NYACP Board Review Question of the Week 
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May 25, 2021
Question Recap: A 60-year-old man presents to clinic with fatigue, leg swelling, and abdominal distension. His symptoms began six to eight months ago. He has no fever and his vital signs are normal. His medical history is significant for type 2 diabetes mellitus, dyslipidemia, and hyperthyroidism. He does not smoke or drink. His BMI is 31. Upon physical exam, there is mild splenomegaly.
Laboratory results include hemoglobin 10 mg/dL, platelets 85,000/cc, leukocytes 7,000/cc, sodium 130 mEq/L, potassium 4.1 mEq/L, creatinine 1 mg/dL, albumin 2.5 g/dL, AST 62 u/L, ALT 49 u/L, INR 1.8. Ascitic fluid analysis reveals albumin 1.2 g/dL, protein 1.7 g/dL, and leukocyte count 450/cc (25% neutrophils). Diuretics are started.
What is the best next step in the management of this patient?
Responses Received from Members (491 Total):
Correct Response is: C. Upper endoscopy
Question Explanation: Given the clinical presentation, elevated INR, thrombocytopenia, splenomegaly, and serum albumin ascites gradient SAAG >1.1, the most likely diagnosis in this case is decompensated liver cirrhosis. All cirrhotic patients should undergo upper endoscopy to detect esophageal varices because of the high mortality associated with this condition.
Non-selective beta blockers like propranolol are indicated as prophylaxis among patients with esophageal varices. They do not stop active bleeding, nor do they prevent the formation of new varices. Endoscopic ligation is reserved for patients with large varices who do not respond to medical treatment. Patients who undergo endoscopic ligation should have repeat upper endoscopy until all varices are ligated.
Fluoroquinolones like moxifloxacin are used to prevent spontaneous bacterial peritonitis (SBP) among ascitic patients. Prophylaxis for SBP is used when the ascitic fluid albumin level is <1 or there has been a previous episode of SBP. This patient’s polymorphonuclear cells is 113/cc, which does not meet criteria of SBP (must be > 250/cc).
While liver biopsy is sometimes used to evaluate hepatocellular carcinoma in cirrhotic patients, the guidelines recommend ultrasound surveillance every six months. Abdominal CT is associated with higher radiation risk and will not aid in ruling out esophageal varices, which is the most important step in the management of this case.
May 18, 2021
Question Recap: Which of the following anti-diabetic medications is associated with euglycemic diabetic ketoacidosis?
Responses Received from Members (547 Total):
Correct Response is: C. Empagliflozin
Question Explanation: Diabetic ketoacidosis (DKA) is defined as a triad of hyperglycemia, anion gap metabolic acidosis, and increased plasma/urine ketones. Euglycemic DKA is a rare entity of DKA but without the hyperglycemia. Euglycemic DKA is associated with partial treatment of diabetes, carbohydrate restriction, and sodium-glucose co-transporter 2 (SGLT-2) inhibitors such as empagliflozin, dapagliflozin, and canagliflozin. Diabetic patients taking SGLT-2 inhibitors who present with nausea, vomiting, fatigue, and metabolic acidosis should be checked for plasma/urine ketones even in the absence of hyperglycemia to rule out euglycemic DKA. Other adverse events of SGLT-2 inhibitors include genital tract infections and increased risk of limb amputation due to gangrene. The mechanism of SGLT-2 induced euglycemic DKA (euDKA) is shown below.
May 11, 2021
Question Recap: A 67-year-old man presents to the emergency department with a one-week history of non-bloody diarrhea and mild abdominal pain. He is not nauseated, and there is no mucus in the stool. Three months ago, he was prescribed antibiotics for urinary tract infection. After he took the antibiotics, he was found to have Clostridioides (Clostridium) difficile infection and was prescribed oral vancomycin for 10 days. His vital signs are normal. Physical examination reveals a soft abdomen with mild tenderness in the left lower quadrant. There is no rebound tenderness. Stool PCR for clostridium difficile is positive.
What is the best therapy?
Responses Received from Members (531 Total):
Correct Response is: A. Oral vancomycin only
Question Explanation: This is a case of recurrent Clostridium difficile infection (CDI). The most common cause of CDI recurrence is the germination of persistent spores from initial infection, not drug resistance. Management of recurrent CDI includes prolonged oral vancomycin (two weeks) or a 10-day course of oral fidaxomicin.
IV metronidazole for CDI is used only in the setting of fulminant infection circulatory shock or hemodynamic instability, toxic megacolon, or ileus.
Vancomycin is never given via IV to treat CDI. If the patient has ileus and can’t take oral medications, vancomycin is used rectally, since vancomycin does not pass the bowel wall in either direction.
With a second recurrence treat with either fidaxomycin or with vancomycin followed by rifaximin.
Initial CDI is treated more effectively with either oral vancomycin or oral fidaxomicin.
