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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October 20th, 2026
MKSAP Set D: Question 2, Question ID: CVMCQ24005
A 69-year-old man is evaluated in the emergency department after 2 hours of severe substernal chest pressure that began while at rest. He received aspirin in the ambulance and arrived in the emergency department with minimal residual chest discomfort. Initial ECG was normal. Shortly after arrival, recurrent chest discomfort develops and radiates to the back with associated diaphoresis and shortness of breath. Medical history is unremarkable, and he takes no medications.
On physical examination, blood pressure is 100/52 mm Hg, pulse rate is 54/min, and oxygen saturation is 92% with the patient breathing ambient air; other vital signs are normal. There is a soft diastolic murmur at the left sternal border. Faint bibasilar crackles are present. There is no lower extremity edema.
ECG and chest radiograph are shown.
Which of the following is the most appropriate next step in management?
A. Emergent CT angiography
B. Emergent percutaneous coronary intervention
C. Intravenous fluids
D. Intravenous unfractionated heparin
E. Thrombolytic therapy
Responses Received from Members (Responses will be uploaded Thursday afternoon):
The Correct Answer is: A. Emergent CT angiography
Educational Objective: Diagnose acute ascending aortic dissection.
The most appropriate next step in management is emergent CT angiography (CTA) (Option A) to establish the likely diagnosis of an acute ascending aortic dissection. Although the presentation of ST-elevation myocardial infarction (STEMI) is often clear, several diagnoses can mimic STEMI. Acute aortic syndromes may cause ST-segment elevation if the dissection involves the right coronary artery ostium, resulting in myocardial ischemia. Diagnostic clues to the presence of aortic dissection include a tearing quality of pain with radiation to the back, differential blood pressures and pulses in the upper extremities, aortic insufficiency, pulsus paradoxus, and mediastinal widening on chest radiograph. Invasive aortic angiography, magnetic resonance angiography, and transesophageal echocardiography have sensitivity and specificity similar to CTA (shown; intimal flap indicated by arrow) in diagnosing acute thoracic aortic disease; however, CTA is most often performed because of speed and widespread availability. Acute thoracic aortic dissection is a surgical emergency requiring emergent thoracic surgery. This patient has findings that suggest acute ascending aortic dissection, including chest pain radiating to the back, evidence of aortic insufficiency (diastolic murmur, wide pulse pressure, hypotension, and pulmonary edema), and a widened mediastinum on chest radiograph. He should undergo immediate CTA and likely emergency surgery.
Although this patient is having an acute myocardial infarction, primary percutaneous coronary intervention (Option B) and the associated need for anticoagulation and dual antiplatelet therapy would delay and complicate the surgical intervention that is needed emergently for this patient.
Although inferior myocardial infarction may be associated with right ventricular infarction requiring intravenous fluids (Option C), this patient has pulmonary edema and aortic valvular insufficiency without evidence of active bleeding. Fluid resuscitation is not indicated.
Neither intravenous anticoagulation, such as unfractionated heparin (Option D), nor thrombolytic therapy Option E) is an appropriate treatment for acute aortic dissection, as they both would increase the risk of bleeding and complicate the pending surgery. Other than blood pressure control, usually with intravenous β-blockers, medical therapy is not effective in type A aortic dissection, and immediate surgery is indicated.
Key Points
- Acute aortic syndromes may cause ST-segment elevation if the dissection involves the coronary artery with resultant myocardial ischemia.
- CT angiography (CTA), magnetic resonance angiography, and transesophageal echocardiography have similar sensitivity and specificity in diagnosing acute thoracic aortic disease; however, CTA is most often performed because of speed and widespread availability.
Reference
Kayali F, Jubouri M, Al-Tawil M, et al. Coronary artery involvement in type A aortic dissection: fate of the coronaries. J Card Surg. 2022;37:5233-5242. PMID: 36177668 doi:10.1111/jocs.16981
Multiple-choice questions reprinted with permission from the American College of Physicians.
