A 68-year-old man with long-standing hypertension has sudden, severe, tearing chest pain that goes through to his back. His blood pressure is 178/96 mm Hg in the right arm and 142/80 mm Hg in the left arm. A chest x-ray shows a widened mediastinum. Which of the following is the most likely diagnosis?
Aortic dissection Sudden tearing chest pain radiating to the back, a blood pressure difference between the arms and a widened mediastinum in a hypertensive patient are classic for aortic dissection. It’s an emergency, usually confirmed with CT angiography.
A 72-year-old woman with hypertension and type 2 diabetes is found to have atrial fibrillation. She has no mitral stenosis or mechanical heart valve, her kidney function is normal and she has no history of bleeding. Which of the following is the most appropriate therapy to reduce her risk of stroke?
Apixaban Her CHA2DS2-VASc score is 4 (age 65 to 74, female sex, hypertension, diabetes), so oral anticoagulation is recommended. For nonvalvular atrial fibrillation, a direct oral anticoagulant such as apixaban is preferred over warfarin, and antiplatelet drugs aren’t an adequate substitute.
A 61-year-old man has had 40 minutes of crushing substernal chest pain. Electrocardiography shows ST-segment elevation in leads II, III and aVF, with ST depression in leads I and aVL. Occlusion of which of the following arteries is most likely?
Right coronary artery ST elevation in II, III and aVF means an inferior myocardial infarction. The inferior wall is supplied by the right coronary artery in most people, so the RCA is the most likely culprit. Reciprocal ST depression in I and aVL supports this.
A 22-year-old tall, thin man who smokes has sudden right-sided pleuritic chest pain and mild shortness of breath. His heart rate is 96/min, blood pressure is 124/78 mm Hg and oxygen saturation is 95% on room air. Breath sounds are decreased on the right, the right chest is hyperresonant to percussion and the trachea is midline. Which of the following is the most likely diagnosis?
Primary spontaneous pneumothorax A tall, thin young male smoker with sudden one-sided pleuritic pain, decreased breath sounds and hyperresonance has a primary spontaneous pneumothorax until proven otherwise. He’s stable with a midline trachea, so it isn’t a tension pneumothorax. A chest x-ray confirms it.
A 34-year-old previously healthy woman has had 3 days of fever and productive cough. She has crackles at the right base, and a chest x-ray shows right lower lobe consolidation. Her vital signs are stable, she’s eating and drinking, and she hasn’t taken antibiotics in the past 3 months. She has no other medical problems. Which of the following is the most appropriate treatment?
Oral amoxicillin This is community-acquired pneumonia in a healthy adult who can be treated at home. For outpatients without comorbidities, current US guidelines recommend high-dose amoxicillin (doxycycline or a macrolide are alternatives in some cases).
A 45-year-old woman has had 10 hours of right upper quadrant pain that began after a fatty meal. Her temperature is 38.4°C (101.1°F), and she stops breathing in when the right upper quadrant is pressed. Her white blood cell count is 14,000/µL. Which of the following is the most appropriate initial imaging study?
Right upper quadrant ultrasonography Fever, right upper quadrant pain and a positive Murphy sign suggest acute cholecystitis. Ultrasonography is the first imaging test: it’s fast, cheap, has no radiation and shows stones, wall thickening and fluid around the gallbladder.
A 71-year-old man has had 2 months of painless jaundice, dark urine, pale stools and a 7-kg (15-lb) weight loss. On examination, he has a palpable, nontender gallbladder. Which of the following is the most likely diagnosis?
Adenocarcinoma of the head of the pancreas Painless jaundice with weight loss in an older adult, plus a palpable nontender gallbladder (Courvoisier sign), points to a malignant blockage of the distal bile duct, most often pancreatic head cancer. Dark urine and pale stools show the jaundice is obstructive.
A 13-year-old boy with a BMI above the 95th percentile has had 3 weeks of dull left knee pain and a limp. He’s afebrile, and the knee examination is normal. When his left hip is flexed, it rotates outward, and internal rotation is limited. Which of the following is the most likely diagnosis?
Slipped capital femoral epiphysis An overweight adolescent with a limp, knee pain that’s really referred hip pain, obligatory external rotation on hip flexion and limited internal rotation has slipped capital femoral epiphysis. Frog-leg and AP x-rays of both hips confirm it, and treatment is surgical pinning.
A 19-year-old woman noticed a single 3-cm oval, pink, scaly patch on her trunk. A week later, many smaller oval scaly patches appeared on her back, lined up along the skin creases. It itches a little. She feels well, her palms and soles are clear and she hasn’t had a new sexual partner. Which of the following is the most likely diagnosis?
Pityriasis rosea A herald patch followed by smaller oval patches along skin lines in a “Christmas tree” pattern is classic pityriasis rosea. It usually clears on its own in 6 to 8 weeks, so treatment is reassurance and itch relief.
A 31-year-old woman has had 3 months of weight loss, palpitations and heat intolerance. On examination, she has a diffuse, nontender goiter, bulging of both eyes and a fine tremor. TSH is low and free T4 is high. Which of the following is the most likely diagnosis?
Graves disease Hyperthyroidism with a diffuse, nontender goiter and exophthalmos is Graves disease. The eye findings are specific to Graves, which is caused by antibodies that stimulate the TSH receptor.