May 4, 2021
Question Recap: A 50-year-old man presents to clinic with epigastric pain that comes once or twice weekly and lasts two or three days in a row. His symptoms began about 12 months ago. There is no vomiting, diarrhea, blood in the stool, or weight loss. He takes omeprazole for GERD. His family history is unremarkable. Vitals are normal and there are no significant findings on physical exam. He is married and sexually active with his wife. He works as a construction worker and drinks a few bottles of beer daily. He does not smoke or use illicit drugs. Upper endoscopy reveals gastric varices near the fundus. HCV antibody is negative. Abdominal X-ray is shown below.
What is the most likely diagnosis?
Responses Received from Members (524 Total):
Correct Response is: D. Splenic vein thrombosis
Question Explanation: The most likely diagnosis in this excessive alcohol drinker is chronic pancreatitis, evident by the pancreatic calcification on X-ray. The splenic vein runs across the posterior surface of the pancreas and chronic pancreatitis can cause splenic vein thrombosis. Gastric variceal bleeding is the most common symptom of splenic vein thrombosis. Esophageal varices are seen with splenic vein thrombosis.
Functional dyspepsia is a diagnosis of exclusion. This patient’s abnormal upper endoscopy makes functional dyspepsia an unlikely diagnosis. Similarly, the history of excessive alcohol use and gastric varices near the fundus makes H. Pylori an unlikely diagnosis.
Liver cirrhosis is associated with portal hypertension and esophageal varices, which were not visible on upper endoscopy.
Gastroparesis is a complication of diabetes mellitus and typically presents with nausea, vomiting, and delayed gastric emptying rate. Additionally, gastroparesis does not case gastric varices.
April 27, 2021
Question Recap: A 39-year-old woman presents to clinic with fatigue, bloating, cold intolerance, and menstrual cycle irregularities. These symptoms began six weeks ago. She was diagnosed with hypothyroidism when she was 23 and has been taking thyroid replacement medications ever since with 100% adherence. However, her TSH has recently became elevated and stayed that way. She takes her levothyroxine on an empty stomach 30-60 minutes before the first meal of the day. She does not take over the counter medications or supplements. She is up to date with all age appropriate vaccines and has no other significant medical issues. She is sexually active with women only. Vitals are normal and physical examination is unremarkable with the exception of enlarged thyroid gland. She does not smoke or drink.
Laboratory results include: hemoglobin 8.5 g/dL, MCV 60 fL, AST 70 U/L, ALT 85 U/L, TSH 20 mU/L, free T4 0.5 ng/dL.
Which of the following should be obtained?
Responses Received from Members (456 Total):
Correct Response is: D. Tissue transglutaminase IgA antibodies
Question Explanation: In the absence of drug interactions (antacids, bile acid sequestrants, estrogen-containing contraceptives) or improper administration of levothyroxine (with meals or coffee), the most likely diagnosis in this case is celiac disease causing decreased thyroid replacement absorption in the intestines. This is also most likely the reason for her anemia (iron malabsorption). Tissue transglutaminase IgA antibodies and endoscopy will confirm the diagnosis.
While a small amount of T3 is released by the thyroid gland itself, the majority of the physiologically active T3 is derived from peripheral conversion of T4. Serum T3 levels do not correlate with physiologic action of the thyroid gland because T3 is usually normal even in profound hypothyroidism.
Thyrotropin-receptor antibodies cause Grave’s disease, in which TSH is significantly suppressed and ophthalmic manifestation is present.
This is a case of primary hypothyroidism, and thyroid peroxidase antibodies will not be useful in the management of the case (thyroid peroxidase antibodies are associated with Hashimoto’s thyroiditis).
If the celiac disease is confirmed, iodine replacement should be initiated to counteract the nutritional deficiency from malabsorption.
CD55 and CD59 are used to diagnose paroxysmal nocturnal hemoglobinuria and will not be useful in this case of hypothyroidism.
April 20, 2021
Question Recap:
A 67-year-old man presents to clinic with constant fatigue that started eight weeks ago. He used to be able to train at the gym and live an active lifestyle but hasn’t been able to do so for a while. He has not lost weight and has no abdominal pain or abnormal bowel movements. He does not drink or smoke. His past medical history includes hypertension and type 2 diabetes mellitus for which he takes chlorthalidone and metformin, respectively.
Vital signs are stable and physical exam is unremarkable. Laboratory results show hemoglobin 8 mg/dL, MCV 65 um, platelets 220,000/cc, leukocytes 6,000/cc, creatinine 1.1 mg/dL, INR 1.0, stool positive for occult blood. Both upper and lower endoscopy are performed and the results are unremarkable. The patient is up to date with all age-appropriate vaccines.
What is the best next step in the management of this patient?
Responses Received from Members (533 Total):
Correct Response is: B. Wireless capsule endoscopy
Question Explanation:
The most likely diagnosis in this case is occult gastrointestinal bleeding. This is supported by the clinical signs and symptoms of iron deficiency anemia, microcytosis, and heme-positive stool.
Patients with heme-positive stool, even those without signs or symptoms of iron deficiency anemia, should undergo colonoscopy. If colonoscopy is negative, upper endoscopy is recommended to localize the source of bleeding.