MKSAP 19. © Copyright 2025 American College of Physicians.
ACP MKSAP. © Copyright 2026 American College of Physicians. All Rights Reserved All Rights Reserved.
October 6th, 2026
MKSAP Set D: Question 1, Question ID: INMCQ24065
A 28-year-old woman is evaluated for recurrent runny nose, nasal itching associated with sneezing, and occasional itching of the ears and throat. Symptoms are bothersome and interfere with concentration at work and sleep. They are worse in the springtime. She has no other medical problems and takes no medications.
On physical examination, vital signs are normal. She has clear rhinorrhea and mildly edematous nasal turbinates.
Which of the following is the most appropriate initial step in treatment?
A. Intranasal fluticasone
B. Intranasal ipratropium
C. Oral cetirizine
D. Oral montelukast
Responses Received from Members (655 Responses):
The Correct Answer is: A. Intranasal fluticasone
Educational Objective: Treat allergic rhinitis.
The most appropriate first step in treatment in this patient with seasonal allergic rhinitis is an intranasal glucocorticoid, such as fluticasone (Option A). Allergic rhinitis causes sneezing, congestion, and rhinorrhea, often secondary to a seasonal allergen or other exposure. It should be distinguished from nonallergic rhinitis, which occurs in response to nonallergic stimuli, such as spicy foods, cold air, and irritants. Watery or red eyes resulting from concomitant allergic conjunctivitis may accompany allergic rhinitis. First-line treatment of allergic rhinitis, as well as nonallergic rhinitis, consists of avoiding precipitating factors and monotherapy with intranasal glucocorticoids. Combination therapy with an intranasal glucocorticoid and an intranasal antihistamine may be used for more significant symptoms. Oral second-generation, nonsedating antihistamines are a reasonable treatment option in patients who do not tolerate glucocorticoids or prefer an oral medication to an intranasal medication. Nonsedating oral antihistamines can also be added to therapy with intranasal glucocorticoids if symptoms persist. This patient has recurrent rhinitis, nasal itching, and sneezing consistent with allergic rhinitis, and an intranasal glucocorticoid such as fluticasone is the most appropriate treatment.
Intranasal ipratropium (Option B) is a treatment option for vasomotor rhinitis but is not recommended as a first-line treatment for allergic rhinitis. It is less effective for allergic rhinitis than intranasal glucocorticoids.
Newer second-generation antihistamines, such as cetirizine (Option C), are effective for treating allergic rhinitis and are less sedating than and preferred to first-generation antihistamines. However, intranasal glucocorticoids are favored as first-line therapy because they are more effective than antihistamine therapy.
A leukotriene antagonist, such as montelukast (Option D), would not be the most appropriate treatment. Leukotriene antagonists are less effective than intranasal glucocorticoids and should not be used as first-line treatment in allergic rhinitis. Furthermore, neuropsychiatric adverse effects have been reported with montelukast, resulting in an FDA boxed warning.
Key Points
• First-line treatment of allergic and nonallergic rhinitis consists of avoiding precipitating factors and monotherapy with intranasal glucocorticoids.
• Patients with allergic rhinitis unresponsive to monotherapy with intranasal glucocorticoids may be treated with combination therapy consisting of an intranasal glucocorticoid and an intranasal antihistamine; oral nonsedating antihistamines are an additional treatment option.
Reference
Wise SK, Damask C, Roland LT, et al. International consensus statement on allergy and rhinology: allergic rhinitis – 2023. Int Forum Allergy Rhinol. 2023;13:293-859. PMID: 36878860 doi:10.1002/alr.23090
Multiple-choice questions reprinted with permission from the American College of Physicians.
MKSAP 19. © Copyright 2025 American College of Physicians.
ACP MKSAP. © Copyright 2026 American College of Physicians. All Rights Reserved All Rights Reserved.