Question 193
A 47-year-old male presents to an acute care clinic with complaints of a cough, fever, and difficulty breathing with exertion. He was diagnosed with asthma 4 years ago, frequently has episodes of allergic rhinitis, and underwent removal of nasal polyps surgically 1 year ago. A complete blood count reveals an elevated concentration of eosinophils (13%). Laboratory testing also reveals the presence of MPO-ANCA (p-ANCA). A chest x-ray reveals patchy infiltrates. Of the following, what would a biopsy of the lung most likely reveal?
A. Granulomatous inflammation and eosinophilic infiltrates of vessels
B. Neoplastic eosinophils
C. Nematode infestation
D. Foreign material, consistent with IV drug abuse
E. Small cell carcinoma
Answer for Question 193
Answer: A (Granulomatous inflammation and eosinophilic infiltrates of vessels)
Explanation: The clinical presentation (male patient in their 40s with a history of asthma, allergic rhinitis, nasal polyps, eosinophilia and pulmonary infiltrates) is consistent with eosinophilic granulomatosis with polyangiitis (formerly known as Churg Strauss syndrome). Some of these patients (about 40%) will have MPO-ANCA (p-ANCA) directed against myeloperoxidase. A biopsy of the lung will reveal granulomatous inflammation and eosinophilic infiltrates of the vessels. Eosinophilic leukemia is very rare. While a nematode infestation could cause the eosinophilia, it would not be associated with the MPO-ANCA.
Question 194
A 61-year-old female presents to the emergency room with her husband. She reports that over the past two days she has had a severe headache and pain in her jaw on the left side, and now for the past 4 hours she has had double vision. Of the following, what is the most likely diagnosis?
A. Temporal arteritis
B. A non-ST elevation myocardial infarct with embolized mural thrombus
C. Aortic dissection with involvement of carotid artery
D. Polyarteritis nodosa
E. Late-onset systemic lupus erythematosus
Answer for Question 194
Answer: A (Temporal arteritis)
Explanation: The clinical presentation (patient >55 years of age, presenting with headache, jaw pain, and visual changes) is consistent with temporal arteritis. Embolization of mural thrombus could cause a stroke; however, the jaw pain associated with an acute myocardial infarct would not likely occur in association with the embolized mural thrombus; instead, the jaw pain would occur at the time of the infarct, but the embolus would occur days or weeks later. There is no history of chest pain to support an aortic dissection and involvement of the common carotid artery (where extension would occur) would likely cause a stroke. While a headache can occur during a stroke, the patient has no focal neurologic change (e.g., weakness, sensation loss or both on one side of her body). Polyarteritis nodosa does not commonly involve the aorta and while SLE can cause vasculitis, the changes in the clinical scenario are most consistent with the distribution of involvement of temporal arteritis.
Question 195
A 60-year-old female presents to the emergency room. She reports that over the past four days she has had a headache, which worsened today, and is now associated with pain in her jaw on the left side. For the past 2 hours she has had blurry vision. Laboratory testing will reveal an increase in which of the following?
A. Troponin I
B. Alkaline phosphatase
C. ESR
D. D-dimer
E. TSH
Answer for Question 195
Answer: C (ESR)
Explanation: The clinical presentation (patient >55 years of age, presenting with headache, jaw pain, and visual changes) is consistent with temporal arteritis. Patients with temporal arteritis will most often have an elevated ESR and elevated C-reactive protein. While a d-dimer can be elevated in patients with thrombosis, thrombosis is not necessarily a component of temporal arteritis, and thus would be less likely to be elevated.
Question 196
A 62-year-old male with systemic hypertension and a 35-pack-year smoking history presents to his primary care physician with complaints that over the past year he has had increasing shortness of breath when walking with his wife. While he used to be able to walk about a half of a mile, he can now only walk about 2 blocks before needing to stop. He also has shortness of breath at night and has started sleeping on two pillows and propped up in bed. Physical examination reveals an S3; however, there is no pitting edema of the lower extremities and his liver is not palpable. Of the following, which additional physical examination finding is most likely to be identified?
