Academic Half Day 2/23

Multiple Choice

This person has a pet with over 1000 followers on instagram

• Anastasia

• Hind

• Diamler

• Gabriela

Multiple Choice

A 28-year-old M is evaluated for an acute knee injury. He experienced a twisting injury to the right knee; heard a pop and immediately felt pain. Swelling and inability to bear weight developed soon thereafter. no chronic medical issues or history of knee problems.

On physical examination, an effusion is noted in the right knee. Range of motion elicits pain. Result of the Lachman test is equivocal.

Radiograph of the right knee shows no fractures. MRI shows an isolated partial tear in the right anterior cruciate ligament.

• Diagnostic arthroscopy

• Glucocorticoid injection

• Immediate surgical repair

• Physical therapy

​Treat anterior cruciate ligament tear.

• Tears to the anterior cruciate ligament account for more than half of acute knee injuries.

• Nonoperative therapy for anterior cruciate ligament tears consists of physical therapy and exercises to strengthen the quadriceps, hamstrings, hip abductors, and core muscles.

• Operative and nonoperative therapies are both reasonable options for ACL injuries. Decision making is complex. Factors that are considered include the severity of the tear; the patient's activity level; knee stability; the presence of other injuries (e.g., meniscal tear, other torn ligaments, fracture); and, in some cases, age. Nonoperative therapy for ACL tears consists of 3 months of physical therapy; anti-inflammatory medication; range-of-motion exercises; and exercises to strengthen the quadriceps, hamstrings, hip abductors, and core muscles. For this patient with an isolated partial ACL tear and a sedentary lifestyle, nonoperative management is probably the best option.

• MRI is accurate in the diagnosis of ACL tear, although accuracy declines when attempting to differentiate between a complete and a partial tear or in the diagnosis of chronic degenerative tears. When MRI is compared with diagnostic arthroscopy, MRI is 86% sensitive and 95% specific. Diagnostic arthroscopy (Option A) is not indicated in this patient with a compatible history and MRI showing an ACL tear.

• Glucocorticoid injection therapy (Option B) is commonly used for soft tissue and articular inflammatory conditions, although the evidence of efficacy is often lacking. Common uses of glucocorticoid injection include inflammatory arthritides, tendinopathies, and nerve compression syndromes, but not ACL tear, which is a mechanical injury not an inflammatory condition.

• If surgical ACL repair is necessary, there is no harm in delaying the procedure for several weeks, particularly if there is a chance that physical therapy will result in symptomatic and functional improvement.

Multiple Choice

A 62-year-old woman is evaluated in the emergency department for a 1-hour history of left-sided weakness. The patient also has hypertension. Medications are amlodipine, chlorthalidone, and low-dose aspirin.

On physical examination, blood pressure is 190/105 mm Hg; all other vital signs are normal. The patient is awake and attentive. The pupils are 2 mm in diameter and reactive to light. A left visual field defect, left-sided hemineglect, left facial weakness, and left arm and leg paralysis on the left are noted.

Hemoglobin 12, INR 1.1, Platelet count 320, ptt/pt wnl.

CT scan - intracerebral hemorrhage in the right basal ganglia with a 1-mm midline shift and no intraventricular extension.

• Intravenous nicardipine

• Intravenous nitroprusside

• Platelet transfusion

• Prothrombin complex concentrate

​Treat acute hypertension in intracerebral hemorrhage.

​For patients with intracranial hemorrhage and a systolic blood pressure (SBP) of 150 mm Hg or greater, acute lowering of SBP to 140 mm Hg is safe and effective in improving functional outcome.

Intravenous nitroprusside is not appropriate in patients with elevated intracranial pressure (ICP) because it can further increase ICP.

​Intravenous nitroprusside (Option B) is not appropriate in a patient with ICH who already is at risk for elevated intracranial pressure (ICP) because nitroprusside can further increase ICP by causing intracerebral vasodilation.

Platelet transfusion (Option C) is not appropriate because the patient does not have thrombocytopenia, and there is no evidence that platelet transfusions reverse the coagulopathy associated with antiplatelet agents or prevent hematoma expansion. Additionally, such transfusions increase the risk of coronary stent thrombosis, volume overload, transfusion-related reactions, and acute lung injury.

Prothrombin complex concentrate (Option D) is used in patients with coagulopathy with prolonged prothrombin time and activated partial thromboplastin time, usually associated with warfarin toxicity and life-threatening hemorrhage. Prothrombin complex concentrates are inappropriate because the patient has no evidence of a coagulopathy, and infusing them could increase the risk of thrombotic complications, such as a pulmonary embolism, for which patients with ICH are already at risk.

