad-spectrum antibiotics as it is possible he has already experienced bowel perforation.
Answer B: Computed tomography angiography (CTA) is useful in the diagnosis of acute mesenteric ischemia, which classically presents with abdominal pain out of proportion to exam (severe pain without much tenderness), vomiting, abdominal distention, and decreased bowel sounds. However, severe peritonitis and obstipation are more characteristic of SBO, and this patient is too hemodynamically unstable to undergo further imaging before proceeding to surgery.
Answers 3 & 4: Nasogastric tube placement with supportive care can be used to conservatively manage patients with uncomplicated SBO. This hemodynamically unstable patient has a fever, guarding, peritoneal signs, and newly worsened abdominal pain, indicative of a complicated SBO. He should be taken emergently to the operating room as the next step in management.
Bullet Summary:
Patients with intestinal obstruction who have a surgical abdomen or hemodynamic instability should undergo immediate surgical intervention.
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240
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A 52-year-old G3P3 woman presents to clinic with a 2-year history of urinary incontinence. She has had frequent, involuntary loss of urine over the last 2 years but presented today because of 10 days of dysuria. She has been treated for 2 urinary tract infections over the past 6 months. She does not endorse any loss of urine with coughing or laughter. She has no chronic medical illnesses and no surgical history. Her temperature is 99.5°F (37.5°C), blood pressure is 120/80 mmHg, pulse is 92/min, and respirations are 15/min. Her BMI is 30 kg/m^2. On pelvic examination, the vagina is dry and atrophic with a 2-cm tender, palpable anterior vaginal mass. The mass does not change with Valsava maneuver. Her postvoid residual volume is 60 mL. Which of the following is the most likely diagnosis?
|
{
"A": "Urethral diverticulum",
"B": "Overflow incontinence",
"C": "Stress urinary incontinence",
"D": "Pelvic organ prolapse",
"E": ""
}
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A
|
This patient is presenting with a history of dysuria, incontinence, and recurrent lower urinary tract infections in conjunction with a tender anterior vaginal wall mass. The most likely diagnosis is a urethral diverticulum.
A urethral diverticulum is an abnormal, localized outpouching of the urethral mucosa often due to recurrent periurethral gland infection. The outpouching can often collect and store urine, resulting in slow postvoid dribbling and recurrent urinary tract infections. Urethral diverticula can often be associated with expressed purulent or bloody discharge on exam. Initial workup includes urinalysis and transvaginal ultrasound. Diagnosis can be confirmed with a pelvic MRI before referral for surgical excision.
Greiman et al. review urethral diverticula and its treatment. They note that surgical repair is challenging. However, it is still recommended to perform surgery in appropriate candidates.
Incorrect Answers:
Answer A: Overflow incontinence (caused by impaired detrusor activity or bladder outlet obstruction) can also present with involuntary loss of urine due to urinary retention. However, this patient’s normal postvoid residual volume (< 150 mL) makes this an unlikely diagnosis. Patients will often present with a constant dribbling of urine and a sensation of incomplete voiding.
Answer B: Pelvic organ prolapse occurs due to weakened pelvic support and increased intraabdominal pressure and can be exacerbated by increasing parity. While it can also present with incontinence, physical exam often reveals a bulging mass that increases with Valsava maneuver - a finding that is absent in this patient.
Answer C: Stress urinary incontinence is caused by urethral hypermobility leading to urinary leakage from increased intraabdominal pressure. This patient’s urinary loss is unrelated to coughing or laughing, and stress incontinence would not explain the anterior vaginal mass. On exam, urine may be released with coughing.
Answer E: Vesicovaginal fistula is an abnormal tract between the vagina and bladder that presents with constant leakage of urine due to the direct draining of urine from the bladder to the vagina. This patient’s incontinence is intermittent and not constant, and a vesicovaginal fistula would not explain the anterior vaginal mass.
Bullet Summary:
A urethral diverticulum presents with dysuria, intermittent urinary incontinence, and a tender anterior vaginal wall mass that may cause recurrent urinary tract infections.
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A 48-year-old woman, gravida 3 para 3, presents to the clinic with a 5-month history of intermittent loss of urine. Her urinary leaking occurs throughout the day and night, and she often has to get up to use the bathroom while asleep. Exercising does not affect the loss of urine. She states that she often cannot make it to the bathroom in time once she senses a need to void. Her last menstrual period was 2 weeks ago. Her urinalysis is unremarkable, and her postvoid residual volume is 40 mL. On pelvic examination, there is no dribbling of urine when the patient coughs. Physical exam is otherwise unremarkable. Which of the following is the most likely diagnosis?
|
{
"A": "Overflow incontinence",
"B": "Urge incontinence",
"C": "Stress incontinence",
"D": "Mixed urinary incontinence",
"E": ""
}
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B
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This patient with a sudden need to void followed by loss of urine with urgency (unable to make it to the bathroom in time) most likely has urinary urge incontinence.
Urge incontinence is a form of urinary incontinence characterized by a sudden urge to urinate, resulting in the involuntary leakage of urine. Normally, bladder contraction occurs due to the stimulation of muscarinic receptors in the detrusor muscle. Urinary urge incontinence is due to detrusor overactivity, leading to a sudden and frequently overwhelming need to void that occurs throughout the day and night. The most common cause is idiopathic, though it may be secondary to neurologic disorders (e.g., spinal cord injury or multiple sclerosis), bladder abnormalities, or chronic bladder inflammation. Workup is first centered on ruling out a urinary tract infection with a urinalysis. The diagnosis is made with urodynamic studies, and first-line treatment involves bladder training and pelvic floor exercises. Should first-line treatment of urge incontinence fail, antimuscarinic medications (such as oxybutynin) which reduce acetylcholine activity on muscarinic receptors can decrease detrusor contraction and thus the sense of urgency.
Nandy and Ranganathan review urge incontinence. They note that it presents with leakage of urine associated with a sudden urge to urinate. They recommend an appropriate history and workup to first rule out other causes.
Incorrect Answers
Answer A: Genitourinary syndrome of menopause represents urinary symptoms (stress and/or urge incontinence) due to vaginal dryness and atrophy from menopause. This patient still has menstrual cycles and no symptoms of ovarian follicle depletion (narrowed introitus, vulvovaginal dryness and irritation, irregular vaginal bleeding), making this an unlikely diagnosis.
Answer B: Mixed urinary incontinence presents with features of both stress and urge incontinence. This patient lacks symptoms of stress incontinence given a lack of incontinence with increases in intrabdominal pressure (such as exercise, coughing, laughing, or sneezing).
Answer C: Overflow incontinence is caused by impaired detrusor muscle activity or bladder outlet obstruction. It presents with constant involuntary dribbling or urine and incomplete bladder emptying. Post-void residual volume is increased in patients with overflow incontinence.
Answer D: Stress incontinence is caused by urethral hypermobility and otherwise insufficient urethral support. It presents with urinary leakage with activities that increase intraabdominal pressure (such as coughing, sneezing, laughing, and exercising). This patient’s symptoms are unrelated to exercise.
Bullet Summary:
Urge incontinence presents with sudden urinary urgency with a normal post-void residual volume and absence of findings consistent with urinary tract infection.
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242
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A 42-year-old man presents to the urgent care clinic with low back pain. He was working on a home improvement project the day prior to presentation when the pain started. He describes the pain as "achy and sore." It is not positional and does not radiate. He denies fevers, chills, paresthesias, and bowel or bladder incontinence. He has a history of a distal radius fracture 2 years ago from falling off a ladder. He drinks 3 alcoholic beverages weekly and denies illicit drug use. The patient’s temperature is 98.4°F (36.9°C), blood pressure is 124/80 mmHg, pulse is 90/min, and respirations are 16/min. His body mass index (BMI) is 22.4 kg/m^2. There is tenderness to palpation of his paravertebral lumbar region bilaterally. Perineal and dermatomal sensation is symmetric and intact. Strength is 5/5 to knee flexion/extension and ankle dorsiflexion/plantarflexion. Patellar and Achilles reflexes are 2+ bilaterally. Raising either leg while the patient is in the supine position does not elicit any pain. Which of the following is the most likely diagnosis?
|
{
"A": "Osteoarthritis",
"B": "Vertebral compression fracture",
"C": "Lumbar strain",
"D": "Disc herniation",
"E": ""
}
|
C
|
This patient presents with low back pain after activity with paravertebral tenderness and without red flag signs/symptoms, such as history of trauma or malignancy, intravenous drug use, saddle anesthesia (reduced perineal sensation), or neurological deficits. The most likely diagnosis is a lumbar strain.
The differential diagnosis of low back pain is broad and includes mechanical causes such as lumbar strain, osteoarthritis, spondylolisthesis, disc herniation, spinal stenosis, and fractures as well as non-mechanical etiologies such as osteomyelitis and malignancy. History and physical should focus on eliciting red flag symptoms, including traumatic etiology, constitutional symptoms (e.g., fever, weight loss), history of malignancy, intravenous drug use, steroid use, and neurological deficits (e.g., saddle anesthesia, incontinence). The presence of any red flags should prompt further evaluation with imaging. Lumbar strain typically presents with acute low back pain after a precipitating event (e.g., lifting weight) with no red flag signs/symptoms and responds well to conservative management including activity modification, ice, and non-steroidal anti-inflammatory drugs. Prevention measures include strengthening of core muscles and education on proper lifting techniques. Physical therapy is a core component of treating patients with muscle strains.
Knezevic et al. review lower back pain. They note the many potential causes and symptoms that may present. They recommend a multimodal interdisciplinary approach to back pain given the many mechanisms, especially in complex cases.
Incorrect Answers:
Answer A: Disc herniation presents with radicular symptoms due to compression of spinal nerve roots as they exit the spinal canal, manifesting as a burning or shooting pain that radiates down either leg. Dermatomal sensory changes or hyporeflexia may be present depending on the spinal level affected (e.g., reduced Achilles reflex with S1 radiculopathy). The straight leg raise reproduces pain radiating down the leg on the affected side.
Answer B: Lumbar stenosis characteristically causes low back pain or lower extremity paresthesias with walking or standing that resolves when leaning forward (“shopping cart sign”). This is referred to as neurogenic claudication. Involvement of spinal nerve roots can lead to sensory loss and weakness in the lower extremities.
Answer D: Osteoarthritis can cause low back pain and stiffness, but is an age-related degenerative disease that is less likely in this patient who presents acutely after activity. The patient also does not have the typical risk factors for osteoarthritis, which include advanced age, female sex, or obesity.
Answer E: Vertebral compression fracture occurs mainly in osteoporotic patients, whose reduced bone mineral density increases their risk for vertebral body collapse under stress. Vertebral compression fractures present with point tenderness at the midline over the site of fracture. Additionally, this patient has no risk factors for osteoporosis (e.g., advanced age, post-menopausal women, low BMI).
Bullet Summary:
Lumbar strain presents as low back pain without red flag signs or symptoms (e.g., constitutional symptoms, neurologic deficits) and is treated conservatively with activity modification, ice, and core strengthening.
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A 24-year-old woman presents to clinic for a routine annual exam. She has generally been feeling well, but notes feeling intermittent palpitations over the past few months. Her past medical history is unremarkable and she is not currently taking any medications. She denies drinking alcohol, smoking cigarettes, or using recreational drugs. She attributes her palpitations to recently drinking more caffeine, but would like to obtain an electrocardiogram since her symptoms are worrisome and affecting her ability to concentrate on her career as a fitness instructor. Her temperature is 36.9°C (98.4°F), blood pressure is 116/76 mmHg, pulse is 55/min, respirations are 12/min, and oxygen saturation is 98% on room air. Her electrocardiogram is shown in Figure A. Which of the following is the most likely diagnosis?
|
{
"A": "First degree atrioventricular block",
"B": "Sinus bradycardia",
"C": "Second degree atrioventricular block, Mobitz type II",
"D": "Second degree atrioventricular block, Mobitz type I",
"E": ""
}
|
D
|
This patient's progressively increasing PR intervals until a P wave is not followed by a QRS complex on ECG is consistent with second degree atrioventricular (AV) block, Mobitz type I, also referred to as Wenckebach phenomenon.
Second degree AV block, Mobitz type I can occur in a variety of settings, such as in the context of digoxin, beta blockers, calcium channel blockers, or increased vagal tone. On ECG, there is progressive lengthening of the PR intervals until a P wave is not followed by a QRS complex (a dropped beat); then, the PR interval resets. Patients are typically asymptomatic, but should undergo evaluation for an underlying etiology of the dysrhythmia, such as electrolyte imbalances, medication side effect, or structural heart disease, as well as a follow-up ECG to evaluate for any progression. If the dysrhythmia is caused by medication, the offending agent should be discontinued, but otherwise there are no specific treatments necessary for asymptomatic patients. Patients who are symptomatic and hemodynamically stable can undergo telemetry monitoring and receive atropine with limited efficacy. Patients who are hemodynamically unstable and not responsive to atropine may need cardiac pacing. Generally, there is a low risk of progression to third degree AV block, and a pacemaker is rarely required (in contrast to second degree heart block type II).
Barold and Hayes review second-degree heart block. They note the changes in AV node conduction time on ECG in this condition. They recommend using the correct definition of the different heart blocks for the correct underlying treatment.
Figure/Illustration A is an ECG showing PR intervals that gradually prolong until a P wave is seen not followed by a QRS complex (note the blue bars that show the progressive lengthening of the PR intervals until the dropped beat).
Incorrect Answers:
Answer A: First degree AV block is seen on ECG with prolonged PR intervals greater than 0.2 sec, but a consistent 1:1 ratio of P waves to QRS complexes. This finding is typically found in younger patients with increased vagal tone or in athletes, and does not require treatment.
Answer C: Second degree AV block, Mobitz type II is seen with fixed PR intervals and occasional dropped QRS complexes. Patients with Mobitz II sometimes present with syncope and frequently progress to third degree AV block. This finding may be associated with fibrotic changes to the conduction system or from acute, subacute, or prior myocardial infarction, and should be treated with placement of a pacemaker in most cases.
Answer D: Sinus bradycardia findings on ECG include normal sinus rhythm with a ventricular rate of less than 60 beats per minute. Patients with sinus bradycardia may be asymptomatic, but may also present with syncope, lightheadedness, chest pain, or hypotension. No treatment is required if the patient is asymptomatic, but atropine may be given to increase the heart rate in symptomatic cases. Pacemaker placement is required for patients with chronic symptoms.
Answer E: Third-degree AV block occurs when the atria and ventricles depolarize independently on ECG. There is no relationship between P waves and QRS complexes. Patients may present with syncope, dizziness, acute heart failure, or hypotension. The treatment is pacemaker placement.
Bullet Summary:
Second degree atrioventricular block, Mobitz type I, is characterized by progressively lengthening PR intervals until a P wave is not followed by a QRS complex.
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A 28-year-old G1P0 woman presents to initiate prenatal care after a positive home pregnancy test. The first day of her last menstrual period was 7 weeks prior to presentation. The patient has no medical conditions and takes no medications. Her temperature is 98.6°F (37.0°C), blood pressure is 110/70 mmHg, pulse is 64/min, and respirations are 17/min. Physical exam is notable for a nontender abdomen. Pelvic exam reveals a closed cervix with no adnexal or uterine tenderness. A urine pregnancy test is positive, and an intrauterine singleton pregnancy measuring approximately 9 weeks gestational age is visualized on transvaginal ultrasound. The patient asks if she should modify her current exercise regimen due to her pregnancy. She typically swims or uses an exercise bike for 45 minutes, 5 days a week, and plays in an office soccer league for 1 hour on 1 day per week. Which of the following is the most appropriate recommendation regarding exercise for this patient?
|
{
"A": "Avoid soccer during pregnancy, continue other activities",
"B": "Avoid exercise during pregnancy",
"C": "Continue the current exercise regimen",
"D": "Reduce to walking only, beginning in the third trimester",
"E": ""
}
|
A
|
This healthy primigravida woman presents to the clinic inquiring about her current exercise regimen involving 285 minutes of moderate to exercise weekly. With the exception of soccer, a contact sport, her exercise regimen is appropriate throughout her pregnancy.
The American College of Obstetricians and Gynecologists (ACOG), recommends that healthy pregnant women engage in moderate-intensity exercise for at least 30 minutes or more for 5-7 days weekly provided there are no contraindications to doing so (certain cardiac or pulmonary conditions, history of cerclage placement, multiple pregnancies, preeclampsia, or severe anemia). Highly active patients may continue their more vigorous pre-pregnancy regimens after consulting with a physician. Exercise in pregnancy can ease gastrointestinal symptoms and may decrease the risk of gestational diabetes, preeclampsia, and cesarean delivery. However, activities that may cause fetal or maternal injury, such as contact sports or activities with a significant fall risk should be avoided. Examples of contact sports include football, basketball, hockey, lacrosse, and wrestling.
Nascimento et al. review exercise in pregnancy. They note that exercise is beneficial in pregnancy and in the postpartum period and recommend engaging in appropriate exercise in this patient population.
Incorrect Answers:
Answer A: Avoiding exercise during pregnancy is not recommended, as at least 150 minutes of moderate exercise weekly is suggested during pregnancy for the health of the mother and the fetus.
Answer C: Continuing the current exercise regimen is not recommended, as soccer is a high-contact sport that could cause injury to the fetus or placenta.
Answer D: Limiting moderate exercise to 30 minutes per day maximum during pregnancy is not recommended, as 30 minutes daily is the minimum recommended time for moderate-exercise. There is no reason for healthy pregnant patients without high-risk pregnancies to significantly limit their exercise.
Answer E: Reducing to walking-only beginning in the third trimester is not necessary, as moderate activities are healthy throughout pregnancy.
Bullet Summary:
Healthy pregnant patients should perform at least 30 minutes of exercise 5-7 days per week and avoid high-contact sports or sports with fall risk.
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A 69-year-old man passes away after a 3-week hospitalization for liver failure, complicated by a myocardial infarction. A medical student rotating in the intensive care unit asked if she can practice performing intubations during her rotation. The resident suggests performing one on the deceased patient, as the student cannot harm him. Which of the following is the most appropriate course of action for the medical student?
|
{
"A": "Ask the resident if the patient’s family or the patient has been consented for this procedure",
"B": "Contact the patient's family to ask for permission to perform the procedure",
"C": "Intubate the patient with the resident's supervision",
"D": "Report the resident to hospital administration",
"E": ""
}
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A
|
This medical student wants to perform a procedure on a deceased patient for educational purposes. Before proceeding, the student should ensure that permission has been obtained from the patient's family or the patient when he was alive.
Performing procedures on deceased patients is ethically permissible with appropriate consent and consideration of risks and benefits for patients, families, learners, staff, and the field of medicine. Supervising physicians must obtain informed consent from the patient while alive and with capacity or from a newly deceased patient’s healthcare proxy or family. During the consent process, the supervisor should outline the patient's and family's rights, wider educational and societal benefits, potential risks, and ensure that performing the procedure would be consistent with the patient's values and wishes. Additionally, the supervising physician has a responsibility to ensure that a medical examiner has cleared the patient and that the patient is not an organ donor before proceeding. Finally, the procedure should be documented in the patient's chart.
Berger and Cassell review the ethics of practicing procedures on deceased patients. They note that some ethical norms may suggest this practice is not appropriate. They recommend performing procedures when consent is obtained and it is ethically acceptable to do so.
Incorrect Answers:
Answer B: Consulting the hospital ethics committee is not necessary, for with proper permission, trainees may perform procedures on deceased patients for educational purposes. The ethics committee should only be consulted when there is no clear course of action (an example may be no advanced directive with family members disagreeing on what the patient's wishes would have been for a critically ill patient).
Answer C: Contacting the patient's family to ask for permission to perform the procedure is incorrect, as the supervising physician needs to verify and document consent. Medical students cannot consent patients and family members. Moreover, the family should not be contacted if the patient has already approved or refused this when he had capacity.
Answer D: Intubating the patient with the resident's supervision is incorrect because proper permission must be ensured prior to performing educational procedures on deceased patients.
Answer E: Reporting the resident to hospital administration is incorrect because it is ethically permissible to perform an intubation on a deceased patient provided there is proper permission. The resident is not asking the medical student to do anything illegal or against hospital policy. Reporting the resident may be indicated if the resident was performing procedures against the patient's will.
Bullet Summary:
Trainees may perform procedures for educational purposes on deceased patients if permission is obtained from the patient prior to death, the patient's family, or a healthcare proxy.
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A 30-year-old woman presents to the emergency department for palpitations. For 2 months, she has experienced intermittent palpitations along with menstrual irregularity and hair loss. At home, the air conditioner is at its coldest setting, but the patient still feels overheated. Her temperature is 99.5°F (37.5°C), blood pressure is 135/90 mmHg, pulse is 120/min, and respirations are 22/min. The patient is diaphoretic with tremulous hands, demonstrates thyromegaly, and protrusion of her eyes is noted. She is given atenolol in the emergency department with improvement of her palpitations and is instructed to follow up with her primary doctor for further management. Which of the following is most likely to be found in this patient after definitive treatment of her condition?
|
{
"A": "Exophthalmos",
"B": "Hair loss",
"C": "Heat intolerance",
"D": "Thyromegaly",
"E": ""
}
|
A
|
This patient presents with palpitations, tachycardia, tremor, heat intolerance, hair loss, menstrual irregularity, goiter, and exophthalmos concerning for hyperthyroidism due to Graves disease. Radioiodine ablation is the preferred definitive management for Graves disease, which can worsen exophthalmos.
Graves disease is an autoimmune hyperthyroid disorder caused by antibodies to the thyroid stimulating hormone receptor (TSHR), which induce production of T4 and triiodothyronine (T3). Overstimulation of the thyroid gland by TSHR antibodies results in diffuse enlargement of the thyroid gland, termed “goiter.” TSHR is also highly expressed in retro-ocular adipocytes and fibroblasts, where overstimulation by TSHR antibodies (and activated T-cells) leads to the expansion of retro-ocular connective tissue and extra-ocular muscle volume. This causes exophthalmos (bulging eyes) and is referred to as Graves ophthalmopathy or orbitopathy. Beta blockers are used to achieve acute sympathetic control in hyperthyroid Graves patients, and antithyroid medications (propylthiouracil or methimazole) are initiated to achieve a euthyroid state. Radioactive iodine ablation is first-line definitive management, particularly, for individuals with unsuccessful anti-thyroid medication management. Radioiodine ablation has been known to increase TSHR-antibodies, likely secondary to the leakage of thyroid antigens, and thus exophthalmos is often worsened after treatment. For this reason, corticosteroids are often co-administrated as a prophylactic measure.
Davies et al. review Graves disease including the pathophysiology and management. They note that Graves orbitopathy may be worsened by radioiodine ablation. They recommend further studies and advancements in care given this lasting complication.
Incorrect Answers:
Answer B: Hair loss can occur in hyperthyroid and hypothyroid states due to altered hair follicle stem cell function. However, this process is typically reversed, not worsened, after achieving a euthyroid state.
Answer C: Heat intolerance occurs in Graves disease due to hyperthyroid-induced sympathetic overactivity, which resolves after successful treatment.
Answer D: Menstrual irregularity occurs in hyperthyroidism through altered levels of sex hormone binding globulin, gonadotropin-releasing hormone, and prolactin. However, treatment of hyperthyroidism typically restores menstrual regularity. After ablation, patients will be hypothyroid; however, the standard of care is to start the patient on levothyroxine which should prevent this complication.
Answer E: Thyromegaly in Graves disease is caused by diffuse overactivation of the thyroid gland by the TSHR antibodies. Once treated with radioactive iodine (I-131), the thyroid gland gradually shrinks in size. Patients who undergo radioactive iodine ablation will later require life-long thyroxine supplementation due to resulting hypothyroidism.
Bullet Summary:
Definitive therapy for Graves disease is radioiodine ablation, which leads to increased TSHR antibodies and worsened exophthalmos from overactivation of TSHR-rich retro-ocular adipocytes and fibroblasts.
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247
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A 72-year-old man presents to the clinic for his annual exam. For the past few months, he has pain in his chest with physical activity. The pain goes away after he takes a break. He reports no chest pain while he is resting, and the pain is not worsening. His past medical history is notable for hypertension, type 2 diabetes mellitus, and hyperlipidemia. His medications include amlodipine, atorvastatin, and metformin. His temperature is 36.5°C (97.7°F), blood pressure is 132/80 mmHg, pulse is 74/min, respirations are 14/min, and oxygen saturation is 98% on room air. He has a regular rate and rhythm, normal S1 and S2, and no murmurs, rubs, or gallops. His anterior, lateral, and posterior chest are non-tender to palpation. His electrocardiogram is shown in Figure A. Troponin I level is < 0.017 ng/mL. Which of the following is the most likely diagnosis?
|
{
"A": "Stable angina",
"B": "Costochondritis",
"C": "ST elevation myocardial infarction",
"D": "Unstable angina",
"E": ""
}
|
A
|
This patient who presents with exertional chest pain that is relieved with rest without increasing frequency or intensity of chest pain, a normal electrocardiogram (ECG), and normal troponin level most likely has stable angina.
Angina pectoris is chest pain secondary to myocardial ischemia and is most commonly caused by atherosclerosis, though it can be caused by any etiology leading to narrowing of the coronary arteries. The pain tends to be substernal, dull, squeezing, or pressure-like and can also radiate to the neck or arm. It may also be associated with shortness of breath, dizziness, lightheadedness, nausea/vomiting, or diaphoresis. In stable angina, the chest pain is precipitated by exertion or stress and is consistently relieved with rest or nitroglycerin. ECG tends to be normal, and troponin I levels are not elevated. Treatment of stable angina includes beta blockers and nitrates (for episodes of pain), as well as therapy to prevent disease progression disease progression which may include antiplatelet therapy (aspirin), lipid-lowering medications, and glycemic control. Lifestyle measures are also the mainstay of therapy and may include smoking cessation, exercise, and dietary modification.
Joshi and de Lemos review stable angina. They note the optimal management of this condition. They recommend lifestyle interventions, lipid-lowering therapy, and antiplatelets to reduce morbidity and mortality.
Figure A shows an electrocardiogram with regular rate and rhythm. Every P wave is followed by a narrow QRS complex, which is consistent with normal sinus rhythm.
Incorrect Answers:
Answer A: Costochondritis presents with pain of the chest wall that can be sharp, aching, or pressure-like and typically worsens with cough or deep breathing. It is typically caused by injury to the chest, physical strain, or can be associated with inflammatory conditions such as arthritis. On exam, the pain can be reproduced with palpation of the chest wall, in particular, the costochondral junction. This patient's chest pain is associated with exertion and relieved with rest, and his pain is not reproduced upon palpation of the chest wall. Thus, he is unlikely to have costochondritis.
Answer B: Non-ST elevation myocardial infarction presents similarly to unstable angina with substernal chest pain that is new-onset, accelerating, or occurring at rest, without ST elevations on ECG. However, ST depressions or T wave inversions may be present on ECG, and troponin I and creatine kinase-MB isoenzyme (CK-MB) would be elevated, indicating myocardial injury.
