Question 1

A 45-year-old woman comes to the office for hypertension follow-up.  She has been taking low-dose amlodipine for the past 2 years, and it has been effective in controlling her blood pressure without adverse effects.  The patient has no other medical conditions.  In the past year, she initiated and maintained an intensive diet and exercise program, resulting in a weight loss of 15 kg (33 lb).  Since then, the patient's blood pressure at home has been consistently 115-120/70-75 mm Hg.  Office blood pressure today is 118/74 mm Hg.  The patient says "I have worked really hard for the past year to lose weight, and I don't like to take pills.  Can I stop taking the blood pressure medication after this visit?"  Which of the following is the best response to address the patient's request?

Accepted Answer

Explanation: 11ec2b69_be60_ad33_8f63_8fc1cff95782_MD0005_00 This patient has excellent blood pressure control on a low-dose, single-drug antihypertensive regimen. Since starting the medicine, she has greatly changed her lifestyle, achieving significant weight loss. She therefore may be able to discontinue the medication while maintaining acceptable blood pressure control. To discontinue a long-acting medication, such as amlodipine, the medication can be taken either every other day or in a lower daily dose (eg, half tablet). For short-acting medications (eg, lisinopril), the medication should be taken daily but in a smaller dose (either a half tablet or a smaller prescribed tablet). The blood pressure should be monitored closely over 1-2 months, and if it remains well controlled, the medication can be discontinued and the blood pressure monitored for an additional 1-2 months. If the blood pressure rises above the target, the previous dose of medication should be reinstated. The same approach can be used to eliminate drugs from a multidrug antihypertensive regimen. (Choice A) If blood pressure is under excellent control, lowering the dose or discontinuing blood pressure medications is appropriate even if hypotensive symptoms are absent. (Choice B) If no lifestyle modifications have been made, discontinuation of antihypertensive medication will typically cause blood pressure to rise to pretreatment levels. However, this patient has instituted major lifestyle modifications, and it is unlikely that her blood pressure will return to pretreatment levels. (Choices C and E) Clonidine is a short-acting alpha-2 agonist that is occasionally used for severe hypertensive episodes, not mild hypertension; abrupt discontinuation can lead to severe rebound hypertension. Likewise, discontinuation of short-acting beta blockers, which also are only occasionally used for hypertension, can cause rebound hypertension. However, amlodipine carries little risk of rebound hypertension. Also, all of these medications can be tapered off within a few weeks (eg, 2-3 months), and a longer taper (eg, 6 months) is unnecessary. Educational objective: Patients who have well-controlled hypertension treated with a single drug and have enacted significant lifestyle modifications can often taper and discontinue the medication under close blood pressure monitoring. References: Withdrawal of antihypertensive medication: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/28486271)

Question 2

A 38-year-old woman comes to the office due to dyspnea on exertion for the past 6 months. She says, "I get out of breath even when I walk less than a block at my usual pace. I climb stairs very slowly." A year ago, the patient was able to walk 10-12 blocks without any limitations. She has no chest pain, palpitations, syncope, cough, or hemoptysis. She has no medical problems. The patient saw a doctor 2 years ago and had a routine physical that did not show any abnormalities. She does not use tobacco, alcohol, or illicit drugs. Her mother has a history of breast cancer and "blood clots" in her legs. Her father had a stroke. The patient takes no prescription or over-the-counter medications. She has no known drug allergies. On examination, she appears comfortable at rest. Temperature is 36.7 C (98 F), blood pressure is 143/91 mm Hg, pulse is 84/min, and respirations are 16/min. Pulse oximetry shows 94% saturation on room air. BMI is 34 kg/m². On cardiac auscultation there is a prominent S2 but no murmurs or additional sounds. The lungs are clear. Peripheral pulses are full and no finger or toe clubbing is present. There is no peripheral edema. Chest-x ray reveals prominent pulmonary arteries but no infiltrates. ECG reveals normal sinus rhythm with right axis deviation. Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_be62_0cc6_8f63_e33e91d8a718_MD0005_00 This patient most likely has pulmonary hypertension (PH), which typically presents with gradually worsening dyspnea on exertion and fatigue; chest pain, palpitations, and syncope or near-syncope may also be present. Physical examination may reveal prominent right ventricular heave, a loud pulmonary component of S2, a holosystolic murmur of tricuspid regurgitation, and signs of right heart failure (eg, jugular venous distension, hepatomegaly, ascites, lower extremity edema). Chest x-ray characteristically reveals enlargement of the main pulmonary arteries with attenuation of peripheral arteries. Chest x-ray Patients with suspected PH should undergo initial evaluation with transthoracic echocardiography, which provides an estimate of pulmonary arterial pressure, evaluates for associated right ventricular dysfunction, and assesses for left ventricular dysfunction or valvular abnormality as a potential secondary cause of PH. Definitive diagnosis with right heart catheterization is required, with mean pulmonary arterial pressure >25 mm Hg providing confirmation. (Choice A) Exercise ECG stress testing is used to evaluate for suspected coronary artery disease; it does not have a role in the evaluation of patients with suspected PH. (Choices C and E) High-resolution CT scan is used to evaluate for interstitial lung disease, a potential secondary cause of PH (group 3), and ventilation/perfusion scan is used to evaluate for chronic thromboembolic PH (group 4). However, echocardiography to estimate pulmonary arterial pressure should precede any specific testing for secondary causes of PH. Acute pulmonary embolism is highly unlikely given this patient's progressive symptoms over the past 6 months. (Choice D) Polysomnography is used to diagnose obstructive sleep apnea, which is a potential cause of secondary PH, especially in patients with comorbid obesity hypoventilation syndrome. However, obstructive sleep apnea does not explain this patient's progressive dyspnea, and echocardiography is needed to evaluate for PH. Educational objective: Transthoracic echocardiography allows for an estimation of pulmonary arterial pressure and should be the initial diagnostic evaluation in patients with suspected pulmonary hypertension. References: Definitions and diagnosis of pulmonary hypertension. (http://www.ncbi.nlm.nih.gov/pubmed/24355641) ACCF/AHA 2009 expert consensus document on pulmonary hypertension: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents and the American Heart Association: developed in collaboration with the American College of Chest Physicians, American Thoracic Society, Inc., and the Pulmonary Hypertension Association. (http://www.ncbi.nlm.nih.gov/pubmed/19332472) 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension: The Joint Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS): endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT). (http://www.ncbi.nlm.nih.gov/pubmed/26320113)