Multiple Choice

A 28-year-old woman is evaluated in the emergency department for an episode of syncope. Before the syncopal event, she was standing motionless in a warm environment for several minutes, and then she felt warm, dizzy, and nauseated. She lost consciousness for less than 30 seconds. She experienced no trauma during the event and had no confusion afterward. She has previously experienced presyncope at work while standing for long periods of time but had never lost consciousness. She has no medical problems and takes no medications.

On physical examination, vital signs and the remainder of the examination are normal.

An ECG is normal. Treatment?

• Avoidance of triggers

• FludrocortisoneFludrocortisone

• Midodrine

• Propranolol

​Treat vasovagal syncope.

• Vasovagal syncope is treated with targeted education about avoiding triggers, such as prolonged standing and warm environments.

• Physical counterpressure measures, such as squatting and leg crossing, as well as increased fluid and salt intake, can decrease the risk for recurrent vasovagal syncope

• In cases of vasovagal (reflex) syncope, explaining the diagnosis to the patient is strongly recommended, along with targeted education about avoiding triggers (e.g., prolonged standing, warm environments) and how to cope with noxious events (e.g., blood draws). In addition, physical counterpressure measures, such as squatting and leg crossing, and increased fluid and salt intake can decrease the risk for recurrence of the syncopal event in selected patients.

• Fludrocortisone (Option B) has mineralocorticoid activity that increases blood volume through sodium and water retention. Hypertension and hypokalemia are expected adverse effects. Fludrocortisone might be considered for patients with vasovagal syncope not responding to avoidance of triggers and physical counterpressure measures. Studies show a 31% non–statistically significant reduction in recurrent syncope in patients with frequent vasovagal syncope after 2 weeks of therapy. Fludrocortisone is not indicated in this patient who has yet to try more effective means of syncope prevention that are associated with fewer side effects.

• Midodrine (Option C) is metabolized to a peripherally active α-agonist that may counter the reduction of sympathetic neural outflow and resultant venous pooling associated with vasovagal syncopal. A meta-analysis suggests that midodrine can reduce recurrent vasovagal syncopal episodes by 43%. However, this patient has yet to try less expensive, and presumably safer, nonpharmacologic options.

• Trials of β-blockers for the prevention of vasovagal syncope have, for the most part, been negative. However, some studies have documented benefit with β-blocker therapy in patients aged 42 years or older. It is unlikely that this young patient needs or will respond to β-blocker therapy, such as propranolol (Option D).

Multiple Choice

A 51-year-old man is evaluated for resistant hypertension. He was first diagnosed with hypertension 10 years ago, and his blood pressure has been increasingly difficult to control. Medications are amlodipine, hydrochlorothiazide, and metoprolol.

On physical examination, his blood pressure is 164/82 mm Hg. The remainder of the examination is normal.

Laboratory testing for secondary causes of hypertension reveals primary aldosteronism.

A CT scan demonstrates a 1-cm left adrenal mass. Adrenal vein sampling does not reveal unilateral elevations in aldosterone levels. Treatment?

• Bilateral adrenalectomy

• Left adrenalectomy

• Start lisinopril

• Start spironolactone

​Treat primary aldosteronism in a patient with idiopathic hyperaldosteronism

• Medical therapy with an aldosterone receptor blocker (spironolactone or eplerenone) is the treatment of choice for primary aldosteronism caused by idiopathic hyperaldosteronism (bilateral hyperplasia of adrenal glands) and in patients with aldosterone-producing adenoma who are not candidates for surgery.

• Aldosterone has direct inflammatory and fibrotic effects that are independent of its blood pressure effects.

• Although an adrenal mass was noted on imaging, adrenal vein sampling demonstrated that this lesion is not producing aldosterone. Primary aldosteronism caused by hyperplasia of both adrenal glands (idiopathic hyperaldosteronism) is the most likely diagnosis.

• Bilateral adrenalectomy (Option A) is not used in the treatment of primary aldosteronism. This procedure poses unacceptable risks to the patient, including the need for lifelong glucocorticoid and mineralocorticoid replacement, which outweigh the potential benefits. Medical therapy with aldosterone receptor blockers is first-line therapy for bilateral disease.

  Adrenalectomy is effective for unilateral disease and reduces plasma aldosterone and its attendant increased risk for cardiovascular disease. This procedure is only indicated when the adrenal vein sampling lateralizes to the adrenal that is the source of excess aldosterone production.

• For this patient with bilateral (idiopathic) hyperaldosteronism, left adenectomy (Option B) is not indicated.