If both upper and lower endoscopy are negative, wireless capsule endoscopy is recommended to evaluate the small bowel. If wireless capsule endoscopy is negative, laparoscopy might be performed.
Angiography is recommended for patients who have overt, high-volume bleeding to facilitate embolization or resection once the lesion is localized.
Tissue transglutaminase antibody titer is elevated in celiac disease. Patients with celiac disease can present with iron deficiency anemia, but the pathology is most likely due to malabsorption rather than occult bleeding. Additionally, this patient underwent upper endoscopy which was negative, making celiac disease an unlikely diagnosis.
Serum lipase is elevated in pancreatic disease, but the level does not correlate with disease severity. Non-pancreatic causes of elevated serum lipase level include ileus, cholecystitis, diabetic ketoacidosis, and kidney disease. Serum lipase will not be beneficial in the evaluation or management of this case.
April 13, 2021
Question Recap: A 60-year-old man presents to clinic with back pain that started a few weeks ago. He tried over the counter analgesics with some relief, but the pain persisted. His father was diagnosed with colon cancer at the age of 65. The patient has no significant medical history. His vital signs are normal and his physical exam reveals no hepatomegaly or splenomegaly. There are no skin rashes, and he is up to date with all age appropriate vaccines. Laboratory results include: hemoglobin 8.7 g/dL, MCV 85 fL, platelets 200,000/cc, sodium 142 mEq/L, potassium 4 mEq/L, chloride 107 mEq/L, HCO3 23 mEq/L, calcium 11.5 mg/dL, creatinine 2.1 mg/dL, albumin 4.0 mg/dL. Serum electrophoresis does not reveal an M-spike. Spine X-ray is shown below.
What is the best next step in the management of this patient?
Responses Received from Members (530 Total):
Correct Response is: D. Urine immunofixation
Question Explanation: The most likely diagnosis in this case is multiple myeloma. Bone pain, hypercalcemia, normocytic anemia, and renal insufficiency are suggestive of the diagnosis. Multiple myeloma diagnosis is confirmed with serum electrophoresis (detecting M-spike) and urine electrophoresis (detecting light and heavy chains). However, 1 in 4 multiple myeloma patients secrete only urine light chains, which does not produce M-spike on serum electrophoresis. Thus, urine immunofixation is necessary to detect monoclonal light chains.
Bone marrow biopsy is sometimes used quantitatively to determine the number of plasma cells. It is most useful in the rare multiple myeloma patient who does not secrete monoclonal proteins (non-secretory multiple myeloma). However, this is an invasive procedure and the patient must be thoroughly investigated through urine immunofixation before undergoing bone marrow biopsy.
Chest and abdomen CT scans are used to look for bone disease among multiple myeloma patients who present with bone pain but have negative X-ray. This patient’s X-ray shows compression fracture at the L4 level; therefore a CT scan is unnecessary. Once a fracture is confirmed with X-ray, a CT does not give additional information.
Persons with no family history of colon cancer should start colonoscopy screening at the age of 50 and every 10 years thereafter. Those with family history of colon cancer should start screening at the age of 40, or 10 years younger than the age at which the relative got diagnosed, whichever comes earlier. Colonoscopy will not alter the course of management in this multiple myeloma case.
Tramadol is a prodrug that is converted by the CYP450 system into morphine and another metabolite that inhibits the reuptake of norepinephrine and serotonin.
April 6, 2021
Question Recap: A 65-year-old man presents to clinic with dyspnea on exertion and tension headaches. His symptoms started eight weeks ago. He is retired and lives alone. His medical history is significant for GERD, COPD, and hypertension. He used to smoke one pack of cigarettes daily but quit 10 years ago. He drinks beer socially. His BP is 150/90 mmHg, pulse 87/min, respiratory rate 15/min, O2 saturation 90% (room air). His BMI is 31. Physical exam is unremarkable.
Laboratory results include hemoglobin 20 g/dL, serum erythropoietin (EPO) 95 IU/L (3x upper normal limit).
Which of the following is most likely to determine a diagnosis?
Responses Received from Members (533 Total):
Correct Response is: C. Exercise Oxygen Saturation
Question Explanation: The most likely diagnosis in this case is secondary polycythemia, evidenced by the high hemoglobin level and elevated EPO. In primary polycythemia or polycythemia vera (PCV), the hemoglobin is raised but the EPO is not. The most common cause of primary PCV is JAK2 mutation, which can be confirmed by bone marrow biopsy and JAK2 testing.
In secondary polycythemia, both hemoglobin and EPO are raised. Causes of secondary polycythemia include:
- Chronic hypoxemia
- EPO producing tumors
- Androgen supplements
- Growth hormone administration
The most likely cause in this case is COPD induced hypoxemia, which in turn stimulates the kidney to produce EPO. The confirmatory test is post-exercise oxygen saturation, which will be markedly decreased. Abdomen CT is used to look for EPO-producing tumors in the kidney or liver if the exercise oxygen saturation is normal.
Upper endoscopy is not useful in the diagnosis of PCV.
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