NYACP/MedQuest Board Review Question of the Week
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May 26, 2020
Question Recap: A 55-year-old woman presents to the emergency room with bilateral leg edema and decreased urinary frequency. Her symptoms started two days ago. Last week, she was diagnosed with cellulitis and prescribed IV cefazolin. Laboratory results reveal serum creatinine 2.3 mg/dL and platelets 123,000/mm 3. Urinalysis shows 10-15 erythrocytes, 15-20 leukocytes, and trace protein. Wright stain of the urine shows eosinophils. The patient does not take any other medications or supplements. What is the next best step in the management of this patient?
Responses Received from Members (461 Total):
Correct Response is: E. Switch Antibiotics
Question Explanation: The most likely diagnosis in this case is acute interstitial nephritis (AIN), which can be caused by infections, autoimmune diseases, and certain medications such as beta-lactam antibiotics. If AIN is drug-induced, the mainstay approach is discontinuation of the offending drug. There is no conclusive evidence that prednisone will be effective in AIN. Steroids are sometimes used if there is progressive worsening of renal failure and increasing proteinuria. Cyclophosphamide is an alkylating agent used in the treatment of lupus nephritis, not AIN. Renal biopsy is used to assess the response of lupus nephritis to medications; it is not typically performed for AIN. If the creatinine continues to rise even after stopping the offending agent, steroids may be used. Chlorthalidone is a thiazide diuretic, and this class has also been implicated in the etiology of AIN. Additionally, forcing urine out of the patient with a diuretic will not tackle the underlying cause, which is the beta-lactam antibiotic.
May 19, 2020
Question Recap: A 39-year-old man from Mexico City who immigrated to New York City five years ago presents to clinic for HIV screening. His bloodwork comes back negative for HIV, but serology for T cruzi is positive. He is feeling well and does not have any symptoms. He works as a bartender and is sexually active with his long-term girlfriend. He does not smoke and occasionally drinks beer on weekends. What is the next best step in the management of this patient?
Responses Received from Members (446 Total):
Correct Response is: C. EKG
Question Explanation: T. cruzi is a parasite that causes Chagas disease. The main mode of infection is through vector-borne transmission. Chagas disease is endemic to Mexico, Central America, and South America. The acute phase of Chagas disease is characterized by high level parasitemia and usually lasts weeks to months. Patients in the acute phase may have non-specific symptoms like fever, malaise, and headaches. However, a few patients may develop inflammation at the site of inoculation called chagoma. Additionally, chronically infected patients who are immunocompetent will typically have very low parasitemia, and PCR will therefore have low sensitivity. This is why serological markers but not PCR are used to aid in the diagnosis of chronic infection. The chronic phase of the infection is usually asymptomatic. However, 1 in 3 persons infected with T. cruzi chronically will develop cardiac disease and gastrointestinal disease. The cardiac manifestations are much more common that the gastrointestinal manifestations. This is because the gastrointestinal manifestations are almost exclusive to in patients who acquire the infection in South America, but not Mexico or Central America. This patient is from Mexico; therefore, barium swallow study is not needed since the main issue here will most likely be cardiac. The most common and earliest manifestation of cardiac disease in T. cruzi infected patients is ventricular conduction abnormalities. This is why EKG is needed to determine if these conduction abnormalities are present. Echocardiography to determine wall motion, ejection fraction, and valve function is needed in patients who have symptoms or abnormalities on the EKG. Antitrypanosomal drugs like benznidazole are used to kill T. cruzi. Symptomatic treatment with anti-arrhythmic drugs like amiodarone is used to manage cardiac conduction abnormalities. USPSTF recommends that all persons aged 18 to 79 should be screened for HCV at least once in a lifetime, regardless of risk.
May 12, 2020
Question Recap: A 31-year-old woman is taken to the emergency department by her husband because she started experiencing progressive weakness in all four limbs a few hours ago. He tells you that his wife started seeing a white halo in the periphery of her vision and feeling severe neck and back pain last night. Upon physical examination, she is noted to have flaccid paralysis in all four limbs. She is intubated and a brain MRI is obtained and shows T2 hyperintensity. Her medical and family histories are unremarkable. She does not smoke or drink and is up to date with all age appropriate vaccines.
What is the most likely diagnosis?
Responses Received from Members (456 Total):
Correct Response is: D. Neuromyelitis optica (NMO)
Question Explanation: Neuromyelitis optica (NMO) is an immune-mediated inflammatory disorder of the CNS characterized by severe demyelination and axonal damage that predominantly targets both optic nerves and spinal cord. NMO commonly presents with transverse myelitis and typically affects women in their third or fourth decade of life. The visual disturbance in this patient is from optic neuritis. The diagnosis is confirmed with finding anti-aquaporin-4 antibodies. While it can present similarly in terms of weakness and sensory loss, spinal artery infarction will not cause vision impairment because there is no optic neuritis. Spinal artery presents with paralysis and sensory loss exclusively below the level of the cord that infarcts. There will be no antibodies to aquaporin 4. Acute inflammatory demyelination polyradiculoneuropathy (AIPD) presents with weakness that is much greater in the lower extremities and moves higher up the body with the loss of reflexes. NMO is more likely to have spasticity and hyperreflexia below the level of the cord involvement. West Nile virus (WNV) can present with flaccid paralysis, so there is definitely overlap with NMO. However, WNV also presents with meningitis or encephalitis with fever, headache, photophobia and altered mental status. ALS causes dysarthria and bulbar weakness and progresses over months to years. ALS would never be this acute and is purely motor, so there would never be the visual disturbance found in NMO.
May 5, 2020
Question Recap: A 37-year-old man with a history of recurrent headache comes to the emergency department complaining of a unilateral headache. These headaches have been happening four times a day and peak 30 minutes after onset. He had imaging on his last headache which was negative. Physical exam is significant for bloodshot right sclera and rhinorrhea.
What is the next step?
Responses Received from Members (490 Total):
A. Sumitriptan (37%)
B. Ibuprofen (9%)
C. Verapamil (29%)
D. Propranolol (13%)
E. CT scan of the head (12%)
Correct Response is: A. Sumitriptan
Question Explanation: This patient has cluster headaches. Recurrent headaches that are characterized by time to peak pain of less than 90 minutes are most likely cluster headaches. The best initial therapy for cluster headaches is sumitriptan or 100% oxygen. Propranolol is used to prevent migraine. Verapamil and other calcium channel blockers are used to prevent cluster headache. Calcium channel blockers do not terminate a cluster headache that has already occurred. Sumatriptan and the other triptans are abortive therapy for both cluster headaches and migraine headaches.
Obermann M, Holle D, Naegel S, Burmeister J, Diener HC. Pharmacotherapy options for cluster headache. Expert Opin Pharmacother. 2015 Jun;16(8):1177-84.
doi: 10.1517/14656566.2015.1040392. Epub 2015 Apr 24. Review. PubMed PMID: 25911317.
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