• Starting lisinopril (Option C) may lead to better control of the hypertension, but it would not block the other adverse effects of hyperaldosteronism. Aldosterone has direct inflammatory and fibrotic effects that are independent of its blood pressure effects; higher cardiovascular morbidity and mortality have been noted in patients with primary aldosteronism compared with those with primary hypertension and similar blood pressure control. Therefore, treating the hypertension with lisinopril without addressing the underlying hyperaldosteronism with an aldosterone receptor blocker would subject this patient to the deleterious effects of excess stimulation of aldosterone receptors.

Multiple Choice

A 67-year-old woman is about to begin highly emetogenic chemotherapy with cyclophosphamide and doxorubicin for stage III breast cancer.

On physical examination, vital signs are normal. There is a healed left lumpectomy incision and a sentinel node sampling incision. The left chest port is in place. Best treatment for potential n/v?

• Lorazepam

• Medical marijuana

• Ondansetron, aprepitant, olanzapine, and dexamethasone

• Ondansetron or dexamethasone

​Manage high-emetic-risk chemotherapy.

• For patients receiving high-emetic-risk chemotherapy, standard antiemetic treatments include a four-drug combination of an NK1 receptor antagonist (aprepitant or netupitant), a 5-hydroxytryptamine-3 receptor antagonist, dexamethasone, and olanzapine.

• Olanzapine, when added to standard antiemetic regimens, has been found to be effective for the treatment of delayed chemotherapy-induced nausea and vomiting.

• Many patients treated with moderate-emetic-risk chemotherapeutic agents (excluding higher-dose carboplatin) can be offered a two-drug combination of a 5-HT₃ receptor antagonist and dexamethasone. Certain chemotherapeutic agents in this category may cause delayed nausea and vomiting (e.g., cyclophosphamide, doxorubicin, and oxaliplatin), and in this case, patients can be offered dexamethasone on days 2 and 3.

• Benzodiazepines, such as lorazepam (Option A), may be used as adjuncts for nausea, although they should not be used as single agents.

• There is insufficient evidence regarding the value of medical marijuana (Option B) for chemotherapy-induced nausea. Evidence is also insufficient for recommending the use of medical marijuana in place of the tested and approved cannabinoids dronabinol and nabilone for the treatment of nausea and vomiting caused by chemotherapy or radiation therapy.

  Patients treated with low-emetic-risk antineoplastic agents should be offered either a single dose of a 5-HT₃ receptor antagonist, such as ondansetron, or a single dose of dexamethasone

• (Option D). A few examples of chemotherapeutic agents with low emetic risk (10%-30%) include fluorouracil, methotrexate, and docetaxel.

Multiple Choice

A 32-year-old man is evaluated in the emergency department for low back pain of several weeks' duration. The pain is in the lumbar area and does not radiate. He has no other symptoms. Medical history is significant for injection drug use.

On physical examination, temperature is 37.4 °C (99.4 °F); other vital signs are normal. Pain is present with gentle palpation of L3 and L4. The pain worsens with hyperextension or flexion of the spine. Marks from injection drug use are seen on the forearms. The remainder of the examination is normal.

Interferon-γ release assay, HIV test results, and blood and urine cultures are pending. Nex step?

• CT of the lumbar spine

• Empirical antibiotic therapy

• MRI of the lumbar spine

• Radiography of the lumbar spine

​Evaluate a patient with suspected osteomyelitis.

• Urgent imaging of the spine is indicated for patients with low back pain and “red flag” symptoms suggesting an underlying process that requires intervention.

• MRI is considered the gold standard in patients with suspected spinal infection, cancer, cord compression, or cauda equina syndrome.

• personal history of cancer or symptoms concerning for cancer (fever, persistent pain, vertebral tenderness, or weight loss) or cauda equina syndrome (bowel or bladder dysfunction, persistent or increasing lower motor neuron weakness, or saddle anesthesia). In this case, the patient's injection drug use and focal vertebral tenderness should heighten suspicion for an acute infection of the spine, such as epidural abscess, diskitis, or osteomyelitis. MRI is considered the gold standard in patients with suspected spinal infection, cancer, cord compression, or cauda equina syndrome.

• CT of the lumbar spine (Option A) would be appropriate if the patient were unable to undergo MRI

• Patients with suspected osteomyelitis-related complications, such as severe sepsis, progressive neurologic deficits, spinal instability, or epidural abscess, should receive empirical antibiotic therapy (Option B). Otherwise, initiation of antibiotic therapy for uncomplicated vertebral osteomyelitis is based on culture results. Blood cultures should be performed in all patients. Testing for Mycobacterium tuberculosis infection (with tuberculin skin testing or an interferon- γ release assay), fungal blood cultures, and serologic tests for Brucella species are appropriate for patients at risk for these pathogens. Image-guided biopsy has a diagnostic yield of approximately 60% and should be used in patients with negative blood culture results.