A 63-year-old man with type 2 diabetes also has heart failure with reduced ejection fraction (35%). His hemoglobin A1c is 8.1% on metformin, and his eGFR is 65 mL/min/1.73 m². Adding which of the following medications has been shown to reduce his risk of hospitalization for heart failure?
Empagliflozin SGLT2 inhibitors such as empagliflozin lower glucose and have been shown in large trials to reduce heart failure hospitalization and cardiovascular death. They’re recommended for patients with type 2 diabetes and heart failure.
A 66-year-old man with stage 4 chronic kidney disease takes lisinopril and spironolactone. He comes in with generalized weakness. His serum potassium is 7.1 mEq/L, and his ECG shows peaked T waves and a widened QRS complex. Which of the following is the most appropriate first step?
IV calcium gluconate Severe hyperkalemia with ECG changes is an emergency. IV calcium is given first because it stabilizes the heart muscle within minutes and protects against arrhythmias. Then you shift potassium into cells (insulin with glucose, albuterol) and remove it from the body.
A 44-year-old woman had a sudden, severe headache, “the worst of my life,” while exercising 12 hours ago. She has neck stiffness, and her neurologic examination is otherwise normal. A noncontrast CT of the head is normal. Which of the following is the most appropriate next step?
Lumbar puncture A thunderclap headache with neck stiffness suggests subarachnoid hemorrhage. CT becomes less sensitive as hours pass, so a normal CT 12 hours later doesn’t rule it out. A lumbar puncture looking for red cells and xanthochromia is the next step.
A 38-year-old man woke up this morning with a droop on the right side of his face. He can’t close his right eye or wrinkle the right side of his forehead. The rest of his neurologic examination, including arm and leg strength and speech, is normal, and there’s no rash in or around the ear. Which of the following is the most appropriate treatment?
Oral prednisone Sudden weakness of one whole side of the face, including the forehead, with an otherwise normal exam is Bell palsy, a peripheral facial nerve palsy. Oral corticosteroids started within 72 hours improve recovery. Eye protection matters too, because he can’t close the eye.
A 52-year-old woman who takes sertraline started tramadol 2 days ago for back pain. She is now agitated and sweating, with diarrhea. Her temperature is 38.9°C (102°F) and heart rate is 118/min. She has hyperreflexia and inducible clonus, more in the legs than the arms. Which of the following is the most likely diagnosis?
Serotonin syndrome Two serotonergic drugs (sertraline and tramadol), a rapid onset, agitation, sweating, diarrhea, fever and especially hyperreflexia with clonus are the hallmarks of serotonin syndrome. Treatment starts with stopping the serotonergic drugs and supportive care.
A 29-year-old man in Connecticut has had 5 days of an expanding red rash on his thigh. It’s now 10 cm across with central clearing. He went hiking 2 weeks ago and feels mildly tired. He has no drug allergies. Which of the following is the most appropriate management?
Oral doxycycline An expanding red rash of 5 cm or more after possible tick exposure in an endemic area is erythema migrans, early Lyme disease. It’s diagnosed clinically and treated with oral doxycycline.
A 34-year-old woman with heavy menstrual periods has had several months of fatigue. Her hemoglobin is 9.6 g/dL and mean corpuscular volume is 72 fL. Which of the following sets of iron studies is most likely?
Low ferritin, high total iron-binding capacity Heavy menstrual bleeding with microcytic anemia points to iron deficiency. Ferritin, the iron stores, is low, and the body makes more transferrin to grab what iron it can, so total iron-binding capacity rises.
A 27-year-old woman has left lower quadrant pain and light vaginal bleeding. Her last menstrual period was 7 weeks ago. Her serum hCG is 5,000 mIU/mL. Transvaginal ultrasonography shows no intrauterine pregnancy and a left adnexal mass. Her vital signs are stable. Which of the following is the most likely diagnosis?
Ectopic pregnancy A positive pregnancy test with an hCG level high enough that an intrauterine pregnancy should be visible, no pregnancy in the uterus and an adnexal mass means ectopic pregnancy until proven otherwise. Stable patients may be candidates for methotrexate; unstable patients need surgery.
A 63-year-old woman develops sudden, severe pain in her right eye with headache and nausea after leaving a dark movie theater. She sees halos around lights, and her vision is blurry. The eye is red, the cornea is cloudy, the pupil is mid-dilated and reacts poorly to light, and the eye feels firm. Which of the following is the most likely diagnosis?
Acute angle-closure glaucoma A painful red eye with halos, a cloudy cornea, a fixed mid-dilated pupil and a hard eye after time in the dark is acute angle-closure glaucoma. It’s an emergency that needs pressure-lowering treatment and urgent ophthalmology care to save vision.
A 45-year-old man is admitted with a bleeding duodenal ulcer, and his hemoglobin is 6.8 g/dL. He is a Jehovah’s Witness. He is alert and oriented, understands that refusing blood could lead to his death and refuses a transfusion. Which of the following is the most appropriate action?
Respect his refusal, document the discussion and offer acceptable alternatives An adult with decision-making capacity has the right to refuse treatment, even life-saving treatment. The right step is to respect the refusal, document his understanding and the discussion, and use alternatives he accepts.
United States · Certification exam