Question 3

A 22-year-old woman is brought to the office by her mother because "she has been passing out."  The patient's first episode occurred about a year ago when she split up with her boyfriend.  A more recent episode was also provoked by strong emotion.  Both episodes were preceded by nausea, light-headedness, weakness, and blurred vision, lasted about a minute, and ended with rapid recovery of consciousness.  The patient sustained no significant injuries in either episode.  She is concerned because one of her childhood friends passed out and died while playing football.  Medical history is otherwise insignificant.  The patient takes no medications and does not use alcohol or illicit drugs.  She has no family history of early coronary artery disease, cardiomyopathy, or sudden cardiac death.  Blood pressure is 110/70 mm Hg while supine and 108/70 mm Hg while standing.  Physical examination findings are within normal limits.  ECG reveals no abnormalities.  Complete blood count and serum chemistries are within normal limits.  Which of the following is the best next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_be64_f2f9_8f63_a9a42eb84a9a_MD0005_00 This patient has experienced recurrent vasovagal syncope, a type of reflex syncope. It is typically triggered by emotional distress, prolonged standing, or painful stimuli, and patients usually experience an autonomic prodrome with nausea, pallor, diaphoresis, or generalized warmth. Spontaneous resolution of the episode occurs within seconds to a few minutes. Patients with vasovagal syncope have an excellent prognosis, and the initial approach is aimed at providing education and reassurance. Patients are advised to avoid triggers and to assume a supine position with raised legs at the onset of prodromal symptoms. In addition, patients may be taught physical counterpressure maneuvers (eg, leg crossing with tensing of muscles, tensing of arm muscles with clenched fists) to improve venous return and cardiac output, and abort an episode of vasovagal syncope during the prodromal phase. (Choice A) 24-hour Holter monitoring may be indicated to assess for cardiac syncope in patients who have clinical features (eg, syncope without autonomic prodrome) or ECG findings suggesting cardiac arrhythmia. Cardiac syncope is unlikely in this young patient who has classic features of vasovagal syncope (eg, provoked by emotion, autonomic prodrome) and normal physical examination and ECG findings. (Choice C) Beta blockers were once thought to interfere with the neurologic pathways responsible for vasovagal syncope; however, these drugs have shown no benefit in preventing vasovagal syncope in randomized trials and are not recommended. (Choice D) Transthoracic echocardiography should be performed in patients with syncope and clinical features (eg, exertional syncope, abnormal cardiac murmur) suggestive of structural heart disease (eg, aortic stenosis). It is not indicated in this patient with a history consistent with vasovagal syncope and a normal physical examination. (Choice E) Vasovagal syncope is usually a clinical diagnosis that requires no further testing if history and physical examination are supportive (as in this case). Upright tilt table testing is typically reserved for patients with an unclear cause of syncope (eg, to differentiate vasovagal syncope from orthostatic syncope). Educational objective: The initial management of vasovagal syncope is aimed at providing education and reassurance about its benign nature and prognosis and advising patients to avoid potential triggers of syncope. In patients with recurrent episodes, physical counterpressure maneuvers can abort or delay an episode of syncope and are recommended during the prodromal phase. References: Reflex syncope: Diagnosis and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/29255499)

Question 4

A 62-year-old man comes to the physician for a preventive visit.  He is being treated for mild hypertension and has no other known medical problems.  He drinks alcohol occasionally but does not use tobacco.  He works as a rancher.  The patient has some lesions on his head, which are pictured below:  Palpation of these lesions reveals small, rough-textured papules.  Which of the following is the most appropriate next step in the management of this patient?

Accepted Answer

Explanation: This patient has numerous actinic keratosis (AK) lesions; this is likely due to chronic sun exposure during his lifetime spent outdoors as a rancher. AK most commonly occurs in areas of heavy sunlight exposure such as the face, scalp, ears, upper chest, and dorsal hands and forearms. AK lesions are characterized by small, rough, erythematous, and keratotic papules that are often easier to feel than they are to see. The skin upon which they occur often shows signs of chronic photodamage such as dyspigmentation, wrinkling, thinning, and telangiectasia. Untreated AK has up to a 20% risk of progression to squamous cell carcinoma. For this reason, any AK lesions that are detected should be removed or destroyed (Choice C). There are numerous acceptable therapies for AK. Individual lesions can be destroyed with liquid nitrogen cryosurgery or by surgical excision or curettage. However, treatment of individual lesions is impractical when numerous small lesions are present; field therapy(an entire region of the body is treated at once) is employed instead. The most commonly used field treatment is 5-fluorouracil cream; it is applied to the entire affected area for a period of 3-6 weeks. Other options include imiquimod cream, topical diclofenac, and photodynamic therapy. (Choice A) An antinuclear antibody assay is a useful test to screen for systemic lupus erythematosus (SLE) or related connective tissue diseases. SLE is associated with a rash in sun-exposed areas that is characterized by erythema and edema in a "butterfly" distribution on the cheeks and bridge of the nose. rash (Choice B) Oral doxycycline is an appropriate therapy for acne rosacea. Rosacea typically presents with facial erythema and edema, often with telangiectasias, papules, pustules, and localized tissue hyperplasia. Rosacea (Choice E) Severe skin inflammation associated with subclinical AK may be seen in patients undergoing systemic chemotherapy for malignancy. Such cases may respond to topical glucocorticoids, but otherwise, glucocorticoids are not recommended for AK treatment. Educational objective: Actinic keratosis is usually treated with excision or destruction of lesions, often with cryotherapy. However, for patients with numerous or widespread lesions, destruction of individual lesions may be impractical and field therapy is recommended. Topical 5-flurouracil cream is the most commonly employed form of field therapy. References: Pharmacotherapy of actinic keratosis. (http://www.ncbi.nlm.nih.gov/pubmed/19925043)

Question 5

A 15-year-old boy comes to the office for a follow-up visit regarding acne.  He first developed acne a year ago and has tried over-the-counter acne washes with no improvement.  His first visit for acne was 3 months ago, at which time he was prescribed a topical retinoid and benzoyl peroxide for inflamed papules and pustules on his cheeks and forehead.  The patient says, "I've been using these 2 ointments every day.  Do you think I should keep using them?  Sometimes my face gets red and stings a little.  I don't feel like my skin looks much better than before."  He takes no other medications and always uses an oil-free, non-comedogenic sunscreen when outdoors.  He has no allergies.  Skin findings on examination are shown below.  Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_be69_adef_8f63_39821c2f3579_MD0005_00 This patient has inflammatory acne vulgaris that is unresponsive to initial therapy (topical retinoids and benzoyl peroxide). Many patients with inflammatory acne often require the addition of topical antibiotics (eg, erythromycin, clindamycin). By decreasing skin colonization with Cutibacterium acnes, topical antibiotics decrease inflammation in acne vulgaris. Oral tetracycline antibiotics (eg, doxycycline, minocycline) are indicated in patients with severe or nodular acne and for acne unresponsive to topical antibiotics. Oral antibiotics are also considered for patients with widespread acne (eg, on the back or upper arms) that makes topical therapy impractical. Neither topical nor oral antibiotics should be used as monotherapy (Choice E) due to rising antibiotic resistance. (Choice A) Spironolactone can be used as an adjunctive treatment for acne in women due to its anti-androgen effects, though antibiotic therapy is usually tried first. Spironolactone is generally avoided in men due to its side effect of gynecomastia. (Choice B) Topical organic acids (eg, salicylic, azelaic, glycolic) are most useful for noninflammatory/comedonal acne. This patient's worsening inflammatory acne (given the presence of pustules and papules) warrants more aggressive therapy. (Choice D) Isotretinoin is an oral retinoid that greatly diminishes sebum secretion but is used primarily in patients with extensive nodulocystic acne who have failed other treatment regimens or have significant scarring. This patient has not yet used topical or oral antibiotics and does not have scarring. Educational objective: Initial treatment for inflammatory acne includes topical retinoids and benzoyl peroxide. Antibiotics (topical or oral) can be added for refractory or more severe cases of inflammatory acne. References: Guidelines of care for the management of acne vulgaris. (http://www.ncbi.nlm.nih.gov/pubmed/26897386)

Question 6

A 44-year-old woman comes to the emergency department with sudden onset of weakness and dizziness.  The patient does not have any chest pain but feels her heart pounding in her chest.  She is otherwise healthy and does not have any other medical problems.  Her maternal uncle died suddenly at age 42.  Blood pressure is 110/60 mm Hg and pulse is 170/min.  Lungs are clear to auscultation and cardiac examination is normal.  Her electrocardiogram (ECG) is shown in this Exhibit.  Which of the following is the best initial treatment for this patient's condition?