  Radiography (Option D) can be useful for detecting pathology of the vertebral bodies, such as metastatic cancer or vertebral compression fractures. but not soft tissue structures of the spine,

Multiple Choice

A 68-year-old man is evaluated in follow-up for constant, moderate epigastric pain that radiates to the back. Chronic pancreatitis was diagnosed 1 week ago. He is a 45-pack-year smoker. He does not currently drink alcohol.

On physical examination, vital signs are normal. Deep abdominal palpation elicits mild epigastric tenderness.

A pancreas-protocol CT scan demonstrated an atrophic pancreas with calcifications throughout, no masses, and no cystic lesions. The pancreatic duct caliber is normal.

NSAIDs and acetaminophen are recommended for pain. Additional treatment?

• Oxycodone

• Pancreatic enzyme therapy

• Surgical pancreatic duct decompression

• Tobacco cessation

​Treat chronic pancreatitis with tobacco avoidance.

• The most appropriate additional treatment for pain is tobacco cessation (Option D). The patient has chronic pancreatitis. Long-term tobacco use is an independent risk factor for acute and chronic pancreatitis, as well as pancreatic cancer. It is synergistic with alcohol in promoting morbidity related to pancreatic disease.

• Initial therapy for chronic pancreatitis pain should entail lifestyle modification, including alcohol and tobacco cessation, and simple analgesics. No direct evidence addresses whether alcohol cessation alters the natural history of chronic pancreatitis pain.

• Both alcohol and smoking cessation are strongly recommended in the American College of Gastroenterology (ACG) guideline on chronic pancreatitis. Amitriptyline and nortriptyline may reduce pain from neuropathic conditions and therefore may be useful in patients with chronic pancreatitis. ACG makes no recommendation for or against these drug therapies in patients with chronic pancreatitis.

• Opioids, such as oxycodone (Option A), should be avoided in the long-term management of chronic pancreatitis. Although they may be helpful for analgesia in acute pancreatitis and during flares of chronic pancreatitis, they may lead to hyperesthesia and opioid tolerance. The ACG recommends that opiates may be considered to treat painful chronic pancreatitis only in patients for whom all other reasonable therapeutic options have been exhausted.

• A large systematic review found conflicting evidence for the efficacy of pancreatic enzyme replacement (Option B) in pain control; however, enzyme therapy may improve fat absorption. The ACG makes a conditional recommendation not to use pancreatic enzyme supplements to improve pain in chronic pancreatitis.

• Patients with chronic pancreatitis often experience pain in the setting of pancreatic duct obstruction due to duct stones and strictures. Although surgical approaches to pancreatic duct decompression (Option C) provide better long-term pain relief than endoscopic approaches, they are rarely first-line therapies; in addition, many surgeons operate only after endoscopic approaches to pancreatic drainage have been exhausted or unsuccessful. This patient does not have evidence of pancreatic duct obstruction.

Multiple Choice

A 40-year-old man undergoes follow-up after antiretroviral therapy initiation 1 year ago when he was diagnosed with HIV infection. A chest radiograph at that time showed no infiltrate. He reports being incarcerated a few years ago. Medications are tenofovir alafenamide, emtricitabine, bictegravir, and trimethoprim-sulfamethoxazole.

On physical examination, vital signs are normal. He has no cervical lymphadenopathy, and the lungs are clear to auscultation.

CD 4 count 54 --> 204

HIV RNA 1500000 -> 50

Interferon y release negative --> ----

Next management?

• Acid-fast bacilli blood cultures for Mycobacterium avium complex infection

• Active tuberculosis treatment

• Latent tuberculosis treatment

• No testing or therapy

• Interferon y release assay

​Screen for tuberculosis in an individual with advanced HIV and recovering CD4 cell count.

• Guidelines recommend that tuberculosis screening be repeated in persons with HIV when the CD4 cell count rises to 200/µL.

• This patient has had an excellent response to his antiretroviral therapy (ART), with a dramatic reduction in his HIV RNA and improvement in his CD4 cell count. The original tuberculosis screening was performed at the same time as his initial HIV diagnosis, which resulted in a negative IGRA. His previous incarceration places him at risk for tuberculosis; if he would have acquired tuberculosis previously, he is also at high risk for progression considering his HIV infection. Guidelines recommend that tuberculosis screening be repeated in persons with HIV when the CD4 cell count rises to 200/µL, especially if previous testing was negative and the patient has significant risk factors.

