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.
If you are interested in receiving these questions bi-weekly, join us as a member!
If you are a member who needs to receive the questions and newsletter via email, let us know!
October 21, 2025
MKSAP 18 Neurology, Question 71
A 39-year-old woman is evaluated for a 4-year history of headaches that typically occur twice weekly and last 8 to 12 hours when not treated early. The pain is bilateral, frontotemporal, vice-like, and aggravated by physical activity. Approximately half of the episodes have become severe and are associated with combined photophobia and phonophobia. She has had no associated nausea, vomiting, or visual or neurologic symptoms and reports no cranial autonomic features. Stress is the only clear trigger. Naproxen resolves the headache when administered early in the headache course. She takes no other medication.
On physical examination, vital signs are normal; BMI is 23. All other physical examination findings, including those from a neurologic examination, are unremarkable.
Which of the following is the most likely diagnosis?
A. Medication-overuse headache
B. Migraine
C. Sinus headache
D. Tension-type headache
Responses Received from Members (Graph is uploaded on Thursday afternoon):
The Correct Answer is: B. Migraine
Educational Objective:
Diagnose migraine.
The patient's headaches meet the diagnostic criteria for migraine. The International Classification of Headache Disorders (third edition [beta version]) (ICHD-3) criteria require at least five episodes lasting 4 to 72 hours when untreated (or unsuccessfully treated) for this diagnosis. Pain should exhibit two of the following four characteristics: unilateral location, throbbing nature, moderate to severe intensity, and worsening with physical activity. Associated features must include either nausea or a combination of photophobia and phonophobia. Neurologic symptoms reflective of aura are described by 30% of patients with migraine. There must be no evidence of a secondary pathologic cause of the headache. Patients with chronic migraine may report milder attacks meeting tension-type headache criteria with at least some attacks meeting full migraine criteria. This patient described 8- to 12-hour severe attacks aggravated by activity with associated combined photophobia and phonophobia; her neurologic examination findings are normal. Neuroimaging is unnecessary in typical migraine presentations such as hers.
Medication overuse headache may result from overtreatment with acute medication in patients with underlying migraine or tension-type headache. Use of triptans, ergot alkaloids, opioids, or combination analgesics for 10 or more days per month or simple analgesics for 15 or more days per month constitutes medication overuse. Naproxen sodium used 8 days per month does not constitute medication overuse.
Over 90% of self- and clinician-diagnosed “sinus” headaches fulfill criteria for migraine. Acute rhinosinusitis may cause discomfort in the head or face, but headache is late in the disease course and typically a minor feature. Correlation of chronic or recurrent headaches with sinonasal pathology is without solid evidence. Weekly episodes of headache without nasal or sinus symptoms have no origins in the sinus cavities.
Episodic tension-type headache (TTH) is characterized by attacks of a nondisabling headache that lacks the typical features of migraine. Episodes may last from 30 minutes to 1 week. The pain of TTH typically is not severe or aggravated by routine physical activity. Photophobia or phonophobia may be present, but not both, according to ICHD-3 criteria. Mild nausea sometimes is noted with chronic TTH (≥15 days/mo) but not episodic TTH (<15 days/mo). Moderate to severe nausea and aura are not found with either TTH subtype.
Key Point
The diagnosis of migraine requires at least five episodes lasting 4 to 72 hours when untreated (or unsuccessfully treated), with pain exhibiting two of the following characteristics: unilateral location, throbbing nature, moderate to severe intensity, and worsening with physical activity; associated features must include either nausea or a combination of photophobia and phonophobia.
Bibliography
MacGregor EA. Migraine. Ann Intern Med. 2017;166:ITC49-ITC64. PMID: 28384749
Copyright 2018, American College of Physicians.
October 7, 2025
MKSAP 19 Nephrology, Question 43
A 66-year-old man is evaluated in the hospital for acute kidney injury following percutaneous coronary angiography and stent placement 48 hours ago. His medical history is also significant for hypertension, hyperlipidemia, type 2 diabetes mellitus, and diabetic kidney disease. Medications are lisinopril, hydrochlorothiazide, basal and prandial insulin, atorvastatin, metoprolol, clopidogrel, and aspirin.
On physical examination, blood pressure is 132/88 mm Hg, and pulse rate is 58/min without postural changes. Skin is warm and dry. The remainder of the examination is normal.
Kidney ultrasound shows a 10.5-cm right kidney, 11.3-cm left kidney, and normal cortical echogenicity; there is no hydronephrosis.
Which of the following is the most likely diagnosis?
A. Acute tubular necrosis
B. Atheroembolic-induced acute kidney injury
C. Hemolytic uremic syndrome
D. Prerenal acute kidney injury
Responses Received from Members (530 responses):
The Correct Answer is: A. Acute tubular necrosis
Educational Objective:
Diagnose contrast-associated acute tubular necrosis.
The most likely diagnosis is acute tubular necrosis (ATN) (Option A) due to contrast-associated nephropathy (CAN). CAN is characterized by an abrupt increase in the serum creatinine level 24 to 48 hours after contrast exposure. This patient's risk factors for CAN include chronic kidney injury, type 2 diabetes mellitus, and a presumptive large volume contrast exposure. Laboratory findings consistent with the diagnosis include a blood urea nitrogen (BUN)-creatinine ratio of 15:1, urine specific gravity of 1.010 (isosthenuria), urine sodium >40 mEq/L (40 mmol/L), and a urine sediment with a few granular casts; notably, pigmented granular casts do not have to be present to diagnose ATN.
Atheroembolic-induced acute kidney injury (Option B) after a vascular intervention is characterized by a slow, stuttering rise in the serum creatinine level, often not apparent until several days or weeks after the procedure. It is often accompanied by stigmata of atheroemboli to the lower extremities, including livedo reticularis. In this patient, serum creatinine levels began rising 24 hours after the procedure and he has no skin findings.
Clopidogrel can be a cause of hemolytic uremic syndrome (Option C). However, this syndrome is typically characterized by a profound decrease in hemoglobin levels and platelet counts, and a longer exposure to the offending agent would be expected before the full manifestations develop. In this patient, the anemia and thrombocytopenia are modest and nonspecific.
Prerenal acute kidney injury (Option D) is unlikely in the absence of physical findings supporting hypovolemia or reduced cardiac output. Additionally, BUN-creatinine ratio >20:1, urine specific gravity >1.020, and a normal microscopic urinalysis or presence of hyaline casts are more typical.
Key Point
Contrast-associated nephropathy is a cause of acute tubular necrosis and is characterized by an increase in the serum creatinine 24 to 48 hours after contrast exposure.
Bibliography
Mehran R, Dangas GD, Weisbord SD. Contrast-associated acute kidney injury. N Engl J Med. 2019;380:2146-2155. PMID: 31141635 doi:10.1056/NEJMra1805256
Copyright 2019, American College of Physicians.