Accepted Answer

Explanation: 11ec2b69_be64_56b8_8f63_bded74740d54_MD0005_00 This patient's electrocardiogram (ECG) shows a regular and narrow QRS complex tachycardia consistent with paroxysmal supraventricular tachycardia (PSVT). Patients with SVT typically present with palpitations, but some may have dizziness, lightheadedness, shortness of breath, diaphoresis, chest pain, presyncope, or syncope. narrow QRS complex tachycardia It is often difficult to distinguish between various types of SVT, which include sinus tachycardia, atrioventricular nodal reentrant tachycardia (AVNRT), AV reentrant tachycardia (AVRT), atrial fibrillation, and atrial flutter. In hemodynamically stable patients, the next step in evaluation is to identify the type of SVT with the use of intravenous (IV) adenosine or vagal maneuvers (carotid sinus massage or Valsalva). Adenosine or vagal maneuvers temporarily slow conduction through the AV node and can aid in diagnosis by unmasking the "hidden" P waves on the surface ECG. They can also cause a transient AV nodal block and terminate AV node-dependent arrhythmias, including AVNRT and orthodromic AVRT. (Choice B) Patients with persistent tachyarrhythmia (narrow or wide complex) causing hemodynamic instability (hypotension, altered mental status) should be managed with immediate synchronized direct-current cardioversion. However, this patient is hemodynamically stable and does not require cardioversion. (Choice C) Esmolol is an ultra-short acting beta-blocker that is used for rate control in patients with rapid atrial flutter or fibrillation. It is not indicated in patients with PSVT. (Choice D) Ibutilide is a class III antiarrhythmic drug and is approved for the pharmacologic cardioversion of atrial fibrillation and atrial flutter. It has no role in the management of patients with PSVT. (Choice E) Lidocaine is a class IB antiarrhythmic that is used to treat ventricular arrhythmias. It is often used in the treatment of hemodynamically stable patients with wide QRS complex tachycardia but is not recommended for narrow-complex SVT. Educational objective: Patients with regular, narrow complex tachycardia should be initially managed with vagal maneuvers (eg, carotid sinus massage) and/or intravenous adenosine. Patients with persistent tachyarrhythmia (narrow or wide complex) causing hemodynamic instability should be managed with immediate synchronized direct-current cardioversion. References: Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. (http://www.ncbi.nlm.nih.gov/pubmed/20956224)

Question 7

A 17-year-old girl is brought to an urgent care center for sunburn.  She was jogging outside for an hour today and subsequently developed redness and pain on the exposed portion of her arms and face.  The patient says, "It wasn't even that sunny today.  I've been outside for a lot longer than this and have never had a sunburn this bad."  Her medical history includes acne vulgaris for which she was prescribed a topical and an oral medication, neither of which she can remember by name.  She does not take any other medications and has no allergies.  The patient is a long-distance runner for her high school track team.  She lives with her father, who has dyslipidemia.  Physical examination shows numerous comedones, papules, and pustules on her face and chest.  Confluent areas of erythema, warmth, and edema are present on the patient's face and upper extremities.  Her left arm is shown in the image below.  Which of the following treatments is indicated for this patient's condition?

Accepted Answer

Explanation: 11ec2b69_be6a_e672_8f63_bf82efe1663e_MD0005_00 Phototoxic reactions secondary to tetracycline usage manifest as an exaggerated sunburn and should be treated as a nonphototoxic sunburn. Treatment of these minor burns with an intact epidermis is supportive, including symptomatic relief of pain and pruritus. Topical measures include cool compresses and application of aloe vera. Nonsteroidal anti-inflammatory drugs (eg, ibuprofen) reduce pain and erythema and can minimize damage to the epidermis if administered immediately after sun exposure. Systemic antihistamines (eg, diphenhydramine) can be used for the relief of pruritus. (Choice A) Benzocaine and other topical anesthetic sprays are not usually recommended due to the risk for allergic contact dermatitis in damaged tissues. (Choice C) Use of either oral or topical corticosteroids is not recommended in the treatment of burns due to risk of infection and impaired wound healing. (Choice D) Benzoyl peroxide is useful for treating inflammatory or nodulocystic acne but is associated with a risk of photosensitivity. (Choice E) Topical silver sulfadiazine is commonly used in partial-thickness burns to prevent infection but is not indicated for burns with an intact epidermis, as in this patient. Educational objective: Treatment for sunburn with an intact epidermis is supportive, including cool compresses and nonsteroidal anti-inflammatory drugs. References: Clinical management of the acute sunburn reaction. (http://www.ncbi.nlm.nih.gov/pubmed/10916693)

Question 8

A 42-year-old man comes to the office due to a painless lump under the skin on his right upper back, which he first noticed 3 months ago. He is incidentally noted to have a blood pressure of 180/110 mm Hg. He has no symptoms. The patient has no history of hypertension or other medical conditions and has not seen a physician since high school. He takes no medications, does not use tobacco, and consumes 1 or 2 alcoholic beverages on weekends. Family history is notable for hypertension in his mother and end-stage renal disease in a maternal uncle. The patient exercised regularly until recently, when he started work as a supervisor at a warehouse. He eats fast food at least 3 days a week. Repeat blood pressure measurements after 15 minutes of rest are 180/105 mm Hg on the right arm and 185/110 mm Hg on the left. Temperature is 36.7 C (98.1 F), pulse is 68/min, and respirations are 12/min. BMI is 26.2 kg/m². Cardiac examination reveals a diffuse and sustained apical impulse with normal heart sounds and no murmurs or gallops. There is a 3-cm, soft, mobile, nontender, subcutaneous mass consistent with a lipoma in the right scapular region. The remainder of the examination, including funduscopy, is normal. Blood cell counts, serum electrolytes, serum creatinine, blood glucose, and urinalysis are within normal limits. The ECG is shown in the exhibit. Which of the following additional tests is most appropriate for this patient?

Accepted Answer

Explanation: 11ec2b69_be60_3802_8f63_e39b98e6252b_MD0005_00 This patient has a new diagnosis of hypertension. Initial evaluation is oriented to the following objectives: Detecting end-organ damage that may require more aggressive management Assessing other cardiovascular risk factors Screening for common secondary causes of hypertension (eg, thyroid disorders, hyperaldosteronism) Identifying concurrent conditions and metabolic abnormalities that could influence the choice of antihypertensive therapy As part of initial workup, a fasting lipid profile should be ordered in all hypertensive patients to calculate the risk for cardiovascular events. The target blood pressure is determined, in part, by this risk, with lower targets recommended for those at increased risk. (Choices A and D) Coronary angiography and stress echocardiography are considered for patients with symptoms of coronary heart disease but not asymptomatic patients with hypertension. Resting echocardiography can be considered, especially for those with signs of left ventricular hypertrophy on ECG. (Choice C) Renal ultrasonography is useful for evaluating patients with clinical features suggesting renovascular hypertension, including atrophic kidney, recurrent flash pulmonary edema, abdominal bruit, and initial onset of severe hypertension (ie, >180/110 mm Hg) at age >55 or in the setting of diffuse atherosclerosis. (Choice E) Some illicit drugs (eg, cocaine, methamphetamines) can transiently raise blood pressure; however, this patient has no signs of acute drug intoxication. Moreover, he has evidence of left ventricular hypertrophy, suggesting long-standing hypertension. Educational objective: Patients with hypertension should be evaluated to identify additional cardiovascular risk factors and end-organ damage. Suggested studies include fasting lipid profile and glucose, urinalysis, serum electrolytes and creatinine, and ECG. References: 2017 ACC/AHA blood pressure treatment guideline recommendations and cardiovascular risk. (http://www.ncbi.nlm.nih.gov/pubmed/30189994)

Question 9

A 45-year-old woman comes to the physician for evaluation of lesions on her chest and axillae.  She initially noticed a small papule at her right axilla 6 months ago, followed by additional lesions in the same area extending toward her right breast.  There is no associated pain, erythema, discharge, or pruritus.  The patient is concerned about the number of lesions and requests further evaluation.  She has a history of asthma treated with an albuterol inhaler as needed.  She does not use tobacco or alcohol.  Her vital signs are within normal limits.  Skin examination of the right axillary region is shown below.  The remainder of her physical examination is normal.  Which of the following is associated with this patient's skin condition?