• Mycobacterium avium complex (MAC) infections can be seen in persons with advanced HIV. However, with a pretreatment CD4 cell count of more than 50/µL and a remarkable increase following effective ART, the risk for MAC-related infection is low. (Option A).

• Starting active tuberculosis treatment without confirmatory testing for tuberculosis infection is not appropriate (Option B).

• Similarly, initiating latent tuberculosis treatment without a firm diagnosis would be inappropriate (Option C). Although treatment regimens are effective, several (especially rifamycin-based regimens) have significant interactions with tenofovir alafenamide and integrase inhibitors like bictegravir or dolutegravir. If a diagnosis of latent tuberculosis were established, then treatment would be provided with isoniazid for 6 to 9 months with continuation of current ART or a weekly isoniazid and rifapentine–based regimen for 12 weeks with modification of his current single-tablet ART regimen. The decision to start latent tuberculosis management should not be made without repeating the IGRA first.

• Repeat screening for tuberculosis is indicated in this patient with HIV and recovering CD4 cell count with the decision to initiate therapy informed by results; therefore, no additional testing is not appropriate (Option E).

Multiple Choice

A 54-year-old man is evaluated in the emergency department 2 hours after the onset of acute, sharp, central chest pain that radiates to the back and has intensified over time. He has hypertension. He quit smoking 2 years ago.

On physical examination, blood pressure in the right arm is 90/56 mm Hg, blood pressure in the left arm is not obtainable, and pulse rate is 120/min. He is confused and diaphoretic. Cardiac examination reveals a summation gallop and a grade 3/6 diastolic murmur at the right upper sternal border. Pulmonary examination reveals crackles. Radial pulses are weakly present on the right and absent on the left. Lower extremity pulses are diminished. Skin is cool and mottled.

Chest radiograph reveals a widened mediastinum, and a CT angiogram shows a type A aortic dissection.

• Coronary angiography

• Intravenous nitroprusside

• Open aortic repair

• Thoracic endovascular aortic repair

​Treat acute ascending aortic dissection with open aortic repair.

​In patients with ascending aortic dissection, immediate open aortic repair is imperative to improve survival and reduce morbidity.

• The most appropriate treatment for this patient with acute type A aortic dissection is immediate open aortic repair (Option C). The in-hospital mortality rate for patients with acute type A aortic dissection is greater than 50% with conservative measures and typically 10% to 20% following surgery. In this patient with hypotension, asymmetric arm blood pressures and pulses, and murmur of aortic regurgitation, emergency repair of the aorta and aortic valve repair or replacement are indicated. Delaying surgical repair has been associated with higher morbidity and mortality rates, and expert consensus guidelines recommend emergency repair in patients without clear contraindications.

A retrospective study evaluated the role of coronary angiography (Option A) in patients with type A aortic dissection who underwent emergency aortic surgery. In-hospital mortality rates were no different in those who underwent coronary angiography compared with those who did not. Furthermore, coronary angiography had no impact on coronary artery bypass grafting, as most of these procedures were performed for coronary artery dissection, not atherosclerotic coronary artery disease. These findings support the need to perform aortic surgery as soon as possible and not delay surgery for coronary angiography.

• Although most guidelines recommend that patients with acute aortic dissection be treated aggressively with blood pressure reduction (systolic blood pressure goal of <120 mm Hg in the first hour), this patient should undergo emergent aortic repair due to evidence of cardiogenic shock. When indicated, intravenous β-blocker therapy is used initially to lower blood pressure; decrease the velocity of left ventricular contraction; and reduce heart rate, contractility, and aortic shear stress. Vasodilator therapy, using agents such as nitroprusside (Option B), follows β-blockade.

• There are reports of endovascular repair (Option D) of ascending aortic dissection; however, open surgical repair remains the standard of care and is recommended by current guidelines. Furthermore, this patient requires aortic valve repair or replacement due to evidence of aortic regurgitation, and endovascular repair has not been shown to be effective in patients with evidence of valvular dysfunction.

Multiple Choice

Which apartment complex had a fire this week

• The Reserve

• Avalon

• Tremont

• Heritage at Stone Ridge

Multiple Choice

A 74-year-old man is evaluated for a 6-month history of progressive bilateral calf pain. The discomfort is worse with walking and improves quickly with rest. Medical history is significant for hypertension and hyperlipidemia. He has a 50-pack-year history of smoking but quit 5 years ago. Medications are rosuvastatin, quinapril, and metoprolol.

