NYACP Board Review Question of the Week
Every other Tuesday, NYACP members are sent a Board Review Question from ACP's MKSAP 18 to test professional knowledge and help prepare for the exam. Participant totals and answer percentages are distributed on the first Thursday of the month in IM Connected, the Chapter's eNewsletter, and are also published on this page.
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April 23, 2024
MKSAP 18 Cardiovascular Medicine, Question 24
Stem:
A 72-year-old man is evaluated for exertional left calf and foot pain. Three weeks ago, the patient developed an ulcer on the medial aspect of the left great toe. His medical history is significant for coronary artery disease, type 2 diabetes mellitus, hypertension, and hyperlipidemia. Medications are low-dose aspirin, lisinopril, metoprolol, metformin, and atorvastatin.
On physical examination, blood pressure is 155/84 mm; other vital signs are normal. There are no palpable pulses in the left leg. Right femoral, popliteal, and pedal pulses are faint. Ankle-brachial index testing:
Right systolic brachial pressure 155 mm Hg
Left systolic brachial pressure 145 mm Hg
Left posterior tibialis pressure 255 mm Hg
Left dorsalis pedis pressure 255 mm Hg
Which of the following is the most appropriate diagnostic test to perform next?
A. Exercise ankle-brachial index
B. Lower extremity CT angiography
C. Toe-brachial index
D. Venous duplex ultrasonography
Responses Received from Members (852 Responses):
The Correct Answer is: C. Toe-brachial index
Educational Objective
Diagnose peripheral artery disease in a patient with noncompressible arteries.
Critique
The most appropriate diagnostic test to perform next in this patient is a toe-brachial index. The diagnostic tool that is most frequently used to identify peripheral artery disease (PAD) is the ankle-brachial index (ABI). To calculate the ABI, the higher ankle pressure in each leg is divided by the higher brachial pressure. An ABI of 0.90 or lower establishes a diagnosis of PAD, whereas an ABI greater than 1.40 indicates the presence of calcified, noncompressible arteries in the lower extremities and is considered uninterpretable. In patients with an ABI greater than 1.40, an appropriate next step is to measure toe pressure or calculate a toe-brachial index (systolic great toe pressure divided by systolic brachial pressure). A great toe systolic pressure below 40 mm Hg or a toe-brachial index below 0.70 is consistent with PAD. Because this patient has a left ABI of 1.65, a toe- brachial index is indicated.
Exercise ABI testing is useful when patients have a borderline ABI (0.91-1.00) or normal ABI (1.00-1.40) and a high likelihood of PAD. The American Heart Association has proposed a postexercise ankle pressure decrease of more than 30 mm Hg or a postexercise ABI decrease of more than 20% as a diagnostic criterion for PAD. Other organizations have proposed a postexercise ABI of less than 0.90 and/or a 30–mm Hg drop in ankle pressure after exercise. This patient's resting ABI value is greater than 1.40; therefore, exercise ABI is not indicated to diagnose PAD.
CT angiography and magnetic resonance angiography are often reserved for planning endovascular or surgical revascularization rather than for diagnosis of PAD.
In patients with venous leg ulcers, venous duplex ultrasonography is indicated to evaluate for chronic venous insufficiency and deep vein thrombosis (acute or chronic). The location of the ulceration and the lack of other findings consistent with venous disease make that diagnosis unlikely, and venous duplex ultrasonography is therefore unnecessary.
Key Points
In patients with an ankle-brachial index greater than 1.40, a toe-brachial index may be used to diagnose peripheral artery disease.
Bibliography
Aboyans V, Criqui MH, Abraham P, Allison MA, Creager MA, Diehm C, et al; American Heart Association Council on Peripheral Vascular Disease. Measurement and interpretation of the ankle-brachial index: a scientific statement from the American Heart Association. Circulation. 2012;126:2890-909. PMID: 23159553 doi:10.1161/CIR.0b013e318276fbcb
Copyright 2018, American College of Physicians.
April 9, 2024
MKSAP 18 Booster Pack B General Internal Medicine Question 14
Stem:
A 62-year-old woman is evaluated for a 3-month history of a palpable nonpainful breast mass. She has no nipple discharge. She underwent menarche at age 14 years and menopause at age 55 years. She has no history of previous breast biopsies and no family history of breast, ovarian, or colorectal cancer. She took hormone replacement therapy for 1 year after menopause because of vasomotor symptoms.
On physical examination, temperature is 37.4 °C (99.3 °F), blood pressure is 135/80 mm Hg, pulse rate is 80/min, and respiration rate is 16/min. There is a firm, nontender mass in the upper outer quadrant of the right breast, approximately 2 cm at its largest dimension. There is no nipple discharge or change in or fixation to the overlying skin. There is no axillary lymphadenopathy. A diagnostic mammogram obtained 2 days before the visit revealed no masses or calcifications.
Which of the following is the most appropriate management of this patient?
A. Breast MRI
B. Breast ultrasonography
C. Core-needle biopsy
D. Reassurance
Responses Received from Members (894 Responses):
The Correct Answer is: C. Core-needle biopsy
Educational Objective
Evaluate a breast mass in a postmenopausal woman.
Critique
This patient should undergo core-needle biopsy of the mass. She presents with a normal mammogram but findings on physical examination that are suspicious for breast cancer. The palpable mass is nonpainful, persistent, and firm. Although her normal mammogram could be interpreted as reassuring, approximately 10% to 20% of palpable breast cancers can be missed by ultrasonography or screening mammography. She requires further evaluation to definitively rule in or rule out malignancy. Core-needle biopsy, with or without ultrasonographic or stereotactic guidance, provides excellent tissue sampling for pathology and receptor status. It is the test of choice for most solid lesions.
Breast MRI would likely better define the breast lesion, which was not visualized on mammography, but would not replace the need for a tissue diagnosis in this patient.
Breast ultrasonography is particularly useful in defining possible cystic lesions identified on examination or mammography. However, given the highly suspicious nature of this patient's breast mass, ultrasonography would not be indicated.
Reassurance is inappropriate because definitive diagnosis of the mass via tissue sampling is imperative in this postmenopausal woman.
Key Points
Core-needle biopsy is the test of choice for most solid breast masses.
Bibliography
Albisinni S, Biaou I, Marcelis Q, Aoun F, De Nunzio C, Roumeguère T. New medical treatments for lower urinary tract symptoms due to benign prostatic hyperplasia and future perspectives. BMC Urol. 2016;16:58. PMID: 27629059 doi:10.1186/s12894-016-0176-0
Copyright 2018, American College of Physicians.