A 36-year-old female presents for evaluation of elevated blood pressure. She is asymptomatic and does not take any medications. On examination her blood pressure is 160/96 mm Hg and her BMI is 26 kg/m2 . Fasting laboratory studies include the following:
Sodium 142 mEq/L (N 136-145)
Potassium 3....
ABFM ITE 2024 QUESTIONS &
ANSWERS COMPLETELY SOLVED!
A 36-year-old female presents for evaluation of elevated blood pressure. She is
asymptomatic and does not take any medications. On examination her blood pressure
is 160/96 mm Hg and her BMI is 26 kg/m2 . Fasting laboratory studies include the
following:
Sodium 142 mEq/L (N 136-145)
Potassium 3.0 mEq/L (N 3.5-5.1)
Creatinine 0.76 mg/dL (N 0.6-1.1)
Glucose 97 mg/dL
Which one of the following additional laboratory evaluations should be performed to
assess her blood pressure?
A) A 24-hour urine collection for 5-hydroxyindoleacetic acid (5-HIAA)
B) A serum aldosterone/renin ratio
C) A serum cortisol level
D) A serum cystatin C level - ANSWERSANSWER: B Primary hyperaldosteronism
should be suspected as a cause for hypertension if a patient has a spontaneously low
potassium level or persistent hypertension despite the use of three or more
antihypertensive medications, including a diuretic. This can be evaluated by checking a
serum renin activity level and a serum aldosterone concentration and determining the
aldosterone/renin ratio. Primary hyperaldosteronism typically presents with a very low
serum renin activity level and an elevated serum aldosterone concentration. A 24-hour
urine collection for 5-hydroxyindoleacetic acid (5-HIAA) would be used to evaluate for a
neuroendocrine tumor, which can present as chronic flushing and diarrhea. Cortisol
levels can be checked if Cushing syndrome is suspected. Hypertension can be present
in Cushing syndrome, but it is typically associated with other signs such as obesity and
an elevated blood glucose level due to insulin resistance. Cystatin C is a marker of renal
function and measurement would not be indicated given this patient's normal creatinine
level.
A 26-year-old male diagnosed with coccidioidomycosis (valley fever) develops a rash on
the extensor surfaces of his lower legs consisting of painful, subcutaneous,
nonulcerated, erythematous nodules. This rash is consistent with which one of the
following?
A) Erythema ab igne
B) Erythema infectiosum
C) Erythema migrans
D) Erythema multiforme
E) Erythema nodosum - ANSWERSANSWER: E Erythema nodosum, a panniculitis that
typically affects the subcutaneous fat on the anterior surface of the lower legs, is
associated with coccidioidomycosis (valley fever) and can suggest the diagnosis. It is a
, manifestation of the patient's immune response and often indicates a good prognosis. In
addition to coccidioidomycosis, it can also be associated with streptococcal infections
as well as tuberculosis. Erythema ab igne is a cutaneous rash caused by prolonged
heat exposure (such as a heating pad) presenting as an otherwise asymptomatic, red,
reticulated pattern on the skin. Erythema infectiosum is associated with parvovirus B19
infection and is usually seen in young children. It manifests as an erythematous rash of
the face (slapped cheek appearance), arms, and legs. Erythema migrans is an
expanding, erythematous, annular rash with or without central clearing and is often
associated with tick exposure (Lyme disease). Erythema multiforme consists of raised,
annular, target-like lesions with central erythema and is usually associated with herpes
simplex virus type 1.
A 50-year-old male presents with chronic abdominal pain. A workup leads you to
suspect peptic ulcer disease, and you refer him for endoscopy, which shows a small
duodenal ulcer. The endoscopist also notes some small esophageal varices without red
wale signs. Further evaluation confirms that the patient has compensated cirrhosis in
the setting of alcohol use disorder. He readily accepts this diagnosis and enters an
Alcoholics Anonymous program. His ulcer symptoms resolve with antibiotic therapy for
Helicobacter pylori. He says he has abstained from alcohol for 6 weeks, and he would
like to further reduce his risks from cirrhosis. The most appropriate next step in the
management of his esophageal varices would be
A) octreotide (Sandostatin)
B) omeprazole (Prilosec)
C) propranolol
D) endoscopic variceal ligation
E) repeat endoscopy in 1-2 years - ANSWERSANSWER: E Primary prevention of
variceal hemorrhage is an important consideration in the management of patients with
cirrhosis. Although this patient's varices were diagnosed incidentally, patients with
cirrhosis and clinically significant portal hypertension should be screened for varices
every 2-3 years with esophagogastroduodenoscopy (EGD). EGD can be deferred in
patients with platelet counts <150,000/mm3 and transient elastography with liver
stiffness <20 kPa. Once esophageal varices are identified, the criteria for initiating
prophylaxis to prevent variceal hemorrhage is based on the risk of bleeding. Findings
associated with a high risk of bleeding include small varices in patients with
decompensated cirrhosis, small varices with red wale signs (thinning of the variceal
wall), and medium to large varices. Patients with small varices not meeting these criteria
have a low risk of hemorrhage and do not require prophylaxis. They should be
rescreened with EGD every 1-2 years. For patients requiring treatment due to high-risk
features, options for primary prophylaxis of hemorrhage include nonselective -blockers
such as propranolol or endoscopic variceal ligation. Treatment decisions are based on
patient preference, other potential contraindications, and local resources. The need for
repeat endoscopy in these cases will depend on the clinical circumstances. If
nonselective -blockers are used, they should be continued indefinitely. Octreotide is
only given intravenously for acute hemorrhage. There is no evidence that omeprazole
slows the progression of esophageal varices.
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