Answer C: ST-elevation myocardial infarction presents with acute onset substernal chest pain that can radiate to the neck, arm, shoulders, or jaw and is sometimes associated with diaphoresis, nausea/vomiting, shortness of breath, lightheadedness, or anxiety. ECG shows ST elevations in a vascular distribution, and troponin I and CK-MB levels are elevated. This patient's ECG does not show ST elevations, and his symptoms are more consistent with stable angina.
Answer E: Unstable angina is characterized by substernal chest pain occurring at rest or occurring with more severity, longer duration, or increasing frequency. ECG may be normal or show ST depression or T wave inversion, and the troponin level is not elevated. It is caused by incomplete coronary artery occlusion by a thrombus or atherosclerosis, commonly due to a ruptured plaque with subsequent clot formation. This patient's chest pain is exertional, does not occur at rest, and is consistently relieved with rest, and thus would be consistent with stable angina.
Bullet Summary:
Stable angina is characterized by exertional chest pain that is not changing in quality or quantity and is relieved with rest.
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A 14-year-old boy is brought to the pediatrician for behavioral issues. At school, he interrupts class by making barking noises. His mother notes that he has been making throat-clearing noises daily for the past 2 years. He has no medical problems and takes no medications. He gets along with his 2 brothers, plays turn-taking games with his friends, and completes his chores. His temperature is 98.4°F (36.9°C), blood pressure is 118/72 mmHg, pulse is 72/min, and respirations are 16/min. On exam, he grimaces several times and blinks his eyes rapidly. He does not appear to be reacting to internal stimuli. His mood and affect are normal. Which of the following is the most appropriate treatment for this patient?
|
{
"A": "Methylphenidate",
"B": "Fluoxetine",
"C": "Haloperidol",
"D": "Dextroamphetamine",
"E": ""
}
|
C
|
This patient presents with multiple motor tics (grimacing, eye blinking) and phonic tics (barking, throat-clearing) on a daily basis for more than 1 year, which are consistent with Tourette syndrome. Tourette syndrome can be medically treated with antipsychotic agents such as haloperidol.
Tourette syndrome presents with multiple motor tics (e.g., grimacing, sniffing) and 1 or more phonic tics (e.g., throat-clearing, barking) that occur for at least 1 year. Tics must begin before the age of 18 years, and their location, frequency, type, complexity, or severity must change over time. Attention-deficit hyperactivity disorder (ADHD) and obsessive compulsive disorder (OCD) are often co-morbid conditions. Common first-line treatments for Tourette syndrome-related tics include habit reversal training and alpha-2 agonists such as guanfacine or clonidine. However, the only pharmacologic treatments approved for Tourette syndrome in the United States are the antipsychotics haloperidol, pimozide, and aripiprazole. Risperidone is also used due to its favorable side effect profile.
Seideman and Seideman review the current treatments for Tourette syndrome. They note it is a hyperkinetic movement disorder that often occurs in children and presents with motor and phonic tics. They recommend treating with both non-pharmacological and pharmacological treatments for optimal care.
Incorrect Answers:
Answer A: Clozapine is an atypical antipsychotic that blocks dopamine D2 receptors but is not approved for treatment of Tourette syndrome. It is typically avoided due to the risk for agranulocytosis and is mainly used for treatment-resistant schizophrenia as a last-line agent. Weight gain is another significant side-effect.
Answer B: Dextroamphetamine is a stimulant commonly used for the treatment of ADHD. ADHD can be comorbid with Tourette syndrome but presents with hyperactivity (e.g., fidgeting, difficulty taking turns, blurting out answers) and/or inattentive symptoms (e.g., daydreaming, difficulty completing tasks) in at least 2 settings. While this patient’s phonic tics are disruptive, he has no difficulty waiting his turn and completing his chores, making Tourette syndrome more likely.
Answer C: Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) that may be used for the treatment of OCD. OCD is often co-morbid with Tourette syndrome but compulsions are present, which manifest as repetitive counting, hoarding, tapping, or error checking. This patient’s behavior is better attributed to his tics rather than compulsions.
Answer E: Methylphenidate is a stimulant used for the treatment of ADHD. ADHD would present with hyperactivity and/or inattentive symptoms. The patient's vocal interruptions are better attributed to his phonic tics.
Bullet Summary:
Tourette syndrome is treated with habit reversal training, alpha-2 agonists (e.g., guanfacine, clonidine), and/or antipsychotics (e.g., haloperidol, risperidone).
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A 52-year-old man presents to the emergency department by ambulance for evaluation of hematemesis. His wife states that he began vomiting bright red blood this evening while eating dinner, and has produced about 5 cups total. He has a history of alcohol use disorder and has vomited small streaks of blood in the past, but has never undergone formal medical workup for it. On exam, he has bright red blood in his mouth and pharynx, and also displays a distended abdomen with a fluid wave, jaundice, scattered spider angiomas, and multiple ecchymoses. His temperature is 98.4°F (36.9°C), blood pressure is 98/68 mmHg, pulse is 125/min, and respirations are 22/min. A rapid point-of-care hemoglobin and platelet count is 8.8 g/dL and 80,000/mm^3, respectively. The patient is given 1L of normal saline. Which of the following is the most appropriate initial step in management?
|
{
"A": "Octreotide",
"B": "Ceftriaxone",
"C": "Nadolol",
"D": "Platelet transfusion",
"E": ""
}
|
A
|
This patient with a history of alcohol use disorder and signs of liver failure (jaundice, ascites, spider angiomas, and ecchymoses) presents with acute hematemesis and hypovolemic shock (hypotension, tachycardia, tachypnea) most concerning for a variceal hemorrhage. The first step in the resuscitation of patients with variceal hemorrhage is rapid administration of intravenous (IV) fluids and octreotide.
Esophageal and gastric varices, most commonly seen in patients with cirrhosis, are abnormally distended veins that are a product of venous congestion from portal hypertension. As these varices can project into the gastrointestinal lumen, they are subject to rupture either spontaneously or by mechanical disruption (e.g., tearing by food particles). Variceal hemorrhage is a life-threatening complication of cirrhosis as it can quickly progress to hemorrhagic shock or airway loss (if profuse vomiting is present). Patients should immediately receive 2 large-bore peripheral IVs (or central IV access) with which to administer IV fluid boluses to increase circulating volume. Blood should be transfused as needed, and a massive transfusion protocol may be needed. Patients should also be given octreotide, a splanchnic vasoconstrictor, in an effort to divert blood away from the hemorrhaging varices. Other treatments that should be given include ceftriaxone (to reduce bacteremia and mortality), proton pump inhibitors, and possibly interventions such as tranexamic acid. Upper GI endoscopy and banding are the definitive therapy.
Stanley et al review the management of acute upper gastrointestinal bleeding with initial IV fluid resuscitation as the first measure to achieve hemodynamic stability. They also report that for patients with cirrhosis, vasoactive drugs such as octreotide should be started as soon as variceal hemorrhage is suspected. Red blood cell transfusion is indicated at a hemoglobin transfusion of 7.0-8.0 g/dL. Definitive therapy is endoscopy with variceal ligation.
Incorrect Answers:
Answer A: Balloon tamponade is often performed in the emergency department or intensive care unit as a temporizing measure to achieve hemostasis for patients with severe and persistent variceal hemorrhage. The balloon is inserted into the esophagus or stomach and inflated to apply direct pressure to the bleeding varices; this buys valuable time in the transition to definitive endoscopic management.
Answer B: Ceftriaxone is administered to patients with cirrhosis who present with an upper gastrointestinal bleed as a prophylactic measure against spontaneous bacterial peritonitis. This patient is hemodynamically unstable, and antibiotics should not delay initial intravenous fluid resuscitation as well as other measures to reduce and/or stop the bleeding. While this patient should receive ceftriaxone, it is more dire to first give fluids, blood, and octreotide.
Answer C: Nadolol or other nonselective beta-blocker therapy is indicated as secondary prophylaxis to prevent future bleeding episodes for patients with a history of variceal hemorrhage. Non-selective beta blockers such as nadolol decrease portal pressure, but are contraindicated in the acute setting as they could exacerbate hypovolemic shock by reducing cardiac output.
Answer D: Platelet transfusion is required for patients with variceal hemorrhage with an initial platelet count < 50,000/mm^3, and for those who receive a significant amount of blood products during their resuscitation (significant dilutional thrombocytopenia can occur after 10-12 units of transfused red blood cells). This patient's platelet count is above 50,000/mm^3, and he has not yet received blood products.
Bullet Summary:
The most appropriate initial step in the management of a cirrhosis patient with acute variceal hemorrhage is the rapid administration of intravenous fluids and octreotide, a splanchnic vasoconstrictor.
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A 66-year-old man presents to the clinic with a 6-week history of bloody stools. He describes the blood as bright red wisps that float on the surface of the stool. He has no pain with bowel movements but notes on occasion he may strain. He does not endorse fatigue, fever, constipation, diarrhea, nausea, vomiting, abdominal pain, weight loss, or dyspnea. His last colonoscopy was 3 years prior to presentation and was benign. He has a medical history significant for hypertension that is well-controlled with lisinopril. He had an uncomplicated appendectomy when he was 23 years old. He has no family history of gastrointestinal malignancy. His temperature is 98.6°F (37.0°C), blood pressure is 140/90 mmHg, pulse is 76/min, and respirations are 16/min. On physical exam, the patient's abdomen is soft, non-distended, and non-tender with normal bowel sounds and without organomegaly or masses. The anus is patent without fissures, hemorrhoids, or skin tags. Which of the following is the most appropriate next step in management?
|
{
"A": "Increase fiber in diet",
"B": "Colonoscopy",
"C": "Observation",
"D": "Sigmoidoscopy",
"E": ""
}
|
B
|
This patient is presenting with painless bright red blood per rectum. Because he is over 50 years old and having rectal bleeding, he should be evaluated for malignancy with a colonoscopy.
Bright red blood per rectum has a broad differential diagnosis including anal fissures, hemorrhoids, angiodysplasia, inflammatory bowel disease, diverticular bleed, infection, polyps, and colon cancer. However, as patients age, their risk for malignancy increases significantly. Therefore, stable patients older than 50 years of age with rectal bleeding, regardless of their symptoms or family history, should receive a colonoscopy to rule out malignancy. Patients younger than 50 with warning signs of colon cancer (abnormal bowel habits, weight loss, family history of colon cancer, iron deficiency anemia) should also be evaluated with a colonoscopy. Often, colonoscopy is performed routinely at the age of 50 or 10 years prior to the age of presentation for malignancy in family members (whichever is sooner). Of note, even if there is an apparent cause for a lower GI bleed in patients 50 or older (such as hemorrhoids) colonoscopy is still indicated to rule out malignancy.
Barry et al. note the guidelines for colon cancer screening. They note the different age cutoffs. The USPSTF recommends screening for colorectal cancer in all adults aged 50-75 years.
Incorrect Answers:
Answer B: Computerized tomography scan of the abdomen and pelvis is incorrect because colonoscopy is the gold standard for diagnosis of suspected colon cancer. A CT scan may detect larger masses and a CTA may be performed if there is active bleeding and concern for an arterial source of bleeding that can be intervened upon.
Answer C: Increasing fiber in the diet may help patients with constipation or hemorrhoidal bleeding. Constipation presents with straining to have bowel movements and hard stools. However, because of this patient's age, he needs a colonoscopy to rule out malignancy.
Answer D: Observation is not appropriate at this patient's age. Patients greater than 50 years old with bright red blood per rectum should receive a colonoscopy to rule out malignancy despite any recent negative colonoscopy results.
Answer E: Sigmoidoscopy is less preferred to colonoscopy, as a smaller portion of the colon would be visualized, and colonic polyps or malignancies may be missed. For this reason, it is not the preferred study in this patient.
Bullet Summary:
Patients with bright red bleeding per rectum over 50 years old or with warning signs of colonic malignancy (weight loss, abnormal bowel habits, positive family history, or anemia) should receive a colonoscopy.
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A 77-year-old man presents to the emergency department with a complaint of sudden onset weakness in his right upper extremity. At home, the patient thought he was simply dehydrated, but he rapidly began to have trouble speaking. When his wife noted this she brought him into the hospital. On arrival to the emergency department, the patient is not responding to verbal stimuli and only withdraws his left upper extremity and lower extremity to pain. His past medical history is notable for hypertension and atrial fibrillation treated with metoprolol, apixaban, and lisinopril. His temperature is 99.0°F (37.2°C), blood pressure is 170/100 mmHg, pulse is 95/min, and respirations are 16/min. The patient has a seizure and subsequently demonstrates agonal breathing. He no longer responds to painful stimuli. A fingerstick blood glucose is 122 mg/dL. Which of the following is the most likely etiology of this patient's symptoms?
|
{
"A": "Intracerebral hemorrhage",
"B": "Subdural hematoma",
"C": "Subarachnoid hemorrhage",
"D": "Epidural hematoma",
"E": ""
}
|
A
|
This patient with a medical history of hypertension on blood thinners (apixaban) is presenting with rapidly progressive neurologic symptoms. Initially, his symptoms are in his right upper extremity, which then progresses to affect his speech and cause altered mental status, obtundation, and seizures, which is suggestive of a left-sided intraparenchymal hemorrhage.
Intraparenchymal (IPH) cerebral hemorrhages often present with sudden-onset focal neurologic deficits. A unique feature is that IPHs tend to present with progressive/worsening symptoms in contrast to ischemic strokes which often demonstrate stable or improving symptoms. It is not uncommon for a patient to present with focal neurologic deficits, which then progress to seizures and obtundation. Risk factors include older age, hypertension, and blood thinners. The prognosis is poor in intraparenchymal hemorrhages, and outcomes are dependent on the size and location of the bleed. Initial workup should be centered on obtaining a fingerstick blood glucose, securing the airway, and obtaining CNS imaging (often with a non-contrast CT scan). Further management is centered on elevating the head of the bed, reversing the patient's anticoagulation status, and possible neurosurgical intervention (though prognosis is very poor in general).
Gross et al. review IPH. They note that IPH has very high morbidity and mortality even when treated. There is ongoing research into minimally invasive approaches for evacuation of primary IPH to optimize and improve outcomes, although immediate medical therapy is needed to reduce mortality which is recommended.
Incorrect Answers:
Answer A: Epidural hematomas present after trauma with the "talk and die" syndrome beginning with a period of unconsciousness, a lucid interval, and then progressive obtundation. A CT of the head would demonstrate a lens-shaped lesion, and a burr hole to drain the collection of blood is the treatment of choice. Acute epidural hematomas do not typically begin spontaneously.
Answer C: Ischemic strokes present with sudden onset, focal neurologic deficits. Generally, after the initial ischemic event, patients will be stable or even note an improvement in their symptoms. It is less likely that this patient's progressive symptoms and seizures are caused by an ischemic stroke when compared to a hemorrhagic stroke or intraparenchymal hemorrhage. This diagnosis is certainly possible, and further workup with CT imaging and possibly MRI is needed to clarify the diagnosis and direct further care.
Answer D: Subarachnoid hemorrhages generally present with a "thunderclap" headache with meningeal signs. It is possible that patients may present with obtundation and confusion with severe subarachnoid hemorrhages. Seizures are uncommon in subarachnoid hemorrhages and generally do not present with such focal neurologic deficits. CT will show blood in the subarachnoid space. The diagnosis can be supported with CTA or a lumbar puncture. Further management may involve nimodipine, neurosurgical intervention, and observation if the bleed is small and has stopped on its own.
Answer E: Subdural hematomas are more common in the elderly patients and patients with alcohol use disorder and present after trauma with a gradual progression of altered mental status to obtundation. Note that large subdural hematomas may present with a rapid progression of symptoms. CT of the head will demonstrate a crescent-shaped lesion that crosses suture lines. Management may involve neurosurgical evacuation with large subdural hematomas causing mass effect.
Bullet Summary:
Intraparenchymal hemorrhages may occur spontaneously in the setting of hypertension and blood thinners and present with progressive neurologic deficits that get worse over time with possible seizures.
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A 75-year-old man presents to the emergency department with fatigue. He has had severe nausea, vomiting, and diarrhea for the past 3 days. Today, his wife noticed that he was confused. The patient has a history of coronary artery disease with a drug-eluting stent placed 1 year ago, obesity, hypertension, and dyslipidemia. He denies chest pain or dyspnea, but complains of diffuse abdominal pain. His temperature is 99.0°F (37.2°C), blood pressure is 100/60 mmHg, pulse is 105/min, and respirations are 22/min. Physical exam reveals a confused man with dry mucous membranes. His abdomen is diffusely tender to palpation. Laboratory studies are ordered and notable for the following:
Serum:
Na+: 147 mEq/L
Cl-: 112 mEq/L
K+: 3.5 mEq/L
HCO3-: 14 mEq/L
BUN: 80 mg/dL
Glucose: 100 mg/dL
Creatinine: 2.1 mg/dL
Troponin: 0.10 mcg/L (normal < 0.01 mcg/L)
An ECG is ordered and is pending. Which of the following is the most appropriate management of this patient's elevated troponin?
|
{
"A": "Aspirin, heparin, clopidogrel, and cardiac catheterization",
"B": "Ringer lactate bolus",
"C": "Metoprolol and aspirin",
"D": "Obtain a urinalysis and creatine phosphokinase level",
"E": ""
}
|
B
|
This patient with likely gastroenteritis (given his nausea, vomiting, and diarrhea) is dehydrated, as indicated by his low blood pressure, tachycardia, dry mucous membranes, and prerenal kidney injury (elevated BUN and creatinine with BUN:creatinine ratio > 20:1) in the setting of an anion gap (anion gap = [Na+] - [Cl-] - [HCO3-] = 147 - 112 - 14 = 21). His elevated troponin is likely secondary to poor renal clearance and dehydration, which is most appropriately addressed with IV fluids such as Ringer lactate.
Troponin is a lab marker classically thought to be elevated when there is an injury to the heart causing leakage of this enzyme from the cardiac myocyte. However, there are many possible causes of an elevated troponin that may not be directly cardiac in nature or related to myocardial ischemia. Acute kidney injury is a common cause of an elevated troponin. For this reason, patients with an elevated troponin with kidney dysfunction without any cardiac symptoms or ECG changes should have their renal etiology addressed, and this will often clear the troponin. In the setting of a prerenal injury (dehydration causing poor kidney perfusion and a BUN:creatinine ratio > 20:1), IV fluids will restore perfusion and treat the underlying cause. Patients with chronic kidney disease or kidney failure should have an ECG obtained and their current troponin should be compared to previous troponin levels to ensure it is not higher than their baseline. If there is uncertainty regarding a troponin level, it can be trended to see if it is rising, falling, or staying the same. Correlation with clinical symptoms is important when evaluating an elevated troponin level.
Masri et al. review the causes of an elevated troponin. They note that a troponin elevation can be seen in myopericarditis, renal failure, heart failure, pulmonary embolism, septic shock, rhabdomyolysis, stroke, and many other possible causes that are not related to myocardial infarction. They recommend keeping a broad differential and correlating the troponin with the patient's clinical presentation.
Incorrect Answers:
Answer A: Aspirin would be appropriate management of an elevated troponin secondary to acute coronary syndrome as its antiplatelet activity reduces mortality. It should be administered prior to performing an ECG in patients with chest pain thought to be from a cardiac etiology.
Answer B: Aspirin, heparin, clopidogrel, and cardiac catheterization is appropriate management of a ST elevation myocardial infarction, which presents with chest pain, diaphoresis, dyspnea, and ST elevation within a vascular distribution with reciprocal changes on ECG. This patient has no cardiac symptoms and has a better alternative explanation for their troponin elevation.
Answer C: Metoprolol and aspirin may be indicated in acute coronary syndrome, and metoprolol would reduce this patient's heart rate. However, note that this patient's tachycardia is secondary to volume depletion; thus, beta-blockade for sinus tachycardia is inappropriate and may make the patient hemodynamically unstable.
Answer D: Obtaining a urinalysis and creatine phosphokinase level may be performed in rhabdomyolysis which presents in the setting of seizures, electrical shock, heatstroke, or with vigorous exertion. Patients will complain of muscle pain, oliguria, and dark urine. Management is centered on the administration of large volumes of fluid to protect the kidney and clear the toxic myoglobin. Note that rhabdomyolysis may elevate the troponin; however, there is nothing in this patient's history that suggests rhabdomyolysis.
Bullet Summary:
Prerenal injury causing an acute kidney injury may elevate the troponin due to decreased renal clearance and should be addressed with the administration of fluids.
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A 65-year-old man presents to the emergency department with sudden-onset altered mental status. He was last seen normal 1 hour ago. His wife noticed that he was confused, slurring his speech, and had notable weakness that caused him to drop his cup of coffee. The patient is confused and not able to answer any questions. Facial drooping of the left lower face is noted, and the patient cannot follow any commands. He has a past medical history of diabetes and atrial fibrillation and is currently taking warfarin. His other medications are not known. His temperature is 98.0°F (36.7°C), blood pressure is 150/90 mmHg, pulse is 115/min, and respirations are 17/min. The patient is not able to follow any commands for further neurologic evaluation but does not appear to be moving his right upper extremity. In addition to further physical exam, which of the following is the most appropriate next step in management?
|
{
"A": "CT head",
"B": "Fingerstick blood glucose",
"C": "Fresh frozen plasma and vitamin K",
"D": "Alteplase",
"E": ""
}
|
B
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This patient is presenting with sudden onset confusion, slurred speech, asymmetric smile, and weakness in the setting of risk factors for stroke (atrial fibrillation, diabetes, and hypertension). The most important initial step in management in a patient with altered mental status and neurological deficits is to obtain a fingerstick blood glucose.
The workup of stroke is first centered on a thorough history and physical and immediately calculating an NIH stroke scale (11-domain assessment of stroke severity involving patient consciousness level, orientation, ability to follow commands, degree of gaze palsy, degree of vision loss, ataxia, motor drift, sensation, inattention, language/speech) as well as ascertaining when the patient was last known to be neurologically normal. While performing the exam and NIH stroke scale, a fingerstick blood glucose should be performed in all patients as hypoglycemia may present identically to a stroke. Severe hypoglycemia may present with lethargy, confusion, focal or global weakness, nausea, vomiting, agitation, and even seizures. If the patient is hypoglycemic, dextrose can be given which will rapidly correct the patient's underlying deficits.
Ohshita et al. review other possible causes of stroke-like symptoms. They note that hypoglycemia may mimic stroke and cause focal neurological signs with common findings being unilateral motor weakness with mild or moderate alteration of consciousness. They noted that all patients improved within 1 hour of glucose injection in this study, thus the recommendation to check a fingerstick blood glucose in all stroke patients.
Incorrect Answers:
Answer A: Alteplase would be indicated if a patient presented with disabling neurologic deficits from an ischemic stroke within 4.5 hours of symptom onset only after a CT scan of the head has ruled out an intracranial bleed. The patient must have no other contraindications to thrombolytics including but not limited to recent trauma, known intracranial hemorrhage, rapidly improving neurologic deficits (spontaneously), and no other clear reversible cause (among many other contraindications).
Answer B: CT head is the most appropriate initial step in the management of an acute stroke; however, a rapid fingerstick blood glucose takes precedence as hypoglycemia can mimic a stroke and be immediately addressed thus removing the need for further workup if there is a complete resolution of symptoms with normoglycemia. While an exam is ongoing, a fingerstick blood glucose is being obtained, and neuroimaging is also often ordered to be performed immediately after.
Answer D: Fresh frozen plasma and vitamin K would be indicated in this patient if he had a hemorrhagic stroke (a CT of the head would need to confirm this) to reverse his anticoagulation with warfarin. Factor concentrate can also be used to rapidly reverse anticoagulation with warfarin.
Answer E: MRI brain would be indicated in the workup of a stroke or transient ischemic attack after all emergency interventions and labs including CT head, serum chemistries, CBC, and ECG. It delineates the extent of the stroke and gives useful prognostic and diagnostic information. It also may elucidate strokes missed on other forms of neuroimaging such as CT perfusion.
Bullet Summary:
A fingerstick blood glucose should be obtained immediately in all patients with stroke-like symptoms or altered mental status.
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254
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A 55-year-old man with a history of polysubstance abuse is found down in his home acutely obtunded. Emergency medical services administered naloxone which immediately woke the patient up and improved his oxygen saturation from 40% to 90%. However, they noted subsequently that the patient demonstrated increased work of breathing and had crackles and wheezing on pulmonary exam. The patient arrives alert and oriented claiming he feels short of breath. He denies any chest pain or other symptoms aside from shortness of breath. He has a history of cocaine-induced cardiomyopathy and myocardial infarction from cocaine use 2 years ago. The patient has a 40 pack-year smoking history. His temperature is 96.0°F (35.6°C), blood pressure is 120/68 mmHg, pulse is 102/min, respirations are 26/min, and oxygen saturation is 88% on room air. Physical exam reveals increased work of breathing, pulmonary crackles, and wheezing. A chest radiograph is performed as seen in Figure A. Which of the following is the most likely etiology of this patient's current symptoms?
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{
"A": "Medication administration",
"B": "Community acquired pneumonia",
"C": "Atypical pneumonia",
"D": "Poor cardiac function",
"E": ""
}
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A
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This patient is presenting after administration of naloxone with respiratory distress, wheezing, crackles, and pulmonary edema on chest radiography, suggesting acute pulmonary edema. Given the presence of symptoms immediately following naloxone administration, the cause of the pulmonary edema is likely the naloxone (medication-induced) that was administered.
Opioid use disorder is a common problem in the United States and can lead to overdose, which is life-threatening if not treated. Patients with symptoms of opioid intoxication including miosis, bradypnea, and altered mental status should be empirically given naloxone, as it may be life-saving and is relatively benign. Naloxone should only be given for patients with unstable vitals or who are failing to ventilate/oxygenate or protect their airway. Naloxone commonly precipitates withdrawal and may cause nausea, vomiting, diarrhea, and pain. It is possible for naloxone to cause pulmonary edema (via a poorly elucidated mechanism). Pulmonary edema presents with wheezing, tachypnea, and pulmonary crackles. The most important intervention when treating pulmonary edema is to address the underlying cause and start the patient on positive pressure ventilation. Diuretics may be administered if the patient is volume overloaded. An echogardiogram can rule out poor cardiac function as the underlying etiology as well.
Lassen et al. review naloxone use and pulmonary edema. They note that naloxone administration can cause non-cardiogenic pulmonary edema and that the mechanism is not well elucidated. They recommend that naloxone should only be used at the lowest dose possible to stabilize the patient.
Figure A is a chest radiograph demonstrating "fluffy" interstitial infiltrates throughout both lung fields suggestive of pulmonary edema.
Incorrect Answers:
Answer A: Atypical pneumonia may present with a dry cough, fever, hypoxia, and increased interstitial markings on chest radiograph. These patients are usually well appearing, and the opacities are not as "fluffy" as pulmonary edema. A common cause is Mycoplasma pneumoniae.
Answer B: Chronic obstructive pulmonary disease (COPD) presents with a flattened diaphragm and increased number of visible ribs on chest radiography as a result of air accumulation in the chest. Pneumonia may be present on chest radiograph and is a common cause of COPD flares. A COPD flare may present with wheezing, poor air movement, hypoxia, and hypercarbia.
