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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November 18, 2025
MKSAP 19 Pulmonary/Critical Care Medicine, Question 71
A 45-year-old woman is evaluated in the ICU for community-acquired pneumonia and septic shock. Appropriate resuscitation efforts are under way.
On physical examination, temperature is 39.2 °C (102.6 °F), blood pressure is 92/50 mm Hg, pulse rate is 120/min, and respiration rate is 25/min. Oxygen saturation is 85% on bilevel positive airway pressure, and FIO2 is 0.60. Auscultation of the lungs reveals decreased breath sounds over the left lung base.
Chest radiograph reveals scattered infiltrates in the lower lungs with dense consolidation in the left lower lobe and a small left pleural effusion.
Which of the following is the most appropriate diagnostic test for evaluation of the pleural effusion?
A. Bedside thoracic ultrasonography
B. Chest CT with contrast
C. Lateral decubitus film
D. Thoracic MRI
Responses Received from Members (701 Responses):
The Correct Answer is: A. Bedside thoracic ultrasonography
Educational Objective:
Evaluate a pleural effusion in the ICU.
The most appropriate diagnostic test to perform is bedside thoracic ultrasonography (Option A). The patient is presenting with septic shock and hypoxemic respiratory failure. Her presentation is secondary to a multifocal pneumonia with an associated left pleural effusion. Once a pleural effusion is detected on chest radiograph, bedside thoracic ultrasonography can be used to characterize the fluid and the feasibility of drainage. Thoracic point-of-care ultrasonography is a helpful addition particularly in patients who are semirecumbent, such as those who are critically ill, and does not necessitate transporting the patient from the ICU or interrupting resuscitation. Thoracic ultrasonography allows for the easy identification of a free-flowing or loculated pleural effusion and can differentiate between solid masses and loculated effusions. The presence of a loculated pleural effusion in the setting of severe community-acquired pneumonia would be an indication for diagnostic sampling and drainage of the effusion.
Advantages of CT imaging with contrast (Option B) include the ability to detect small amounts of pleural fluid; assessment of coexisting intrathoracic abnormalities such as pulmonary masses and malignant pleural disease; and identification of an empyema, as enhancement of the pleura around the fluid creates a lenticular-shaped opacity. However, CT imaging requires the patient to be removed from the ICU and exposes the patient to irradiation.
A lateral decubitus film (Option C) would also differentiate between a free-flowing and a loculated pleural effusion. However, it is now rarely used in the ICU because bedside ultrasonography is easy to access and to use. In addition, a lateral decubitus film would not demonstrate the feasibility of drainage as ultrasound does.
Finally, a thoracic MRI (Option D) can effectively display pleural tumors, chest wall invasion, spinal cord invasion, and pleural effusions. However, it is not as useful as thoracic ultrasonography and CT for evaluation of parapneumonic effusions, it is expensive, and it requires the patient to be moved from the ICU.
Key Point
Thoracic ultrasonography allows for the easy identification of a free-flowing or loculated pleural effusion and can differentiate between solid masses and loculated effusions.
Thoracic point-of-care ultrasonography is a helpful addition particularly in patients who are semirecumbent, such as those who are critically ill, and does not necessitate moving the patient from the ICU.
Bibliography
Porcel JM. Chest imaging for the diagnosis of complicated parapneumonic effusions. Curr Opin Pulm Med. 2018;24:398-402. PMID: 29517587 doi:10.1097/MCP.0000000000000485
Copyright 2019, American College of Physicians.
November 4, 2025
MKSAP 19 General Internal Medicine 1, Question 13
A 59-year-old man undergoes follow-up evaluation for persistent major depressive disorder of several years' duration. He is currently being treated with venlafaxine; he previously took fluoxetine titrated to the maximum dosage before it was tapered off owing to lack of response and intolerable sexual side effects. He also takes aripiprazole and receives psychotherapy. He reports no improvement in his symptoms, which do not include mania or hypomania. He has not had suicidal ideation. He has no other medical conditions and takes no other medications.
On physical examination, vital signs are normal. He appears tired, with a sad, blunted affect. Score on the PHQ-9 is 17, unchanged from his previous score.
Which of the following is the most appropriate treatment?
A. Add intranasal esketamine
B. Add lithium
C. Discontinue aripiprazole and initiate risperidone
D. Discontinue venlafaxine and initiate sertraline
Responses Received from Members (468 Responses):
The Correct Answer is: A. Add intranasal esketamine
Educational Objective:
Treat resistant depression with esketamine.
The most appropriate treatment is the addition of intranasal esketamine (Option A). This patient, who has severe major depressive disorder that is unresponsive to maximal combination oral therapy with a second-generation antidepressant (SGA) and an antipsychotic agent as well as psychotherapy, is a candidate for intranasal esketamine. Intranasal esketamine is approved as an adjunct to oral antidepressant agents for treatment-resistant major depressive disorder and major depressive disorder with suicidal ideation. Esketamine is a glutamate receptor modulator, which offers a novel mechanism of action for depression treatment. Unlike most other antidepressant therapies, treatment effect is almost immediate; however, there are several barriers to its use. Labeling indications restrict the drug to patients whose symptoms have failed to respond to two courses of appropriately prescribed antidepressant therapy, and patients cannot drive or operate machinery for 24 hours after administration. Esketamine must be administered intranasally in a physician's office under direct supervision, and physicians must be enrolled in an FDA-mandated Risk Evaluation and Mitigation Strategies (REMS) program. Esketamine carries a black box warning for dissociation, sedation, and suicidal thoughts. The cost of the month-long induction is very expensive.
Lithium (Option B) is indicated for the treatment of bipolar 1 disorder and schizoaffective disorder. It is not an approved therapy for major depressive disorder. This patient reports no symptoms of mania that would justify the use of this therapy.
Risperidone (Option C), an antipsychotic agent, is not indicated for the treatment of major depressive disorder. However, the addition of other antipsychotic medications to SGAs is an appropriate strategy for treatment failure. Approved regimens include olanzapine plus fluoxetine, and aripiprazole or quetiapine plus any SGA.
Selective serotonin reuptake inhibitors (SSRIs) are one of four classes of SGAs considered first-line therapy for major depressive disorder. Other SGAs include serotonin-norepinephrine reuptake inhibitors, serotonin modulators, and atypical antidepressants. Sertraline (Option D) is an SSRI. This patient's symptoms have already failed to respond to treatment with one SSRI (fluoxetine) at
maximum doses. In addition, the sexual side effects he experienced can occur with all SSRIs and are likely to recur with sertraline; therefore, this drug is not a good option for the patient.
Key Point
Intranasal esketamine can be added to oral antidepressant agents for treatment-resistant major depressive disorder.
Unlike most other antidepressant therapies, esketamine has an almost immediate effect on depression symptoms.
Bibliography
Daly EJ, Singh JB, Fedgchin M, et al. Efficacy and safety of intranasal esketamine adjunctive to oral antidepressant therapy in treatment-resistant depression: a randomized clinical trial. JAMA Psychiatry. 2018;75:139-48. PMID: 29282469 doi:10.1001/jamapsychiatry.2017.3739
Copyright 2019, American College of Physicians.