A 45-year-old obese woman with a history of obstructive sleep apnea and obesity hypoventilation syndrome presents with worsening shortness of breath. She is afebrile and requires supplemental oxygen. On examination, she has a right-sided heave with a loud S2 and a systolic murmur along the right sternal border. Her liver is pulsatile. The patient is admitted and a right heart catheterization is performed.
Which of the following best represents the likely findings during this procedure? (Note: LVEF is left ventricular ejection fraction, RAP is right atrial pressure, PAP is mean pulmonary artery pressure, PCWP is pulmonary capillary wedge pressure.)
Normal LVEF, ≠ RAP, ≠ PAP, normal PCWP. In patients with chronic hypoxemia (obstructive sleep apnea, obesity hypoventilation syndrome), there is an increased risk of pulmonary hypertension; therefore, treatment of these underlying conditions is essential to prevent this, since pulmonary hypertension has a high morbidity and mortality. The findings on examination support that this patient has right heart failure. Because the primary problem is hypertension in the pulmonary arteries, the PCWP (equivalent to the left atrial pressure) will be normal, and LVEF will often be normal as long as the left ventricle gets sufficient preload.
A 22-year-old African American woman presents for evaluation of scars on her earlobes. The patient reports that 1 year ago she had her ears pierced. Since the piercing, her ear lobes have not healed and have formed large scars that are itchy and painful. Physical examination reveals excessive scar tissue on the left and right earlobes. Both earlobes are tender to palpation.
Which of the following is the best treatment for this condition?
Intralesional corticosteroids. This patient is presenting with keloids on her bilateral earlobes. Keloids are benign fibrous growths that develop in scar tissue and result from excessive extracellular matrix and dermal fibroblast production. Keloids can be painful and are more common in African American patients. The best way of treating keloids is with intralesional corticosteroids. (A) There is a high rate of recurrence with surgical excision, though the earlobes often have a lower rate of recurrence. (B, D) Cryosurgery and topical corticosteroids are not effective. (E) Nickel allergies are common and can cause severe erythema and swelling. Excessive scar tissue that extends beyond the site of original trauma is by definition a keloid (vs. a hypertrophic scar, in which there is excessive scar tissue limited to the site of trauma).
A 51-year-old man presents with fever, chills, productive cough, and wheezing. The patient also endorses night sweats. His is diagnosed with pneumonia and started on a fluoroquinolone antibiotic. Two of his sputum samples are positive for acid-fast bacilli (AFB). The nurses are concerned about their exposure to this patient.
Which of the following is the best course of action for individuals exposed to TB?
Place PPD now and repeat in 3 months. It is recommended by the Center for Disease Control (CDC) that all health care workers who are exposed to a contagious patient with TB immediately receive a PPD test. If negative, the PPD test is repeated in 3 months to monitor any change in status that might have occurred from exposure to TB.
A 65-year-old man undergoes a right carotid endarterectomy for a 90% stenosis. Four months following surgery, carotid ultrasound demonstrates 40% stenosis of the right internal carotid.
What is the most likely etiology of the restenosis?
Endothelial hyperplasia. Endothelial hyperplasia is a common cause of early re-stenosis following carotid endarterectomy, and this often regresses over time. (A) Redevelopment of atherosclerotic disease in such a short time frame would be unlikely. (C) Hyaline arteriosclerosis is associated with hypertension. (D) Vasospasm is a complication of filter devices placed during the procedure, but is unlikely to occur after the procedure.
A 34-year-old man presents with a low-grade fever, chest pain, and dyspnea. A few days ago he states that he felt fatigued and had myalgias. He has no past medical history. A chest radiograph shows a widened mediastinum.
What is the most likely diagnosis?
Anthrax. The respiratory symptoms and a widened mediastinum on chest radiograph make pulmonary anthrax the most likely diagnosis. This disease progresses from flu-like symptoms to mediastinitis and pulmonary hemorrhage. (A, B) Influenza and pulmonary embolism would not produce a widened mediastinum on chest x-ray. (D) Aortic dissection produces a widened mediastinum on chest x-ray, but the patient is young without any obvious risk factors, and the presence of fever also makes this less likely. (E) A pneumothorax would be seen on chest x-ray.
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