Answer C: Community-acquired pneumonia presents with a fever, cough, hypoxia, and a lobar consolidation on chest radiograph. This infiltrate is usually confined to one lobe and is thus often called "lobar pneumonia." Streptococcus pneumoniae is the most common cause.
Answer E: Poor cardiac function can cause pulmonary edema via increased hydrostatic pressure backing up into the lungs causing fluid leakage. Though the appearance of pulmonary edema would be the same, naloxone causes non-cardiogenic pulmonary edema. In this patient with a previous myocardial infarction, a low ejection fraction may plausibly be contributing to this patient's pulmonary edema; however, the association of symptoms with naloxone administration makes this a less likely etiology for this case.
Bullet Summary:
Naloxone can cause non-cardiogenic pulmonary edema.
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255
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A 68-year-old woman presents to the emergency room with several days of frequent, nonbloody, watery stools. She recently completed a course of clindamycin 2 weeks ago for a tooth infection. Her medical history is notable for hypertension and hyperlipidemia for which she takes amlodipine and atorvastatin. She traveled recently and has no sick contacts. Her temperature is 37.0°C (98.6°F), blood pressure is 118/82 mmHg, pulse is 98/min, respirations are 14/min, and oxygen saturation is 98% on room air. On exam, her abdomen is soft, non-distended, and non-tender to palpation; however she has diffuse discomfort upon palpation of the abdomen with no rebound, rigidity, or guarding. Which of the following is most likely to confirm the diagnosis?
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{
"A": "CT imaging of abdomen and pelvis",
"B": "Rectal swab for selective anaerobic culture",
"C": "Abdominal radiograph",
"D": "Stool toxin assay",
"E": ""
}
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D
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This patient presenting with cramping abdominal pain and frequent watery diarrhea a few weeks after finishing a course of antibiotics most likely has Clostridioides difficile infection, for which the most appropriate confirmatory test is a stool toxin assay.
C. difficile infection should be suspected in patients with acute and clinically significant diarrhea with no obvious alternative explanation. It is associated with risk factors such as recent antibiotic use, hospitalization, and advanced age. Diagnosis is established via a positive enzyme immunoassay for C. difficile toxins and C. difficile glutamate dehydrogenase (GDH), or a positive nucleic acid amplification test (NAAT) for C. difficile toxins. The GDH enzyme immunoassay is highly sensitive for detecting C. difficile, but not specific for toxin-producing C. difficile, and thus the toxin enzyme immunoassay is submitted in conjunction. If the results of both are discordant, then NAAT is used to make the diagnosis. Treatment for C. difficile infection differs by disease severity and recurrence. Commonly used medications include fidaxomicin and oral vancomycin.
McDonald et al. review the guidelines for diagnosis and treatment of C. difficile and provide the algorithm for C. difficile testing as mentioned above. The authors also note that only liquid stool from patients with clinically significant and acute diarrhea should be submitted for testing. The authors recommend that formed stool from asymptomatic patients should not be tested because the presence of the C. difficile toxin gene does not distinguish between infection and asymptomatic carriage.
Incorrect Answers:
Answer A: Abdominal radiograph is an appropriate adjunctive diagnostic tool in patients with severe disease (e.g., severe abdominal pain and distension, fever, hypovolemia, lactic acidosis, marked leukocytosis) or fulminant colitis (marked by hypotension and ileus) to evaluate for toxic megacolon, bowel perforation, or other findings that warrant surgical intervention. In patients who are stable with low concern for severe disease or fulminant colitis, it would not be the preferred initial test for diagnosis nor would it be confirmatory.
Answer B: CT imaging of the abdomen and pelvis with oral and intravenous contrast is the preferred modality for detecting the presence of toxic megacolon, bowel perforation, or other findings that warrant surgical intervention in the setting of C. difficile colitis. Colonic dilatation of > 7 cm in diameter in the clinical setting of severe C. difficile infection is diagnostic. Other findings may include small bowel dilatation or scalloping of the bowel wall due to submucosal edema. While it would be reasonable to perform a CT scan in this patient, it would not confirm the diagnosis.
Answer C: Flexible sigmoidoscopy would be appropriate for cases in which an alternative diagnosis is suspected that requires direct visualization and/or biopsy of the bowel mucosa. It may also be helpful for patients with ileus or colitis in the absence of diarrhea as it allows for visualization of pseudomembranes on the inflamed mucosal surface, which are highly suggestive of C. difficile infection. In general, colonoscopy is a preferred and more accurate test.
Answer D: Rectal swab for selective anaerobic culture involves culture on a selective medium with toxin testing of isolated C. difficile. It is a highly sensitive test, but culture cannot distinguish toxin-producing strains from non-toxin-producing strains. A second test is required to detect toxin production by the cultured C. difficile strain (either enzyme immunoassay or nucleic acid amplification testing). Culture takes several days to finalize and as such, it is seldom used to establish a clinical diagnosis. It is most useful in patients with ileus and suspected C. difficile infection.
Bullet Summary:
The most appropriate confirmatory test for diagnosis of Clostridioides difficile infection is a stool toxin assay.
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256
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A 49-year-old man presents with 3 months of generalized weakness. He has had a chronic cough and a 20 pound unintentional weight loss over the past 6 months. He has a medical history significant for high blood pressure, hyperlipidemia, and seasonal allergies with no prior surgical history. He has no history of tobacco use. He moved from India 7 years prior to presentation. He currently lives in Oregon and has not left the west coast since moving. His temperature is 99°F (37.2°C), blood pressure is 100/70 mmHg, pulse is 76/min, and respirations are 16/min. His physical exam is significant for hyperpigmentation of the oral mucosa and temporal muscle wasting. Radiography of the abdomen demonstrates bilateral adrenal calcifications. Laboratory values are as follows:
Serum:
Na+: 130 mEq/L
Cl-: 96 mEq/L
K+: 5.2 mEq/L
HCO3-: 24 mEq/L
Morning cortisol: 2 ug/dL
30-minute cortisol during cosyntropin test: 8 ug/dL (normal > 18 ug/dL)
Morning adrenocorticotropic hormone (ACTH) concentration (serum): 80 pg/mL (normal 10-60 pg/mL)
Which of the following is the most appropriate next step in management?
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{
"A": "Prednisone taper",
"B": "Bilateral adrenalectomy, prednisone, and fludrocortisone",
"C": "Rifamycin, isoniazid, pyrazinamide, ethambutol, and hydrocortisone therapy",
"D": "Hydrocortisone and immunoglobulin therapy",
"E": ""
}
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C
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This man from India presents with generalized weakness, chronic cough, unintentional weight loss, skin hyperpigmentation, hyponatremia, hyperkalemia, hypocortisolism, cosyntropin stimulation test failure, elevated ACTH, and bilateral adrenal calcifications on radiography. These symptoms and signs in this patient are most consistent with adrenal tuberculosis requiring RIPE therapy (rifamycin, isoniazid, pyrazinamide, ethambutol) as well as glucocorticoid and mineralocorticoid therapy.
Adrenal insufficiency occurs when the adrenal glands do not produce enough cortisol and aldosterone. Primary adrenal insufficiency is due to dysfunction at the level of the adrenal glands themselves, as opposed to upstream factors such as the pituitary gland. Primary adrenal insufficiency in developed nations is most often caused by autoimmune disease. In developing nations, adrenal tuberculosis is a significant cause of primary adrenal insufficiency. Adrenal tuberculosis often presents with a history of tuberculosis or tuberculosis symptoms, as well as symptoms of adrenal insufficiency such as fatigue, unintentional weight loss, and hyperpigmentation. Patients often have hyponatremia, hyperkalemia, low morning cortisol, a failed cosyntropin test, and high ACTH concentrations. Radiography may demonstrate bilateral adrenal calcifications, and/or adrenal enlargement. Tuberculosis can infect all cortices of the adrenal glands bilaterally, and therefore treatment requires eradicating the infection with multi-drug therapy (RIPE therapy) as well as replacement of glucocorticoids and mineralocorticoids, which may be achieved by high-dose hydrocortisone or other combinations of steroids that together provide glucocorticoid and mineralocorticoid replacement.
Vinnard and Blumberg outline the signs and symptoms, histopathology, lab results, imaging, differential diagnosis, and treatments associated with adrenal tuberculosis. They recommend early recognition and treatment.
Incorrect Answers:
Answer A: Bilateral adrenalectomy, prednisone therapy, and fludrocortisone therapy are incorrect because medical therapy should first be attempted to eradicate the infection before undergoing surgery. Bilateral adrenalectomy may be considered if there is suspicion of lung cancer with metastasis to the bilateral adrenal glands. Patients will require lifelong replacement therapy.
Answer B: Dexamethasone alone is incorrect because this patient likely has tuberculosis and should be treated for it. Additionally, this patient has signs of mineralocorticoid deficiency (hyponatremia, hyperkalemia), and patients often require mineralocorticoid therapy or a high dose of a glucocorticoid with mineralocorticoid activity (e.g., hydrocortisone). Dexamethasone has minimal to absent mineralocorticoid activity.
Answer C: Hydrocortisone therapy and immunoglobulin therapy are incorrect because this patient has adrenal tuberculosis. Although autoimmune adrenalitis can cause primary adrenal insufficiency, immunoglobulins are not used to treat this condition.
Answer D: Prednisone taper would be appropriate for acute conditions such as an asthma or COPD exacerbation. While prednisone will treat the symptoms of primary adrenal insufficiency, it will not treat active tuberculosis infection. Primary adrenal insufficiency in developed nations is most often caused by autoimmune adrenalitis (Addison disease) and presents with fatigue, unintentional weight loss, abdominal pain, hyperpigmentation, and muscle weakness. In this condition, long-term steroid therapy is indicated.
Bullet Summary:
Patients with adrenal tuberculosis should be treated with rifamycin, isoniazid, pyrazinamide, ethambutol, as well as glucocorticoid and mineralocorticoid replacement.
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A 67-year-old man presents with a recurrent episode of syncope. He states that this has happened to him multiple times, particularly when he changes body position from sitting to standing, exerts himself, or turns his head quickly. He says that he notes numbness, vertigo, and sometimes even trouble with speaking immediately prior to fainting. The episodes usually last 1-5 minutes. When he wakes up, he is mildly confused but typically returns to baseline within a minute. The patient has a past medical history of diabetes, dyslipidemia, and hypertension. His temperature is 98.5°F (36.9°C), blood pressure is 153/89 mmHg, pulse is 90/min, respirations are 11/min, and oxygen saturation is 97% on room air. The patient's neurological exam is unremarkable. However, when he is asked to stand up and start walking, he experiences the same numbness and tingling and feels like he may faint. Which of the following is the most likely diagnosis?
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{
"A": "Vagal event",
"B": "Seizure",
"C": "Blood vessel narrowing",
"D": "Stroke",
"E": ""
}
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C
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This elderly patient with risk factors for vascular disease (diabetes, dyslipidemia, hypertension) is presenting with episodes of dizziness, vertigo, numbness/tingling, dysarthria, and syncope, which seem to be provoked by standing rapidly and changing head position. This is concerning for vertebrobasilar syndrome, caused by blood vessel narrowing.
Vertebrobasilar syndrome is caused by narrowing (via causes such as atherosclerosis, dissection, or congenital narrowing among others) of the vertebrobasilar vascular system. It is a common cause of syncope that may be worsened by changes in head position or standing rapidly. Other unique features include numbness/tingling, a sensation of vertigo, nausea, vomiting, dysphagia, and dysarthria. Note the episodes of syncope in this condition are intermittent and specifically provoked and do not have lasting/permanent neurological deficits in contrast to a stroke. Management is first centered on vascular imaging which may include a CTA head/neck or an MRA head/neck. Further care depends on the symptoms present but typically involves smoking cessation, glycemic control, blood pressure control, aspirin, and a statin.
Xuan-Ting et al. review posterior circulation strokes which occur more frequently in patients with atherosclerosis of the vertebrobasilar system. They note that MRI is one of the most accurate tests for assessing posterior circulation strokes which may present with dizziness and syncope. It is far superior to CT imaging. For this reason, they recommend that CT imaging alone cannot definitively rule out a posterior circulation stroke.
Incorrect Answers:
Answer B: Cardiac dysrhythmias such as ventricular tachycardia can cause sudden onset and offset syncope without prodromal symptoms. The differentiating feature of this form of syncope is the rapid onset and offset in a high-risk patient. The diagnosis can be confirmed with an ECG; however, many patients will require prolonged observation on telemetry.
Answer C: Seizure presents with impaired consciousness, tonic-clonic activity, and a post-ictal state which gradually improves over hours. The lactate may be elevated after a seizure, and the prolactin level is a more specific indicator of a seizure. However, the diagnosis is most appropriately made based on history, exam, and EEG.
Answer D: Stroke involving the vertebrobasilar system may cause syncope in addition to ongoing dizziness and vertigo with ataxia. However, this patient's symptoms seem to be positional and have entirely resolved; thus, a stroke is unlikely. He is at higher risk of stroke given his vertebrobasilar insufficiency and an MRI should still be performed in this patient.
Answer E: Vagal event presents with a warm prodrome with palpitations, flushing, and syncope. Muscle twitching (but no tonic-clonic activity) may be seen. Patients may wake up slightly confused but return to baseline within seconds.
Bullet Summary:
Vertebrobasilar insufficiency may present with positional episodes of syncope caused by insufficient blood flow through the vertebrobasilar blood vessels.
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258
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A 67-year-old woman presents from a nursing home with altered mental status. She was last known to be normal the night before. The patient has dementia at baseline and is minimally interactive. This morning, she was found to be obtunded. No further history was provided from the nursing home, and the patient is unable to provide any history. Her temperature is 95.0°F (35.0°C), blood pressure is 84/54 mmHg, pulse is 50/min, respirations are 9/min, and oxygen saturation is 98% on room air. Physical exam reveals an obtunded woman who only withdraws her extremities to pain. Her skin is cool and pale, and her hair is thin. There are no signs of trauma noted on exam. Laboratory values are notable for a whole blood sodium of 120 mEq/L. The patient is given several intravenous boluses of fluids and her blood pressure improves to 100/60 mmHg. Which of the following is most likely to confirm the underlying cause of this patient's symptoms?
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{
"A": "Perform an echocardiogram",
"B": "Administer glucagon",
"C": "Check serum TSH and free T4 levels",
"D": "Perform a CT scan of the head",
"E": ""
}
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C
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This patient is presenting with obtundation, bradycardia, hypotension, hypothermia, thinning of her hair, and hyponatremia, which are concerning for myxedema coma. A serum TSH and free T4 would be most informative in confirming this diagnosis.
Myxedema coma (decompensated hypothyroidism) is the most life-threatening manifestation of hypothyroidism. Key clinical features include hypothermia (often the temperature is <95.9°F (35.5°C)), bradycardia, hypotension, bradypnea (causing a respiratory acidosis), hypoxia, and obtundation. Immediate management is centered on warming the patient, warmed IV fluids, and protecting the patient's airway, if needed. If there is high clinical suspicion for myxedema coma, then IV levothyroxine can be given empirically. Otherwise, the TSH and free T4 should be checked, which will reveal an elevated TSH and a low free T4. Patients are often critically ill and require active rewarming and close monitoring in an ICU setting.
Wall reviews myxedema coma. Wall notes that myxedema coma is a life-threatening manifestation of hypothyroidism. She recommends that generally IV T4 (levothyroxine) is preferred over IV T3 in initial management.
Incorrect Answers:
Answer A: Administering glucagon would be appropriate in a beta-blocker overdose, which presents with bradycardia, hypotension, and altered mental status. There is no indication that this patient intentionally overdosed, and her hyponatremia and thinning hair supports a diagnosis of hypothyroidism. Other treatments that can be given in a beta-blocker overdose including epinephrine, calcium, insulin, dextrose, and lipid emulsion therapy.
Answer C: Obtaining blood cultures and a serum lactate is the appropriate management of sepsis/septic shock. Generally, patients with septic shock present with hypotension (refractory to fluid resuscitation), tachycardia, and fever or hypothermia. Though myocardial depression may happen in critically ill patients who are about to undergo cardiac arrest, hypothyroidism better explains this patient's constellation of symptoms. It would be appropriate to obtain cultures and a serum lactate in this patient while the differential is being narrowed.
Answer D: Performing a CT scan of the head would be indicated at some point in the workup of patients with altered mental status if there was a suspected central nervous system etiology such as a subdural hematoma. However, hemodynamically unstable patients should never be sent to the CT scanner prior to stabilization and resuscitation. A subdural hematoma is more common in older patients and patients with alcohol use disorder who experience head trauma as the atrophy of their brain makes the bridging veins more vulnerable.
Answer E: Performing an echocardiogram may show reduced cardiac function; however, it is unlikely to reveal the underlying cause of this patient's hypotension and bradycardia other than showing poor cardiac function.
Bullet Summary:
Myxedema coma presents as a critically ill, obtunded patient who is hypothermic, bradycardic, and hypotensive, and the diagnosis can be supported with a high TSH and a low free T4.
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A 55-year-old man presents to the emergency department with epistaxis for the past hour. He has never had epistaxis before and has been unable to control it with pressure, head elevation, and ice. The patient has a past medical history of atrial fibrillation and is currently taking metoprolol and warfarin. His temperature is 98.5°F (36.9°C), blood pressure is 123/81 mmHg, pulse is 90/min, respirations are 13/min, and oxygen saturation is 97% on room air. Physical exam reveals a comfortable man in no distress. Inspection reveals active bleeding in the anterior nares. There is not a clear, single bleeding vessel. Which of the following is the most appropriate initial step in management?
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{
"A": "Placement of posterior nasal packing",
"B": "Intravenous tranexamic acid",
"C": "Topical oxymetazoline",
"D": "Cauterization with silver nitrate",
"E": ""
}
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C
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This patient on warfarin is presenting with epistaxis from the anterior nares (and is currently hemodynamically stable) suggesting anterior epistaxis. Prior to more invasive measures, topical therapy with oxymetazoline should be tried as it is very successful in reducing or resolving epistaxis.
Epistaxis can be a benign or life-threatening presentation. For anterior epistaxis, the management is centered on compression of the anterior nares as most cases are caused by bleeding from Kiesselbach plexus. If this fails, the next step in management is having the patient blow their nose to remove any clots, followed by vigorous application of topical oxymetazoline which vasoconstricts the vessels in the nares and is highly effective in treating epistaxis. If this fails, other topical agents include topical tranexamic acid, and thrombogenic foams. If pressure and topical therapy fail to resolve epistaxis, then anterior nasal packing (such as nasal tampons) may be used.
Kucik and Clenney review treatments for epistaxis. They note that the first-line treatment of anterior epistaxis is compression of the anterior nares. If this fails, they recommend other measures such as topical vasoconstrictors, cautery, and packing.
Incorrect Answers:
Answer A: Cauterization with silver nitrate is appropriate for anterior epistaxis, but generally should be reserved for patients who have failed initial medical therapy with topical agents. It may also be appropriate first-line therapy in patients with recurrent epistaxis from a clear, single bleeding vessel (which is not present in this patient).
Answer B: Fresh frozen plasma and intravenous phytonadione is the appropriate reversal agent for warfarin. While this may stop the patient's epistaxis, he is hemodynamically stable and the bleeding is not life-threatening; thus, the risk of thrombus from atrial fibrillation is likely greater than the risk of bleeding in this case of epistaxis. Less invasive medical therapy should be started/tried first.
Answer C: Intravenous tranexamic acid would be appropriate in an acutely hemorrhaging patient to reduce bleeding in the setting of hemorrhagic shock. Topical (not intravenous) tranexamic acid may be an appropriate first-line agent for anterior epistaxis.
Answer D: Placement of posterior nasal packing would be indicated if there was persistent bleeding in the setting of posterior epistaxis (often from bleeding from the sphenopalatine artery), which presents with more profuse bleeding that may threaten the airway. This patient's bleeding is clearly anterior as it can easily be visualized in the anterior nares; thus, this intervention is not needed.
Bullet Summary:
Topical oxymetazoline and other topical agents such as tranexamic acid are appropriate first-line agents in the management of epistaxis if pressure alone fails to resolve symptoms.
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260
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A 59-year-old man presents to the emergency department after a sudden onset of slurred speech and right upper extremity weakness. His symptoms lasted 20 minutes but by the time he arrived at the emergency department he was symptom-free. The patient denies any preceding symptoms. He has a history of diabetes, obesity, and hypertension but does not see a physician for his underlying conditions. His temperature is 99.2°F (37.3°C), blood pressure is 140/85 mmHg, pulse is 82/min, respirations are 16/min, and oxygen saturation is 100% on room air. Physical exam reveals normal vision, strength, and sensation with a stable gait. Finger-nose testing and tandem gait are unremarkable. A CT scan of the head is performed and is unremarkable. Which of the following is the most appropriate next step in management?
|
{
"A": "CTA head/neck",
"B": "MRI brain",
"C": "Labetalol",
"D": "Aspirin",
"E": ""
}
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D
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This patient is presenting with a transient episode of neurologic dysfunction (slurred speech and right upper extremity weakness) that has completely resolved, which is concerning for a transient ischemic attack. In the setting of his normal head CT, aspirin should be administered next.
A transient ischemic attack (TIA) is a brief episode of focal neurologic dysfunction that completely resolves without any residual deficits. Patients with a TIA are at high risk for future TIAs and stroke. For this reason, management is immediately centered on a thorough neurological exam followed by a CT scan of the head to rule out a hemorrhage. Subsequently, aspirin should immediately be administered which reduces the incidence of future stroke. Patients will subsequently be discharged on aspirin in addition to other morbidity-lowering agents including a statin and tight blood pressure and glycemic control as well as a second antiplatelet agent in appropriate patients. Further workup for a TIA may include a CTA head/neck, an MRI brain, and an echocardiogram. Modification of risk factors is also critical in these patients including weight loss, smoking cessation, exercise, glycemic control, and blood pressure control.
Clissold et al. review transient ischemic attacks. They note that transient ischemic attacks (TIA), if untreated, carry a high risk of early subsequent stroke. They recommend, after appropriate diagnostic workup, early administration of an antiplatelet agent.
Incorrect Answers:
Answer B: Atorvastatin is an important initial intervention in the management of patients who have TIA/stroke. However, this intervention takes weeks of consistent therapy in order to have a significant effect on morbidity, thus it would not be the most important next step in management when compared to aspirin, which is more important in reducing acute stroke risk. Further, a lipid panel is generally performed first to determine if a statin is needed.
Answer C: CTA head/neck is a part of the workup of a TIA to rule out carotid stenosis/dissection/atherosclerosis as the cause of the patient's symptoms. It is more important to give aspirin early in TIA/stroke prior to obtaining further imaging (though this study would still be performed).
Answer D: Labetalol and other blood pressure medications are important in risk factor modification to prevent future strokes/TIAs. Patients with diabetic nephropathy should be on an ACE inhibitor or angiotensin-receptor blocker which are nephroprotective. Of note, his blood pressure currently is not very elevated nor is it causing end-organ dysfunction.
Answer E: MRI brain should be performed to further characterize whether there was any ischemic injury to the brain; however, this usually will occur after a CTA head/neck and certainly after the patient receives an aspirin. It can more accurately characterize if a stroke occurred, and the extent of the injury.
Bullet Summary:
The workup of a transient ischemic attack should be centered on a thorough neurological exam, a non-contrast CT scan of the head, and administration of aspirin assuming there is no intracranial bleed.
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A 27-year-old nurse presents to the emergency department with a 30-minute history of palpitations and chest pain. She has been experiencing nausea, vomiting, and diarrhea after eating leftovers 2 days ago. Her husband tells the physician that he is concerned that the patient has been increasingly obsessed about her weight recently. She has a history of major depressive disorder for which she takes escitalopram. Her temperature is 98.6°F (37.0°C), blood pressure is 110/72 mmHg, pulse is 110/min, and respirations are 11/min. Physical examination is notable for dry mucous membranes and tachycardia with regular rhythm. Laboratory testing shows the following results:
Serum:
Na+: 135 mEq/L
Cl-: 96 mEq/L
K+: 2.9 mEq/L
HCO3-: 36 mEq/L
Venous blood gas shows a pH of 7.52. Which of the following tests is most appropriate in differentiating between different etiologies of this patient's lab abnormalities?
|
{
"A": "Serum glucose",
"B": "Complete blood count",
"C": "Urine chloride",
"D": "Arterial blood gas",
"E": ""
}
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C
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This patient who presents with hypokalemia and metabolic alkalosis may either be vomiting or engaging in diuretic abuse. A urine chloride test can be used to distinguish between these possibilities because urine chloride will be high in diuretic abuse and will be low/normal in surreptitious vomiting.
Metabolic alkalosis is an acid-base disorder that is due to an increased level of serum bicarbonate. This increase can be secondary to increased bicarbonate intake or loss of hydrogen ions. Etiologies consistent with increased intake include antacid use or milk-alkali syndrome. Etiologies consistent with hydrogen ion loss include gastrointestinal losses such as vomiting or renal losses such as hyperaldosteronism, Bartter syndrome, or diuretic abuse. Urine chloride can distinguish between gastrointestinal and renal losses because urine chloride levels will be high in patients with renal tubule dysfunction or diuretic abuse. This is due to increased urinary excretion of ammonium chloride in cases of diarrhea. On the other hand, urine chloride will generally be low in hyperaldosteronism due to loss of chloride with vomiting.
Wu et al. studied the causes of chronic hypokalemia as well as laboratory findings that can be used to distinguish between different etiologies. They show how urine sodium and chloride can be helpful for identifying the surreptitious use of diuretics. The authors recommend the use of the sodium-to-chloride excretion ratio to help diagnose patients with chronic normotensive hypokalemia.
Incorrect Answers:
Answer A: Arterial blood gas is useful for determining the acid-base state of a patient because it simultaneously measures carbon dioxide and bicarbonate levels. This test is not as useful in determining different causes of metabolic alkalosis because all of these etiologies will have similar findings (high bicarbonate and compensatory high carbon dioxide), especially in patient who has already received a venous blood gas.
Answer B: Complete blood count is useful for determining whether a patient is anemic resulting in decreased oxygen delivery to end organs due to decreased carrying capacity for oxygen. In cases of severe anemia and hypoperfusion, peripheral tissues produce lactic acid which will result in an anion gap metabolic acidosis rather than metabolic alkalosis.
Answer C: Serum glucose elevation can result in increased diuresis as well as pseudohyponatremia (decreased measured sodium due to increased glucose). Alternatively, acidosis may also be caused by insulin deficiency in diabetic ketoacidosis. Neither of these findings is consistent with the lab results seen in this patient.
Answer E: Urine toxicology can be used to determine whether the patient is taking any substances of abuse. There is no pathognomonic acid-base finding that can aid in diagnosing overdose and/or substance abuse. However, most standard urine toxicology screens do not detect the use of diuretics.
Bullet Summary:
Urine chloride can distinguish between gastrointestinal and renal causes of metabolic alkalosis.
