Prepared by Tiffany Avery, MD, Premraj Makkuni, MD, Janani Rangaswami, MD, Michaela Schulte, MD, and Steven L. Sivak, MD, Department of Internal Medicine, Albert Einstein Medical Center, Philadelphia, Pa

QUESTIONS

1. A 56-year-old black man is being evaluated for difficult-to-control hypertension. He was diagnosed with hypertension 6 years ago and has recently required escalation of his initial treatment to the following regimen: atenolol (Tenormin) 50 mg/day, lisinopril (Prinivil, Zestril) 40 mg/day, amlodipine (Norvasc, Amvaz) 10 mg/day, and hydrochlorothiazide (Hydro-Par) 25 mg/day. There is no evidence of end-organ damage, and his renal function is normal. He assures you he is compliant with therapy. Today, his blood pressure (BP) in the office is 180/110 mm Hg, and his pulse rate is 64 beats/min.

What is the next step in management for him?

A. Increase the beta-blocker dose to 50 mg twice daily, and repeat BP reading in 2 weeks

B. Tell the patient you suspect he is not taking his medications, since there is no way his BP would be out of control with 4 different antihypertensive drugs

C. Consider adding a centrally acting agent

D. Consider renal artery imaging with either Doppler ultrasonography or magnetic resonance angiography (MRA)

2. A 26-year-old woman with no significant medical history complains of increasingly frequent episodes of severe headache that have occurred about once weekly during the past 2 months. She says the headaches are typically unilateral and throbbing, and the pain worsens as she moves around. During the attacks she is intolerant to light and experiences nausea and vomiting, which prevents her from taking any medication. She is forced to rest in a dark room. The episodes resolve spontaneously after 4 to 8 hours.

In the past she had similar episodes 2 to 3 times annually. The frequency of the headaches increased recently, when she was promoted to a middle-management position, which made her job significantly more stressful. Now she is afraid that if she misses any more days of work, she could lose her job.

In addition to prescribing a parenteral triptan to treat the acute attacks, which medication would be most appropriate to prevent further attacks?

A. Verapamil (Calan) 160-320 mg/day

B. Acetaminophen/oxycodone (eg, Endocet, Percocet, Roxicet) 625 mg/10 mg 3 times daily

C. Divalproex (Depakote) 500-600 mg twice daily

D. Methysergide (Sansert) 1-6 mg/day

E. Propranolol (Inderal) 40-120 mg/day

3. An 81-year-old woman presents to the emergency department with generalized weakness, lethargy, and fatigue that have been gradually worsening over the past week. She denies fever, cough, shortness of breath, diarrhea, vomiting, or urinary symptoms. Her medical history includes hypertension, hypercholesterinemia, and breast cancer that was treated with lumpectomy, radiation, and chemotherapy 12 years ago. She has taken aspirin, lovastatin (Mevacor), and lisinopril (Prinivil, Zestril), at the same dosages, for over 5 years.

On physical examination her vital signs are stable. She appears tired but is able to follow commands. With the exception of dry mucous membranes, findings are unremarkable.

Initial lab test results include: hemoglobin, 11.5 g/dL; creatinine, 1.8 mg/dL; blood urea nitrogen, 64 mg/dL; calcium, 12.1 mg/dL; albumin, 3.5 g/dL.

In addition to initiating saline infusion and stopping the lisinopril, what is the most appropriate treatment for this patient’s hypercalcemia?

A. Loop diuretic

B. IV zoledronate (Zometa)

C. Calcitonin-salmon (Miacalcin)

D. Hemodialysis

E. Oral alendronate (Fosamax)

4. A 47-year-old white man with advanced cirrhosis caused by alcohol abuse presents with a 1-week history of confusion and lethargy. There were no recent changes in his medications or diet. He has not had nausea, vomiting, abdominal pain, or bleeding. Review of systems reveals shortness of breath on walking. His medical history is significant for type 2 diabetes. ?He had an episode of hepatic encephalopathy 2 months ago, but the viral hepatitis panel was negative at the time. His current medications are rifaximin (Xifaxan), insulin glargine (Lantus), and lactulose (Cephulac). His family history is significant for asbestosis in his father. The patient is a nonsmoker who worked in a shipyard in the past and is currently abstinent from alcohol.