On physical examination, vital signs are normal. A right femoral bruit is noted. Bilateral femoral pulses and pedal pulses are faint. Motor and sensory examinations are normal; reflexes are normal.

The ankle-brachial index is 0.92 on the right and 0.94 on the left.

• Exercise ankle-brachial index testing

• Invasive angiography

• Magnetic resonance angiography

• Segmental lower extremity blood pressure testing

​Diagnose peripheral artery disease in a patient with normal ankle-brachial index values.

The most appropriate next step is exercise ankle-brachial index (ABI) testing (Option A). This patient has limb symptoms consistent with peripheral artery disease (PAD).

Generally, patients with claudication have an ABI of 0.40 to 0.90,

whereas patients with ischemic rest pain, ulceration, or gangrene have an ABI less than 0.40.

A resting ABI greater than 1.40 indicates the presence of noncompressible, calcified arteries in the lower extremities and is considered uninterpretable.

Exercise ABI testing is useful in patients with ABI values between 0.91 and 1.40 and high pretest probability of PAD. It requires ABI measurements at rest and after treadmill walking or plantar flexion exercises. A post-exercise ankle pressure drop of 30 mm Hg or more or significant decline in the ABI suggests PAD.

• Invasive angiography (Option B) is often reserved for patients with an indication for revascularization, usually either intermittent claudication or chronic limb-threatening ischemia. Likewise, noninvasive anatomic imaging studies, including arterial duplex ultrasonography, CT angiography, and magnetic resonance angiography (Option C), are used to plan for endovascular or surgical revascularization. This patient with typical limb symptoms, normal resting ABI values, and no contraindication to exercise should undergo noninvasive physiologic testing, such as exercise ABI, to confirm the diagnosis of PAD before anatomic assessment is considered.

• Segmental blood pressure measurements (Option D) of the lower extremities are typically performed in patients with abnormal resting ABI values to localize diseased vessels or segments. This procedure involves pulse volume recordings (measurement of the magnitude and contour of blood pulse volume in the lower extremities) and blood pressure measurements at several locations in the lower extremities. In this patient, the resting ABI was normal; thus, the indication for segmental blood pressure measurement is unclear.

Multiple Choice

A 77-year-old man is evaluated in the hospital for shortness of breath, dry cough, pleuritic chest pain, and unintentional 9-kg (20-lb) weight loss over the past 6 months.

On physical examination, the patient appears chronically ill. Vital signs are normal. BMI is 19. There are decreased breath sounds at the right base.

Chest radiograph demonstrates an apparent pleural effusion on the right side, but CT scan reveals a nodular pleura-based mass on the right side.

Occupational Exposure?

• Asbestos

• Coal

• Cobalt

• Silica

​Diagnose asbestos-related lung disease.

​Malignant mesothelioma is associated with occupational asbestos exposure in up to 70% of cases; the radiographic manifestation is usually a unilateral pleural effusion or pleural thickening.

Mesothelioma can have a long latent period, extending into decades after asbestos exposure; therefore, it is essential to obtain a thorough employment history.

• Coal dust (Option B) may result in coal worker's pneumoconiosis. Coal dust may contain high concentrations of silica and silicates, which can result in a rapidly progressive lung disease with imaging characteristics that include honeycombing and ground-glass opacification. Inhalation of coal dust without substantial amounts of silica can result in nodular opacities and eventually massive pulmonary fibrosis. Pleural effusions are not commonly seen.

  Inhalation of hard metal dusts can result in pneumoconiosis.

• Exposure to the hard metal cobalt (Option C) may occur during the processing of cobalt or the use of cobalt by diamond polishers. Cobalt exposure can result in accumulation of alveolar macrophages and multinucleated giant cells in the alveolar space, known as giant cell pneumonia. Chest imaging may show nodular and reticular opacities and small cystic spaces. Pleural effusions are uncommon.

Silicosis describes a spectrum of fibrotic lung disease that results from exposure to silica dust (Option D). Any occupation that disturbs the earth's crust involves potential risk. Workers in industries that cut or grind silica-containing materials, perform sandblasting, or conduct hydraulic fracking for natural gas are at risk. On chest imaging, the disease presents with ground-glass, nodular, interstitial, or fibrotic infiltrates. Pleural effusions are uncommon with silicosis.

Multiple Choice

A 56-year-old woman is evaluated for a 2-year history of osteoarthritis involving the fingers, bases of the thumbs, hips, and knees. She has tried physical and aquatic therapy with minimal benefit, and she is enrolled in a weight loss program. She has no other medical problems and takes no medications.