Accepted Answer

Explanation: 11ec2b69_be6d_5777_8f63_cb601deb20df_MD0005_00 This patient's skin lesions are consistent with acrochordons (skin tags), benign outgrowths of normal skin. Acrochordons usually appear as pedunculated, skin-colored papules, most commonly in areas of friction (eg, axillae, neck, inframammary, inguinal regions). Up to 25% of adults have skin tags, and they occur more frequently with age. Many studies have noted an association between skin tags and obesity, insulin resistance, overt diabetes, and metabolic syndrome. Skin tags also occur more commonly during pregnancy and in patients with colonic polyps. Diagnosis is based on clinical appearance. Skin tags do not usually require treatment, although it may be considered if there is associated irritation or for cosmetic reasons. Treatment options include snip excision or cryosurgery. (Choice A) Celiac disease is associated with dermatitis herpetiformis, which appears as pruritic, erythematous, and grouped papulovesicular lesions. dermatitis herpetiformis (Choice B) Crohn disease is associated with perianal skin tags rather than axillary skin tags, as seen in this patient. Crohn disease is also associated with pyoderma gangrenosum, which presents as a purulent ulcer. perianal skin tags pyoderma gangrenosum (Choice C) Hepatitis C is associated with lichen planus, porphyria cutanea tarda, and cryoglobulinemia causing leukocytoclastic vasculitis. However, these lesions usually do not appear as pedunculated skin masses. lichen planus porphyria cutanea tarda leukocytoclastic vasculitis (Choice D) Acute HIV can present with a generalized rash appearing as small and well-circumscribed red macules or papules. Chronic HIV has been associated with a variety of skin lesions, including molluscum, Kaposi sarcoma, and recurrent herpes zoster. molluscum Kaposi sarcoma herpes zoster Educational objective: Acrochordons (skin tags) are benign outgrowths of normal skin that appear as pedunculated, skin-colored papules in areas of friction. Skin tags are associated with obesity, insulin resistance, overt diabetes, and metabolic syndrome. References: Skin disorders in overweight and obese patients and their relationship with insulin. (http://www.ncbi.nlm.nih.gov/pubmed/24238328) Acrochordons as a cutaneous sign of metabolic syndrome: a case-control study. (http://www.ncbi.nlm.nih.gov/pubmed/24761238)

Question 10

A 14-year-old girl is brought to the office by her father for a well-patient visit. She has intermittent asthma and allergies to peanuts, tree nuts, and shellfish. She uses an albuterol inhaler as needed and has an epinephrine auto-injector at home. The patient lives at home with her parents and 12-year-old brother. She is in ninth grade and is a straight-A student. She participates in student council, theater club, soccer, and field hockey. During the physical examination, the patient says that the acne on her forehead and nose is "so embarrassing! My friend told me to use water-based makeup to help cover my blemishes, which makes me feel better. I shower every night and use an unscented acne facial scrub at least twice a day. I read on the Internet about certain foods to avoid, but the list was really long." BMI is 21 kg/m². Physical examination shows an oily complexion and closed comedones with minimal inflammation on the forehead. Examination shows no hirsutism or acanthosis nigricans. The patient and her father say that they prefer to avoid medication. Which of the following is the best next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_be6c_6d14_8f63_833650ccf793_MD0005_00 This patient has comedonal acne vulgaris. Contributing factors include increased sebum production, follicular hyperkeratinization, and bacterial colonization (Cutibacterium acnes). Pharmacologic management for comedonal acne without inflammation includes topical retinoids and organic acid preparations (eg, salicylic acid, azelaic acid). Lifestyle interventions should be offered to all patients with acne, including this patient who prefers to avoid pharmacologic therapy. Patients should be advised to use pH-neutral detergent cleansers, as opposed to more alkaline soaps, with warm water twice daily. Cleansers should be applied gently without vigorous scrubbing, which can both aggravate existing and create new acne. Patients should also be encouraged to use water-based rather than oil-based skin products (eg, moisturizers, cosmetics, sunscreens) (Choice D). (Choice A) Vitamin E, a topical agent in many over-the-counter moisturizers and cosmetics, has not been shown to prevent or reduce scarring. This patient with comedonal acne would not improve with this therapy, and gentle cleansing should be advised. (Choice B) Although there is a correlation between foods with a high glycemic index and acne, there is no definitive data linking diet to acne. A restricted diet should not be advised solely for the purpose of acne control. (Choice E) Picking or expressing acne lesions can lead to scarring and should be discouraged. Educational objective: Lifestyle interventions to manage acne include avoidance of vigorous scrubbing and use of water-based skin products and pH-neutral detergent cleansers. References: Cleansing and moisturizing in acne patients. (http://www.ncbi.nlm.nih.gov/pubmed/19209947)

Question 11

A 52-year-old woman comes to the emergency department with left leg pain and swelling. She is a commercial truck driver and first noticed the swelling 3 days ago. The patient initially attributed the swelling to a long haul truck ride as she often gets mild "puffiness" of her ankles by the end of the day. However, the swelling has persisted and now involves her entire left leg below the knee. She has discomfort with walking but no chest pain, palpitations, syncope, or difficulty breathing. The patient has a history of hypothyroidism and hypertension and takes levothyroxine and hydrochlorothiazide. She has also been on menopausal hormone therapy using estrogen-progestin for intractable hot flashes. She smokes a pack of cigarettes daily and drinks 2 beers each night. Temperature is 37.2 C (99 F), blood pressure is 134/89 mm Hg, and pulse is 78/min. BMI is 31 kg/m². Extremity examination reveals a normal right leg and pitting edema and warmth over the left lower leg. ECG shows normal sinus rhythm, and chest x-ray is normal with no infiltrates. Serum creatinine level is 0.7 mg/dL. Duplex ultrasound of the lower extremities reveals noncompressibility of the left popliteal and femoral veins. Which of the following is the best next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_be67_63fc_8f63_5127095f71e1_MD0005_00 This patient on menopausal hormone therapy with unilateral lower extremity edema has ultrasound evidence of a deep venous thrombosis (DVT). Recent clinical guidelines by the American College of Chest Physicians recommend ≥3 months of an oral factor Xa inhibitor (eg, rivaroxaban) for patients with DVT or pulmonary embolism (PE). Factor Xa inhibitors are considered the first-line therapy because they are administered orally (unlike low-molecular-weight heparin) and do not require a heparin bridge or laboratory monitoring (unlike warfarin). (Choice A) A CT scan of the chest is typically recommended for patients with DVT who have pulmonary symptoms (eg, chest pain, shortness of breath, hemoptysis). Treatment of PE is often the same as for DVT. (Choice B) Antiplatelet therapy such as aspirin is often used for primary or secondary prevention of cardiovascular disease (eg, coronary artery disease, heart attack, stroke). Antiplatelet therapy is not commonly used in the treatment of DVT. (Choice D) Oral vitamin K antagonists such as warfarin take several days to achieve full effect and may transiently result in a hypercoagulable state; patients initiated on vitamin K antagonists require several days of heparin bridging. (Choice E) Protein C, protein S, and antithrombin III deficiencies are congenital causes of hypercoagulability that can increase risk of DVT. Testing for an inherited thrombophilia is typically considered for patients who are young, have a strong family history of DVT, or have had multiple occurrences of DVT. This patient has several risk factors for acquired DVT including menopausal hormone therapy and immobility. In addition, screening for congenital causes is not immediately undertaken as an active thrombus often interferes with testing results. Educational objective: Patients with deep venous thrombosis or pulmonary embolism are typically treated with ≥3 months anticoagulation with an oral factor Xa inhibitor such as rivaroxaban.

