A 38-year-old nurse comes to the emergency department after leaving work early because of a "bad headache." She has had a "cold" with sinus congestion for the past week, and yesterday she began taking an over-the-counter combination of diphenhydramine and pseudoephedrine. She tells you she has a history of "migraines," multiple allergies, premenstrual syndrome and depression, for which she takes phenelzine (a monoamine oxidase inhibitor). Vital signs are:
Which of the following is the most appropriate action?
Correct Answer B:
This patient has hypertension secondary to the effects of the pseudoephedrine and her monoamine oxidase inhibitor. The inhibition of MAO-A causes the rise of norepinephrine, dopamine and serotonin in the synaptic cleft, of MAO-B only of dopamine. Pseudoephedrine displaces norepinephrine from synaptic terminals. For this reasons, nasal sprays such as the one this patient is taking are to be avoided when MAOIs are used. Phentolamine is a reversible alpha-adrenergic receptor blocker that will blunt the effects of the excess catecholamines on arteriolar vasoconstriction.
A 58-year-old man presents to your office with a history of having an episode of sudden visual loss in his right eye. The patient describes the loss of vision as similar to someone pulling a cover over his right eye. Vision returned to the right eye after 10 minutes.
This visual field defect is secondary to which one of the following?
Amaurosis fugax refers to a transient loss of vision in one or both eyes. Patients with transient visual loss almost always present after the episode has resolved; that's why the neurologic and ophthalmologic examination is usually normal. Transient visual obscurations due to papilledema typically last seconds. Thromboembolic events from carotid disease or elsewhere generally last 1 to 15 minutes and only rarely an hour or more. Migraine aura typically lasts 10 to 30 minutes. Transient visual loss from any cause can be described as mild blurring or fogging to complete blackness, and may involve a part of or all of the visual field. Transient monocular visual loss descending over the field of vision (like a curtain or shade) or, less commonly, ascending from below, is highly suggestive of retinal ischemia.
> Scotoma is an area of depressed vision in the visual field, surrounded by an area of less depressed or of normal vision (blind spot).
> Strabismus is a condition in which the visual axes of the eyes are not parallel and the eyes appear to be looking in different directions.
> Esotropia (cross-eye) is a form of strabismus.
> Nyctalopia - night blindness, impaired vision in dim light and in the dark, due to impaired function of certain specialized vision cells in the retina.
A 51-year-old man complains of a 6-month-history of shortness of breath and cough. Physical examination reveals hypertension, digital clubbing and fine bibasilar inspiratory crackles.
Which one of the following is the most likely diagnosis?
Correct Answer D:
Idiopathic pulmonary fibrosis (IPF), also known as cryptogenic fibrosing alveolitis, is a chronic, progressive interstitial lung disease with an unknown cause. It is one of the two classic interstitial lung diseases, the other being sarcoidosis.
IPF is slightly more common in males and usually presents in patients greater than 50 years of age. Average survival from time of diagnosis varies between 2.5 and 3.5 years, depending on severity, although some patients live greater than 10 years.
Symptoms are gradual in onset. The most common are dyspnea (difficulty breathing), but also include nonproductive cough, clubbing (a disfigurement of the fingers), and fine bibasilar inspiratory crackles (Velcro crackles).
→ In COPD thoracic examination reveals barrel chest (hyperinflation), wheezing, which is frequently heard on forced and unforced expiration, diffusely decreased breath sounds, hyperresonance on percussion, and prolonged expiration. In addition, coarse crackles (not fine as in IPF) beginning with inspiration may be heard.
→ Sarcoidosis is an immune system disorder characterized by non-caseating granulomas (small inflammatory nodules). It most commonly arises in young adults. The cause of the disease is still unknown. Virtually any organ can be affected; however, granulomas most often appear in the lungs or the lymph nodes. Common symptoms are vague, such as fatigue unchanged by sleep, lack of energy, weight loss, aches and pains, arthralgia, dry eyes, blurry vision, shortness of breath, a dry hacking cough or skin lesions such as erythema nodosum.
A 35-year-old woman is brought to the ER in severe distress. She has had the "flu" for three days. Past history reveals a six month history of fatigue and malaise. Physical exam reveals BP 120/65 mm Hg supine, 90/58 mm Hg standing, and darkened areas of skin on the knuckles, creases of the palm, elbows and an abdominal scar. Laboratory values are Na 122 mmol/L, K 5.8 mmol/L, Cl 95 mmol/L, CO2 18 mmol/L.
Which one of the following laboratory tests is most likely to assist in confirming your diagnosis?
Addison's disease (adrenal insufficiency) is an insidious, usually progressive hypofunctioning of the adrenal cortex. It produces various symptoms, including hypotension and hyperpigmentation, and can lead to adrenal crisis with cardiovascular collapse.
Diagnosis is clinical and is made by finding elevated plasma ACTH with low plasma cortisol. Treatment depends on the cause but generally includes hydrocortisone and sometimes other hormones.
A 40-year-old female presents with the gradual onset of weakness, fatigue, anorexia, and nausea. She has lost 15 lb (7 kg) over the past 3 months. A physical examination is unremarkable except for the patient's tired appearance, a blood pressure of 90/60 mm Hg, and diffuse hyperpigmentation of the skin and mucous membranes. Laboratory evaluation includes a sodium level of 130 mmol/L (N 136-145) and a potassium level of 5.8 mmol/L (N 3.5-5.1).
Which one of the following is the best test to further evaluate this patient's condition?
Primary adrenal insufficiency (Addison's disease) is an uncommon condition in clinical practice, and typically has an autoimmune etiology. Patients often experience the insidious onset of weakness, fatigue, and gastrointestinal symptoms. Physical findings typically include hypotension and diffuse hyperpigmentation of the patient's skin and mucous membranes. Due to the loss of aldosterone, serum sodium levels tend to be low, and hyperkalemia is common.
Cosyntropin is a synthetic analogue of ACTH. The cosyntropin stimulation test is performed by administering 250 µg of cosyntropin intravenously or intra-muscularly and measuring serum cortisol 30-60 minutes later. A normal response is serum cortisol > 500 nmol/L. A lower level suggests adrenal insufficiency.
In primary adrenal insufficiency, TSH and ACTH levels may be elevated, but this is variable and ACTH continues to demonstrate diurnal variation. The dexamethasone suppression test is used in the evaluation of cortisol excess.
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