On physical examination, vital signs are normal. BMI is 29. Heberden and Bouchard nodes and squaring of the bilateral first carpometacarpal joints are present. The first carpometacarpal joints and medial joint line of both knees are tender to palpation. There is pain in the anterior left groin on internal rotation of the hip. There is bony enlargement of the knees, with crepitus on range of motion.

• Acetaminophen

• Duloxetine

• Gabapentin

• Piroxicam

• Tramadol

​Use NSAIDs for initial osteoarthritis treatment.

• NSAIDs are often the initial treatment of choice for osteoarthritis if used judiciously in low-risk patients, with minimizing and monitoring of adverse effects.

• Acetaminophen provides no benefit for hip or knee osteoarthritis; it may be considered as add-on therapy for short-term and episodic use but not as initial therapy.

• Systematic reviews and meta-analyses suggest that acetaminophen (Option A) provides no benefit for hip or knee OA. Acetaminophen may be considered as add-on therapy for short-term and episodic use but is not appropriate as initial therapy for this patient.

• Duloxetine (Option B), a serotonin-norepinephrine reuptake inhibitor with central nervous system activity, has shown efficacy for OA pain and would also be reasonable for this patient. However, it should be used only if NSAIDs are inadequate and is not the best choice for initial therapy.

• Gabapentin (Option C) and pregabalin are more effective than placebo in the treatment of neuropathic pain conditions, such as postherpetic neuralgia and diabetic neuropathy. There is no evidence of their effectiveness for chronic OA pain. Furthermore, they may be associated with dose-dependent dizziness and sedation. Thus, gabapentin is not appropriate for this patient.

• Opioid therapy provides limited benefit for chronic pain control in patients with OA and poses a high risk for toxicity and dependence. Opioid use should be avoided for OA treatment. Tramadol (Option E), a partial opioid with fewer adverse effects and less addictive potential than pure opioids, may be considered in some patients, but it should be used only in limited circumstances, and never as an initial therapy.

Multiple Choice

A 26-year-old woman is evaluated for a 1-week history of a pruritic rash on the chin. She has no other medical problems and takes no medications.

Skin findings are shown.

Treatment?

• Mupirocin ointment

• Oral cephalexin

• Oral doxycycline

• Oral valacyclovir

• Triamcinolone cream

​Treat impetigo.

​Nonbullous impetigo, characterized by eroded erythematous papules or plaques with honey-colored crust, can be treated with topical antibiotics, such as mupirocin or retapamulin.

This patient has typical nonbullous impetigo, characterized by eroded erythematous papules or plaques with honey-colored crust. Impetigo is a superficial infection of the epidermis most commonly caused by Staphylococcus aureus or group A streptococci. Impetigo is classified as bullous or nonbullous; ecthyma is a deeper ulcerative form. Impetigo is most commonly seen in children but can present in adults. Bullous impetigo is usually caused by S. aureus, which produces exfoliative toxins targeting the adhesion molecule desmoglein-1 between keratinocytes.

• Topical antibiotics are as effective as oral antibiotics in the treatment of impetigo. There is no evidence to support the combined use of a topical and an oral antibiotic for impetigo. Systemic antibiotics, such as cephalexin (Option B) and doxycycline (Option C), are helpful in cases of widespread bullous impetigo or when methicillin-resistant S. aureus is suspected or confirmed. However, this patient has localized nonbullous impetigo, and topical antibiotics, such as mupirocin ointment, are effective.

  The classic presentation of cutaneous herpes simplex is a group of painful, small vesicles on an erythematous base, transitioning to pustules and subsequent crusting of the lesions over time. The diagnosis is typically made on clinical grounds. Oral antiviral agents (acyclovir, valacyclovir, or famciclovir) (Option D) can be used to treat primary infections and episodic or secondary recurrences, and as suppression or prophylaxis for patients with six or more recurrences per year.

  Topical glucocorticoids, such as triamcinolone cream (Option E), will most likely cause this localized infection to enlarge. Topical glucocorticoids are used for their anti-inflammatory effects and are most commonly indicated in patients with eczematous dermatosis; they should not be applied to patients with bacterial, viral, or fungal infections.

Multiple Choice

A 68-year-old woman is seen in consultation regarding recently diagnosed JAK2 V617F mutation–positive essential thrombocythemia. She is asymptomatic, has no other medical problems, and takes no medications.

On physical examination, vital signs are normal. The spleen is palpable 2 cm below the left costal margin.