Question 12

A 17-year-old girl is brought to an urgent care center for sunburn.  She was jogging outside for an hour today and subsequently developed redness and pain on the exposed portion of her arms and face.  The patient says, "It wasn't even that sunny today.  I've been outside for a lot longer than this and have never had a sunburn this bad."  Her medical history includes acne vulgaris for which she was prescribed a topical and an oral medication, neither of which she can remember by name.  She does not take any other medications and has no allergies.  The patient is a long-distance runner for her high school track team.  She lives with her father, who has dyslipidemia.  Physical examination shows numerous comedones, papules, and pustules on her face and chest.  Confluent areas of erythema, warmth, and edema are present on the patient's face and upper extremities.  Her left arm is shown in the image below.  
Which of the following medications most likely influenced the severity of this patient's sunburn?

Accepted Answer

Explanation: This patient has developed an exaggerated sunburn while under treatment for inflammatory acne vulgaris. Medications used in the treatment of inflammatory acne include benzoyl peroxide, topical retinoids, and topical/oral antibiotics. The most common agent that causes significant photosensitivity is doxycycline, an oral tetracycline antibiotic. Photosensitivity can also occur with other tetracyclines (eg, minocycline), benzoyl peroxide, and retinoids. Presentation can range from a mildly erythematous rash to blistering that develops minutes to hours after skin is exposed to sunlight. Prevention includes avoidance of direct sunlight (eg, protective clothing) and use of sunscreen. Because the incidence of doxycycline photosensitivity is dose dependent, nonacute management can include decreasing the dosage or discontinuing the medication. (Choices A, B, and D) Topical azelaic acid, dapsone, and erythromycin are also used in the treatment of inflammatory acne. The most common side effects include local erythema, dryness, and pruritus. Pigment changes can also be seen with the use of azelaic acid and dapsone. Photosensitivity is not seen. (Choice E) Spironolactone is a potassium-sparing diuretic that can be used to treat acne in women through its androgen receptor-blocking effects. Dermatologic side effects are not seen. Educational objective: Oral doxycycline is used in the treatment of inflammatory acne and is a photosensitizing agent that may cause exaggerated sunburn. References: Drug-induced photosensitivity: culprit drugs, management and prevention. (http://www.ncbi.nlm.nih.gov/pubmed/21879777)

Question 13

A 38-year-old woman comes to the office due to dyspnea on exertion for the past 6 months. She says, "I get out of breath even when I walk less than a block at my usual pace. I climb stairs very slowly." A year ago, the patient was able to walk 10-12 blocks without any limitations. She has no chest pain, palpitations, syncope, cough, or hemoptysis. She has no medical problems. The patient saw a doctor 2 years ago and had a routine physical that did not show any abnormalities. She does not use tobacco, alcohol, or illicit drugs. Her mother has a history of breast cancer and "blood clots" in her legs. Her father had a stroke. The patient takes no prescription or over-the-counter medications. She has no known drug allergies. On examination, she appears comfortable at rest. Temperature is 36.7 C (98 F), blood pressure is 143/91 mm Hg, pulse is 84/min, and respirations are 16/min. Pulse oximetry shows 94% saturation on room air. BMI is 34 kg/m². On cardiac auscultation there is a prominent S2 but no murmurs or additional sounds. The lungs are clear. Peripheral pulses are full and no finger or toe clubbing is present. There is no peripheral edema. Chest-x ray reveals prominent pulmonary arteries but no infiltrates. ECG reveals normal sinus rhythm with right axis deviation. Echocardiography demonstrates increased right-sided pressures, right ventricular dilation, and normal left ventricular size and function. Right heart catheterization reveals a mean pulmonary artery pressure of 40 mm Hg (normal: <20 mm Hg) and a pulmonary capillary wedge pressure of 10 mm Hg. Further studies, including pulmonary function test, ventilation/perfusion scan, and polysomnography, are unremarkable. This patient would benefit most from an antagonist of which of the following receptors?

Accepted Answer

Explanation: This patient's right heart catheterization confirms pulmonary hypertension (PH) (mean pulmonary arterial pressure >25 mm Hg). Pulmonary capillary wedge pressure <18 mm Hg rules out PH due to left heart failure, and unremarkable pulmonary function testing, ventilation/perfusion scan, and polysomnography rule out PH due to structural lung disease (eg, interstitial lung disease), chronic thromboembolic pulmonary disease, and sleep disorder, respectively. These findings are consistent with group 1 pulmonary hypertension, or idiopathic pulmonary arterial hypertension (PAH), a condition that typically affects young adults. group 1 pulmonary hypertension Because there is no specific therapy to target the underlying cause of idiopathic PAH, advanced therapy is used to dilate the pulmonary arteries. Endothelin is a potent vasoconstricting hormone that is produced by endothelial cells, and endothelin receptors are abundant in the pulmonary arteries of patients with idiopathic PAH. Endothelin receptor antagonists (eg, bosentan, ambrisentan) have demonstrated delayed progression of disease in symptomatic patients with idiopathic PAH. Other advanced therapies available for patients with idiopathic PAH include phosphodiesterase-5 inhibitors (eg, sildenafil, tadalafil) and prostacyclin pathway agonists (eg, epoprostenol, treprostinil, iloprost). For patients with a positive vasoreactive test during right heart catheterization, calcium channel blockers (eg, long-acting nifedipine) are another option. (Choice A) Adenosine receptor antagonists (eg, theophylline) are sometimes used in the management of asthma but have no role in the management of PAH. (Choice B) Alpha-1 adrenergic antagonists (eg, doxazosin, terazosin) are often used for the treatment of symptomatic benign prostate hyperplasia and are sometimes used for systemic hypertension. However, these drugs are not indicated in the management of PAH. (Choice C) Left ventricular systolic dysfunction leads to elevated left atrial pressures and is a common cause of secondary (group 2) PH. Angiotensin receptor blockers (eg, losartan, valsartan) are indicated in these patients to decrease afterload and minimize cardiac remodeling; however, these drugs have no role in the management of PAH. (Choice E) Muscarinic antagonists (eg, ipratropium, tiotropium) are useful in the management of patients with PH secondary to chronic obstructive pulmonary disease (group 3), but these drugs are not indicated for PAH. Educational objective: When possible, the treatment of pulmonary hypertension is directed at the underlying cause of the disease. As there is no available therapy to target the underlying cause of idiopathic pulmonary arterial hypertension (group 1 pulmonary hypertension), advanced therapy (eg, endothelin receptor antagonists) to dilate the pulmonary arteries is the treatment of choice in symptomatic patients. References: 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension: The Joint Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS): endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT). (http://www.ncbi.nlm.nih.gov/pubmed/26320113)

Question 14

A 32-year-old woman returns to the office due to acne.  For the past 3 months, the patient has been applying topical clindamycin, benzoyl peroxide, and tretinoin on the face and neck, with only partial improvement.  In addition, she has been using a salicylic acid-containing gel cleanser morning and evening.  The acne tends to worsen before menses, which occur every 28-30 days and last 5-7 days.  During menses, the patient also craves chocolate, sometimes eating multiple bars a day.  Medical history includes recurrent vaginal candidiasis and a bilateral tubal ligation.  Examination reveals comedones, papules, and pustules on the lower cheeks, chin, and neck but no scarring.  Facial and body hair distribution is normal.  Which of the following is the most appropriate next step in management of this patient's acne?

