MKSAP Questions of the Week

Pulmonary and Critical Care Medicine Q35

A 72-year-old woman is evaluated during a routine visit. She has a 30-pack-year smoking history and quit 5 years ago. She has a history of mild COPD and breast cancer diagnosed 15 years ago, currently in remission. A chest radiograph from 5 years ago showed no signs of disease recurrence. Medications are albuterol and tiotropium inhalers. On physical examination, vital signs are normal. Lung examination reveals prolonged expiration and diminished breath sounds throughout. The breast examination is unremarkable. A screening low-dose chest CT scan shows a peripheral 9-mm solid pulmonary nodule in the left upper lobe and emphysema but no mediastinal or hilar lymphadenopathy and no pleural effusion. A PET/CT scan using fluorodeoxyglucose (FDG) is performed and the nodule is intensely hypermetabolic. There is no evidence of distant uptake.

Publish date: 03/10/2021

Neurology Q59

A 67-year-old man is evaluated for a carotid bruit detected on routine medical examination. He reports no history of previous focal neurologic symptoms or visual loss. He has type 2 diabetes mellitus and hyperlipidemia treated with metformin, moderate-intensity pravastatin, and aspirin. On physical examination, blood pressure is 128/64 mm Hg, pulse rate is 78/min and regular, and respiration rate is 16/min. A left carotid bruit is heard on cardiac examination. All other physical examination findings, including those from a neurologic examination, are unremarkable. Results of laboratory studies show an LDL cholesterol level of 82 mg/dL (2.12 mmol/L). The carotid ultrasound report describes a mixed-density plaque at the origin of the left internal carotid artery with stenosis estimated to be 60% to 80%.

Publish date: 03/03/2021

Nephrology Q45

A 38-year-old woman is evaluated during a follow-up visit for primary membranous glomerulopathy. Diagnosis was made by kidney biopsy 4 months ago, and she was found to be positive for anti–phospholipase A2 receptor (PLA2R) antibodies. Medications are furosemide, losartan, and simvastatin. Recent age- and sex-appropriate cancer screening tests were normal. On physical examination, vital signs are normal. There is pitting lower extremity edema to the mid shins bilaterally.

Publish date: 02/24/2021

Infectious Disease Q42

A 36-year-old man is evaluated for a 10-day history of abdominal cramping, diarrhea, malaise, and nausea. Diarrhea is watery without mucus or blood. He returned 2 weeks ago from a 7-day trip to Lima, Peru. On physical examination, temperature is 37.7 °C (99.9 °F); the remaining vital signs are normal. On abdominal examination, bowel sounds are present with diffuse tenderness to palpation. The abdomen is not distended; no guarding or rebound is noted. Stool polymerase chain reaction assay is positive for Cyclospora.

Publish date: 02/17/2021

Hematology -Oncology Q14

A 67-year-old woman undergoes follow-up evaluation for an elevated globulin fraction of total serum protein level. She has no symptoms. Medical history is notable for hypertension treated with hydrochlorothiazide and atorvastatin. On physical examination, vital signs are normal. No lymphadenopathy or hepatosplenomegaly is noted. Serum protein electrophoresis and immunofixation show an IgG monoclonal spike of 0.7 g/dL. Serum free light chain assay and 24-hour urine protein electrophoresis are normal. Skeletal survey shows no lytic lesions.

Publish date: 02/10/2021

General IM Q37

A 37-year-old woman is evaluated for contraceptive advice. She is married and has a 1-year-old child. The patient describes the conception of this child as an “accident” because she often missed taking her previous oral contraceptive. Her menstrual periods have resumed and are regular but heavy and, in that regard, bothersome to her. Medical history is unremarkable. She drinks a glass of wine every night and smokes a pack of cigarettes daily. She has no other health issues and takes no medications. The result of a pregnancy test performed today is negative. The patient is provided with a brief smoking cessation intervention. She is not ready to stop smoking but will consider it again at a later time.

Publish date: 02/03/2021

Gastroenterology Q18

A 65-year-old man is evaluated after a screening ultrasound for abdominal aortic aneurysm showed incidental gallbladder findings. He reports no symptoms. He continues to smoke cigarettes, 1 pack per day. He has no other medical problems and takes no medications. On physical examination, vital signs are normal, as is the remainder of the examination. The results of all laboratory studies, including a complete blood count and alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, and total bilirubin levels, are within normal limits. The abdominal ultrasound shows numerous layering gallstones and an immobile 8-mm gallbladder polyp.

Publish date: 01/27/2021

Endocrinology Q19

A 54-year-old woman is evaluated for flushing of the face of 1 year's duration. These episodes occur two or three times per week and last about 30 minutes. She went through menopause at age 50 and is on estrogen and progesterone hormone therapy. She also experiences episodes of anxiety, diaphoresis, and tachycardia. Medical history is significant for increasingly frequent migraine headaches, difficult to control hypertension, and gastroesophageal reflux disease. Medications are amitriptyline, chlorthalidone, metoprolol, conjugated estrogens, progesterone, and omeprazole. On physical examination, blood pressure is 156/92 mm Hg; the remainder of the vital signs is normal. BMI is 32. The remainder of the examination is unremarkable

Publish date: 01/21/2021

Dermatology Q28

A 40-year-old man is evaluated for a firm, flesh-colored lesion that has been growing on the back for several months. Foul-smelling material can be expressed from the lesion. The patient is bothered by the periodic drainage. He is otherwise healthy and takes no medications. On physical examination, vital signs are normal. There is a 3-cm subepidermal nodule with a central punctum on the upper back. There is no erythema or warmth of surrounding skin.

Publish date: 01/13/2021

Cardiology Q45

A 59-year-old man is evaluated during a routine examination. He feels well and has no symptoms. Medical history is significant for hypertension. He does not smoke, and he does not have diabetes mellitus. He is active, performing aerobic exercise for 20 to 30 minutes four times per week. Medications are lisinopril and chlorthalidone. On physical examination, the patient is afebrile, blood pressure is 122/74 mm Hg, and pulse rate is 76/min. Cardiac examination is unremarkable.

Publish date: 01/06/2021

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