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262
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A 23-year-old man presents to the emergency department after he was rescued while hiking in Alaska. The patient was found on a mountain trail non-responsive. His temperature is 91°F (32.8°C), blood pressure is 103/61 mmHg, pulse is 60/min, respirations are 11/min, and oxygen saturation is 97% on room air. The patient is placed under a warm air circulator, and his extremities are bathed in warm water. An ECG is performed as seen in Figure A. Dark bullae are noted on the patient's extremities. His mental status rapidly improves with warming. Laboratory studies are ordered and are pending. Which of the following is most likely to be found in this patient?
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{
"A": "Hypocalcemia",
"B": "Hypophosphatemia",
"C": "Hypomagnesemia",
"D": "Red blood cells on urine microscopy",
"E": ""
}
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A
|
This patient is presenting after being found outside with hypothermia and frostbite (dark bullae noted on the extremities in the setting of being out in the cold). Frostbite can lead to rhabdomyolysis, which may cause hyperkalemia (causing ECG changes including peaked T waves and QRS widening as seen in this patient) and hypocalcemia (the most common electrolyte finding in frostbite).
Frostbite occurs when there is an extensive freezing injury to tissues and can cause benign swelling, erythema, and pain, all the way to insensate extremities with necrosis and permanent dysfunction. More severe forms of frostbite can cause rhabdomyolysis or breakdown of the muscles. Breakdown of the muscle cells leads to leakage of the intracellular contents. Common electrolyte derangements include hyperkalemia and hypophosphatemia. Hypocalcemia is the most common electrolyte derangement in rhabdomyolysis. It occurs due to the deposition of calcium in the necrotic muscle cells and the sequestration of calcium in the exposed sarcoplasmic reticulum. Note that hypocalcemia requires no treatment unless it is causing symptoms or ECG changes (such as QT prolongation). The management of rhabdomyolysis is centered on fluid administration to protect the kidney from myoglobin which is released from damaged muscles and is nephrotoxic.
Zimmerman and Shen review rhabdomyolysis. They note that rhabdomyolysis can be commonly associated with myoglobinuria, hyperkalemia, hypocalcemia, and hyperphosphatemia. They suggest that an elevated creatine kinase level is indicated to support the diagnosis.
Figure/Illustration A is an ECG demonstrating peaked T waves (blue arrows) which are associated with hyperkalemia.
Incorrect Answers:
Answer A: Elevated troponin may be seen in rhabdomyolysis. This is a non-cardiac cause of an elevated troponin; however, this is less common than hypocalcemia in rhabdomyolysis and is neither sensitive nor specific.
Answer C: Hypomagnesemia is not a common electrolyte disturbance seen in rhabdomyolysis; however, hypomagnesemia may cause hypocalcemia (from impaired PTH release) and hypokalemia (from renal wasting of potassium). Note that this mechanism is separate from rhabdomyolysis.
Answer D: Hypophosphatemia is common in refeeding syndrome and malnourished patients (such as those with alcohol use disorder) and presents with diffuse muscle weakness. Rather, hyperphosphatemia would be seen in rhabdomyolysis as it is released from damaged muscle cells.
Answer E: Red blood cells on urine microscopy would be seen in a nephritic syndrome in addition to red blood cell casts. Note that the urine dipstick will be positive for red blood cells in rhabdomyolysis due to cross-reactivity with myoglobin; however, there are minimal/no red blood cells actually present.
Bullet Summary:
Frostbite can result in rhabdomyolysis which commonly causes hyperkalemia, hyperphosphatemia, and hypocalcemia (the most common derangement).
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263
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A 32-year-old man presents to the emergency department with pain upon defecation. His symptoms started a few weeks ago but have been worsening. Sometimes he notes blood on the toilet paper. He has to strain to have bowel movements and has trouble defecating secondary to pain. He is generally healthy and does not smoke. The patient is a software engineer and enjoys hiking, going to nightclubs, and dancing. His temperature is 98.1°F (36.7°C), blood pressure is 112/83 mmHg, pulse is 83/min, respirations are 13/min, and oxygen saturation is 98% on room air. Physical exam reveals a small, superficial fissure that is lateral to the anus and lateral to the midline. Which of the following is the most appropriate management for this patient?
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{
"A": "Testing for HIV, fecal occult blood, and sexually transmitted diseases",
"B": "CT scan of the abdomen and pelvis",
"C": "Surgical excision",
"D": "Topical lidocaine, sitz baths, and fiber supplements",
"E": ""
}
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A
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This patient is presenting with pain upon defecation, constipation, and a fissure lateral to the midline which is suggestive of an anal fissure. Anal fissures lateral to the midline are associated with inflammatory and infectious etiologies; thus, further workup (testing for HIV, fecal occult blood testing, and sexually transmitted disease testing) is needed rather than merely symptomatic treatment.
Anal fissures present with exquisite pain upon defecation which may lead to fecal retention and constipation. Commonly, anal fissures are caused by constipation, local trauma (such as anal intercourse), or a tight anal sphincter. Anal fissures that occur secondary to trauma are usually midline. On the other hand, lateral anal fissures are a harbinger of more serious alternative diagnoses and require further workup. Lateral anal fissures can be caused by infections (HIV being one of the most concerning as well as syphilis or tuberculosis), Crohn disease, granulomatous disease, malignancy, as well as foreign bodies. For this reason, lateral anal fissures should not only be treated symptomatically but require testing for sexually transmitted diseases, inflammatory conditions, and malignancy to determine the underlying etiology based on the patient’s risk factors and associated symptoms.
Steele and Madoff review anal fissures. They note that while both operative and non-operative interventions may be indicated in the management of an anal fissure after alternative diagnoses have been ruled out, advances in medical management may spare patients sphincter-dividing surgery. They recommend considering all modalities.
Incorrect Answers:
Answer A: CT scan of the abdomen and pelvis followed by an MRI may be the most appropriate testing if a perirectal abscess is suspected. These abscesses can track very deep. For this reason, further imaging and drainage in the operating room followed by antibiotics are indicated rather than a simple bedside incision and drainage. Imaging may be indicated in this patient after medical workup fails to elucidate an etiology.
Answer B: Incision, drainage, ciprofloxacin, and metronidazole may be indicated for a perianal abscess (note, this is not a perirectal abscess), which presents with a tender, fluctuant mass right next to the anus. The diagnosis can be made clinically or supported by an ultrasound.
Answer C: Surgical excision may be performed in the management of a perianal fistula, which presents with a draining tract next to the anus that releases purulence or fecal contents causing staining of the patient’s underwear and irritation of the skin. The diagnosis is made with an exam and a CT, MRI, or fistulogram followed by a fistulotomy.
Answer E: Topical lidocaine, sitz baths, and fiber supplements are the appropriate management of an anal fissure that is midline and secondary to a clear cause such as trauma or constipation. It would be inappropriate to only treat this patient symptomatically with a lateral anal fissure as this is a sign of a more serious diagnosis.
Bullet Summary:
Anal fissures that are lateral to the midline require workup for sexually transmitted infections, cancer, and autoimmune disease.
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264
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A 66-year-old man presents to the emergency department with shortness of breath. He typically has poor exercise tolerance and is only able to walk from his house to his mailbox before becoming dyspneic. He now has shortness of breath even at rest. He had a cold recently but has no new medical problems. His past medical history is notable for a myocardial infarction 7 years ago, COPD, heart failure with a left ventricular ejection fraction of 22%, obesity, diabetes, and peripheral vascular disease. His temperature is 97.7°F (36.5°C), blood pressure is 124/82 mmHg, pulse is 140/min, respirations are 32/min, and oxygen saturation is 78% on room air. Physical exam reveals an uncomfortable man with increased work of breathing. He demonstrates bilateral crackles and wheezing on pulmonary exam. The patient is started on BiPAP, and his oxygen saturation improves to 94%. An ECG is performed, as seen in Figure A, and a chest radiograph is performed, as seen in Figure B. Which of the following is the most appropriate next step in management?
|
{
"A": "Digoxin",
"B": "Albuterol and prednisone",
"C": "Intubation",
"D": "Metoprolol",
"E": ""
}
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A
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This patient with a history of heart failure with reduced ejection fraction is presenting with respiratory distress (increased work of breathing, hypoxia, wheezes, and crackles) in the setting of atrial fibrillation (ECG with irregularly irregular rhythm without P waves) with rapid ventricular response and pulmonary edema on chest radiograph. Digoxin is an appropriate medication that can both control the heart rate in atrial fibrillation and increase cardiac contractility and potentially improve respiratory symptoms in this decompensated patient with heart failure.
Atrial fibrillation presents on ECG with an irregularly irregular rhythm without discernible P waves. The initial management of atrial fibrillation with rapid ventricular response is rate control. If the patient is stable, possible first-line agents include beta-blockers (e.g., metoprolol) or calcium channel blockers (e.g., diltiazem). These agents may reduce cardiac contractility and worsen complications such as pulmonary edema in the setting of heart failure with reduced ejection fraction when the patient is in a decompensated state. If the patient has a reduced ejection fraction and requires rate control, then digoxin is a highly effective medication that blocks the AV node and increases cardiac contractility. Any hemodynamically unstable patient with atrial fibrillation with rapid ventricular response should immediately be cardioverted.
Moskowitz et. al review the management of atrial fibrillation. They note that in the management of atrial fibrillation with rapid ventricular response, metoprolol is commonly used in the intensive care setting, is more successful than amiodarone, and had better rate control when compared to diltiazem.
Ehle et. al note that digoxin is approved to control ventricular response in patients with chronic atrial fibrillation and is the only oral agent with positive inotropic effects approved for the management of mild to moderate heart failure.
Figure/Illustration A is an ECG demonstrating an irregularly irregular rate/rhythm (note the spacing of the blue arrows indicating the QRS complexes) without P waves, which is suggestive of atrial fibrillation. Figure B is a chest radiograph demonstrating bilateral, hazy interstitial infiltrates, which are concerning for pulmonary edema.
Incorrect Answers:
Answer A: Albuterol and prednisone would be appropriate management of a COPD flare, which presents in a patient with a history of smoking with dyspnea, wheezing, increased work of breathing, and a barrel chest. While this patient’s wheezing may be secondary to his COPD, it is much more likely to be a cardiac wheeze given his chest radiograph findings including pulmonary edema. Treating his atrial fibrillation is more likely to alleviate his pulmonary symptoms. Other treatments in COPD include ipratropium and BiPAP.
Answer C: Diltiazem would be an appropriate rate control agent for atrial fibrillation with rapid ventricular response, particularly in the setting of a COPD flare as it will not impair the mechanism of albuterol (which should be given as a nebulizer in COPD flares). In this patient, further impairing cardiac contractility with a calcium channel blocker may worsen his underlying pulmonary edema (given his reduced ejection fraction).
Answer D: Intubation would be indicated if this patient’s respiratory status were worsening, including failure to oxygenate, failure to ventilate, or impending respiratory failure. This patient’s respiratory status has improved on BiPAP; thus intubation is not needed.
Answer E: Metoprolol, like diltiazem, would reduce cardiac contractility and may worsen pulmonary edema, in particular, in a patient with a reduced ejection fraction. It also may cause COPD symptoms to emerge, as beta-2 blockade may cause bronchoconstriction (even though metoprolol is beta-1 selective). It would be indicated as outpatient rate control for a patient with atrial fibrillation who can tolerate a beta-blocker, and is preferred in patients with a history of acute coronary syndrome, as it reduces mortality.
Bullet Summary:
Patients with atrial fibrillation with rapid ventricular response with a reduced ejection fraction may be optimally managed with digoxin, which blocks the AV node and increases cardiac contractility.
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265
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A 37-year-old woman presents to the emergency department in cardiac arrest. She was found to have altered mental status at home, and during transport to the hospital, she became pulseless. Cardiopulmonary resuscitation is ongoing and 2 intravenous lines are placed. The patient is obese, and her only medication is an oral contraceptive pill. She recently underwent Achilles tendon repair. She otherwise is known to smoke cigarettes on occasion. Physical exam is notable for a critically ill patient with chest compressions ongoing. The monitor shows pulseless electrical activity. Her right lower extremity is in a post-operative splint. The patient regains her pulse after several rounds of CPR and epinephrine. A bedside echocardiograph is notable for a dilated and hypokinetic right ventricle with septal bowing into a hyperkinetic left ventricle. Which of the following is the most likely diagnosis?
|
{
"A": "Obstructive shock",
"B": "Hemorrhagic shock",
"C": "Cardiogenic shock",
"D": "Septic shock",
"E": ""
}
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A
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This obese patient on oral contraceptive pills with recent orthopedic surgery (Achilles tendon repair) is presenting in cardiac arrest. Given the bedside echocardiograph that is notable for a dilated and hypokinetic right ventricle with septal bowing into a hyperkinetic left ventricle, the most likely diagnosis is a pulmonary embolism that is causing obstructive shock.
Pulmonary embolism is most commonly caused by a deep vein thrombosis in the veins of the lower extremity that travels to the pulmonary circulation. Patients will present with pleuritic chest pain, hypoxia, sinus tachycardia, and hemoptysis. Massive pulmonary emboli can cause hemodynamic instability. Patients may become hypotensive, tachycardic, and ultimately pulseless. The pulmonary embolism can obstruct blood flow from the right ventricle to the pulmonary artery, leading to a dilated and hypokinetic right ventricle with septal bowing and a hyperdynamic left ventricle. This is a type of obstructive shock. Treatment of a massive pulmonary embolism causing hemodynamic instability may involve thrombolytics or thrombectomy.
Standl et al. review obstructive shock. They note that obstructive shock is caused by an obstruction of blood flow out of (or in the case of tamponade, into) the heart. They recommend that treating the underlying cause is the only effective management option.
Incorrect Answers:
Answer A: Cardiogenic shock is caused by cardiac dysfunction in conditions such as myocardial infarction or heart failure. Cardiac dysfunction then leads to impaired systemic perfusion. Initial management includes treating the underlying cause (e.g., cardiac catheterization for an ST-elevation myocardial infarction) and vasopressors (e.g., norepinephrine) to maintain the patient’s blood pressure.
Answer B: Hemorrhagic shock is a common cause of shock in trauma and presents with hypotension and tachycardia secondary to blood loss. A narrowed pulse pressure may be the first sign of hemorrhagic shock. The mainstay of management is blood transfusion and an intervention to stop the bleeding.
Answer C: Neurogenic shock occurs when there is central nervous system trauma (often to the cervical spine) leading to decreased sympathetic tone systemically. Patients will present with hypotension and bradycardia (contrast with tachycardia in hemorrhagic shock), and management is centered on vasopressors to maintain blood pressure and neurosurgical intervention for the underlying etiology. IV fluids can also be given to maintain blood pressure.
Answer E: Septic shock occurs when a systemic infection leads to vasodilation and endothelial dysfunction with hypotension refractory to fluid resuscitation. The mainstay of management includes fluids, blood cultures, vasopressors, and broad-spectrum antibiotics. Early administration of antibiotics improves outcomes.
Bullet Summary:
Pulmonary embolism is a common cause of obstructive shock.
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266
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A 57-year-old man is brought to the emergency department by his wife with confusion. He was seen in the emergency department 2 days ago for profuse epistaxis. His primary care provider was concerned and had advised him to go to the hospital, as the patient is on warfarin for atrial fibrillation. However, his bleeding resolved with pressure and nasal packing. Upon presentation to the ED today, his temperature is 97.6°F (36.4°C), blood pressure is 64/33 mmHg, pulse is 160/min, respirations are 32/min, and oxygen saturation is 100% on room air. Physical exam reveals an obtunded man who cannot answer questions. A dark, purpuric rash is noted on his torso and extremities. The patient’s nasal packing is removed with no further bleeding. The patient is given IV fluids and blood cultures are drawn. Which of the following should be administered first?
|
{
"A": "Penicillin",
"B": "Piperacillin-tazobactam",
"C": "Meropenem",
"D": "Clindamycin",
"E": ""
}
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D
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This patient is presenting with nasal packing, hypotension, tachycardia, a dark, purpuric rash, and confusion, which are concerning for toxic shock syndrome. The most important initial step in management is to administer clindamycin.
Toxic shock syndrome is a life-threatening diagnosis caused by Streptococcus pyogenes or Staphylococcus aureus and occurs commonly secondary to retained tampons or nasal packing. Patients are critically ill and require immediate management with fluids, vasopressors, and blood cultures. Source control is imperative, and the foreign body causing the infection must be removed. Next, broad-spectrum antibiotics should be started immediately. Clindamycin is often preferred as the first agent as this lincosamide antibiotic not only covers Staphylococcus aureus and Streptococcus pyogenes, but also has the theoretical benefit of suppressing toxin production. Further management is centered on fluid administration, vasopressors, and monitoring and care in an ICU setting as these patients are typically critically ill.
Russell and Pachorek review the treatments for toxic shock syndrome. They note that clindamycin is particularly important in toxic shock syndrome that is complicated by toxin production. They recommend that administration may reduce toxin production and could improve outcomes.
Incorrect Answers:
Answer B: Meropenem is a broad-spectrum antibiotic that covers most organisms except for MRSA. It is generally not used as a first-line agent unless the patient has allergies to other antibiotics or the infectious organism is only sensitive to this agent. Even in toxic shock syndrome, it would not be used as a first-line agent.
Answer C: Penicillin may be used for infections such as streptococcal pharyngitis, which presents with a sore throat, fever, and tonsillar exudates. It is a relatively weaker antibiotic and would not be used in a critically ill patient with toxic shock syndrome.
Answers 4 & 5: Piperacillin-tazobactam and vancomycin represent a powerful broad-spectrum regimen of antibiotics that covers gram-positives, gram-negatives, Pseudomonas aeruginosa, and anaerobes (piperacillin-tazobactam) as well as further gram-positive coverage and MRSA (vancomycin). Though this is a potent antibiotic combination, neither of these takes priority over clindamycin given the possible benefit of toxin suppression from clindamycin. In this patient, clindamycin and piperacillin-tazobactam would be an appropriate antibiotic regimen.
Bullet Summary:
Clindamycin may suppress toxin production and should be given early in toxic shock syndrome.
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267
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A 43-year-old man presents to the emergency department acutely with altered mental status. He uses intravenous drugs and is unable to offer a history. He was found unconscious in a park. His temperature is 99.0°F (37.2°C), blood pressure is 80/40 mmHg, pulse is 156/min, and respirations are 26/min. Physical exam reveals an obtunded man covered in vomit, with track marks on his arm and several skin abscesses. The patient is given 4 liters of Ringer lactate and intravenous antibiotics. As the fourth liter of fluids is finishing, the patient is noted to have jugular venous distension and an oxygen saturation of 92% on nonrebreather. He is subsequently intubated. An ECG is obtained as seen in Figure A. The patient is started on norepinephrine, and his blood pressure is subsequently found to be 85/44 mmHg. Which of the following is the most appropriate next step in management?
|
{
"A": "Cardioversion",
"B": "Epinephrine",
"C": "Phenylephrine",
"D": "Hydrocortisone",
"E": ""
}
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B
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This patient who uses intravenous drugs with skin abscesses (the likely source of his infection) is hypotensive and tachycardic, with a blood pressure that is not responding to IV fluids; this is concerning for septic shock. Given his persistent hypotension, he should be started on vasopressors of which norepinephrine is first line and epinephrine is second line.
Septic shock is a life-threatening, systemic bacterial infection that leads to vasodilation and endothelial dysfunction. Early management is centered on IV fluids, blood cultures, broad-spectrum antibiotics, and workup to uncover the source. If the patient's blood pressure does not respond to IV fluids (by definition, their blood pressure will not respond to fluids in septic shock), vasopressors should be started with a goal mean arterial pressure > 65 mmHg. The first line vasopressor is norepinephrine, which can be titrated up for maximal effect. If this vasopressor fails to reach blood pressure goals, then the next vasopressor is either vasopressin or epinephrine (either is acceptable). If the second line vasopressor fails to increase blood pressure, then the third line vasopressor is vasopressin or epinephrine (whichever was not used as the second line pressor). Finally, the fourth line vasopressor for septic shock is phenylephrine.
Levy et al. review sepsis. They update the Surviving Sepsis campaign which gives the most up to date management guidelines of sepsis including adequate fluid resuscitation, broad-spectrum antibiotics, and vasopressors. They recommend early antibiotics and resuscitation to minimize morbidity and mortality.
Figure/Illustration A is an ECG demonstrating sinus tachycardia. Note the presence of P waves (red arrows highlighting several examples) that are present throughout all leads.
Incorrect Answers:
Answer A: Cardioversion would be appropriate in an unstable patient with unstable vital signs in the setting of atrial fibrillation with rapid ventricular response to convert the patient to normal sinus rhythm. Atrial fibrillation would present with an irregularly irregular rhythm without P waves. Cardioversion would not be indicated in sinus tachycardia.
Answer C: Hydrocortisone is a potent glucocorticoid that also has mineralocorticoid properties. While giving an IV steroid may have a permissive effect on blood pressure (via upregulating alpha-1 receptors on the vasculature) there is no reason that this patient would have a low cortisol level (such as in chronic steroid use). Epinephrine is a better answer in this case, though steroids can be considered. Steroids are typically reserved for patients failing at least 2 vasopressors (unless they have a known cortisol-deficient state).
Answer D: Normal saline is unlikely to benefit this patient as he has already been sufficiently fluid resuscitated. Moreover, it seems the patient may be developing pulmonary edema (hypoxia, jugular venous distension), a sign of fluid overload.
Answer E: Phenylephrine is the fourth line vasopressor and is an alpha-1 agonist. It is much less potent than norepinephrine and epinephrine, and would not be started in the management of septic shock until the patient has received epinephrine, norepinephrine, and vasopressin.
Bullet Summary:
In septic shock, the vasopressors given (in order) are norepinephrine, epinephrine/vasopressin, then phenylephrine.
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A 24-year-old man presents to his primary care physician with left groin pain. The pain started a year ago and has progressed. He now has 8/10 pain when climbing stairs or rising from a seated position. He localizes the pain to the front of his groin. He denies any erythema or swelling. He has a history of hypertension, sickle cell anemia, and a splenectomy. He drinks a glass of wine with dinner every night and took up scuba diving 2 months ago but otherwise does not exercise. His temperature is 97.5°F (36.4°C), blood pressure is 124/68 mmHg, pulse is 82/min, and respirations are 16/min. His body mass index (BMI) is 18.1 kg/m^2. Physical exam reveals left groin pain at the terminal ranges of hip abduction and internal rotation. There is no point tenderness. A radiograph is obtained as in Figure A. Which of the following components of this patient’s history most strongly predisposed him to this condition?
|
{
"A": "Low BMI",
"B": "Scuba diving",
"C": "Alcohol use",
"D": "History of sickle cell disease",
"E": ""
}
|
D
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This patient with sickle cell disease (SCD) presents with anterior groin pain, especially with weight-bearing, and radiographic findings of amorphous lytic and sclerotic lesions of the femoral head, consistent with avascular necrosis. SCD is a predisposing factor for avascular necrosis.
Avascular necrosis has a multitude of direct causes, including irradiation, trauma (history of femoral neck fracture), hematologic diseases such as leukemia, SCD, and idiopathic etiology. In traumatic causes, injury to the medial femoral circumflex artery supplying the femoral head causes vascular disruption with resulting osteonecrosis. In SCD, the propensity for sickle-shaped erythrocytes to stick to one another and occlude blood vessels results in loss of circulation to the femoral head with consequent osteonecrosis. Avascular necrosis of the femoral head presents with insidious onset of anterior groin pain. The diagnosis can be secured with plain radiographs, although magnetic resonance imaging has the highest sensitivity and specificity for uncertain cases. Treatment consists of bisphosphonates with crutches (non-weight-bearing) and/or surgery depending on the degree of femoral head collapse and etiology.
Akinyoola et al. studied the risk factors associated with avascular necrosis of the femoral head in patients with sickle cell disease. The authors found that the rate of pain crises and annual hospitalizations are associated with avascular necrosis. The authors recommend further study to explain differences in the prevalence of osteonecrosis in different populations with sickle cell disease.
Figure/Illustration A shows a plain radiograph of the left hip in a skeletally mature individual, demonstrating amorphous cortical lesions (red arrows) in the femoral head and cortical irregularity (blue arrow) typical of avascular necrosis.
Incorrect Answers:
Answer A: Excess alcohol use has been associated with the risk of avascular necrosis. This patient uses alcohol in moderation (2 drinks or fewer per day for men) and has no history of alcohol use disorder.
Answer C: Lack of physical activity is a predisposing factor for osteoporosis but is not associated with avascular necrosis. Osteoporosis may increase the risk of a hip fracture, which would present with a painful, shortened, and externally rotated lower extremity.
Answer D: Low BMI is not a predisposing factor for avascular necrosis. In contrast, obesity has been associated with an increased risk of avascular necrosis.
Answer E: Scuba diving can indirectly predispose patients to avascular necrosis through decompression sickness (Caisson Disease). In decompression, dissolved gases in the arterial supply form gas emboli, leading to microvascular occlusion and dysbaric osteonecrosis. However, this patient’s symptoms have been present for 1 year whereas he only recently began scuba diving.
Bullet Summary:
Sickle cell disease is a predisposing factor for avascular necrosis of the femoral head, which presents as insidious anterior groin pain.
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269
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A 26-year-old man presents to his primary care physician with a 6-month history of increasing lower back pain. He first felt the pain while lifting boxes at work but thought that he had just strained a muscle. The pain appears to be worse in the mornings and after rest. Exercise and physical activity appear to temporarily make the pain better. He has taken acetaminophen and ibuprofen for the pain. He has no significant medical history and takes no medications. His temperature is 98.6°F (37.0°C), blood pressure is 115/70 mmHg, pulse is 70/min, and respirations are 12/min. On physical exam, he is found to have limited flexion and extension of his spine as well as tenderness to palpation over the insertion of his patellar tendons bilaterally. Results from laboratory tests are shown below:
Serum:
Erythrocyte sedimentation rate (ESR): 61 mm/hr
C-reactive protein (CRP): 36 mg/L (normal <10 mg/L)
Which of the following is the most accurate test for this patient's condition?
|
{
"A": "Magnetic resonance imaging",
"B": "Bone scan",
"C": "Ultrasound",
"D": "Computed tomography",
"E": ""
}
|
A
|
This young man presents with low back pain that is relieved by physical activity, decreased spinal mobility, enthesitis of his patellar tendons, and elevated ESR/CRP values most likely has ankylosing spondylitis (AS). The most accurate diagnostic test for early ankylosing spondylitis is MRI.
Multiple imaging tests can diagnose ankylosing spondylitis. Radiographs of the spine will show squaring of vertebrae with vertical or marginal syndesmophytes resulting in a "bamboo spine" appearance. The earliest radiographic sign is the erosion of the iliac side of the sacroiliac joint, but this finding is not sensitive in the early stages of the disease. MRI is sensitive in detecting sacroiliac inflammation, which makes this the best modality for early detection of ankylosing spondylitis in young patients. Initial therapy for ankylosing spondylitis includes lifestyle modifications (exercise, smoking cessation, physical therapy) and non-steroidal anti-inflammatory drugs (NSAIDs). Therapy for patients with inadequate response to NSAIDs includes tumor necrosis factor inhibitors (etanercept, infliximab, adalimumab) and interleukin 17 inhibitors (secukinumab, ixekizumab).