A. Elevated jugular venous distention
B. Massive splenomegaly
C. Crackles on auscultation of the chest
D. Bruit in the midportion of the right side of the back
E. Deviation of the tongue when extended
Answer for Question 196
Answer: C (Crackles on auscultation of the chest)
Explanation: Chronic dyspnea, manifested as dyspnea on exertion and orthopnea (i.e., shortness of breath at night requiring pillows) associated with a history of risk factors for coronary artery atherosclerosis (the hypertension and smoking history) and the physical finding of an S3, is consistent with congestive heart failure. As there is no pitting edema of the lower extremities or hepatosplenomegaly, this individual has left-sided heart failure, and, of the choices, crackles on auscultation of the chest is the most likely additional finding and which would be caused by fluid in the lungs. Elevated jugular venous distention is consistent with right sided failure. While it could be possible for an individual to have right sided heart failure and an elevated jugular venous distention without pitting edema or hepatosplenomegaly, the better choice is still crackles, as individuals with right sided symptoms due to left sided failure should also have fluid in the lungs. Although right sided heart failure can lead to splenomegaly, it is not likely massive, and, as above, the absence of pitting edema and hepatosplenomegaly greatly decrease the chance that the right side of the heart is failing. A bruit in the right mid back could suggest renal artery stenosis, which could be present in an older male with risk factors for atherosclerosis, but does not have to be present. And, deviation of the tongue would indicate hypoglossal nerve injury, which is not related to the case presentation, unless there were a subtle stroke.
Question 197
A 48-year-old male presents to an acute care clinic complaining of worsening shortness of breath with exertion. He has not seen a physician in 20 years and considers himself healthy, eating a balanced diet and getting plenty of exercise. Physical examination reveals a harsh, late-peaking systolic murmur that is heard best at the 2nd right intercostal space and radiates to the carotid arteries. In addition, the point of maximal impulse is sustained and the second heart sound is difficult to hear. Of the following, what is the most likely diagnosis?
A. Aortic stenosis due to degenerative calcification of a bicuspid aortic valve
B. Aortic stenosis due to degenerative calcification of a tricuspid aortic valve
C. Aortic regurgitation
D. Mitral stenosis
E. Mitral regurgitation
Answer for Question 197
Answer: A (Aortic stenosis due to degenerative calcification of a bicuspid aortic valve)
Explanation: The murmur is characteristic for aortic stenosis. The muffled 2nd heart sound is due to the fact that the valve is relatively immobile. Given the young age of the patient, the aortic stenosis is most likely due to a calcified bicuspid aortic valve, as aortic stenosis due to calcification of a tricuspid aortic valve normally occurs later in life.
Question 198
A 63-year-old female presents to her primary care physician. Yesterday she passed out while doing dishes, and for the past two weeks she has felt like her heart was beating irregularly and she sometimes she has shortness of breath while working in her vegetable garden. Her past medical history includes a laparoscopic cholecystectomy 25 years ago. Physical examination reveals an irregularly irregular pulse. Auscultation of her chest reveals no murmurs, gallops, or other abnormalities. If her disease process is not treated, of the following, which is she at greatest risk for?
A. Mitral stenosis
B. Atrial myxoma
C. Acute pericarditis
D. Local thrombosis of a coronary artery leading to acute myocardial infarct
E. Pulmonary hypertension
F. Acute cerebral infarct
Answer for Question 198
Answer: F (Acute cerebral infarct)
Explanation: The physical examination reveals an irregularly irregular pulse, which is consistent with atrial fibrillation. Atrial fibrillation can cause syncope and palpitations, as the patient reports. Individuals with atrial fibrillation are at risk for forming mural thrombi in the left atrium. If these mural thrombi break loose and embolize, they can lead to a cerebral infarct (among other conditions). While embolism can lead to an acute myocardial infarct, atrial fibrillation would not predispose to the development of a thrombus within a coronary artery itself. If a thrombus forms locally, it is not an embolus. A thrombus can embolize; however, if this were the case, the thrombus would not have developed locally – it would have developed at a remote location and been carried by blood flow to the point where it caused symptoms. Atrial fibrillation can occur as a result of left atrial dilation and hypertrophy from mitral stenosis, but it is not a direct cause of mitral stenosis.