Accepted Answer

Explanation: 11ec2b69_be6c_e245_8f63_6365abcea70b_MD0005_00 This patient has moderate inflammatory acne that has responded inadequately to maximal topical therapy. Systemic treatment is warranted; options include hormonal therapy and oral antibiotics. Evidence comparing relative efficacy is limited, and the choice depends on acne characteristics, patient preference, and comorbid conditions. Hormonal therapy (eg, estrogen/progestin oral contraceptives) works best for acne that exhibits premenstrual flares and is located on the lower face and neck, as in this patient. Estrogen functions as an antiandrogen and suppresses production of sebum, which occludes hair follicles and promotes Cutibacterium acnes proliferation. Patients with concurrent menstrual irregularities or hyperandrogenic states (eg, polycystic ovarian syndrome) may derive additional benefits. In contrast, oral antibiotics (eg, doxycycline, minocycline) eradicate C acnes and diminish C acnes-triggered inflammation. However, tetracyclines are potentially teratogenic, and concurrent use of effective contraception is required for women of childbearing potential. In addition, oral antibiotics can increase the risk of vaginal candidiasis, which makes them a less-than-ideal choice for patients, such as this one, with a history of recurrent candidiasis (Choice D). (Choice B) Progestin-only oral contraceptives are not recommended for treating acne because of the androgenic effects of progestins used in these pills. (Choice C) Despite coverage in the lay media, chocolate has not been shown to promote acne formation. (Choice E) Salicylic acid-containing gel cleansers are recommended for acne. Salicylic acid is comedolytic, and gel-based vehicles have low oil content, making them less comedogenic than cream-based cleansers. However, exfoliating facial scrubs are not recommended because the mechanical trauma can worsen inflammatory acne. Educational objective: Combined estrogen/progestin oral contraceptives suppress sebum production and have antiandrogenic effects. They can be used to treat moderate inflammatory acne, especially for patients with premenstrual acne flares and acne on the lower face and neck. References: Acne vulgaris: diagnosis and treatment (http://www.ncbi.nlm.nih.gov/pubmed/31613567)

Question 15

A 36-year-old man comes to the emergency department due to loss of consciousness.  He was standing in a crowded subway station when he felt lightheaded, had a pounding sensation in his chest, and passed out.  On awakening, he felt short of breath for a little while and then was "completely fine."  He has had no similar episodes, nor chest pain, confusion, tongue biting, or urinary incontinence.  The night before, he was at a party with friends and consumed alcohol.  Later he was nauseated and had 3 episodes of vomiting and one episode of diarrhea.  In the emergency department, blood pressure is 124/68 mm Hg and pulse is 80/min.  There is a small laceration above his right eyebrow.  Cardiac examination shows normal heart sounds with regular rhythm.  The lungs are clear to auscultation.  Neurologic examination shows no abnormalities.  ECG is shown in the exhibit. The patient is hospitalized for observation.  His serum electrolytes are within normal limits.  Echocardiogram shows normal left ventricular size and function and no significant valvular abnormalities.  During the hospital stay, he has another episode of lightheadedness when the telemetry revealed brief supraventricular tachycardia that resolved spontaneously.  Which of the following is the most appropriate next step in management?

Accepted Answer

Explanation: The overall incidence of sudden cardiac death in patients with Wolff-Parkinson-White (WPW) pattern on ECG is low (<1%), but the risk is significantly increased in patients with episodes of tachyarrhythmia. Tachyarrhythmia due to atrial fibrillation is especially dangerous because impulses can conduct from the atria to the ventricles at a very fast rate, potentially causing rhythmic degeneration to ventricular fibrillation. This patient with WPW pattern on ECG, recent syncope event, and documented supraventricular tachycardia with associated symptoms meets criteria for WPW syndrome, and definitive therapy is indicated. Catheter ablation is the recommended therapy in patients with WPW syndrome. It has a nearly 90% efficacy rate and <5% risk of complications, replacing surgical ablation as the preferred treatment for accessory pathways. The need for catheter ablation in asymptomatic patients with WPW pattern on ECG is controversial; ablation is sometimes favored in young patients, but observation is often favored in older patients who have demonstrated a relatively longer symptom-free period. (Choice B) Coronary angiography is an invasive procedure indicated for management of acute coronary syndrome. This patient does not have findings to suggest acute coronary syndrome and would be better managed with catheter ablation therapy. (Choice C) A loop event recorder allows ambulatory ECG monitoring when patients have symptoms (eg, palpitations, lightheadedness) that are suspected to be the result of paroxysmal arrhythmia. However, additional diagnostic cardiac monitoring is not needed in this patient as the resting ECG findings combined with documentation of symptomatic supraventricular tachycardia on telemetry are diagnostic of WPW syndrome. (Choice D) Nuclear stress testing can be used for diagnosis of coronary artery disease but has no role in managing patients with WPW syndrome. (Choice E) Tilt-table testing can be used in the evaluation of recurrent syncope (particularly vasovagal syncope) and is reserved for patients who have been ruled out for heart disease (structural or conductive). This patient has conductive evidence of WPW and would not benefit from a tilt-table test. Educational objective: Patients with Wolff-Parkinson-White syndrome are at risk of sudden cardiac death because the accessory pathway can lead to atrial fibrillation that can degenerate into ventricular fibrillation. Catheter ablation to obliterate the accessory pathway is the preferred treatment. References: ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias--executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Supraventricular Arrhythmias). (http://www.ncbi.nlm.nih.gov/pubmed/14557344)

Question 16

A 67-year-old man undergoes coronary angiography due to stable angina and a positive stress test.  Medical history is notable for type 2 diabetes mellitus, hypertension, and peripheral arterial disease.  Access is obtained through the right femoral artery, and a high-grade lesion is diagnosed in the mid left anterior descending artery.  A drug-eluting stent is successfully placed.  After the procedure, the femoral arterial sheath is removed and manual compression is applied.  The patient is discharged the next morning.  Two days later, he comes to the office for follow-up due to right groin pain and discomfort that he thought would be gone by now.  He has no chest pain, dyspnea, lightheadedness, or abdominal pain.  The patient has been taking dual antiplatelet therapy prescribed on discharge.  Blood pressure is 118/74 mm Hg and pulse is 82/min.  Physical examination shows mild swelling and bruising of the right groin with accentuated pulsation.  Skin color and perfusion are normal over both lower extremities.  Popliteal and dorsalis pedis pulses are symmetric.  Which of the following is the best next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_be61_4974_8f63_1795bee943c3_MD0005_00 This patient with persistent pain, swelling, and accentuated pulsation near the access point for recent cardiac catheterization likely has a pseudoaneurysm of the right common femoral artery. Pseudoaneurysm occurs when bleeding from an inadequately sealed arterial puncture site remains confined within the periarterial connective tissue. The result is a contained hematoma that has ongoing communication with the arterial lumen. Diastolic pressure equalizes between the artery and the confined hematoma, resulting in blood flow in and out of the hematoma cavity with systole. An arterial pseudoaneurysm usually presents as a tender, pulsatile mass with a systolic bruit, and the diagnosis is confirmed by ultrasonography. Small pseudoaneurysms can be treated with ultrasound-guided compression or thrombin injection into the pseudoaneurysm cavity. Larger or rapidly expanding pseudoaneurysms are at risk of rupture and should be managed with surgical repair. diagnosis is confirmed The main risk factor for pseudoaneurysm formation is inadequate post-procedural manual compression to achieve arterial hemostasis. (Choice A) Femoral arteriovenous fistula presents with localized pain, no mass, and a continuous bruit, and is sometimes evaluated by lower extremity angiography if initial ultrasonography is incompletely diagnostic. Angiography can also be used to evaluate for femoral artery dissection or thrombosis in a patient with evidence of distal leg ischemia. This patient has intact lower extremity pulses and angiography is not indicated. (Choice B) Noncontrast CT scan of the abdomen and pelvis is indicated for suspected retroperitoneal hematoma, a serious complication of cardiac catheterization that involves massive extension of post-procedural arterial bleeding. The condition presents with rapidly developing hemodynamic instability and ipsilateral flank or back pain, both of which this patient lacks. (Choices C and D) Reassurance and symptomatic treatment alone is appropriate for a small, localized hematoma (evidenced by non-pulsatile swelling and no bruit); however, it is not appropriate for pseudoaneurysm, which carries the risk of expansion, rupture, and catastrophic bleeding. Temporary discontinuation of dual antiplatelet therapy carries significant risk of stent thrombosis in this patient with a drug-eluting stent placed 2 days previously, and is not recommended in the absence of life-threatening bleeding. drug-eluting stent Educational objective: Pseudoaneurysm is a potential complication of arterial access for cardiac catheterization; it occurs when arterial bleeding remains confined within the periarterial connective tissue, resulting in a contained hematoma that communicates with the arterial lumen. Patients typically have a tender, pulsatile mass with a systolic bruit at the puncture site, and the diagnosis is confirmed by ultrasonography. References: Contemporary management of postcatheterization pseudoaneurysms. (http://www.ncbi.nlm.nih.gov/pubmed/17515479) Access site complications following cardiac catheterization assessed by duplex ultrasonography. (http://www.ncbi.nlm.nih.gov/pubmed/18756886) Incidence and outcome of femoral vascular complications among 18,165 patients undergoing cardiac catheterisation. (http://www.ncbi.nlm.nih.gov/pubmed/18617281)