Laboratory studies show a hemoglobin level of 13.5 g/dL (135 g/L), leukocyte count of 6000/μL (6 × 10⁹/L), and platelet count of 685,000/μL (685 × 10⁹/L).

Which of the following is the most appropriate treatment?

• Aspirin

• Hydroxyurea plus aspirin

• Ruxolitinib

• Stem cell transplantation

​Treat essential thrombocythemia with the JAK2 V617F mutation.

• In patients with essential thrombocythemia who have the JAK2 V617F mutation, hydroxyurea plus aspirin should be the initial treatment choice.

• Patients with essential thrombocythemia who are older than 60 years should be treated with aspirin and hydroxyurea regardless of mutation status.

• patient is older than 60 years, hydroxyurea should be included in the treatment plan. Aspirin alone would be insufficient (Option A).

  Ruxolitinib is an oral JAK1/JAK2 inhibitor approved for use in polycythemia vera and myelofibrosis (Option C). It has been shown to be effective at reducing spleen volume and symptom burden in these diseases, but it is not approved for use in ET.

• Stem cell transplantation is the only curative option in BCR-ABL–negative myeloproliferative neoplasms (Option D). However, stem cell transplantation has an associated mortality risk and significant potential morbidity. Therefore, it is not considered in patients with ET or polycythemia vera because prognosis in these diseases is generally excellent with other therapies. Stem cell transplantation is typically reserved for those with higher risk myelofibrosis whose prognosis is otherwise estimated to be poor.

Multiple Choice

A 66-year-old woman is evaluated during a wellness visit. She reports no symptoms. She does not recall the last time she had a Pap smear, and medical records from her previous physician are not available. She has no history of sexually transmitted infection, gynecologic cancer, or surgical history.Which of the following is the most appropriate cervical cancer screening strategy for this patient?

• Cervical biopsy

• Cervical cytology with human papillomavirus testing

• Colposcopy

• Discontinue cervical cancer screening

​Screen for cervical cancer in older adults.

• Routine screening for cervical cancer can be discontinued at age 65 years in non–high-risk women, provided that the patient has undergone adequate prior screening.

• The U.S. Preventive Services Task Force defines adequate prior screening as three consecutive negative cytology results or two consecutive negative cytology tests plus human papillomavirus test results within the past 10 years, with the most recent test occurring within 5 years.

Multiple Choice

A 42-year-old man is evaluated during a follow-up visit for recently confirmed primary hypertension. Hypertension was confirmed with multiple home blood pressure monitoring readings that averaged 148/98 mm Hg. Chlorthalidone was initiated 1 month ago, and home blood pressure monitoring showed readings above target despite adherence to lifestyle interventions and medication. He has no other medical problems and takes no other medication.

On physical examination, blood pressure is 144/94 mm Hg, and pulse rate is 72/min; other vital signs are normal. BMI is 22. The remainder of the examination is normal.

Laboratory studies show a serum creatinine level of 1.0 mg/dL (88.4 µmol/L) and a serum potassium level of 3.5 mEq/L (3.5 mmol/L).Which of the following is the most appropriate additional treatment?

• Amlodipine

• Doxazosin

• Hydralazine

• Metoprolol

Multiple Choice

Which resident was a surgery intern previously?

• Sophia

• Shelia

• Cristina

• Julie

​Treat hypertension in a patient who is unresponsive to initial therapy.

• Except for the combination of ACE inhibitors and angiotensin receptor blockers (ARBs), regimens containing a combination of thiazide diuretics, calcium channel blockers, ACE inhibitors, and ARBs are preferred to achieve blood pressure goals in patients requiring dual antihypertensive therapy.

• The most appropriate additional treatment is amlodipine (Option A). In this patient, a blood pressure (BP) target <130/80 mm Hg is reasonable. Two or more antihypertensive medications are recommended to achieve a BP target of <130/80 mm Hg in most adults with hypertension. According to the American College of Cardiology/American Heart Association guideline, four drug classes (thiazide diuretics, CCBs, ACE inhibitors, or ARBs) lower BP and reduce cardiovascular or renal outcomes. Except for the combination of ACE inhibitors and ARBs, regimens containing a combination of these classes are reasonable to achieve the BP target.

  Doxazosin, hydralazine, and metoprolol (Options B-D) are not recommended drugs for either initial therapy or as add-on therapy in patients with hypertension without the presence of compelling indications. Doxazosin might be considered in male patients with bothersome lower urinary symptoms due to benign prostatic hyperplasia; hydralazine and metoprolol in selected patients with heart failure; or metoprolol in patients with a recent MI