PE

Q. A patient who has recently undergone hip fracture repair develops the sudden

onset of shortness of breath. His pulse is 110 per minute. The chest is clear to auscultation.

Chest x-ray is normal, and the EKG shows sinus tachycardia. ABG shows

pH 7.48, pCO2 28, pO2 75. What is the next best step in management?

a. Heparin

b. V/Q scan

c. Spiral CT scan

d. D-dimers

e. Lower extremity Doppler

f. Angiography

Answer: A.

When the case so clearly suggests a pulmonary embolus with sudden onset

of shortness of breath and clear lungs in a patient with a risk factor, the first thing to

do after the chest x-ray and blood gas is to start heparin. Do not wait for the results of

V/Q scan or spiral CT to start heparin.

HIGH ACTH LEVEL

 Q. A man with hypercortisolism is found to have an elevated ACTH level that suppresses

with high-dose dexmethasone. MRI of this pituitary shows no visible

lesion. What is the next best step in management?

a. Remove the pituitary

b. Repeat the dexamethasone suppression test

c. Use ketoconazole

d. Do petrosal venous sinus sampling

e. Order a PET scan of the brain

Answer: D.

MRI and CT of the brain lack both sensitivity and specificity in diagnosing

endocrine disorders. It is important to confirm the identity of an adrenal disorder

functionally prior to scanning the patient. This patient has high cortisol with a high

ACTH, indicating either the pituitary or an ectopic source of hyperadrenalism. The fact

that the ACTH levels suppress with high-dose dexamethasone indicates a pituitary

adenoma, which is the cause of Cushing syndrome in about 45 percent of patients. If

the tests point to a pituitary source but the scanning is indeterminant, inferior petrosal

sinus sampling is used to confirm it. Petrosal sinus sampling is also used to localize the

lesion, as well to see which half of a pituitary should be removed.

  

CHEST PAIN

Q. A 56-year-old man comes to the office a few days after an episode of chest pain.

This was his first episode of pain, and he has no risk factors. In the emergency

department, he had a normal EKG and normal CK-MB and was released the next

day. Which of the following is most appropriate in his further management?

a. Repeat CK-MB

b. Statin

c. LDL level

d. Stress (exercise tolerance) testing

e. Angiography

Answer: D.

Stress test when the case is equivocal or uncertain for the presence of CAD. Do not do an angiography unless the stress test is abnormal. Exercise tolerance, or “stress,” testing detects coronary artery disease when the heart rate is raised and ST segment depression is detected. This case is asking you to know that a stress test is a way of increasing the sensitivity of detection of CAD beyond an EKG and enzymes.

  

COLON CA SCREENING QUESTION

Q. An otherwise healthy 32-year-old man asks you about screening tests for colon cancer. He reports that his 2 older sisters had colon cancer at age 40 and 42, his mother had colon cancer at age 40 and endometrial cancer at age 45, and a maternal aunt had breast cancer at a young age. He notes that there was not a history of colon polyps in any family member. What should you

recommend for this patient?

a. Annual fecal occult blood testing

b. Colonoscopy now and every 1 to 2 years thereaft er

c. Colonoscopy with random biopsies to look for infl ammatory bowel disease—if not present, follow routine screening recommendations for average-risk Americans

d. Prophylactic colectomy

e. Reassurance only, since no polyps were found in family members

Ans: Answer b.

With his family history, this patient is at very high risk for colon cancer. It is unlikely that he would have a hereditary polyposis syndrome since no family member had polyps. His family history is highly concerning for hereditary nonpolyposis colorectal cancer (Lynch syndrome) because multiple fi rst-degree relatives were aff ected at an early age and because there is a family history of breast and endometrial cancer. Th is syndrome is associated with a defect in mismatch repair enzymes and leads to microsatellite instability. Screening with fecal occult blood testing is not adequately sensitive for patients at high risk—or even normal risk. Infl ammatory bowel disease does signifi cantly increase the risk of colon cancer, but nothing in the patient’s history suggests that it is present. Prophylactic colectomy would be a consideration only if testing is positive for the defective gene. (See Rex et al and Umar et al in the “Suggested

Reading” list.)

EPISCLERITIS

Q. 45-year-old woman with ulcerative colitis of 3 years’ duration presents with a red eye. She has no pain or headache, and her vision is normal. She has been taking mesalamine at her usual dose.She recently quit smoking. What is the most likely cause of her red eye?
a. Uveitis
b. Giant cell arteritis
c. Episcleritis
d. Nicotine withdrawal and insomnia
e. Viral conjunctivitis

Answer c.

A patient with inflammatory bowel disease who has a red eye most likely has either episcleritis or uveitis. Uveitis is associated with pain in the eye. Episcleritis is typically painless.

Giant cell arteritis typically does not manifest with red eye and is usually associated with headache or visual loss.