Jung et al. studied whether signs of inflammation on MRI are correlated with bone quality in patients with ankylosing spondylitis. The authors find that bone marrow edema is negatively correlated with the trabecular bone score. The authors recommend control of active bone inflammation to prevent osteoporosis in patients with ankylosing spondylitis.
Incorrect Answers:
Answer A: Bone scan will show inflammation in the sacroiliac joints, but this study lacks specificity for this disease compared with other inflammatory forms of arthritis.
Answer B: CT will show bony changes but not active inflammation, so it is most commonly used to diagnose cervical fractures in patients with ankylosing spondylitis. While it can support the diagnosis, it is less accurate than an MRI.
Answer D: Radiographs will show erosion of the iliac side of the sacroiliac joint, but this finding is not sensitive in the early stages of the disease when bony ankylosis has not yet occurred. Radiographs may be an appropriate initial test.
Answer E: Ultrasound is useful in evaluating muscle strains or tendon tears; however, it is not able to detect bony abnormalities and is therefore of limited use in ankylosing spondylitis.
Bullet Summary:
MRI is the most sensitive and accurate test for the early detection of ankylosing spondylitis.
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270
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A 7-year-old boy presents to the emergency department after an episode of jerking his extremities followed by confusion. This has happened in the past, but his mother thought he was fabricating his symptoms. She has taken him to a free health clinic to have him seen by a doctor who prescribed medication; however, she has been unable to fill the prescription. He has had an MRI of the brain with no acute findings in the past. The mother states this episode lasted about 3 minutes and involved full-body jerking. After the episode, the child was non-responsive but was breathing on his own. The child has a history of migraine headaches with aura that resolve with ibuprofen. He is otherwise healthy and has no medical problems or recent illness and is up to date on his vaccinations. His temperature is 97.6°F (36.4°C), blood pressure is 100/64 mmHg, pulse is 90/min, respirations are 12/min, and oxygen saturation is 99% on room air. The patient is protecting his airway but is unable to answer questions. He is able to move the right upper and lower extremity. He initially is unable to move his left upper and lower extremity and has a left facial droop; however, after a few minutes, he has 4/5 strength in the affected side with resolution of his facial weakness. The mother notes that this is similar to his past episodes. Which of the following is the most appropriate management?
|
{
"A": "Diazepam",
"B": "Observation",
"C": "Sumatriptan",
"D": "CT head",
"E": ""
}
|
B
|
This patient is presenting after a seizure (tonic-clonic jerking of his extremities) and is currently postictal given that he is obtunded. Given that the patient is not moving the left side of his body, he is likely suffering from Todd paralysis, which can occur after seizures and resolves on its own with only observation.
A generalized tonic-clonic seizure may present with full-body tonic-clonic activity with altered mental status. After a generalized tonic-clonic seizure, patients can be postictal and appear to be obtunded. Other than ensuring adequate oxygenation/ventilation and evaluating for the cause of the seizure, there is no further intervention needed as this postictal state will improve with time. After seizures, some patients present with Todd paralysis, which is a focal paralysis after a seizure. This may mimic a stroke, and thus the patient’s risk factors and known seizure history should be factored into the decision. Todd paralysis does not require any intervention and will improve with time and observation only.
Xu et al. review Todd paralysis. They note that Todd paralysis is characterized by temporary limb weakness or hemiplegia and usually occurs following a seizure. They recommend that it can be difficult to differentiate Todd paralysis from a stroke in certain patient populations.
Bullet Summary:
Answer A: Alteplase is a thrombolytic that could be used in an acute ischemic stroke if given within 4.5 hours of symptom onset without any contraindications to its use. It would only be given after the CT scan of the head has been performed and other reversible causes have been addressed in the setting of acute ischemic stroke. Alteplase is not given when neurologic symptoms are thought to be secondary to Todd paralysis. In fact, seizure and Todd paralysis would be a contraindication to thrombolytic use in stroke.
Answer B: CT head, in addition to a fingerstick blood glucose, should immediately be performed in all patients with sudden onset focal neurologic deficits thought to be secondary to a stroke. A stroke would present with sudden onset focal neurologic deficits. However, it is common for patients to be obtunded and have focal neurologic deficits after a seizure and this would not warrant a stroke workup unless clinical suspicion exists. This patient has no risk factors for stroke and his improving strength suggests against a stroke. Moreover, he has a history of a normal MRI of the brain.
Answer C: Diazepam would only be given for a patient who is actively seizing as it is a benzodiazepine with a long half-life. Note that it is not indicated in a postictal patient as there is no ongoing seizure. Benzodiazepines are not given as preventive measures for seizures.
Answer E: Sumatriptan may be indicated to treat a migraine, which presents with a pulsatile, unilateral headache and is more common in women. Hemiplegic migraine can cause focal neurologic deficits, and it would be reasonable to treat a migraine headache if a patient had focal neurologic deficits and a history of known hemiplegic migraines. Patients will either have a frequent history of hemiplegic migraines themselves or in their family.
Bullet Summary:
Focal neurologic deficits (Todd paralysis) can be seen after a seizure and will resolve with observation.
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271
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A 55-year-old man presents to the emergency department with worsening dyspnea over the past 48 hours. He recently had a cold that kept him home from work for the past week. He has a past medical history of diabetes, obesity, and hypertension. He had his Achilles tendon repaired 4 weeks ago and he has been less mobile. His temperature is 99.2°F (37.3°C), blood pressure is 150/85 mmHg, pulse is 82/min, respirations are 16/min, and oxygen saturation is 100% on room air. Physical exam is notable for dyspnea provoked by walking short distances. Jugular venous distension is noted on exam. The patient’s blood pressure is 130/70 mmHg during inspiration. A bedside echocardiogram demonstrates impaired diastolic filling with normal ventricular contractility. An ECG is performed as seen in Figure A. Which of the following is the most likely diagnosis?
|
{
"A": "Restrictive cardiomyopathy",
"B": "Myocardial infarction",
"C": "Constrictive pericarditis",
"D": "Pulmonary embolism",
"E": ""
}
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C
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This patient is presenting with a preceding viral illness, dyspnea, jugular venous distension, pulsus paradoxus (blood pressure drop from 150/85 to 130/70 mmHg during inspiration), an echocardiogram with impaired diastolic filling, and diffuse ST elevation with PR depression on ECG. This constellation of symptoms is concerning for constrictive pericarditis.
Constrictive pericarditis occurs when the pericardium becomes thickened and fibrotic. In contrast to other types of pericarditis, in constrictive pericarditis, there is impaired diastolic filling and thus impaired cardiac function. There are many possible etiologies of constrictive pericarditis including infection, inflammatory conditions, or idiopathic. Patients will present with dyspnea, hypotension, tachycardia, a pericardial friction rub, and positional chest pain (usually worsened by laying back and relieved by leaning forward). Patients may also demonstrate jugular venous distension, lower extremity edema, worsening dyspnea, and congestive hepatopathy. ECG may demonstrate diffuse ST elevation with PR depression, and an echocardiogram will demonstrate impaired diastolic filling and may demonstrate a thickened pericardium. The diagnosis can be supported with pulsus paradoxus (a drop of blood pressure by > 10 mmHg during inspiration).
Welch reviews constrictive pericarditis. He discusses constrictive pericarditis and how the inelastic pericardium inhibits cardiac filling possibly causing unexplained heart failure. Welch notes making the diagnosis is very challenging and requires meticulous echocardiograph assessment.
Figure/Illustration A demonstrates diffuse ST elevation (blue arrows) with PR depression (black arrows). This is consistent with pericarditis.
Incorrect Answers:
Answer A: Cardiac tamponade can occur after trauma, in the setting of infection, or in the setting of autoimmune disease and is more likely to occur with a rapid accumulation of pericardial fluid. While pulsus paradoxus would be present in this condition, muffled heart sounds and electrical alternans would be more likely to be seen on ECG. Echocardiography would demonstrate an echogenic rim of fluid around the heart.
Answer C: Myocardial infarction presents with chest pain, dyspnea, hypotension, tachycardia, and ST elevation in a vascular distribution. Note that this patient’s ST elevation is diffuse and there is no reciprocal ST depression. Moreover, the pattern of chest pain in myocardial infarction is typically exertional and not positional.
Answer D: Pulmonary embolism may present with pleuritic chest pain, shortness of breath, tachycardia, hypoxia, hemoptysis, a history of hypercoagulability, and recent stasis or surgery (such as this patient’s recent Achilles tendon surgery). It can cause obstructive shock leading to hypotension and tachycardia. Note that right heart strain and sinus tachycardia would be seen on ECG.
Answer E: Restrictive cardiomyopathy presents very similarly to restrictive pericarditis. Note that in restrictive cardiomyopathy, patients will also have impaired diastolic filling; however, it is due to a myocardium that will not expand rather than the pericardium impairing filling. It can occur secondary to conditions such as amyloidosis or hemochromatosis as well as other chronic inflammatory states. The ECG findings are nonspecific but may include low voltage QRS complexes, ST segment changes, T wave changes, bundle branch blocks, and pathologic Q waves (abnormally deep and wide Q waves). The diagnosis can be supported with an ultrasound demonstrating impaired diastolic filling and possible myocardial speckling if a protein (amyloid) is present and deposited in the myocardial wall. The diagnosis can only definitively be confirmed with a biopsy which is highly invasive.
Bullet Summary:
Restrictive pericarditis presents with chest pain that is positional, pulsus paradoxus, a friction rub, and diffuse ST elevation with PR depression on ECG.
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272
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A 17-year-old boy presents to the emergency department after a car accident. He drove his car into a pole while speeding at night. He has no past medical history and takes no medications. The patient is unable to offer a history and repetitively asks the nurses what happened. He knows his name and address and is able to remember other information about himself. He is complaining of a headache. His temperature is 97.6°F (36.4°C), blood pressure is 122/74 mmHg, pulse is 90/min, respirations are 12/min, and oxygen saturation is 98% of room air. Physical exam reveals a confused young man. Cranial nerves 2-12 are intact and the patient has normal strength and sensation. He demonstrates a stable gait. Throughout the exam, he continuously asks what happened to him. A head CT scan is ordered. Which of the following is the most likely diagnosis?
|
{
"A": "Diffuse axonal injury",
"B": "Epidural hematoma",
"C": "Concussion",
"D": "Subarachnoid hemorrhage",
"E": ""
}
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C
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This patient is presenting after a motor vehicle accident with confusion, repeated questioning, and a normal neurologic exam aside from his inability to remember the events that occurred. This constellation of symptoms is concerning for a concussion.
A concussion occurs after blunt trauma to the head and is common in athletics and motor vehicle collisions. Patients may present initially with symptoms including confusion, repeat questioning, repeating themselves, and amnesia surrounding the event. A thorough neurological exam is important as there should be no neurologic deficits in a concussion. Patients with a classic history and reassuring exam require rest from physical and cognitive activity. Post-concussive syndrome may present with chronic headaches, dizziness, trouble sleeping, trouble focusing, nausea, and difficulties with learning and concentrating. Mood changes such as depression and anxiety are common. Any patient with a concerning mechanism or symptoms should have a head CT to rule out other more severe diagnoses.
Pertab et al. review concussion and its presentation. They note that concussion can cause many symptoms including trouble focusing, mood changes, headaches, and also autonomic nervous system anomalies. They recommend reviewing the constellation of symptoms to make the diagnosis.
Incorrect Answers:
Answer A: Cerebral contusions are common after head trauma and may present with confusion, obtundation, neurologic deficits, and amnesia. While a severe concussion and a cerebral contusion have overlap, given this patient’s age, mechanism, and symptoms, concussion is more likely. A head CT would demonstrate contusion (hyperdense intraparenchymal lesion) with a possible contrecoup injury.
Answer C: Diffuse axonal injury occurs after a severe CNS injury with an obtunded patient who is typically unresponsive. CT imaging will show blurring of the gray-white interface with punctate hemorrhages. These patients have a very poor prognosis. They often are obtunded with minimal neurologic function.
Answer D: Epidural hematoma presents with trauma and the classic “talk and die” syndrome including a lucid interval followed by progressive obtundation and fixed, dilated pupils. Symptoms are rapidly progressive as this is an arterial bleed. CT scan would demonstrate a hyperdense lens-shaped lesion (composed of blood). A burr hole may relieve pressure and can be life-saving.
Answer E: Subarachnoid hemorrhage may present after trauma with a severe headache and meningeal signs. Patients may demonstrate focal neurologic deficits in severe cases. CT scan will demonstrate blood in the subarachnoid space and lumbar puncture would demonstrate blood in the CSF. A CTA may also localize the site of bleeding and if any aneurysm is present.
Bullet Summary:
A severe concussion can present with confusion, repeat questioning, and amnesia.
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273
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A 44-year-old man presents to the emergency department with palpitations. He has a history of anxiety managed with fluoxetine and lorazepam. He also has hypertension but does not take any medications. Today, his symptoms have been persistent despite taking his medications. He says that he feels lightheaded and can’t walk. His temperature is 98.7°F (37.1°C), blood pressure is 120/72 mmHg, pulse is 183/min, respirations are 25/min, and oxygen saturation is 99% on room air. Physical exam reveals a somnolent and uncomfortable man. His pulse is rapid and regular. An ECG is performed as seen in Figure A. During the exam, the patient states that he feels lightheaded and appears occasionally somnolent. Which of the following is the most appropriate treatment for this patient?
|
{
"A": "Adenosine",
"B": "Amiodarone",
"C": "Procainamide",
"D": "Cardioversion",
"E": ""
}
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D
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This patient is presenting with palpitations and an ECG demonstrating a wide complex tachycardia with a delta wave which are concerning for a tachydysrhythmia secondary to Wolff Parkinson White syndrome. Given his poor CNS perfusion (somnolence during his tachycardia despite a “normal” blood pressure), the most appropriate next step in management is cardioversion.
Wolff Parkinson White syndrome (WPW) is a pre-excitation syndrome where an accessory electrical pathway exists between the atria and ventricles that bypasses the AV node. WPW can demonstrate antidromic conduction where the accessory pathway leads to anterograde conduction causing a wide-complex tachycardia that is often mistaken for ventricular tachycardia. In this circumstance, the QRS is wide and a delta wave is often present but may be difficult to discern. If ever uncertain as to whether the diagnosis is ventricular tachycardia or WPW, cardioversion is a safe and effective intervention for both rhythms. Unstable patients with either WPW or ventricular tachycardia should undergo cardioversion immediately. Other treatments for WPW in stable patients may include procainamide. Ablation may present future episodes.
Bartlett and Friedman review the pathophysiology of WPW. They discuss the congenital presence of impulse-conducting fascicles leading to this condition. They also delve into the management and recommend rhythm agents and ablation as a modality of treatment.
Figure/Illustration A is an ECG demonstrating a wide complex (red arrow) tachycardia with a delta wave (blue arrow). These ECG findings are characteristically seen in WPW syndrome.
Incorrect Answers:
Answer A: Adenosine would be indicated after vagal maneuvers in the management of supraventricular tachycardia (SVT). SVT presents as a narrow complex tachycardia without P waves. It is regular (in contrast to atrial fibrillation). Failure to respond to vagal maneuvers or adenosine warrants cardioversion. If this patient was perfusing his CNS, a trial of adenosine could be appropriate given it has a short half-life and may differentiate ventricular tachycardia from SVT with aberrancy or a bundle branch block.
Answer B: Amiodarone may be used in stable ventricular tachycardia to control the rhythm and convert it to sinus. It would not be appropriate in a hemodynamically unstable patient. It can be used in other dysrhythmias as well including atrial fibrillation and atrial flutter.
Answer D: Defibrillation is only indicated in pulseless, shockable rhythms including ventricular fibrillation (disorganized electrical activity), pulseless ventricular tachycardia (wide complex tachycardia), and pulseless torsades des pointes (twisting of the QRS complexes around an isoelectric baseline). It could cause cardiac arrest if performed on a patient with a pulse.
Answer E: Procainamide is an antidysrhythmic that can be used in tachydysrhythmias that occur in WPW. Given that this patient is unstable, it is more appropriate to perform cardioversion.
Bullet Summary:
Unstable tachyarrhythmias in the setting of Wolff Parkinson White syndrome require cardioversion.
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A 23-year-old woman presents to labor and delivery at 40 weeks gestation with abdominal contractions and leakage of fluid from her vagina. She subsequently undergoes an uncomplicated vaginal delivery. The child is healthy and is heated, suctioned, and stimulated. While holding her newborn, the mother endorses a headache, blurry vision, and abdominal pain. Her temperature is 98.0°F (36.7°C), blood pressure is 194/104 mmHg, pulse is 100/min, respirations are 18/min, and oxygen saturation is 98% on room air. Physical exam reveals an uncomfortable woman. There is blood in her vagina and her uterus is contracted. Her cranial nerve exam is unremarkable and she has normal strength and sensation. Laboratory studies and a urinalysis are pending. Which of the following is the most appropriate next step in management?
|
{
"A": "Magnesium",
"B": "Labetalol",
"C": "Ondansetron and morphine",
"D": "CT head",
"E": ""
}
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A
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This postpartum patient is presenting with hypertension, headache, blurry vision, and abdominal pain, which are concerning for a diagnosis of preeclampsia. The most appropriate initial intervention is magnesium.
Preeclampsia classically presents after 20 weeks gestation (or earlier in the setting of a molar pregnancy) with hypertension and proteinuria. Other symptoms that may be indicative of preeclampsia with severe features include headaches, visual changes, and abdominal pain. Other features consistent with preeclampsia include thrombocytopenia, kidney insufficiency, impaired liver function, and pulmonary edema. The diagnosis can be supported when a pregnant patient is both hypertensive and demonstrates an elevated protein in her urine. It is possible for postpartum patients to experience preeclampsia. Though the fetus and placenta have been delivered, which is the definitive treatment of preeclampsia, further medical management is still needed. The most important initial step in management is to administer magnesium which is neuroprotective and also modestly lowers blood pressure. Further care involves blood pressure control and benzodiazepines as needed to abort seizure episodes (though note that if a patient with preeclampsia is having seizures, by definition, they have eclampsia).
Al-Safi et al. discuss preeclampsia and eclampsia. They note that postpartum preeclampsia and eclampsia can occur within the first week after delivery. They recommend that mothers should be educated on what symptoms to look for.
Incorrect Answers:
Answer A: CT head may be indicated, in particular, if an intracranial hemorrhage was thought to be the cause of this patient’s headache and vision changes. A subarachnoid hemorrhage would present with the classic “thunderclap” headache with blood in the subarachnoid space on head CT. A CTA may localize a bleeding aneurysm and a lumbar puncture would show an elevated red blood cell count in the CSF. It would not explain this patient’s hypertension and abdominal pain. Note that a CT head is not a CTV which is specific venous imaging.
Answer B: Labetalol is an appropriate blood pressure medication to give in pregnancy; however, it is more appropriate to first give magnesium as this agent is neuroprotective and is the first-line agent of choice in preeclampsia.
Answer D: MRV head or a CTV head would be appropriate in the workup of cerebral venous thrombosis which is common in the setting of hypercoagulability (such as in the postpartum period) and presents with headache, blurry vision, and seizures. Note that it would not explain this patient’s profound hypertension. It would be more reasonable to first empirically treat this patient's possible preeclampsia.
Answer E: Ondansetron and morphine would be appropriate symptomatic management of this patient but would not treat her underlying preeclampsia. It is more appropriate to first treat the life-threatening diagnosis before symptom management. If this patient’s hypertension was thought to be due to pain, then morphine could be helpful.
Bullet Summary:
Preeclampsia can occur in the postpartum period and should be managed with magnesium sulfate.
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275
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A 33-year-old woman presents to the emergency department with foul-smelling vaginal discharge. She states that it started 1 day ago and has not improved with hygiene products. She is sexually active and uses condoms. She does not complain of any abdominal or pelvic pain but states she has some mild burning when urinating. Her temperature is 97.6°F (36.4°C), blood pressure is 111/74 mmHg, pulse is 81/min, respirations are 12/min, and oxygen saturation is 98% on room air. Physical exam is notable for thick, white discharge from the cervix. There is no cervical motion or adnexal tenderness or masses. Some whitish discharge is noted from the urethra. A urine pregnancy test is negative. Which of the following is the most appropriate treatment for this patient?
|
{
"A": "Metronidazole",
"B": "Ceftriaxone",
"C": "Ceftriaxone and doxycycline",
"D": "Ceftriaxone and azithromycin",
"E": ""
}
|
C
|
This nonpregnant woman is presenting with a thick, white cervical discharge, dysuria, and urethral discharge without cervical motion tenderness or adnexal tenderness which is concerning for urethritis without pelvic inflammatory disease. She should be treated with ceftriaxone and doxycycline to cover for the most common organisms.
The most common bacterial sexually transmitted infections include Neisseria gonorrhoeae and Chlamydia trachomatis. They can cause urethritis, cervicitis, and pelvic inflammatory disease. The diagnosis is made clinically with the appropriate history (vaginal discharge, high-risk sexual behavior) and physical exam (purulent cervical discharge +/- cervical motion tenderness, adnexal tenderness). The diagnosis should be confirmed with PCR; however, this should not delay treatment. Treatment should be given empirically, and the preferred regimen is ceftriaxone and doxycycline in men and nonpregnant women. In pregnant women, ceftriaxone and azithromycin may be used. Metronidazole is added empirically to cover for Trichomonas vaginalis.
Jennings and Krywko review pelvic inflammatory disease. They note that pelvic inflammatory disease is an inflammation of the upper genital tract due to an infection that can affect the uterus, fallopian tubes, and ovaries. They discuss the need for treatment and complications that can occur without treatment. They recommend timely diagnosis and treatment.
Incorrect Answers:
Answer A: Azithromycin is only indicated to cover chlamydia in pregnancy since doxycycline cannot be given to pregnant patients. Coverage for gonorrhea is also mandatory given this patient’s symptoms.
Answer B: Ceftriaxone is insufficient coverage for chlamydia or gonorrhea as chlamydia requires treatment with doxycycline, and gonorrhea requires double coverage from ceftriaxone in addition to doxycycline.
Answer C: Ceftriaxone and azithromycin is the preferred regimen to treat chlamydia and gonorrhea in pregnant patients since pregnant patients cannot receive doxycycline.
Answer E: Metronidazole is an appropriate treatment for bacterial vaginosis which presents with a fishy odor, white/gray vaginal discharge, and positive clue cells on wet mount.
Bullet Summary:
The treatment of choice for urethritis is ceftriaxone and doxycycline in nonpregnant patients.
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A 15-month-old boy presents with his mother for his well-child exam. His mother is concerned about his vision, as she noticed him squinting while watching television. The patient was born at 39 weeks of gestation via spontaneous vaginal delivery. He is up to date with routine vaccinations. He is able to walk alone, speak 3 words, and scribble with a crayon. His temperature is 98.6°F (37.0°C), blood pressure is 80/55 mmHg, pulse is 105/min, and respirations are 25/min. On exam, his pupils are round and reactive to light. A photograph of his eyes is shown in Figure A. When focusing on the pediatrician's penlight, the patient's left eye wanders. However, when the right eye is covered, the left eye refocuses on the light. The rest of his neurological exam, including extraocular movements, is within normal limits. Which of the following is the most appropriate next step in management for this patient?
|
{
"A": "Perform a Bielschowsky head tilt test",
"B": "Brain MRI",
"C": "Patch the left eye",
"D": "Patch the right eye",
"E": ""
}
|
D
|
This patient, with a history that suggests decreased visual acuity, a positive cover test (refixation of the misaligned eye upon covering the appropriately aligned eye), and an asymmetric corneal light reflex in Figure A, is presenting with strabismus. Of the answer choices, only patching the sound eye (right eye) is an appropriate treatment.
Strabismus occurs when a patient's eyes are not aligned properly. It often presents in children with one or both eyes turning inward, outward, upward, or downward. Patients will often tilt their heads or squint their eyes to correct this misalignment. Without proper treatment, there is a significant risk of developing amblyopia. Amblyopia is a developmental disorder in the visual cortex caused by abnormal visual stimuli. Untreated strabismus is the most common cause of amblyopia; it is secondary to visual loss from the deviated eye. The treatment of choice is wearing an eye patch over the appropriately tracking eye (sound eye), thereby encouraging the use of the deviated eye and preventing vision loss in this eye. Other treatments include surgical correction of strabismus, pharmacological penalization of the sound eye with atropine, and dichoptic movies and video games.
Gopal et al. discuss the pathophysiology, prevention, and therapy for amblyopia as it relates to strabismus. The authors find that the earlier clinically refractive error and strabismus are detected and treated, the greater the likelihood of preventing amblyopia. The authors recommend treating amblyopia with the correction of refractive errors, patching, and pharmacologic treatments.
Figure/Illustration A shows displacement of the light reflex from the center of the pupil in this patient's right eye, as indicated by the black arrow. This is known as an asymmetric corneal light reflex and is seen in strabismus.
Incorrect Answers:
Answer A: Brain MRI is part of the initial workup for retinoblastoma. Retinoblastoma typically presents in early childhood with visual loss, leukocoria, and an abnormal red reflex, which this patient does not have.
Answer B: Head CT in a pediatric patient could be used to rule out hemorrhage following blunt head trauma. This patient has not experienced head trauma and has no symptoms of traumatic brain injury (abnormal neurologic exam, loss of consciousness seizures). CT scans are not preferred in pediatric patients to avoid radiation exposure.
Answer C: Patching the left eye (the inappropriately tracking eye) would not treat this patient's strabismus and would likely increase his risk for amblyopia due to further decreasing his visual stimuli in this eye.
Answer E: The Bielschowsky head tilt test is used to help diagnose trochlear nerve (CN IV) palsy. Patients with a unilateral trochlear nerve and subsequent superior oblique palsy experience double vision when tilting their head to one side, which is improved by tilting the head towards the shoulder on the unaffected side. A trochlear nerve palsy typically presents with difficulty looking down and a head tilt away from the side of the lesion, unlike this patient who appears to have a visual acuity deficit.
Bullet Summary:
Patching the appropriately aligned eye is the treatment of choice for strabismus to prevent progression to amblyopia.
