MKSAP Questions of the Week

Cardiology Q91

A 72-year-old man is evaluated for a 1-year history of bilateral lower extremity edema and abdominal distention. Eight years ago he had esophageal carcinoma treated with radiotherapy. Medical history is otherwise significant for hypertension, type 2 diabetes mellitus, and hypercholesterolemia. Medications are bumetanide, atorvastatin, metformin, and lisinopril. On physical examination, the patient is afebrile, blood pressure is 170/90 mm Hg, pulse rate is 90/min, and respiration rate is normal. Jugular venous distention is present to the angle of the mandible while seated, with prominent pulsations. Cardiac examination reveals an early diastolic sound at the apex. The liver is palpable 5 cm below the costal margin. The abdomen is distended with ascites. There is bilateral pitting edema to the level of the thighs. Pulmonary examination reveals no crackles. Laboratory studies are significant for a B-type natriuretic peptide level of 96 pg/mL (96 ng/L).

Publish date: 06/09/2021

Rheumatology Q43

A 67-year-old woman is evaluated for a 3-year history of severe rheumatoid arthritis. She had an inadequate response to methotrexate and low-dose prednisone. She responded well to the addition of infliximab, but eventually the drug lost effect and she required a change in biologic therapy. She has done well with tocilizumab and methotrexate over the past year. She notes several months of prominent fatigue. History is also significant for type 2 diabetes mellitus, hypertension, and hyperlipidemia. Current medications are methotrexate, folic acid, tocilizumab, basal insulin, lisinopril, metoprolol, atorvastatin, ibuprofen, and omeprazole. On physical examination, vital signs are normal. Joint examination reveals no swollen or tender joints. The remainder of the physical examination is normal.

Publish date: 06/02/2021

Pulmonary and Critical Care Medicine Q46

A 46-year-old man is evaluated for 6 months of exertional dyspnea, fatigue, and ankle edema. Recently he experienced near-syncope walking up two flights of stairs. He has no other medical problems and takes no medications. On physical examination, blood pressure is 106/70 mm Hg, pulse rate is 94/min, and respiration rate is 18/min. Oxygen saturation is 90% breathing ambient air. On cardiac examination, a prominent jugular venous a wave is present along with widened splitting of S2. Lung examination is unremarkable. A transthoracic echocardiogram demonstrates a normal size left ventricle with ejection fraction of 65% and right ventricular enlargement. The estimated pulmonary artery systolic pressure is 58 mm Hg. Spirometry, lung volumes, and ventilation-perfusion scan are unremarkable; DLCO is 42% of predicted. CT angiogram of the chest is negative for pulmonary embolism and interstitial lung disease. Right heart catheterization demonstrates a mean pulmonary arterial pressure of 36 mm Hg, with no change with inhaled nitric oxide. Pulmonary capillary wedge pressure is normal.

Publish date: 05/26/2021

Neurology Q63

A 76-year-old man is evaluated for recent worsening of balance. He has no dizziness or lightheadedness. The patient has an 8-year history of Parkinson disease treated with carbidopa-levodopa and entacapone. On physical examination, vital signs are normal; no orthostatic decrease in blood pressure is noted. The patient has masked facies, a resting tremor, and bradykinesia. Gait assessment reveals mild shuffling without freezing. Findings from cognitive, cerebellar, and sensory examinations are unremarkable.

Publish date: 05/20/2021

Nephrology Q62

A 28-year-old woman is evaluated during a follow-up visit for elevated blood pressure measurements during pregnancy. She is at 12 weeks' gestation of her first pregnancy. She feels well, and the pregnancy has been otherwise uncomplicated. She did not have routine medical care before her pregnancy. Family history is significant for hypertension in her father and sister. Her only medication is a prenatal vitamin. On physical examination, blood pressure is 155/95 mm Hg; other vital signs are normal. Funduscopic, neurologic, and cardiac examinations are normal. Laboratory studies are normal.

Publish date: 05/11/2021

Infectious Disease Q85

A 22-year-old man is evaluated in the emergency department for a 2-day history of painful rash on the left side of his posterior chest. Medical history is unremarkable, and he takes no medications. On physical examination, temperature is 37.5 °C (99.5 °F), blood pressure is 115/62 mm Hg, pulse rate is 78/min, and respiration rate is 20/min. A vesicular rash is shown.

Publish date: 05/06/2021

Hematology-Oncology Q60

An 81-year-old man is evaluated for increasing fatigue. He has no other symptoms to report. Medical history is significant for diabetes mellitus and hypertension. He does not drink alcohol or smoke. Medications are metformin and lisinopril. On physical examination, vital signs are normal. The examination is unremarkable. Serum levels of vitamin B12 and folate are normal. Peripheral blood smear is shown.

Publish date: 04/30/2021

General IM Q44

During a routine health examination, a patient asks about an article that recommended avoiding statin therapy because of the risk for memory loss. The findings were based on cross-sectional data analysis of a well-validated national health survey, which was conducted by random sampling of patients according to zip code of residence. The analysis showed that patients who self-reported memory loss were more likely to also report having taken statin drugs (odds ratio, 1.8; 95% CI, 1.2-2.7; P = 0.046).

Publish date: 04/22/2021

Gastroenterology Q33

A 32-year-old woman is evaluated for a 6-month history of loose stools, bloating, and a 3.2-kg (7-lb) weight loss. Her medical history is otherwise unremarkable. Her brother has type 1 diabetes mellitus, and her mother has autoimmune thyroid disease. She reports no other symptoms and takes no medication. On physical examination, vital signs and other findings are normal; BMI is 19.

Publish date: 04/15/2021

Endocrinology Q45

A 37-year-old woman is unable to achieve pregnancy despite 7 months of unprotected intercourse. Her menstrual cycles are normal, occurring every 28 days with associated breast tenderness and bloating. There have been no prior pregnancies or attempts to achieve pregnancy by either the patient or her male partner. There is no history of previous sexually transmitted infections. She is otherwise healthy. Medical history is significant for appendicitis at age 26 for which she had an uncomplicated appendectomy. Her only medication is a prenatal vitamin. On physical examination, vital signs are normal. She has a well-healed abdominal scar. Thyroid, skin, and pelvic examinations are all unremarkable. There is no elicitable breast discharge, no signs of hyperandrogenism, and no visual field cuts.

Publish date: 04/08/2021

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