Question 17

A 65-year-old man is brought to the emergency department after a syncopal episode.  He was sitting at the kitchen table when his wife saw him suddenly slump over.  She estimates he was unresponsive for 30 seconds.  He felt "completely fine" after the incident and was not confused.  The patient sustained no trauma and does not remember any symptoms prior to the event.  He has a history of benign prostate hyperplasia, hypertension, and a myocardial infarction requiring stent placement 3 years ago.  He takes aspirin, carvedilol, atorvastatin, ramipril, and tamsulosin.  Temperature is 36.7 C (98 F), blood pressure is 130/80 mm Hg, pulse is 60/min, and respirations are 14/min.  Pulse oximetry shows 96% on room air.  Physical examination reveals moist mucous membranes, normal jugular venous pressure, clear lung fields, and normal first and second heart sounds.  There is trace edema of the lower extremities bilaterally.  Neurologic examination is within normal limits.  Complete blood count, basic metabolic panel, troponin, and chest x-ray are normal.  ECG reveals normal sinus rhythm, Q waves in leads V2 to V4, normal QRS complex duration, and normal QTc interval.  Transthoracic echocardiogram shows an apical wall motion abnormality with ejection fraction of 40%.  Which of the following is the most likely cause of this patient's syncope?

Accepted Answer

Explanation: 11ec2b69_be66_799b_8f63_1d6eabccd79e_MD0005_00 This patient most likely experienced cardiac syncope due to ventricular tachycardia (VT); scarring from previous myocardial infarction (evidenced by Q waves on ECG and wall motion abnormality on echocardiogram) increases the risk of ventricular arrhythmia. Syncope due to VT usually has no warning symptoms (other than palpitations in some patients). The arrhythmia spontaneously terminates within 1-2 minutes, resulting in restoration of cardiac output and rapid patient recovery with no residual symptoms. The recognition of cardiac syncope is crucial because these patients are often at high risk of sudden cardiac death. Absence of autonomic prodromal symptoms (eg, nausea, pallor, diaphoresis, feeling of warmth), which are usually present prior to a benign syncope event, suggests cardiac syncope. The presence of underlying structural heart disease (eg, ischemic scarring, cardiomyopathy with low ejection fraction) specifically suggests cardiac syncope due to VT. This patient warrants further evaluation with electrophysiology testing, likely followed by placement of an implantable cardiac defibrillator. (Choice A) Acute pulmonary embolism presents with syncope in approximately 15% of cases. However, absence of jugular venous distension, significant hypoxemia, and findings of right ventricular strain on echocardiogram makes the diagnosis less likely. (Choice B) Carotid sinus hypersensitivity refers to recurrent episodes of syncope triggered by pressure on the carotid sinuses (eg, due to a tight collar). The syncope is reflex mediated and often preceded by autonomic prodromal symptoms. (Choice C) Syncope due to orthostatic hypotension can result from medication adverse effects (eg, tamsulosin, an alpha-1 antagonist). It usually occurs with a change in position from supine or sitting to standing. Syncope that occurs after going from standing to sitting position is not consistent with orthostatic syncope. (Choice D) Vasovagal syncope is commonly triggered by prolonged standing, emotional stress, or painful stimuli, and is usually accompanied by an autonomic prodrome. This patient's history of ischemic heart disease and absence of a prodrome make cardiogenic syncope more likely. Educational objective: Cardiac syncope due to ventricular tachycardia is suggested by the presence of underlying structural heart disease and the abrupt onset of syncope without prodrome. Patients with cardiac syncope are at risk of sudden cardiac death and require definitive evaluation and management. References: Guidelines for the diagnosis and management of syncope. (http://www.ncbi.nlm.nih.gov/pubmed/19713422) Evaluation and management of syncope. (http://www.ncbi.nlm.nih.gov/pubmed/21135810) Syncope: a review of emergency department management and disposition. (http://www.ncbi.nlm.nih.gov/pubmed/27752576)

Question 18

A 36-year-old man comes to the emergency department due to loss of consciousness.  He was standing in a crowded subway station when he felt lightheaded, had a pounding sensation in his chest, and passed out.  On awakening, he felt short of breath for a little while and then was "completely fine."  He has had no similar episodes, nor chest pain, confusion, tongue biting, or urinary incontinence.  The night before, he was at a party with friends and consumed alcohol.  Later he was nauseated and had 3 episodes of vomiting and one episode of diarrhea.  In the emergency department, blood pressure is 124/68 mm Hg and pulse is 80/min.  There is a small laceration above his right eyebrow.  Cardiac examination shows normal heart sounds with regular rhythm.  The lungs are clear to auscultation.  Neurologic examination shows no abnormalities.  ECG is shown in the exhibit. 
Which of the following is the most likely cause of this patient's syncope?

Accepted Answer

Explanation: 11ec2b69_be68_274d_8f63_cda118551577_MD0005_00 This patient's ECG shows a Wolff-Parkinson-White (WPW) pattern, a type of cardiac preexcitation caused by an accessory pathway. Normal electrical impulses pass from the atria to the ventricles via the atrioventricular (AV) node/His-Purkinje system; however, in patients with WPW there is an extra conduction pathway (accessory pathway) that directly connects the atria to the ventricles and bypasses the AV junction. The accessory pathway conducts faster than the AV node and excites the ventricles prematurely, manifesting on resting ECG as a short PR interval with a characteristic delta wave and widened QRS complex (>0.12 sec). ECG Although patients with a WPW pattern on ECG can be asymptomatic, some develop tachyarrhythmias; the combination of WPW findings on ECG and symptomatic tachyarrhythmia constitutes WPW syndrome. Paroxysmal supraventricular tachycardia is the most common arrhythmia; it is usually a regular, narrow complex tachycardia. If patients with WPW develop atrial fibrillation, they can conduct down the accessory pathway from the atria to the ventricles at a very fast rate, commonly resulting in syncope. This patient's ingestion of alcohol, a known precipitant of atrial fibrillation, likely placed him at risk for such a scenario. (Choice A) Acute coronary syndrome can sometimes present with nausea, vomiting, palpitations, or syncope, rather than chest pain. However, it is unlikely in this young patient with no significant risk factors for coronary artery disease and ECG showing no ST segment elevation/depression to suggest myocardial ischemia. (Choice B) Bradyarrhythmias generally arise from sinoatrial node dysfunction or AV nodal conduction block, and typically present with syncope or presyncope. However, this patient's WPW pattern on ECG and palpitations before passing out make a tachyarrhythmia more likely. (Choice C) Orthostatic hypotension is defined as a decrease in systolic blood pressure ?20 mm Hg with change in position from supine to standing; it can be due to an inadequate autonomic response or volume depletion. Although this patient may be hypovolemic from vomiting and diarrhea, his presentation is more consistent with WPW syndrome given the palpitations and classic ECG findings. (Choice E) Vasovagal (neurocardiogenic) syncope can have many triggering factors (eg, stress, pain) and is caused by decreased sympathetic drive (causing vasodilation) combined with increased parasympathetic response (causing bradycardia). The ECG findings in this patient make cardiogenic syncope due to WPW more likely. Educational objective: The classic Wolff-Parkinson-White pattern on ECG consists of short PR interval, delta wave, and wide QRS complex. Some patients can become symptomatic with tachyarrhythmias, and syncope can result. References: WPW and preexcitation syndromes (http://www.ncbi.nlm.nih.gov/pubmed/18368860)