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A 67-year-old man presents to the emergency room with a 2 day history of progressively worsening fatigue and shortness of breath. His past medical history is significant for previous myocardial infarction, a 30-pack-year smoking history, gastroesophageal reflux disease, and poorly controlled hypertension. The patient’s only home medication is omeprazole. His temperature is 98.6°F (37°C), blood pressure is 140/90 mmHg, pulse is 90/min, respirations are 30/min, and oxygen saturation is 88% on room air. Physical exam is significant for a jugular venous pressure of 15 cm, an S3 heart sound, bibasilar crackles, and 2+ pitting edema to the knees bilaterally. His abdomen is soft and non-tender. His neurological exam is nonfocal and he walks with a steady gait. An arterial blood gas shows the following:
pH: 7.56 (normal 7.35-7.45)
pCO2: 25 mmHg (normal 35-45 mmHg)
HCO3: 29 mEq/L (normal 22-26 mEq/L)
pO2: 62 mmHg (normal 80-100 mmHg)
SaO2: 87% (normal 95-100%)
Which of the following is the most appropriate treatment?
|
{
"A": "Sacubitril and valsartan",
"B": "Furosemide",
"C": "Ivabradine",
"D": "Metoprolol",
"E": ""
}
|
B
|
This patient with multiple risk factors for heart failure (previous myocardial infarction, smoking history, hypertension), worsening fatigue, shortness of breath, respiratory alkalosis, and signs of fluid overload (S3 heart sound, elevated jugular venous pressure (JVP), bibasilar crackles, peripheral edema) most likely has acute decompensated heart failure (ADHF). The most appropriate initial management for patients in ADHF is a loop diuretic such as furosemide.
Heart failure (HF) is a condition in which the heart does not pump effectively and can be due to either difficulty with relaxation in diastole or contraction in systole or a combination of both. Risk factors for this condition include myocardial infarction, diabetes mellitus, valvular disease, cigarette smoking, hypertension, and obesity. Left-sided HF leads to decreased forward flow into the systemic circulation and increased congestion in the pulmonary circulation which clinically manifests as shortness of breath, pulmonary edema, and crackles on lung exam. Early pulmonary edema leads to a ventilation/perfusion (V/Q) mismatch which causes hypoxia. Hypoxia leads to a compensatory increase in the respiratory rate, which leads to hypocapnia and respiratory alkalosis. The most appropriate initial treatment for patients in ADHF is a loop diuretic such as furosemide, which helps alleviate fluid overload. Other treatments for acute exacerbations may include nitroglycerin (in hypertensive patients) and BIPAP.
Yancy et al. discuss the most recent ACC/AHA guidelines for the management of heart failure. They review current testing and treatment regimens. Acute episodes may be managed with loop diuretics to reduce volume overload and improve symptoms.
Incorrect Answers:
Answer B: Ivabradine inhibits the funny current, an electrical current that leads to spontaneous depolarization in pacemaker cells, leading to decreased heart rate. It reduces the risk of hospitalization in patients with chronic heart failure with reduced ejection fraction (HFrEF). However, it should not be started in ADHF due to lack of mortality benefit and should be held in ADHF patients with severe decompensation due to decreased heart rate leading to decreased cardiac output.
Answer C: Metoprolol is a beta-blocker that reduces mortality when used in patients with chronic HFrEF. However, beta-blockers can worsen decompensated HFrEF due to negative inotropy and should not be started in ADHF.
Answer D: Sacubitril and valsartan is a combination angiotensin receptor-neprilysin inhibitor (ARNI) that improves mortality in patients with chronic HFrEF. ARNIs, angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) should not be started in ADHF due to concern for hypotension and worsening renal function. However, either an ARNI, ACE inhibitor or ARB should be started prior to discharge.
Answer E: Spironolactone is a mineralocorticoid receptor antagonist that reduces mortality in chronic HFrEF. However, high-dose spironolactone does not improve outcomes as first-line therapy in ADHF (Anstrom et al. JAMA Cardiology 2017).
Bullet Summary:
Patients with acute decompensated heart failure present with fatigue, dyspnea, bibasilar crackles, respiratory alkalosis on arterial blood gas, edema, and other signs of fluid overload.
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A 30-year-old man presents to the emergency department with diarrhea. He states he has had profuse, watery diarrhea for the past 24 hours. He notes that eating and drinking make him defecate more, thus he has been refraining from drinking. He is otherwise healthy and takes no medications. His temperature is 97.7°F (36.5°C), blood pressure is 84/64 mmHg, pulse is 130/min, respirations are 17/min, and oxygen saturation is 99% on room air. Physical exam reveals dry mucous membranes with an otherwise benign exam. The patient is given 1L of normal saline and drinks 1L of oral fluids. His blood pressure is subsequently 120/70 mmHg and pulse 95/min. Which of the following is the most appropriate next step in management?
|
{
"A": "Stool PCR",
"B": "Ciprofloxacin",
"C": "Stool ova and parasite study",
"D": "Rest and oral rehydration",
"E": ""
}
|
D
|
This patient is presenting with a likely diarrheal illness given he has profuse, watery diarrhea and his vitals normalized with oral and IV hydration. Since the patient is young and healthy, oral hydration and rest are all that is needed for management.
Diarrheal illness is a common chief complaint with variable workups pending on the patient's clinical status. Young, healthy, non-immunosuppressed patients who can tolerate an oral diet require only reassurance and oral hydration, as most cases of viral and bacterial diarrhea will resolve on their own. Moreover, most cases of diarrhea are caused by viral etiologies which simply require supportive therapy. This is even true in bacterial diarrhea as long as the patient's vitals normalize and they can tolerate an oral diet. It is important to consider inflammatory causes of diarrhea (such as ulcerative colitis or Crohn disease) as this would change the workup and management.
Schiller et al. discuss different types of diarrhea. They review the management and diagnosis of diarrhea and its different forms, including chronic forms. They recommend noting the difference between different causes and working up and treating them appropriately.
Incorrect Answers:
Answer A: Ciprofloxacin is an antibiotic that can be used for bacterial/infectious diarrhea. It should not be given in young, healthy patients and would only be indicated in the setting of bacterial diarrhea in ill patients, patients with persistent symptoms, or patients who are immunosuppressed. Bacterial diarrhea would present with fever, abdominal pain, and bloody/purulent diarrhea.
Answer C: Stool culture should not be empirically performed in young, well-appearing patients. It may be performed in hospitalized patients who are more ill or in patients who are going to start antibiotic therapy. It may also be performed in patients with persistent diarrhea.
Answer D: A stool ova and parasite study would not be performed unless there was a suggestive history or exposure (such as drinking unfiltered water) in the setting of fatty, foul-smelling diarrhea. This would raise suspicion for Giardia lamblia which would be treated with metronidazole.
Answer E: Stool PCR for viral etiologies of diarrhea is not useful as the management of viral diarrhea is supportive therapy in most cases. On occasion, it may be performed in critically ill patients to determine the etiology of their symptoms. It should not be performed routinely.
Bullet Summary:
Healthy patients with limited diarrheal illness require supportive therapy only (in particular, oral hydration) and do not need more invasive diagnostic tests.
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279
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A 44-year-old man presents to the emergency department acutely confused. The patient’s wife states she found him lethargic at home. He has been sick the past week with diarrhea and has been staying home from work. He is otherwise healthy and does not take any medications. His temperature is 97.5°F (36.4°C), blood pressure is 62/32 mmHg, pulse is 185/min, respirations are 25/min, and oxygen saturation is 98% on room air. The patient has profuse, bloody diarrhea while in the emergency department. The patient is given 3L of ringer lactate and subsequently appears less confused, with a blood pressure of 100/70 mmHg. He is able to drink oral fluids and protect his airway. An ECG is performed as seen in Figure A. He continues to have diarrhea while in the emergency department. Which of the following is contraindicated in the management of this patient?
|
{
"A": "Loperamide",
"B": "Norepinephrine",
"C": "Ceftriaxone",
"D": "Normal saline",
"E": ""
}
|
A
|
This patient is presenting with infectious diarrhea (given his bloody diarrhea and hypotension) with unstable vitals that improve with fluids. In bloody diarrhea, loperamide is contraindicated and could worsen illness.
Bacterial diarrhea is commonly caused by organisms such as Campylobacter, Shigella, and Escherichia coli. It may present with bloody or purulent diarrhea and fever and may progress to sepsis or septic shock. Immediate management is centered on hydration. Unstable patients or those who cannot tolerate PO require IV fluids immediately. Otherwise, patients can rehydrate orally. Loperamide is an antimotility agent that decreases diarrheal output. It is contraindicated in bloody diarrhea as it can decrease the rate of fecal shedding and lead to bacteremia and a worsening clinical picture. Loperamide may be appropriate in controlling diarrhea in milder infectious forms of diarrhea, or in non-infectious conditions such as irritable bowel syndrome.
Baker reviews loperamide. He discusses its indications, contraindications, and mechanism of action. They recommend that loperamide should not be given in invasive diarrhea.
Figure/Illustration A demonstrates U waves on ECG (red arrows) that are significant for hypokalemia, which would be expected in a dehydrated patient with profuse diarrhea.
Incorrect Answers:
Answer A: Ceftriaxone would be appropriate in this patient who has bacterial diarrhea and appears septic as his critically ill state warrants antibiotics. Note that this patient may receive broader antibiotics than ceftriaxone given how ill he appears. Antibiotics should not be routinely used for bacterial diarrhea in young, healthy patients with stable vitals.
Answer C: Magnesium could be appropriate in this patient even though his magnesium level is not stated as he is hypokalemic given his ECG is demonstrating U waves. The serum magnesium level does not adequately reflect intracellular magnesium levels. It requires replacement in many cases of hypokalemia.
Answer D: Norepinephrine could be appropriate in this patient if he remained persistently hypotensive despite fluid administration. Note that this patient could receive more fluids and is not frankly unstable. While norepinephrine may not be appropriate at this time, it is not contraindicated.
Answer E: Normal saline is generally avoided in diarrheal illness in patients who can tolerate PO as oral hydration is preferred to IV. However, IV fluids are not contraindicated and would be appropriate in this persistently hypotensive patient. Normal saline has a very high sodium and chloride load and can cause a hyperchloremic metabolic acidosis. For this reason, a lower-chloride solution may be preferred (e.g, Lactated Ringer).
Bullet Summary:
Loperamide is contraindicated in bloody diarrhea.
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280
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A 77-year-old man presents to the emergency department acutely obtunded. The patient lives alone and was found unresponsive by his son. Generally, the patient manages his own finances, medications, and works part-time. He has not been responding to phone calls for the past 3 days. The patient is unable to offer a history. He has a past medical history of hypothyroidism, depression, and diabetes. His temperature is 88.0°F (31.1°C), blood pressure is 92/62 mmHg, pulse is 35/min, respirations are 9/min, and oxygen saturation is 92% on room air. The patient is cold to the touch and moves all extremities to painful stimuli. His pupils are reactive and sluggish, and he does not follow commands. There are no signs of trauma or skin infections. The patient is started on IV fluids and hydrocortisone, is externally warmed, and is started on a norepinephrine drip. An ECG is performed as seen in Figure A. Which of the following is the most appropriate next step in management?
|
{
"A": "Levothyroxine administration",
"B": "Free T4 level",
"C": "Thyroid stimulating hormone and free T4 level",
"D": "Triiodothyronine administration",
"E": ""
}
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A
|
This elderly patient with a past medical history of hypothyroidism is presenting with altered mental status, hypotension, hypothermia, and bradycardia, which are concerning for myxedema coma. Empiric and immediate treatment with levothyroxine is the appropriate management of this condition prior to confirming the diagnosis with lab studies.
Myxedema coma is a life-threatening complication of hypothyroidism. It presents with stupor/obtundation, bradycardia, hemodynamic instability, and hypothermia. With a high clinical suspicion, appropriate history, physical exam, and vitals, it is appropriate to first treat the patient with IV hydrocortisone (or another highly potent steroid) and levothyroxine prior to confirming the diagnosis given the high morbidity and mortality associated with this condition. Triiodothyronine is given in some circumstances as well (in more ill patients) but is less dire than first giving levothyroxine. Subsequently, the diagnosis can be confirmed with a serum thyroid stimulating hormone (TSH) and free T4 level. Patients are critically ill and typically require further care in an ICU.
Wall discusses the management of myxedema coma. He notes this is a potentially lethal condition. He recommends immediate administration of IV levothyroxine.
Figure A is an ECG with sinus bradycardia.
Incorrect Answers:
Answers 1, 3, & 4: Thyroid stimulating hormone and free T4 levels should certainly be obtained; however, the mortality for myxedema coma is so high that empiric treatment with levothyroxine should be started with clinical suspicion alone prior to confirming the diagnosis with laboratory studies, as a delay in therapy could increase morbidity and mortality. After administration of levothyroxine and initial supportive therapy, the diagnosis can be supported with laboratory studies.
Answer E: Triiodothyronine or T3 could be appropriate in patients with myxedema coma in severe scenarios where patients do not respond to levothyroxine. In some cases, it may also be given empirically but does not take priority over T4 administration.
Bullet Summary:
In myxedema coma, empiric treatment with levothyroxine is appropriate with a high clinical suspicion for the diagnosis prior to laboratory confirmation.
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281
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A 22-year-old man presents to the emergency department with difficulty breathing. He has experienced similar symptoms before. Today, he was hit in the face with a football, followed by significant swelling of his lips and tongue. The patient speaks with a muffled voice. His temperature is 98.1°F (36.7°C), blood pressure is 120/83 mmHg, pulse is 80/min, respirations are 16/min, and oxygen saturation is 98% on room air. Physical exam reveals swollen lips and a protruding, enlarged tongue. His breath sounds are clear. He demonstrates no rash and his abdomen is soft and nontender. Which of the following is the most effective therapy for this patient?
|
{
"A": "Diphenhydramine",
"B": "Dexamethasone",
"C": "Fresh frozen plasma",
"D": "Epinephrine",
"E": ""
}
|
C
|
This patient is presenting with recurrent episodes of significant swelling of his lips and tongue with minor trauma, which are concerning for hereditary angioedema. Fresh frozen plasma is the most effective therapy for hereditary angioedema of the options listed.
Angioedema is a potentially life-threatening condition that presents with severe edema of the gastrointestinal and respiratory tracts. It can be caused by antigens, medications, and trauma or may occur spontaneously. It often presents with notable edema of the lips and tongue and may threaten the airway. There are 3 subtypes. Hereditary and acquired angioedema occur secondary to a deficiency of C1-esterase inhibitor. As a result, the most effective therapy is to administer fresh frozen plasma which has C1-esterase inhibitor. On the other hand, drug-induced angioedema (often from angiotensin-converting enzyme inhibitors and angiotensin receptor blockers) does not respond well to C1-esterase inhibitor replacement and supportive therapy; discontinuing the offending agent is the mainstay of therapy. Other effective but costly treatments that can be used in hereditary angioedema include: icatibant, ecallantide, and C1 inhibitor.
Paige and Anderson note the management of hereditary angioedema. They review the different treatments and discuss C1-esterase inhibitor replacement. They recommend this treatment for acute episodes.
Incorrect Answers:
Answer A: Dexamethasone and other steroids can be given in acute allergic reactions and may reduce the recurrence of symptoms but are unlikely to be effective in angioedema, nor are they the most effective therapy. Steroids can take up to 4 hours to begin having any effect.
Answer B: Diphenhydramine is an antihistamine that could be given for anaphylaxis or urticaria and works immediately; however, it is not the mainstay of therapy for angioedema nor is it the most effective therapy. It is the mainstay of therapy for urticaria. It can also be given in anaphylaxis.
Answer C: Epinephrine is the treatment of choice for anaphylaxis which presents with urticaria, upper airway swelling, hypotension, nausea/vomiting, and wheezing. It is often given in angioedema but has limited efficacy when compared to fresh frozen plasma.
Answer E: Tranexamic acid is effective in treating angioedema and current evidence supports its use; however, the mainstay of therapy is still fresh frozen plasma. Tranexamic acid is also used in hemorrhagic shock to stop fibrinolysis and reduce bleeding.
Bullet Summary:
A possible treatment in hereditary or acquired angioedema is the administration of fresh frozen plasma to replace C1-esterase inhibitor.
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282
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A 64-year-old man presents with nausea, vomiting, and weakness. He states that his wife made him come in when he fainted today while attempting to stand up. He otherwise states he has noticed some visual changes, including noting a yellow tint to objects. He has a history of heart failure with reduced ejection fraction, obesity, diabetes, hypertension, acute coronary syndrome, atrial fibrillation, and peripheral vascular disease. His temperature is 98.5°F (36.9°C), blood pressure is 153/91 mmHg, pulse is 40/min, respirations are 15/min, and oxygen saturation is 97% on room air. Physical exam reveals a frail man who is unable to ambulate secondary to lightheadedness. His neurological exam is otherwise non-focal. An ECG is performed as seen in Figure A. Which of the following is the most likely etiology of this patient’s symptoms?
|
{
"A": "Amiodarone",
"B": "Digoxin",
"C": "Diltiazem",
"D": "Procainamide",
"E": ""
}
|
B
|
This patient with a history of heart failure with reduced ejection fraction and atrial fibrillation is presenting with nausea, vomiting, visual changes, bradycardia, and premature ventricular complexes, which are concerning for digoxin toxicity. Note that digoxin can be given in patients with poor cardiac function and atrial fibrillation; thus it is a plausible home medication for this patient.
Digoxin is a cardiac glycoside that is used in conditions such as heart failure with reduced ejection fraction and atrial fibrillation. While it does not lower mortality, it may reduce symptoms of heart failure. Digoxin toxicity classically presents with gastrointestinal symptoms (nausea/vomiting), blurred vision or yellow halos, and cardiac dysrhythmias. While there is a myriad of dysrhythmias, digoxin can cause bradycardia, atrioventricular block, and premature ventricular contractions. ST-segment scooping can be seen with digoxin use both in toxicity but also with regular therapeutic use. Toxicity is treated with anti-digoxin antibodies.
Patocka et al review digoxin toxicity. They note that this medication has a narrow therapeutic range and recommend close monitoring. Toxicity depends on severity and can be treated with anti-digoxin antibodies.
Figure/Illustration A is an ECG demonstrating bradycardia and premature ventricular complexes (red circles). This is consistent with digoxin toxicity.
Incorrect Answers:
Answer A: Amiodarone is an antidyshythmic agent with toxicities including bradycardia, heart block, a prolonged QT interval, hepatitis, interstitial lung disease, hypothyroidism, corneal deposits and optic neuropathy. This patient could use amiodarone for his atrial fibrillation, but the visual disturbances are more typical of digoxin toxicity.
Answer C: Diltiazem is a calcium channel blocker that would cause hypotension, bradycardia, and hyperglycemia. Treatment would involve immediate administration of calcium and vasopressors such as epinephrine. Other treatments in severe toxicity may include glucagon, dextrose, and insulin (to increase cardiac contractility).
Answer D: Procainamide is the preferred antidysrhythmic in tachydysrhythmias associated with Wolff Parkinson White syndrome. It may cause drug-induced lupus and other dysrhythmias in overdose but would not cause this patient’s constellation of symptoms. Procainiamide is used rarely for atrial fibrillation and is only available for intravenous infusion in the US.
Answer E: Propranolol toxicity would present with bradycardia, hypotension, confusion, seizures, and hypoglycemia. Treatment is centered on glucagon, calcium, and vasopressors such as epinephrine. In severe toxicity, lipid emulsion therapy and insulin/dextrose should be administered.
Bullet Summary:
Digoxin toxicity may present with nausea, vomiting, visual changes, bradycardia, and premature ventricular complexes.
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283
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A 33-year-old man presents to the emergency department with dizziness. He states he has a constant sensation that the room is spinning. He is now having trouble walking and has been vomiting intermittently. He has no past medical history and takes no medications. His temperature is 98.0°F (36.7°C), blood pressure is 122/84 mmHg, pulse is 80/min, respirations are 16/min, and oxygen saturation is 98% on room air. Physical exam reveals a young man who is vomiting. His gait is ataxic and he exhibits rightward nystagmus. His dizziness is constant and unchanged with performance of the Dix-Hallpike maneuver. The head impulse test reveals a corrective saccade and there is no skew deviation. Which of the following is the most appropriate next step in management?
|
{
"A": "Prednisone",
"B": "Epley maneuver",
"C": "MRI brain",
"D": "CT head",
"E": ""
}
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A
|
This young, healthy patient is presenting with constant vertigo, ataxia, vomiting, and a head impulse test revealing a corrective saccade, nystagmus, and test of skew (HINTS) exam, which suggests a peripheral etiology of vertigo, most likely vestibular neuritis. As the diagnosis can be made clinically, steroids are the only treatment needed.
Differentiating peripheral (the vestibular system) versus central (the brain) vertigo is critical in management. Peripheral vertigo is commonly caused by benign paroxysmal positional vertigo, vestibular neuritis, and labyrinthitis. Vertigo that is constant is more consistent with vestibular neuritis or labyrinthitis but could also be a cerebellar stroke. To differentiate, age, risk factors, and onset of symptoms are critical. Moreover, the HINTS exam can point toward 1 cause of vertigo versus another. HINTS is a mnemonic for: Horizontal head impulse testing (Head Impulse), Direction-changing nystagmus in eccentric gaze (Nystagmus), and Vertical skew (Test of Skew). Findings that are suggestive of a peripheral cause of vertigo include a positive head impulse exam, positive nystagmus (also seen in stroke), and a negative test of skew. In the appropriate clinical context with appropriate risk factors, peripheral causes such as vestibular neuritis or labyrinthitis can be managed with steroids (which may improve outcomes) and meclizine (for symptom control).
Kattah et al. discuss the HINTS exam. They note how it can be used to differentiate peripheral from central vertigo. It is recommended to perform this exam when differentiating central versus peripheral vertigo.
Incorrect Answers:
Answers 1 & 3: Head imaging such as a CT head or MRI brain is not necessary in patients with a clear peripheral cause of their vertigo/dizziness with a HINTS exam suggesting a peripheral etiology. Clinically, this patient has vestibular neuritis and can be treated accordingly. Imaging would be needed if the patient had an acute cerebellar stroke.
Answer D: The Epley maneuver is only indicated in cases of benign paroxysmal peripheral vertigo, which presents with severe vertigo (with changes in head position) that diminish with time and keeping the head stationary. Note that this patient’s Dix-Hallpike maneuver is negative and that his vertigo is constant rather than intermittent or positional.
Answer E: Tissue plasminogen activator is indicated within 4.5 hours in the setting of an ischemic stroke after a head CT rules out a head bleed, other reversible causes are treated, and assuming there are no contraindications to thrombolytics. Tissue plasminogen activator can be given in posterior circulation strokes.
Bullet Summary:
Peripheral causes of vertigo generally do not require head imaging, and causes such as labyrinthitis or vestibular neuritis can be treated with steroids.
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284
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A 45-year-old man with a past medical history of obesity presents with a concern about his sexual performance. He has a history of depression which is well managed with fluoxetine. He states that since starting the medication, his sexual drive has increased, yet he is unable to achieve orgasm. As a result, he refuses to take the medication anymore. He has a past medical history of diabetes and notes that his home blood glucose readings have been higher lately. His temperature is 98.3°F (36.8°C), blood pressure is 127/82 mmHg, pulse is 88/min, respirations are 14/min, and oxygen saturation is 99% on room air. Physical exam reveals an obese man in no acute distress with a normal affect and non-focal neurologic exam. The physician agrees to change the patient’s antidepressant. Which of the following is the most appropriate treatment for this patient?
|
{
"A": "Electroconvulsive therapy",
"B": "Mirtazapine",
"C": "Bupropion",
"D": "Phenelzine",
"E": ""
}
|
C
|
This patient is presenting with anorgasmia in the setting of treatment with a selective serotonin reuptake inhibitor (SSRI). Given his obesity, worsening home blood glucose levels, and desire for improved sexual performance, bupropion is an appropriate medication.
Bupropion is an antidepressant that is not used first-line except in certain circumstances. Situations where bupropion is an appropriate agent for the management of depression include smoking cessation as it decreases smoking cravings. Bupropion is also weight neutral and is preferred in obese patients, patients who are gaining weight on other medications, and patients with poorly-managed diabetes. Finally, it does not have any sexual side effects in contrast to SSRIs. However, bupropion lowers the seizure threshold and should be avoided in patients at higher risk for seizures. Bupropion is sometimes given with other antidepressants for patients with persistent or refractory symptoms.
Patel et al. review bupropion. They note the effectiveness of bupropion in managing depression and note that it can be given with other agents. They recommend its use, in particular, for smoking cessation or patients who need a more weight-neutral treatment.
Incorrect Answers:
Answer B: Electroconvulsive therapy is a highly effective therapy for depression; however, it is generally used in cases of severe suicidality, malnutrition due to food refusal secondary to depressive disorder, or last line when other medications have failed. This patient is primarily experiencing sexual side-effects and has gained weight, making bupropion a more viable initial alternative.
Answer C: Escitalopram is merely a different SSRI that will lead to similar side effects. Thus, it would not be appropriate. Changing SSRIs is appropriate if the first SSRI does not work after an appropriate trial period of at least 4 weeks in the management of depression. Other changes when an SSRI fails to control symptoms include increasing the dose.
Answer D: Mirtazapine is an antidepressant that increases appetite and leads to weight gain and would further worsen this patient’s obesity. It is preferred in conditions such as anorexia nervosa given weight gain is preferable in this population.
Answer E: Phenelzine is a monoamine oxidase inhibitor and is usually used third-line (or later) in the management of depression given side-effects such as hypertensive crisis and the long washout period and interactions with other medications. Bupropion is a safer initial alternative.
Bullet Summary:
Patients with depression who experience sexual side effects or weight gain on SSRIs may be switched to bupropion.
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285
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A 55-year-old man presents to his primary care physician with persistent symptoms of depression. He started taking fluoxetine 3 weeks ago when he was diagnosed with major depressive disorder after a divorce. Since then, he notes that his symptoms are roughly unchanged. His other medications include albuterol. His temperature is 99.3°F (37.4°C), blood pressure is 132/88 mmHg, pulse is 77/min, respirations are 14/min, and oxygen saturation is 99% on room air. Physical exam reveals a depressed affect. His neurologic exam is non-focal. A serum thyroid stimulating hormone (TSH) resulted from his last visit and is noted to be 4.8 µU/mL (normal: 0.5-5 µU/mL). Which of the following is the most appropriate next step in management?
|
{
"A": "Change medication to bupropion",
"B": "Increase dose of current medication",
"C": "Maintain dose of current medication",
"D": "Change medication to escitalopram",
"E": ""
}
|
C
|
This patient is presenting with major depressive disorder but has not given his current selective serotonin reuptake inhibitor (SSRI) at least 4 weeks to begin working. Thus, he should be reassured and maintained on the current dose of his SSRI, with follow-up after the 4 week mark to see if his symptoms have improved.
Major depressive disorder is managed initially with cognitive behavioral therapy and pharmacotherapy. The typical first-line medication is an SSRI. SSRIs may take at least 4 weeks or more to begin working, so patients that return before this time period should be reassured and encouraged to let the medication take effect as long as they are not experiencing suicidal thoughts or intent. If the medication is not working after at least 4 weeks, the next steps in management could include increasing the dose of the current medication, changing SSRIs, adding another antidepressant agent, or adding a low dose of levothyroxine. All patients with suicidal ideation and either intent or a plan to hurt themselves should be hospitalized involuntarily.
Gautam et al. discuss the current management algorithms for major depressive disorder. They note different options including CBT and pharmacotherapy. They recommend appropriate treatment with a first-line agent based on the patient and their circumstances.
