MKSAP Questions of the Week

General IM Q5

A 23-year-old woman is evaluated for depression as she prepares for discharge from the hospital to home hospice care. She was diagnosed with metastatic ovarian cancer 2 years ago, and she progressed through four lines of chemotherapy, a trial of immunotherapy, and a failed attempt at a phase 1 clinical trial. Her life expectancy is measured in weeks. She is currently hospitalized with volume depletion, and after consultation with her oncologist and palliative care team, she has decided to be discharged home with hospice care. On physical examination, the patient exhibits substantial fatigue and poor concentration. She has a flat affect except when intermittently tearful. Previously upbeat despite all of the setbacks, she is now withdrawn and describes feeling hopeless. She has pervasive guilt over the burden she believes she has caused her family. Medications are a fentanyl patch, oxycodone, ondansetron, polyethylene glycol, senna, and zolpidem.

Publish date: 09/23/2021

 
General IM Q4

A 67-year-old man is evaluated for a 2-year history of worsening pain in his feet. He describes the pain as long-standing aching and burning. The pain is persistent, sometimes waking him from sleep. Medical history is otherwise significant for type 2 diabetes mellitus, hypertension, and hyperlipidemia. Medications are insulin glargine, insulin aspart, valsartan, aspirin, and simvastatin. On physical examination, vital signs are normal. The feet are insensate to monofilament testing, and vibratory sensation is absent in the feet and ankles. No evidence of skin breakdown is noted

Publish date: 09/15/2021

 
General IM Q3

A 49-year-old man is scheduled for total right knee arthroplasty. Medical history is otherwise unremarkable. He takes no medications. On physical examination, vital signs are normal. The right knee demonstrates bony hypertrophy and crepitus with passive movement. Low-molecular-weight heparin and intermittent pneumatic compression will be initiated and continued during the hospital stay.

Publish date: 09/09/2021

 
General IM Q2

A 40-year-old woman seeks advice on whether she should undergo breast cancer screening with mammography. Her family history is negative for breast and ovarian cancers, and she has no other risk factors for breast cancer. On physical examination, vital signs and the remainder of the examination are normal. The patient is engaged in a discussion of the potential benefits and harms of initiating mammography now, including the potential for false-positive results and overdiagnosis. After the discussion, she states that she is not overly concerned about her risk for breast cancer but is anxious about the potential harms associated with screening.

Publish date: 09/01/2021

 
General IM 1

A 35-year-old woman is evaluated after laboratory test results showed an elevated LDL cholesterol level during routine screening. Family history is remarkable for myocardial infarction in her father at age 45 years. She takes no medications. On physical examination, vital signs are normal. BMI is 30. The remainder of the examination is unremarkable. The patient is instructed in therapeutic lifestyle changes to lower her risk for atherosclerotic cardiovascular disease (ASCVD)

Publish date: 08/25/2021

 
Rheumatology Q49

A 48-year-old woman is evaluated for a 2-month history of increased dyspnea, wheezing, and nonproductive cough. She also reports intermittent pain and swelling in the wrists and knees for the past 6 months. She was diagnosed with scleritis of the left eye 1 month ago that improved with glucocorticoid drops. She also had two episodes of right pinna pain, redness, and swelling. Medications are prednisolone acetate ophthalmic and ibuprofen as needed for joint pain. On physical examination, vital signs are normal. There is no rash. Sclerae are normal. Hearing is normal. The trachea is tender. On lung auscultation, wheezing is heard in both lung fields with no crackles or rubs. Swelling of the wrists and knees is present. The ear findings are shown. Laboratory studies show an erythrocyte sedimentation rate of 60 mm/h and a normal complete blood count with differential except for a hemoglobin level of 11 g/dL (110 g/L). Chest radiograph is normal. CT of the chest reveals bronchial thickening with strictures; there is air trapping distal to the strictures.

Publish date: 08/18/2021

 
Pulmonary and Critical Care Medicine Q54

A 38-year-old man is evaluated for a 6-month history of dyspnea on exertion. He has gastroesophageal reflux disease and Raynaud phenomenon. He does not smoke and has no cough or wheezing. Current medications are lansoprazole and amlodipine. On physical examination, vital signs are normal. Oxygen saturation is 91% breathing ambient air. He has scattered telangiectasias on the face and trunk and sclerodactyly. Lung fields are clear on auscultation. The only abnormality on pulmonary function testing is a DLCO of 43% of predicted. High-resolution CT of the chest shows no evidence of parenchymal lung disease.

Publish date: 08/11/2021

 
Neurology Q71

A 39-year-old woman is evaluated for a 4-year history of headaches that typically occur twice weekly and last 8 to 12 hours when not treated early. The pain is bilateral, frontotemporal, vice-like, and aggravated by physical activity. Approximately half of the episodes have become severe and are associated with combined photophobia and phonophobia. She has had no associated nausea, vomiting, or visual or neurologic symptoms and reports no cranial autonomic features. Stress is the only clear trigger. Naproxen resolves the headache when administered early in the headache course. She takes no other medication. On physical examination, vital signs are normal; BMI is 23. All other physical examination findings, including those from a neurologic examination, are unremarkable.

Publish date: 08/04/2021

 
Nephrology Q77

A 71-year-old man is evaluated in the hospital for an elevated serum creatinine level. He was hospitalized 2 days ago for a 4-day history of progressive right lower leg cellulitis. History is also significant for type 2 diabetes mellitus with prior episodes of cellulitis. Medications are basal and prandial insulin. On physical examination, temperature is 38.9 °C (102.0 °F), blood pressure is 150/100 mm Hg, pulse rate is 100/min, and respiration rate is 20/min. A well-defined area of tender erythema and edema is present over the right foot and leg to just below the knee. The remainder of the examination is unremarkable. Kidney biopsy shows endocapillary proliferation on light microscopy, co-dominant granular staining for C3 and IgA on immunofluorescence microscopy, and subepithelial hump-like deposits on electron microscopy.

Publish date: 07/28/2021

 
Infectious Disease Q86

A 57-year-old woman is hospitalized with a 1-month history of diminished concentration, memory, and judgment, with recent mental status fluctuations and gait disorder. Medical history is remarkable for hypertension. Medications are enalapril and hydrochlorothiazide. On physical examination, vital signs are normal. She is somnolent but responds to verbal commands. The neck is supple. Deep-tendon reflexes are increased in the upper extremities and decreased in the lower extremities. Movement of the extremities is associated with myoclonus. The remainder of the examination is normal. Complete blood count, comprehensive metabolic profile, thyroid studies, and vitamin B12 measurements are normal. Gram stain of cerebrospinal fluid is negative. Polymerase chain reaction of cerebrospinal fluid for herpes simplex virus is negative. Brain MRI shows abnormally increased T2 and FLAIR signal intensity in the putamen and head of the caudate.

Publish date: 07/23/2021

 
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