Question 19

A 17-year-old girl is brought to an urgent care center for sunburn. She was jogging outside for an hour today and subsequently developed redness and pain on the exposed portion of her arms and face. The patient says, "It wasn't even that sunny today. I've been outside for a lot longer than this and have never had a sunburn this bad." Her medical history includes acne vulgaris for which she was prescribed a topical and an oral medication, neither of which she can remember by name. She does not take any other medications and has no allergies. The patient is a long-distance runner for her high school track team. She lives with her father, who has dyslipidemia. Physical examination shows numerous comedones, papules, and pustules on her face and chest. Confluent areas of erythema, warmth, and edema are present on the patient's face and upper extremities. Her left arm is shown in the image below. Over the next several months, the patient consistently uses a topical retinoid, a topical antibiotic, and an oral antibiotic. She is also prescribed a daily oral contraceptive as adjunctive therapy for acne. Six months later, the patient returns to the office for a follow-up appointment. She says she is not sexually active, and review of systems is positive for occasional feelings of anxiety with school workload. Current BMI is 19 kg/m². Blood pressure is 90/60 mm Hg, and pulse is 68/min. Examination shows oily skin on the forehead, nose, and cheeks. Inflammatory and nodular acne is present on the face, back, and upper arms. There is also scarring on the forehead. The patient has no hirsutism or acanthosis nigricans. Urine β-hCG is negative. The patient desires the most effective treatment, and appropriate pharmacotherapy is discussed. Which of the following should also be discussed prior to prescribing the new medication?

Accepted Answer

Explanation: Isotretinoin is a highly effective oral treatment for nodulocystic acne, acne that has failed other topical/oral therapy, and acne leading to scarring. Acne may initially flare up and subsequently improve within the first few weeks of isotretinoin therapy (Choice E). One course of treatment over a period of 4-6 months usually provides a permanent improvement in acne. Use of isotretinoin is limited due to adverse side effects, most notably teratogenicity (eg, spontaneous abortion, congenital malformations). Female patients of childbearing potential, regardless of sexual activity, must have 2 negative pregnancy tests before starting therapy. Those who are sexually active must also use 2 concurrent methods of contraception (eg, oral contraceptive pill and condom) a month before, during, and a month after treatment. Isotretinoin use in a male sexual partner is not associated with teratogenicity as minimal amounts of the drug are excreted in semen. Patients should also be counseled on other common side effects of isotretinoin, including dry skin and mucous membranes and myalgias. Because of the increased risk for adverse effects (eg, pseudotumor cerebri with concomitant tetracycline use), other systemic treatments for acne should be discontinued in patients initiating isotretinoin therapy (Choice B). (Choice A) Isotretinoin commonly causes transient hypertriglyceridemia, and lipids should be monitored during therapy. A family history of hypertriglyceridemia is not a contraindication to initiating therapy, and dyslipidemia rarely requires discontinuation of therapy. (Choice C) Spironolactone, a diuretic and an androgen receptor blocker, is an adjunctive treatment for women with acne (particularly around the lower face and jaw) and hirsutism. This patient does not have hirsutism. In addition, isotretinoin is the most effective treatment for acne with scarring. Educational objective: Isotretinoin, used in the treatment of nodulocystic acne, is teratogenic. Female patients with childbearing potential must have 2 negative pregnancy tests and commit to 2 forms of contraception prior to initiating therapy. References: Preventing and managing the side effects of isotretinoin. (http://www.ncbi.nlm.nih.gov/pubmed/18786498)

Question 20

A 70-year-old man is brought to the emergency department by his wife after he passed out earlier this morning.  The patient was sitting in a chair watching TV when he lost consciousness for approximately 3 minutes before spontaneously recovering.  He did not fall off the chair, and his wife did not observe any convulsive limb movements.  There was no soiling of his clothes by urine or stool.  She says, "Doc, it has never happened to him before.  He was completely unresponsive and looked pale.  I got really scared."  In the emergency department the patient has no headache, nausea, chest discomfort, or shortness of breath.  He has no recollection of what happened and did not feel anything out of the ordinary beforehand.  Medical history includes hypertension, hyperlipidemia, type 2 diabetes mellitus, and coronary artery disease.  The patient had an anterolateral myocardial infarction 2 years ago and underwent coronary stent placement.  Since then, he has had no episodes of angina.  His lifestyle is sedentary and he spends little time outdoors.  He becomes short of breath when climbing a flight of stairs.  On initial evaluation the patient appears comfortable and asks if he can go home.  Temperature is 36.7 C (98 F), blood pressure is 130/86 mm Hg sitting and 125/85 mm Hg standing, pulse is 78/min, and respirations are 16/min.  Pulse oximetry shows 98% on room air.  Neurologic examination is nonfocal.  ECG shows normal sinus rhythm with anterolateral Q waves, unchanged from prior ECG.  Blood cell counts, serum chemistry studies, and chest x-ray are within normal limits.  Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_be65_b64a_8f63_4fe2eb19bb01_MD0005_00 This patient most likely experienced cardiac syncope due to ventricular tachycardia (VT). Syncope due to VT usually has no warning symptoms (other than palpitations in some patients). The arrhythmia spontaneously terminates within a few minutes, resulting in cardiac output restoration and rapid patient recovery with no residual symptoms. Recognition of cardiac syncope is crucial due to the high risk of sudden cardiac death. Absence of autonomic prodromal symptoms (eg, nausea, diaphoresis, feeling of warmth), which are usually present prior to a benign syncopal event, suggests cardiac syncope. The presence of underlying structural heart disease (eg, Q waves suggesting ischemic scarring from previous myocardial infarction, cardiomyopathy with low ejection fraction) specifically suggests cardiac syncope due to VT. This patient should be admitted to undergo telemetry monitoring (to attempt to detect arrhythmia) and echocardiography (to evaluate left ventricular function and identify wall motion abnormality). Depending on the findings, treatment with some combination of pharmacologic therapy (eg, amiodarone), catheter ablation, or placement of an implantable cardiac defibrillator may be indicated. (Choice B) This patient is at risk of experiencing recurrent VT that could result in sudden cardiac death; therefore, discharge home with a Holter monitor is not appropriate and inpatient monitoring and workup are indicated. (Choice C) CT scan of the head without contrast is appropriate for patients with suspected stroke or seizure or following a fall, but it is not indicated in the workup of syncope. This patient did not fall off the chair and has no evidence of trauma, has no focal neurologic deficits (making stroke less likely), and experienced no abnormal movements or incontinence (making seizure less likely). (Choice D) This patient may require coronary angiography if echocardiogram shows a new wall motion defect or markedly reduced left ventricular ejection fraction; however, coronary angiography is not indicated prior to other workup. (Choice E) Reassurance and discharge home with syncope education are appropriate following vasovagal syncope, commonly triggered by prolonged standing or emotional stress and usually accompanied by autonomic prodrome. This patient's absence of prodrome and history of ischemic heart disease make cardiac syncope more likely. Temporary pallor may occur with any cause of syncope due to transient hypoperfusion. Educational objective: Cardiac syncope due to ventricular tachycardia is suggested by the abrupt onset of syncope without prodrome and the presence of underlying structural heart disease. These patients are at risk of sudden cardiac death and require definitive evaluation and management. References: Guidelines for the diagnosis and management of syncope. (http://www.ncbi.nlm.nih.gov/pubmed/19713422) Syncope: a review of emergency department management and disposition. (http://www.ncbi.nlm.nih.gov/pubmed/27752576)

Exam 1: Advanced Clinical Medicine