Incorrect Answers:
Answer A: Administering levothyroxine is appropriate as an augmenting agent in patients who do not have an improvement in symptoms on SSRIs or other antidepressants even if their TSH is within the normal range. However, it would not be attempted at this point given this patient has not given his current medication sufficient time to begin working. There is limited evidence to support its use overall. Note that this patient's TSH is within normal limits. In some cases, T3 administration is used in refractory depression.
Answer B: Changing the medication to bupropion could be appropriate in patients who want to avoid weight gain, those who want to quit smoking, or those who are trying to avoid sexual side effects. It also is an appropriate second-line agent or could be added to a first-line agent; however, this patient’s current medication should be tried for at least 4 weeks before changing medications.
Answers 3 & 4: Changing medication to escitalopram or increasing the dose of the current medication are both viable strategies if a patient has failed to improve on their first medication after at least 4 weeks on the medication. Increasing the dose early may lead to symptoms of serotonin excess when the drug takes effect.
Bullet Summary:
SSRIs are the first-line agents in the management of major depressive disorder and should be tried for at least 4 weeks before changing the treatment regimen.
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286
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A 60-year-old man presents to his primary care physician with weight gain. He states that ever since his wife died 4 months ago, he has been eating and sleeping more and no longer engages in any activities he once enjoyed such as hiking or fishing. He feels guilty for not spending more time with his wife before she died. He was recently fired for making several major bookkeeping mistakes at work as an accountant as he had trouble focusing. The patient is requesting oxycodone at this appointment as he states he has burning pain in his legs that feels worse now than it has in years past. The patient has a past medical history of obesity, poorly controlled diabetes, hypertension, and peripheral vascular disease. His temperature is 98.7°F (37.1°C), blood pressure is 129/82 mmHg, pulse is 83/min, respirations are 15/min, and oxygen saturation is 99% on room air. Physical exam reveals a stable gait and reduced sensation symmetrically over the lower extremities. He complains of electric pain when touching his lower extremities. His affect seems depressed. Which of the following is the most appropriate treatment for this patient?
|
{
"A": "Venlafaxine",
"B": "Bupropion",
"C": "Amitriptyline",
"D": "Escitalopram",
"E": ""
}
|
A
|
This patient is presenting with sleep changes, interest loss, guilt, decrease in energy, and trouble concentrating for greater than 2 weeks concerning for major depressive disorder. In the setting of his diabetic neuropathy (lower extremity burning pain in the setting of poorly managed diabetes), a serotonin-norepinephrine reuptake inhibitor (SNRI) such as venlafaxine is the most appropriate initial treatment for this patient.
Major depressive disorder should always initially be managed with cognitive behavioral therapy and often medication. Typically, the first-line medication is a selective serotonin reuptake inhibitor (SSRI). However, SNRIs such as venlafaxine and duloxetine are viable first-line options. They are particularly preferred in patients with diabetic neuropathy as they treat both diabetic neuropathy and depression. SNRIs are also generally considered to be less sedating than SSRIs. For this reason, SNRIs are often a better initial drug in depression than SSRIs in diabetic patients with peripheral neuropathy.
Sansone and Sansone discuss SNRIs and their uses. They discuss how there are different efficacies and propensities of the different SNRIs. They recommend choosing an appropriate SNRI based on the patient's needs and comorbidities.
Incorrect Answers:
Answer A: Amitriptyline is a tricyclic antidepressant that can be used to treat depression in patients who also suffer from other neuropathic pain conditions or conditions such as fibromyalgia or irritable bowel syndrome. While it may also be used in diabetic neuropathy and depression, there is higher toxicity with this medication than SNRIs. For this reason, SNRIs are preferred. A TCA might be appropriate if the patient had already failed other first-line agents.
Answer B: Bupropion is a weight-neutral antidepressant that can be used in smoking cessation and patients who are trying to avoid the sexual side effects of SSRIs (anorgasmia). It would not address this patient's diabetic neuropathy, though it could be beneficial for his obesity.
Answer C: Escitalopram is an SSRI that could be used first-line for major depressive disorder. However, if a patient has a concomitant condition, it is better to choose a single agent that addresses both problems; thus, SNRIs are better first-line medications in this patient with diabetic neuropathy.
Answer D: Phenelzine is a monoamine oxidase inhibitor that can be used in atypical depression or as a third-line or later agent in the management of depression. This agent can cause a hypertensive crisis in the setting of tyramine consumption, has many medication interactions, and a long washout period. Thus, it is not usually a first or second-line agent. However, it is highly effective in patients who have failed other first-line agents and should still be used in appropriate candidates.
Bullet Summary:
SNRIs are appropriate first-line agents for major depressive disorder in patients with diabetic neuropathy.
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A resident physician places a patient’s home medications in for their admission orders during an overnight admission. They order the patient’s home medications including clobazam; however, they accidentally order clonazepam. Subsequently, the patient is over-sedated and has to be transferred to the ICU for airway monitoring. Which of the following is the most appropriate method for preventing future similar occurrences?
|
{
"A": "Verify the patient’s home medications with the patient",
"B": "Add an alert in the electronic medical system for medications that sound similar",
"C": "Have nursing perform the medication reconciliation",
"D": "Reprimand and educate the resident to check medications more carefully",
"E": ""
}
|
B
|
A medical error occurred where 2 similar-sounding medications were confused, leading to an adverse event. The most appropriate way to prevent this error from occurring is a system-based approach, such as adding an alert in the electronic medical system for medications that sound similar.
Medical errors commonly occur in the medical system given the complexity of delivering patient care. The best way to prevent future errors from occurring is a systems-based approach where the system is built to catch errors rather than relying on the diligence of staff. In a systems-based approach, there is an algorithmic method set in place for situations where errors are common. Examples of systems-based approaches to avoiding medical errors include time-outs for procedures, use of the electronic medical record and ordering system to generate stops and checks, and built-in procedures such as a pharmacist verifying all medical orders. The best way to prevent future errors, when possible, is a systems-based approach as it does not rely solely on individuals given that individuals are fallible and may not always avoid mistakes.
Condren et al. review a systems based approach in the medical system. They note that a systems-based approach reduces medication errors. For this reason, systems-based approaches are recommended whenever possible.
Incorrect Answers:
Answer B: Entering medications only on morning rounds with multiple providers is not a plausible strategy as patients will not receive medications they may need at other times, such as overnight. It is always a good idea to verify medications with the team on morning rounds to catch any possible errors that may be missed, but this would not necessarily fix errors that occur at other times of the day.
Answer C: Having nursing perform the medication reconciliation is not the best solution in this case, as the core problem was that the wrong medication was entered due to similar-sounding medication names. However, it is always a good idea to have multiple providers (e.g., nurses, pharmacists) verify information, check this with the physician team, and then verify the dose and route of administration when giving the medication.
Answer D: Reprimanding and educating the resident to check medications more carefully is not a solution to this problem. It does not seem that the resident does not understand the pharmacology or medication prescribed but made an understandable error. Explaining the need for care is important; reprimanding the resident is not.
Answer E: Verifying the patient’s home medications with the patient should always be performed, but it would not fix this issue with similar-sounding medications. It would catch errors such as new medications that are not on the patient’s medication list or out-of-date medications remaining on the list.
Bullet Summary:
A systems-based approach is the most appropriate way to prevent future errors from occurring.
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288
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At a local community hospital staffed only by attending physicians, it is noted that the time to tissue plasminogen activator administration in suspected stroke patients is roughly 10 minutes from presentation. At a teaching hospital with residents, the time to tissue plasminogen activator administration is roughly 2 hours. This has led to many adverse outcomes and increased morbidity at the teaching hospital. Which of the following is the most appropriate next step in further elucidating the problem?
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{
"A": "Perform a systems-based approach implementation",
"B": "Perform a root cause analysis of the process",
"C": "Empirically scan patients with concerning neurologic symptoms",
"D": "Automatically consult neurology for patients with concerning neurologic symptoms",
"E": ""
}
|
B
|
This case outlines a delay in treating strokes at a teaching hospital. To determine the underlying cause, a root cause analysis to determine the underlying issue is the most appropriate way to begin to address this issue.
When a problem is found in healthcare, it is important to elucidate the underlying cause. A root cause analysis is the current preferred method of determining the underlying cause of a problem. A root cause analysis outlines all the people, materials, equipment, and processes in place and outlines them. It then locates the problem and attempts to find the breakdown or issue in all these inputs that lead to the problem. Once the problem is identified, then a strategy or intervention can be implemented to fix the underlying problem.
Percarpio et al. review root cause analysis. They note the ubiquity of root cause analysis. They call into question its cost and efficacy despite it being such a widespread practice and recommend a careful assessment of the costs and benefits.
Incorrect Answers:
Answer A: Automatically consulting neurology for patients with concerning neurologic symptoms may be appropriate if the issue was lack of access to timely neurologist assessment in the workup of stroke. While may hospitals have this as a default for patients with stroke-like symptoms, it would be premature to implement this as a solution without a root cause analysis to first determine what the problem is.
Answer B: Empirically scanning patients with concerning neurologic symptoms would be wasteful and not plausible in a healthcare system. There are many concerning neurologic chief complaints including those that originate in the brain, the spine, or the peripheral nerves; thus, merely CT scanning everyone with a neurological chief complaint is an inefficient use of resources.
Answer C: Improving resident education is assuming that the problem is a lack of knowledge based on the residents. Before proposing a solution, it is important to first find the underlying cause and address said cause as the delayed intervention may not be the fault of the residents.
Answer E: A systems-based approach is the best solution when fixing a medical error. However, a root cause analysis is first needed to determine which solution is needed. If an error in the process is noted, a systems-based approach would be the best method to address it.
Bullet Summary:
When an error is noted in patient care, the most appropriate initial step in fixing the issue is conducting a root cause analysis.
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289
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A study is performed that looks at individuals who suffer from opioid use disorder and the effect the disorder has on their daily life and functionality. Individuals are surveyed using a validated method and followed up in 6-month intervals for 5 years. At the end of the study period, 40% of individuals have replied to the survey throughout the entire period. Analyzing only those subjects who responded throughout the entire period, it is determined that opioid use disorder only minimally impairs individuals in their daily functioning. Which of the following most likely occurred in this study?
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{
"A": "Confounding variable",
"B": "Recall bias",
"C": "Volunteer bias",
"D": "Attrition bias",
"E": ""
}
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D
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This study following individuals who abuse opioids with a 40% follow-up response rate suggests that opioid use disorder (known for impairing daily functioning) has only a minor effect on patient functionality. This is most likely secondary to attrition bias, or a loss to follow-up of participants in a non-random fashion whereby more severe cases stopped responding and were thus left out.
Bias in studies distorts outcomes and can make interpreting results challenging. For this reason, it is important to be meticulous when designing a study with every effort to minimize bias. The attrition bias can occur when individuals are lost to follow-up in a non-random fashion. For example, consider the assessment of daily functionality via a validated method in individuals with coronary artery disease. Those who are severely impaired from disease progression may not follow up in this study, thus altering results and removing more severe cases from the analysis. Having a higher response rate can help mitigate this bias, but is more costly as it may be difficult to ensure that every participant follows up.
Nunan et al. discuss the attrition bias. They note how it can affect studies and the data collected. They recommend mitigating the attrition bias for more accurate results and clinical application.
Incorrect Answers:
Answer B: Confounding variables are variables that are correlated with the studied variable that better explain the difference between 2 groups. For example, it may be found that alcohol is associated with lung cancer when in reality, the confounding variable of smoking (more common in individuals who drink alcohol) explains this difference.
Answer C: Late-look bias occurs when patients with severe disease are not studied because they are dead, critically ill, or unavailable to be studied, making the disease overall appear less severe. For example, patients with HIV may not have increased morbidity and mortality in a study. However, this may be a result of all the critically ill cases being too sick or dead and thus unable to participate thus distorting the outcome.
Answer D: Recall bias occurs when individuals with disease or an adverse outcome are more likely to recall an exposure given the occurred outcome, skewing their memory and thus the results. For example, pregnant mothers who have a newborn with a defect or condition may be more likely to recall certain exposures (such as exposure to pollution).
Answer E: Volunteer bias occurs when people who volunteer for a study are fundamentally different from the general population or those who do not volunteer. An example may be individuals volunteering in a study involving exercise as those who are interested in participating in an exercise study may be more motivated or healthier at baseline.
Bullet Summary:
Attrition bias occurs when individuals are lost to follow-up in a non-random fashion leading to skewed results.
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290
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A 55-year-old man presents to his primary care physician with fatigue, malaise, and a painful rash. The patient states that his symptoms have been worsening over the past week. He also has experienced abdominal pain and diarrhea. He has a medical history of obesity and smokes regularly. His temperature is 97.5°F (36.4°C), blood pressure is 142/82 mmHg, pulse is 85/min, respirations are 15/min, and oxygen saturation is 98% on room air. Physical exam is notable for an erythematous rash with papules and plaques on the patient's face, torso, and extremities. He states that the rash is painful. A fingerstick blood glucose is unable to accurately read his blood glucose and gives a reading of > 500 mg/dL. Which of the following is the most likely underlying pathophysiology of this patient’s condition?
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{
"A": "Alpha cell tumor",
"B": "Hypercortisolism",
"C": "Beta cell destruction",
"D": "Insulin resistance",
"E": ""
}
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A
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This patient is presenting with necrolytic migratory erythema (a painful, erythematous rash with papules and plaques) with gastrointestinal symptoms (abdominal pain and diarrhea) and hyperglycemia, which are concerning for a glucagonoma. A glucagonoma is a tumor of the alpha cells.
A glucagonoma is a tumor of the alpha cells of the pancreas. This tumor pathologically secretes glucagon leading to profound hyperglycemia that is refractory to the normal treatments for diabetes. Patients also present with a classic rash termed necrolytic migratory erythema which presents with painful, erythematous papules and plaques. Other findings include gastrointestinal symptoms including anorexia, abdominal pain, and diarrhea. Hematologic findings include a normocytic, normochromic anemia. The diagnosis can be supported with a glucagon level, which will be elevated. Imaging of the pancreas by CT or MRI (more accurate) can further support the diagnosis.
Zandee et al. review glucagonoma. They note the presentation and symptoms associated with a glucagonoma, including the classic rash and elevated blood glucose. They recommend considering this diagnosis in patients who present with rash and hyperglycemia refractory to typical treatments.
Incorrect Answers:
Answer B: Beta-cell destruction is the pathophysiology of type I diabetes mellitus which presents with polydipsia, polyuria, weight loss, and hyperglycemia (typically in a pediatric patient). It can progress to diabetic ketoacidosis which presents with hyperglycemia, an anion gap acidosis, altered mental status, and Kussmaul respirations.
Answer C: Beta-cell tumor describes an insulinoma, which would present with hypoglycemia refractory to glucose administration. This condition is caused by increased release of insulin. The diagnosis should be suspected in the setting of hypoglycemia, an elevated insulin level, and an elevated C-peptide level. Imaging of the abdomen/pancreas with an MRI will reveal the insulin-secreting mass.
Answer D: Hypercortisolism can cause Cushing syndrome which presents with hyperglycemia, obesity, striae, limb/muscle atrophy, mood changes, and hypertension. A buffalo hump and moon faces may also be seen. This condition can either be from endogenous ACTH production or cortisol production or can be from exogenous steroid use.
Answer E: Insulin resistance is the pathophysiology of type 2 diabetes mellitus and presents with obesity, hyperglycemia, and an elevated hemoglobin A1c. The mainstay of management is weight loss, though medications such as metformin, sulfonylureas, or insulin are often needed.
Bullet Summary:
A glucagonoma is a tumor of the alpha cells of the pancreas that hypersecretes glucagon.
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291
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A 44-year-old nurse presents to the emergency department with confusion. This has happened several times this past month with increasing frequency. Each time her symptoms improved with eating. She is otherwise healthy. She lives with her mother who has diabetes whose medications include metformin, insulin, lisinopril, amlodipine, and glyburide. Her temperature is 98.0°F (36.7°C), blood pressure is 132/81 mmHg, pulse is 85/min, respirations are 16/min, and oxygen saturation is 98% on room air. Physical exam reveals a confused woman. She is moving all her extremities but follows commands poorly. Laboratory studies are ordered as seen below.
Hemoglobin: 14 g/dL
Hematocrit: 41%
Leukocyte count: 7,500/mm^3 with normal differential
Platelet count: 199,000/mm^3
Serum:
Na+: 140 mEq/L
Cl-: 102 mEq/L
K+: 4.0 mEq/L
HCO3-: 23 mEq/L
BUN: 30 mg/dL
Glucose: 29 mg/dL
Creatinine: 1.4 mg/dL
Ca2+: 10.2 mg/dL
Sulfonylurea level: undetectable
C-peptide level: 55 ng/mL (normal < 5 ng/mL)
Which of the following is the most likely etiology of this patient’s symptoms?
|
{
"A": "Insulin overdose",
"B": "Beta cell tumor",
"C": "Sulfonylurea overdose",
"D": "Beta cell destruction",
"E": ""
}
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B
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This patient is presenting with confusion, profound hypoglycemia, an elevated C-peptide level, and a negative sulfonylurea level, which are concerning for an insulinoma. An insulinoma is a beta cell tumor that secretes insulin.
An insulinoma is a beta cell tumor of the pancreas. The beta cells normally secrete insulin in response to increased circulating fuel substrate (such as glucose or fat). In the setting of an insulinoma, insulin is pathologically and continuously secreted. This leads to profound, recurrent episodes of hypoglycemia. When a patient presents with hypoglycemia of unclear etiology; a blood glucose level, C-peptide level, and sulfonylurea level should be ordered. An infectious workup may be indicated as sepsis can also cause hypoglycemia. In an insulinoma, patients will be hypoglycemic, have an elevated C-peptide level (as this is a marker of endogenous insulin release), and a negative sulfonylurea level (important to rule out as a sulfonylurea overdose can also cause hypoglycemia in the setting of an elevated C-peptide level). Further workup will involve imaging of the abdomen such as a CT scan or MRI (more accurate) to delineate this insulin-secreting mass.
Mathur et al. discuss insulinoma. They note that it is a rare endocrine tumor, and note its association with multiple endocrine neoplasia type 1. They recommend workup for an insulinoma should occur in patients with recurrent episodes of hypoglycemia without a clear cause.
Incorrect Answers:
Answer A: Alpha cell tumor describes a glucagonoma, which pathologically secretes glucagon leading to profound hyperglycemia, a classic rash termed necrolytic migratory erythema (presents with painful, erythematous papules and plaques), and gastrointestinal symptoms including anorexia, abdominal pain, and diarrhea.
Answer B: Beta cell destruction describes the pathophysiology of type I diabetes mellitus, which presents in pediatric patients (most commonly) with hyperglycemia, weight loss, polydipsia, and polyuria. Treatment involves the administration of insulin. An initial presentation of type I diabetes may be diabetic ketoacidosis which presents with dehydration, abdominal pain, nausea, vomiting, Kussmaul respirations, and an anion gap acidosis.
Answer D: Insulin overdose would present with hypoglycemia, somnolence, confusion, and tremulousness. Note that exogenous insulin administration would not elevate the C-peptide level, which is a marker of endogenous insulin production.
Answer E: Sulfonylurea overdose would cause hypoglycemia that is often persistent given the long half-life of sulfonylureas. It would also elevate the C-peptide level as these medications increase the endogenous release of insulin. However, the sulfonylurea level was negative in this patient. While iatrogenic use of medications is plausible in this patient who has knowledge of medications (as she is a nurse), her repeat episodes and her workup suggesting against an iatrogenic etiology makes an insulinoma a more likely diagnosis.
Bullet Summary:
Insulinomas are beta cell tumors of the pancreas and lead to severe hypoglycemia and an elevated insulin and C-peptide level.
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292
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A 72-year-old man presents to his primary care physician for a general checkup. He states that he has been a bit more fatigued lately but believes it is secondary to poor sleep at his new house. The patient is otherwise healthy and takes no medications. His temperature is 98.0°F (36.7°C), blood pressure is 141/90 mmHg, pulse is 82/min, respirations are 16/min, and oxygen saturation is 98% on room air. Physical exam is notable only for minor pallor but is otherwise unremarkable. Basic laboratory studies are ordered as seen below.
Hemoglobin: 10 g/dL
Hematocrit: 30%
Leukocyte count: 67,500/mm^3
Platelet count: 119,000/mm^3
Serum:
Na: 141 mEq/L
Cl: 103 mEq/L
K: 4.0 Eq/L
HCO3-: 24 mEq/L
BUN: 22 mg/dL
Glucose: 109 mg/dL
Creatinine: 1.2 mg/dL
Ca: 10.0 mg/dL
Which of the following is the most likely diagnosis?
|
{
"A": "Chronic lymphocytic leukemia",
"B": "Acute lymphoblastic leukemia",
"C": "Hairy cell leukemia",
"D": "Chronic myelogenous leukemia",
"E": ""
}
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A
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This elderly patient is presenting with minor fatigue, anemia, thrombocytopenia, and a leukocyte count >50,000/mm^3, which is most likely caused by chronic lymphocytic leukemia (CLL).
CLL is a monoclonal proliferation of incompetent mature B-cells. It is common in elderly men and is the most common form of leukemia in the United States. Patients are often asymptomatic when the diagnosis is made or may present with vague constitutional symptoms including fatigue, malaise, and weight loss. It is important to note that symptoms may be subtle or absent. Other findings include non-tender lymphadenopathy and splenomegaly. The diagnosis is supported when the white blood cell count is >50,000/mm^3 and can be supported with a peripheral smear which will show smudge cells. The cells in CLL may be CD5, CD20, and CD23 positive. The most common cause of death in this population is infection given the lack of competent B-cells.
Hallek reviews CLL. They discuss updated guidelines on the diagnosis and management of CLL. They recommend the use of targeted agents in initial therapy and acknowledge the need for further clinical trials to guide therapy.
Incorrect Answers:
Answer A: Acute lymphoblastic leukemia (ALL) is a common malignancy seen in children and presents with pancytopenia, anemia, fatigue, leukopenia (leading to recurrent infections), and thrombocytopenia (leading to bleeding). Other findings may include fever, bone pain, lymphadenopathy, splenomegaly, and hepatomegaly. Translocations in ALL include: t(12:21) which is the most common and denotes a favorable prognosis and t(9:22) (the Philadelphia chromosome) which is less common and denotes a poor prognosis
Answer B: Acute myelogenous leukemia occurs secondary to the proliferation of myeloblasts and presents in older patients. Patients will present with fatigue, malaise, weight loss, anorexia, fever, leukocytosis, anemia, thrombocytopenia, and neutropenia. Auer rods are frequently present on a blood smear.
Answer D: Chronic myelogenous leukemia is a neoplastic proliferation of myeloid stem cells and presents with a leukocyte count often >50,000/mm3. The increased myeloid lines include red blood cells, granulocytes, monocytes, and platelets. Many patients present in the chronic phase with minimal symptoms; however, the blast phase can lead to a hematologic emergency termed a blast crisis which may cause a hyperviscosity syndrome. This condition is more symptomatic and less common than CLL.
Answer E: Hairy cell leukemia occurs when there is a neoplastic proliferation of mature B cells with abundant cytoplasm with “hairy” cytoplasmic processes. The cells are tartrate-resistant acid phosphatase positive. Patients will present with splenomegaly, pancytopenia, weakness, and fatigue. This is a more rare diagnosis when compared to CLL.
Bullet Summary:
Chronic lymphocytic leukemia (CLL) presents in elderly patients with malaise, fatigue, and other nonspecific signs (but can also be asymptomatic), with anemia, thrombocytopenia, and a white blood cell count often >50,000/mm^3.
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293
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A 57-year-old man presents to the emergency department with several days of malaise, weakness, and night sweats. Today, he experienced a headache with blurry vision, thus prompting his presentation. The patient has a history of diabetes and is followed closely by an endocrinologist. Otherwise, he has lost 10 pounds over the past month. His temperature is 100°F (37.8°C), blood pressure is 122/90 mmHg, pulse is 84/min, respirations are 16/min, and oxygen saturation is 99% on room air. Physical exam is notable for a thin man but is otherwise unremarkable. His visual acuity is 20/100 in both eyes, though he says that he normally has 20/20 vision. His gait is mildly ataxic as well, but his neurological exam is otherwise nonfocal. Laboratory studies are ordered as seen below.
Hemoglobin: 10 g/dL
Hematocrit: 31%
Leukocyte count: 57,500/mm^3 with 35% blasts
Platelet count: 109,000/mm^3
Serum:
Na+: 139 mEq/L
Cl-: 100 mEq/L
K+: 4.1 Eq/L
HCO3-: 22 mEq/L
BUN: 20 mg/dL
Glucose: 99 mg/dL
Creatinine: 1.1 mg/dL
Calcium: 10.0 mEq/L
Which of the following is the most likely diagnosis?
|
{
"A": "Acute lymphoblastic leukemia",
"B": "Chronic lymphocytic leukemia",
"C": "Multiple myeloma",
"D": "Chronic myelogenous leukemia",
"E": ""
}
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D
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This patient is presenting with symptoms of malignancy (malaise, weakness, and night sweats) and has a white blood cell count > 50,000/mm^3 in the setting of > 20% blasts, which are concerning for chronic myelogenous leukemia (CML). Given the blurry vision and ataxia in the setting of increased blasts, this patient may be suffering from a hyperviscosity syndrome secondary to a blast crisis, which can be seen in CML.
CML is a neoplastic proliferation of myeloid stem cells. Patients are often asymptomatic and may present with a white blood cell count > 50,000/mm^3. There are many different presentations. The chronic phase presents with < 10% blasts and is often asymptomatic. The accelerated phase has increased blasts, and patients present with fatigue, weight loss, malaise, night sweats, abdominal pain, and hepatosplenomegaly. Finally, the blast phase presents similar to the accelerated phase but with more severe symptoms. The blast phase may evolve into a blast crisis (> 20% blasts) which could cause a hyperviscosity syndrome. Hypervicosity syndrome may require IV fluids and leukapheresis. The most common translocation in CML is the 9;22 translocation which forms the BCR:ABL gene product.
Jain et al. review CML. They note the outcomes in patients in the blast phase in CML and how there are more poor outcomes associated with this phase. They recommend paying close attention and obtaining a CBC with a differential to determine the percent blasts.
Incorrect Answers:
Answer A: Acute lymphoblastic leukemia is more common in pediatric patients and presents with pancytopenia, fatigue, recurrent infections (from leukopenia), and bleeding (from thrombocytopenia). Other findings include systemic symptoms, malaise, fever, bone pain, lymphadenopathy, splenomegaly, and hepatomegaly.
Answer B: Acute myelogenous leukemia is a malignancy of myeloblasts and presents in the elderly. Patients will present with fatigue, malaise, weight loss, anorexia, fever, leukocytosis, anemia (causing fatigue), thrombocytopenia (causing bleeding), and neutropenia (leading to life-threatening infections). Auer rods can be seen on peripheral smear.
Answer C: Chronic lymphocytic leukemia is a monoclonal proliferation of incompetent mature B cells that occurs in elderly men and is the most common form of leukemia in the west. Patients are often asymptomatic and may have a white blood cell count > 50,000/mm^3. When symptomatic, patients may experience chills, weight loss, and weakness (note these symptoms are nonspecific). Peripheral smear will show smudge cells.
Answer E: Multiple myeloma is common in the elderly and presents with CRAB: hyperCalcemia, Renal insufficiency, Anemia, and lytic Bone lesions/Back pain. The diagnosis is supported with protein electrophoresis and confirmed when biopsy demonstrates increased plasma cells.
Bullet Summary:
Chronic myelogenous leukemia presents with increased white blood cells which may be >50,000/mm^3 (possibly with elevated blasts).
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294
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A 5-year-old boy presents to his primary care physician for recurrent colds, fatigue, and fussiness. Over the past several weeks, the child has been more fatigued and his parents state that “he always seems to be sick.” They state that sometimes he complains about his bones hurting and they note that he is less playful. He is up to date on his vaccinations. His temperature is 102°F (38.9°C), blood pressure is 92/60 mmHg, pulse is 115/min, respirations are 23/min, and oxygen saturation is 99% on room air. Physical exam is notable for diffuse non-tender lymphadenopathy. Abdominal exam reveals hepatosplenomegaly. Laboratory studies are ordered as seen below.
Hemoglobin: 8.0 g/dL
Hematocrit: 23%
Leukocyte count: 27,500/mm^3 with 35% lymphoblasts
Platelet count: 49,000/mm^3
Serum:
Na+: 139 mEq/L
Cl-: 101 mEq/L
K+: 4.0 Eq/L
HCO3-: 24 mEq/L
BUN: 16 mg/dL
Glucose: 100 mg/dL
Creatinine: 0.7 mg/dL
Which of the following is the most likely diagnosis?
|
{
"A": "Parvovirus B19 infection",
"B": "Acute lymphoblastic leukemia",
"C": "Chronic myelogenous leukemia",
"D": "Acute myelogenous leukemia",
"E": ""
}
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B
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This pediatric patient is presenting with recurrent colds, fatigue, non-tender lymphadenopathy, hepatosplenomegaly, and leukocytosis with increased lymphoblasts, which are concerning for acute lymphoblastic leukemia (ALL).
ALL is the most common hematologic cancer in pediatric patients. It initially presents with a vague constellation of symptoms including fatigue, fevers, easy bleeding/bruising, bone pain, lymphadenopathy, hepatosplenomegaly, and possibly testicular enlargement. The diagnosis is supported when the white blood cell count (which can be low, normal, or high) demonstrates increased lymphoblasts. Further confirmatory testing may include testing for the 12:21 translocation, which is more common with a better prognosis, or the 9:22 translocation (the Philadelphia chromosome), which is less common and denotes a poor prognosis.
Onciu reviews ALL. He notes that ALL has a high cure rate with intensive chemotherapeutic regimens and that new research is improving outcomes in this very common condition. He recommends early treatment with these regimens for an improved prognosis.
Incorrect Answers:
Answer B: Acute myelogenous leukemia is a malignancy of myeloblasts and is more common in the elderly. Patients will present with systemic symptoms, weight loss, anorexia, leukocytosis, anemia (causing fatigue), thrombocytopenia (causing bleeding including gingival bleeding and bleeding from the gastrointestinal tract), and neutropenia (predisposing patients to life-threatening infection). Myeloblasts produce increased amounts of myeloperoxidase which can lead to the formation of Auer rods that can be seen on peripheral smear.
Answer C: Chronic myelogenous leukemia is a neoplastic proliferation of myeloid stem cells and presents with a leukocyte count > 50,000/mm3. There are different presentations for this condition. Most patients present in the chronic phase with minimal symptoms (and a low blast count); however, they can also present with an accelerated phase and a blast phase which can lead to a hematologic emergency termed a blast crisis which may cause a hyperviscosity syndrome.
Answer D: Leukemoid reaction is an overly robust immune reaction (often to infection) that resembles chronic myelogenous leukemia. However, the leukocyte alkaline phosphatase level is elevated. This elevated level indicates it is a robust immune response rather than increased cell levels from malignancy.
Answer E: Parvovirus B19 infection presents with erythema infectiosum (fifth disease) which may include "slapped cheek" rash, fever, malaise, and possibly respiratory symptoms. In healthy patients, symptoms are usually minimal and self-limited. However, in patients with hemoglobinopathies (such as sickle cell disease), the transient halt in erythropoiesis that occurs in addition to hemolysis may lead to significant anemia requiring transfusion.
Bullet Summary:
Acute lymphoblastic leukemia presents in pediatric patients with pancytopenia, fatigue, repeat infections, easy bleeding, bone pain, lymphadenopathy, hepatosplenomegaly, and increased blast cells on peripheral smear.
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295
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A 67-year-old man presents to the emergency department after fainting. He was outside tending to his lawn for several hours in the heat, when he stood up suddenly from pulling weeds and fainted. He denies any preceding symptoms and returned to baseline within 1 minute. The patient is not aware of any medical problems and just started seeing a primary care physician last week. He recently used a friend's prescription for ondansetron for nausea. His temperature is 99.3°F (37.4°C), blood pressure is 142/88 mmHg, pulse is 107/min, respirations are 14/min, and oxygen saturation is 99% on room air. Physical exam reveals intact cranial nerves, normal strength and sensation, and a stable gait. His abdomen is soft and nontender. An ECG is performed as seen in Figure A. Which of the following is the most likely diagnosis based on this patient’s ECG?
|
{
"A": "Previous myocardial ischemia",
"B": "Acute myocardial infarction",
"C": "Intermittent torsades des pointes",
"D": "Pulmonary embolism",
"E": ""
}
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A
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This patient is presenting after syncope, likely secondary to dehydration and orthostatic hypotension given his outdoor gardening in the heat and symptoms when standing up rapidly. The patient’s ECG reveals deep, pathologic Q waves, which in this case are an incidental finding indicative of a previous myocardial infarction or a previous ischemic event.
The Q wave is a negative deflection just prior to the R wave. Q waves are a normal finding when they are small and are seen on most ECGs. However, pathologic Q waves are indicative of myocardial ischemia. Pathologic Q waves are generally diagnosed when they are >2 mm deep, >1 mm wide, >25% of the QRS complex height, or are seen in leads V1-V3. The interpretation of Q waves depends on other findings on ECG and the patient's symptoms. Deep Q waves in the setting of ST elevation indicate an acute myocardial infarction. On the other hand, pathologic Q waves found incidentally indicate a previous myocardial infarction or previous ischemic event.
Rovai et al. review Q waves. They discuss how Q waves can be used to predict the location and size of a myocardial infarction as correlated with MRI. They recommend testing such as cardiac MRI to assess for previous infarction in the appropriate patient population.
Figure/Illustration A is an ECG demonstrating pathologic Q waves (red arrows). Note the deep and wide Q waves; this raises concern for a past ischemic event.
Incorrect Answers:
Answer A: Acute myocardial infarctions would present with ST elevation in a vascular distribution on ECG with possible reciprocal depressions. While T wave inversions may be indicative of new or acute ischemia, deep pathologic Q waves without ST elevation are indicative of previous infarction.
Answer B: Hypokalemia would cause U waves on ECG, which appear as a small, "second T wave" after the initial T wave. Note they are not U-shaped despite their name. Management is centered on repletion of potassium and often magnesium as well.
Answer C: Intermittent torsades de pointes can cause syncope and should be suspected in a patient with syncope in the setting of a prolonged QT interval. This patient’s QT interval is not particularly prolonged, and his syncope seems to be secondary to orthostatic hypotension. Management is centered on cessation of QT-prolonging medications and magnesium administration. Note that while ondansetron does prolong the QT interval, it is unlikely to cause torsades given the patient took it a week ago.
Answer E: Pulmonary emboli would present on ECG with sinus tachycardia in addition to pleuritic chest pain and hypoxia. Note that the ECG is a nonspecific test for pulmonary emboli, and CT angiography is the preferred confirmatory test for this condition. Syncope is a possible presentation of larger pulmonary emboli (though the patient would also be hemodynamically unstable).
Bullet Summary:
Pathologic Q waves are indicative of a previous myocardial infarction.
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296
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A 55-year-old man presents to the emergency department with chest pressure and diaphoresis. His symptoms started at work when he was lifting boxes. He states that he currently feels crushing pressure over his chest. He is given aspirin and an ECG is performed in triage, as seen in Figure A. His past medical history is notable for diabetes and obesity. He has smoked 1 pack of cigarettes per day for the past 30 years. His temperature is 97.9°F (36.6°C), blood pressure is 155/99 mmHg, pulse is 110/min, respirations are 22/min, and oxygen saturation is 98% on room air. Physical exam reveals an uncomfortable, diaphoretic man. His heart and breath sounds are unremarkable. A repeat ECG in the emergency department is performed, also seen in Figure A. The patient’s chest pain is worse when the ECG in the emergency department is taken, compared to the one taken in triage. He is given nitroglycerin, with minimal improvement in his symptoms. A troponin level is drawn. Which of the following is the most appropriate next step in management?
|
{
"A": "Repeat ECG in 10 minutes",
"B": "Cardiac catheterization",
"C": "Heparin",
"D": "Chest radiograph",
"E": ""
}
|
A
|
This patient is presenting with a pattern of chest pain (pressure and diaphoresis) that is highly concerning for an acute myocardial infarction. This patient initially has ST depressions (in triage) followed by ST segment normalization and possibly hyperacute T waves which raises concern for an acute ST elevation myocardial infarction (STEMI) requiring frequent ECGs to determine if a STEMI evolves.
A STEMI presents with crushing substernal chest pain, diaphoresis, chest pressure, nausea, vomiting, and abdominal pain among many other possible presentations. When a patient presents with symptoms concerning for a STEMI, aspirin should be administered and an ECG should be performed. Early in a myocardial infarction, ST depressions with hyperacute T waves may be present. As the infarction evolves, the T waves may become more acute and the ST segment will begin to elevate. There may be a brief period of pseudonormalization where the ST segment appears to be normal. If the patient appears better, this can be reassuring. However, ongoing chest pain in the setting of these findings raises concern for pseudonormalization of the ST segment (an ST segment that is going to continue to rise). Nitroglycerin can be administered to see if the patient can become chest pain-free, and serial ECGs should be performed to determine if a STEMI is present. If symptoms resolve and the ECG is stable, this is reassuring and medical optimization and an elective catheterization may be performed. If the ECG evolves into a STEMI, then cardiac catheterization is indicated emergently.
Daga et al. discuss STEMI and its workup. They note the ECG manifestations, and the pathophysiology in addition to the appropriate workup of acute coronary syndrome. They recommend aspirin and catheterization in an acute STEMI.
Figure/Illustration A demonstrates an initial ECG with ST depression (blue arrows) followed by pseudonormalization of the ST segment (green arrows) and possibly hyperacute T waves (black arrows), which are concerning for ischemia.
Incorrect Answers:
Answer A: Cardiac catheterization may be required in this patient; however, if the patient’s chest pain improves or if the troponin is negative, it is unlikely he is having an acute myocardial infarction requiring immediate catheterization. Repeating the ECG will allow for triaging of the patient and will aid in determining if emergency cardiac catheterization is needed.
Answer B: Chest radiography is appropriate in the workup of chest pain as it can rule out diagnoses such as pneumothorax or may suggest diagnoses such as an aortic dissection (type A) if there is a widened mediastinum. In this patient, the ST segment changes and characteristic history make acute coronary syndrome a more likely diagnosis, and while a chest radiograph should be performed at some point, repeating the ECG is a more dire initial step in management.
Answer C: CK-MB level could be helpful in determining if a myocardial infarction has occurred as it elevates rapidly and also decreases fairly rapidly. This makes it useful when diagnosing a new myocardial infarction after a recent infarction as the troponin may still be elevated from the previous infarction. This patient has no history of recent myocardial infarction, and a repeat ECG is more dire to determine if this patient needs emergent intervention. Of note, the decision for emergent catheterization should not wait on cardiac biomarkers.
Answer D: Heparin should not be given empirically to patients in chest pain. It does not necessarily decrease mortality but does increase the risk of bleeding. It is often given to patients with an NSTEMI.
Bullet Summary:
Pseudonormalization occurs when an ST depression begins to elevate and appears normal in the setting of a myocardial infarction, requiring close monitoring and serial ECGs to ensure that a ST elevation myocardial infarction does not occur.
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https://step2.medbullets.com/testview?qid=216617
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297
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A previously healthy 15-year-old boy presents to the emergency department in cardiac arrest. He was in class when he suddenly fainted and became unresponsive. His teacher began chest compressions and he has received epinephrine and defibrillation from paramedics while in transport. On arrival, the patient remains pulseless and is pronounced dead. An autopsy is performed and is notable for no clear abnormalities. The patient’s laboratory studies were unremarkable from a visit to the pediatrician 3 weeks ago. A previous ECG is seen in Figure A. Which of the following is the most likely underlying etiology of this patient’s death?
|
{
"A": "Short QT syndrome",
"B": "Ventricular tachycardia",
"C": "Complete heart block",
"D": "Torsades des pointes",
"E": ""
}
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A
|
This healthy pediatric patient is presenting with cardiac arrest and an ECG demonstrating a short QT segment. Short QT syndrome is lethal and can lead to cardiac arrest in young, otherwise healthy patients.
Short QT syndrome is an inherited condition that is caused by ion channel mutations (the most common identified mutation is a mutation in the cardiac myocyte potassium channel). There is no strict criteria for short QT syndrome, but the QT segment is often < 320 ms. Patients are usually young and healthy, and it is very common for the first presentation of this disease to be syncope or sudden cardiac death. ECG features suggestive of this condition include a short QT interval (without a clearly defined value but often < 360 ms) that is fixed (does not change with exercise or rest), peaked T waves, short or even absent ST segments, and episodes of atrial fibrillation or ventricular fibrillation in a patient in whom this would not be expected (such as a young patient). The only effective intervention is the placement of an implantable cardioverter-defibrillator.
Bjerregaard and Gussak discuss short QT syndrome. They note it is a heritable condition of the conduction system of the heart that can lead to lethal dysrhythmias. They discuss the management of this condition and recommend an implantable cardioverter-defibrillator.
Figure/Illustration A is an ECG demonstrating a short QT segment (red arrow). Note the T waves appear peaked which can be seen in this syndrome. This may suggest hyperkalemia, but this patient’s labs were normal at his appointment when the ECG was taken.
Incorrect Answers:
Answer A: Complete heart block is more common in elderly patients with acute coronary syndrome and presents with regular P-P and R-R intervals with complete P-R dissociation. It may cause syncope but is not associated with short QT syndrome. Management involves the placement of a pacemaker.
Answer C: Torsades des pointes is associated with a prolonged QT segment that progresses to the classic twisting of the QRS complexes around an isoelectric baseline. It can lead to cardiac arrest and requires immediate cessation of QT-prolonging medications and administration of magnesium. Note that this patient’s QT segment is short rather than long.
Answer D: Ventricular fibrillation presents with disorganized electrical activity with no discernible rhythm. While this patient may have arrested from ventricular fibrillation, the most likely underlying etiology for his cardiac arrest given his age, ECG, and risk factors is an underlying condition such as short QT syndrome. For this reason, short QT syndrome is a better answer.
Answer E: Ventricular tachycardia could also occur in short QT syndrome and may have caused this patient’s cardiac arrest. It presents with a monomorphic wide complex tachycardia that may cause arrest. Unstable patients require cardioversion while pulseless patients require defibrillation. Note that if this patient arrested from ventricular tachycardia, it was likely secondary to short QT syndrome.
Bullet Summary:
Short QT syndrome is a rare but possible diagnosis in young, healthy patients who present with recurrent syncope or cardiac arrest.
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https://step2.medbullets.com/testview?qid=216625
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298
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A 55-year-old man presents to the emergency department after feeling lightheaded then fainting while he was carrying boxes upstairs. The patient works on a farm and does not see a doctor often. He has a history of hypertension but does not take medications routinely. He has not had any chest pain, dyspnea, or weakness during this time frame and currently feels at his baseline. He smokes cigarettes occasionally. His temperature is 98.1°F (36.7°C), blood pressure is 152/93 mmHg, pulse is 86/min, respirations are 15/min, and oxygen saturation is 98% on room air. Physical exam is unremarkable and the patient walks with a stable gait and no focal weakness. An ECG is performed as seen in Figure A. Laboratory studies are ordered as seen below.
Hemoglobin: 12 g/dL
Hematocrit: 36%
Leukocyte count: 6,500/mm^3 with normal differential
Platelet count: 197,000/mm^3
Serum:
Na+: 140 mEq/L
Cl-: 102 mEq/L
K+: 4.3 mEq/L
HCO3-: 24 mEq/L
BUN: 20 mg/dL
Glucose: 139 mg/dL
Creatinine: 1.1 mg/dL
Troponin: < 0.01 ng/mL
Which of the following is the most likely diagnosis?
|
{
"A": "Wolff Parkinson White syndrome",
"B": "ST elevation myocardial infarction",
"C": "Torsades des pointes",
"D": "Left ventricular hypertrophy",
"E": ""
}
|
D
|
This patient with chronic untreated hypertension is presenting with syncope and an ECG demonstrating large voltages in leads V1-V6 and a left ventricular strain pattern (ST depressions in V5/V6 and aVL), which are concerning for left ventricular hypertrophy.
Left ventricular hypertrophy occurs secondary to chronic hypertension or conditions that increase afterload such as aortic stenosis. This leads to an increase in the mass of the left ventricle. There are many possible criteria on ECG for left ventricular hypertrophy including left axis deviation, large R waves, a large S wave in aVR, or ST segment depression and T wave inversion in the left heart leads (referred to as left ventricular strain). A more simple method of recalling left ventricular hypertrophy is very large voltages in the ECG leads that serve the left ventricle. Left ventricular hypertrophy should be considered in presentations such as syncope. Note that while ECG findings suggest left ventricular hypertrophy, the diagnosis must be supported with echocardiography. Management involves treating the underlying cause (most commonly, this is hypertension).
Artham et al. discuss left ventricular hypertrophy. They note that it is a risk factor for future cardiac events and increased mortality. They recommend early diagnosis and management to improve outcomes.
Figure/Illustration A is an ECG with very large voltages (red arrows) and ST segment depressions/T wave inversions (blue arrows, a more classic left ventricular strain pattern), concerning for left ventricular hypertrophy.
Incorrect Answers:
Answer B: Non-ST elevation myocardial infarction would present with nonspecific ST segment and T wave changes with an elevated troponin. While this patient does demonstrate ST depressions in the lateral leads, the troponin level is normal.
Answer C: ST elevation myocardial infarction would present with ST elevation in a vascular distribution on ECG in the setting of chest pain, diaphoresis, and an elevated troponin level. Note that this patient’s lack of symptoms (pain) and normal troponin in the setting of the ST elevation in leads V1-V3 make this unlikely to be ST elevation myocardial infarction and more likely to be left ventricular hypertrophy.
Answer D: Torsades des pointes occurs in patients with a prolonged QT interval that evolves into twisting of the QRS complexes around an isoelectric baseline. It may cause syncope or cardiac arrest. Note there is no QT prolongation on this patient’s ECG that would predispose him to this condition.
Answer E: Wolff Parkinson White syndrome presents with a delta wave on ECG (a slurred upstroke into the QRS complex) and may undulate with supraventricular or ventricular tachycardia. There is no delta wave in this patient’s ECG supporting this diagnosis. Ablation is the most effective long-term treatment.
Bullet Summary:
Left ventricular hypertrophy can be associated with syncope and presents with large voltages in the leads that serve the left ventricle and a left ventricular strain pattern.
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https://step2.medbullets.com/testview?qid=216626
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299
|
A 7-year-old adopted boy presents to the emergency department after fainting. He just switched from being home-schooled to public school and joined the basketball team. He has fainted several times during basketball practices. He did not sustain any injuries or have any prodromes prior to these episodes. He is usually unconscious for less than a minute. He is otherwise healthy and has met all developmental milestones. He does not currently take any medications. His temperature is 97.6°F (36.4°C), blood pressure is 104/54 mmHg, pulse is 100/min, respirations are 19/min, and oxygen saturation is 98% on room air. Physical exam reveals a well-appearing and playful boy. An ECG is performed as seen in Figure A. An echocardiogram is ordered and pending. Which of the following is the most likely diagnosis?
|
{
"A": "Brugada syndrome",
"B": "Wolff Parkinson White syndrome",
"C": "Hypertrophic obstructive cardiomyopathy",
"D": "Arrhythmogenic right ventricular dysplasia",
"E": ""
}
|
D
|
This adopted pediatric patient is presenting with recurrent syncope and an ECG demonstrating an epsilon wave and T wave inversions, which are concerning for arrhythmogenic right ventricular dysplasia.
An epsilon wave is a small positive deflection at the end of the QRS complex. This is an ominous finding and suggests a diagnosis of arrhythmogenic right ventricular dysplasia (ARVD) though it may also be seen in other infiltrative diseases such as sarcoidosis or after ischemic events. ARVD is an autosomal dominant condition where there is fatty infiltration of the right ventricular wall predisposing the patient (classically younger patients) to sudden cardiac death from lethal ventricular dysrhythmias. The epsilon wave is the most specific finding; however, other findings include T wave inversion in V1-V3 or a left bundle branch appearance with frequent premature ventricular complexes among other possibilities. This is a potentially lethal diagnosis and requires management with antiarrhythmics (such as beta-blockers or amiodarone) and the placement of an implantable cardioverter-defibrillator.
Kayser et al. review AVRD. They note the presentation and management of ARVD and how it may present initially only with syncope. Cardiac arrest is a possible presentation as well. They recommend early detection and treatment with an implantable cardioverter-defibrillator to prevent death in this population.
Figure/Illustration A is an ECG with an epsilon wave (red arrow) and inverted T waves in V1/V2 (blue arrows) concerning for ARVD.
Incorrect Answers:
Answer B: Brugada syndrome is an autosomal dominant mutation in cardiac ion channels that presents with a possible right bundle branch pattern with ST segment elevation in V1-V3 or ST coving in these same leads. It may present with syncope.
Answer C: Hypertrophic obstructive cardiomyopathy presents with syncope, sudden death, or cardiac arrest in a young patient associated with exertion or dehydration. It can cause obstruction of the left ventricular outflow tract. A systolic murmur can be heard on cardiac auscultation and echocardiography can confirm the diagnosis. ECG will demonstrate large voltages in V1-V5.
Answer D: QT prolongation can lead to torsades des pointes which presents with twisting of the QRS complexes around an isoelectric baseline. It may present with syncope, hemodynamic instability, or cardiac arrest. Medications, infection, and congenital conditions may prolong the QT interval.
Answer E: Wolff Parkinson White syndrome presents with a delta wave on ECG or a slurred upstroke of the QRS complex. It may cause syncope and evolve into other dysrhythmias including supraventricular tachycardia and ventricular tachycardia.
Bullet Summary:
Arrhythmogenic right ventricular dysplasia (ARVD) may cause syncope or cardiac arrest, and presents on ECG with an epsilon wave.
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https://step2.medbullets.com/testview?qid=216634
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300
|
A 55-year-old man presents to the emergency department after fainting while moving furniture. He states that he has been working in a hot, humid attic all day and forgot his water bottle. He felt dizzy when standing up and then fainted and was unconscious for roughly 1 minute. He awoke at his neurologic baseline afterwards. The patient has a history of hypertension being managed by his primary care doctor. His temperature is 98.7°F (37.1°C), blood pressure is 149/82 mmHg, pulse is 86/min, respirations are 15/min, and oxygen saturation is 99% on room air. Physical exam reveals a diaphoretic man. He demonstrates an unremarkable cardiopulmonary exam. The patient walks with a steady gait and his neurologic exam is non-focal. An ECG is performed as seen in Figure A. The patient is given 2 liters of oral fluids and feels back to his baseline. Which of the following conditions is most likely to occur in this patient based on his current history and ECG?
|
{
"A": "Atrial fibrillation",
"B": "Torsades des pointes",
"C": "Stroke",
"D": "Complete heart block",
"E": ""
}
|
D
|
This patient is presenting with dizziness and syncope in the setting of likely dehydration (working in a hot/humid environment without water) and feels better after rehydration, suggesting a diagnosis of orthostatic hypotension. An ECG is performed and incidentally demonstrates a bifascicular block, which is at high risk of progressing to a complete heart block.
Bifascular block is a conduction abnormality in 2 of the 3 fascicles that conduct electricity from atria to ventricles. This leaves conduction to the ventricles via the single remaining fascicle. There are different possibilities that may present on ECG. One possibility is a right bundle branch block with a left anterior fascicular block; the other is a right bundle branch block with a left posterior fascicular block. Note that the pathophysiology of complete heart block is an inability to conduct electricity from the atria to the ventricles. If there is only 1 fascicle left to conduct electricity, the patient would be in complete heart block if this fascicle were to no longer work, which is a common outcome in patients with bifascicular block. Treatment of complete heart block involves the placement of a pacemaker.
Wiberg et al. discuss bifascicular block. They note the possible outcome of a complete heart block. It is recommended to look for this finding on ECG and appropriately workup patients to prevent progression of disease.
Figure/Illustration A is an ECG demonstrating bifascicular block. Note the left axis deviation as suggested by the net upward deflection of the QRS in lead I and net downward deflection in lead II (blue arrows). Then, note the appearance of a right bundle branch block with the RSR pattern in aVR (black arrow) and upward R’ in lead V1 (green arrow). This is a classic pattern for bifascicular block. Contrast this to the other pattern of bifascicular block which would present with a right bundle branch block and right axis deviation (upward QRS in lead II and downward in lead I), which was not seen in this case.
Incorrect Answers:
Answer A: Atrial fibrillation may occur secondary to aging, hypertension, or ischemia and presents with an irregularly irregular rate and rhythm with an absence of P waves. It may cause complications such as stroke. Management typically involves rate control agents such as beta-blockers or calcium channel blockers.
Answer C: Myocardial infarction is a likely outcome in individuals with risk factors such as obesity, hypertension, smoking, and dyslipidemia, in particular, without proper preventive measures and medical therapy including statins, beta blockers, and ACE inhibitors. This patient may be at risk of a myocardial infarction with his hypertension, and his underlying bifascicular block could suggest undiagnosed cardiac ischemia; however, it is more likely this patient progresses to complete heart block in the setting of his bifascicular block.
Answer D: Stroke is a possible complication of atrial fibrillation. For this reason, most patients with atrial fibrillation are on blood thinners to prevent this complication. It occurs secondary to stasis of blood in the fibrillating left atrium. Patients are often risk stratified prior to starting blood thinners with tools such as CHADS2VASC and HASBLED. Isolated syncope is a rare manifestation of stroke.
Answer E: Torsades des pointes is a progression from QT prolongation which may occur secondary to genetic conditions, medications, and/or infection. It presents on ECG with QRS complexes that twist in amplitude around the electrical baseline. Treatment involves the administration of magnesium sulfate and, if needed, electrical cardioversion.
Bullet Summary:
A bifascicular block can progress to complete heart block.
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https://step2.medbullets.com/testview?qid=216637
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