On physical examination, he is comfortable at rest and fully alert and oriented. Vital signs include: heart rate, 61 beats/min; BP, 131/75 mm Hg; oxygen saturation, 96% on room air. Mild scleral icterus is observed. Cardiovascular and lung exams are normal. His abdomen is?soft, with normal bowel sounds and no signs of ascites. There is no peripheral cyanosis, but he does have digital clubbing. Neurologic examination is normal. He has significant dyspnea on gait testing. Closer examination shows he develops dyspnea, and oxygen saturation drops to 75% on room air, when he is upright; both conditions resolve when he is recumbent. His international normalized ratio is 2.2. Serum metabolic profile and complete blood cell count are normal.

Which of the following studies would help make the diagnosis?

A. Chest x-ray

B. Computed tomography (CT) of the chest

C. Liver function tests/liver profile

D. Contrast-enhanced 2-dimensional echocardiography (bubble study)

E. Pulmonary function testing

5. A 35-year-old man comes to your office for a follow-up visit. He went to the emergency department 2 weeks ago, complaining of abdominal pain and diarrhea. He was diagnosed with gastroenteritis at that time, and his symptoms have since resolved. As part of his workup he had a CT scan, which showed a 2-cm homogenous left adrenal mass. You obtain a thorough history and find that he is otherwise healthy, with no significant medical history. There were no abnormal findings on review of systems. His BP is 140/85 mm Hg, and his heart rate is 74 beats/min. The remainder of his physical examination is within normal limits. What would you recommend at this point?

A. No further workup, since the patient is asymptomatic, and the mass is <4 cm

B. Magnetic resonance imaging (MRI) of the abdomen

C. Overnight dexamethasone test and measurement of fractionated plasma free metanephrines, plasma aldosterone, and plasma renin activity

D. CT-guided biopsy of the adrenal mass

BRCA-1

BRCA-2

BRCA-2

6. A 53-year-old black woman presents to your primary care clinic for her first visit. Upon taking a family history, you discover that her sister was diagnosed with ovarian cancer 5 years ago, and she has a maternal aunt with breast cancer. You suggest genetic testing for and mutations. The test for a germline mutation of is positive. Which of the following therapies has been proven to decrease this patient&#8217;s risk of developing ovarian cancer?

A. Prophylactic salpingo-oophorectomy

B. Tamoxifen (Soltamox)

C. Regular measurement of CA-125 combined with ultrasonography

D. A diet high in selenium

E. A diet high in calcium

7. An 80-year-old man was admitted to the hospital for evaluation of right upper-quadrant abdominal pain, which is found to be due to gallstones. During the workup, his hepatic profile was normal, except for an elevated total protein level of 10 g/dL (normal, 6-8 g/dL). Further laboratory studies revealed hemoglobin, hematocrit, platelet count, calcium, and creatinine levels within the normal range. Serum protein electrophoresis showed a 2.8-g/dL monoclonal protein spike, which is later found to be immunoglobulin M by immunofixation. Bone marrow biopsy reveals 5% plasmacytosis. The one skeletal survey is negative. What is the most appropriate next step in this patient&#8217;s management?

A. Monthly parenteral bisphosphonate therapy

B. Perform flow cytometry for further diagnostic workup

C. Repeat serum protein electrophoresis in 6 months

D. Begin treatment with bortezomib (Velcade)

E. Begin treatment with melphalan (Alkeran) and prednisone (Deltasone)

8. A 72-year-old man presents to your office for his initial visit after switching from his previous primary care physician. His medical history includes hypertension, type 2 diabetes, congestive heart failure, essential thrombocythemia (diagnosed 3 years ago), a nonhemorrhagic cerebrovascular accident 2 years ago, and peptic ulcer disease with an episode of upper gastrointestinal bleeding that required hospitalization 6 months ago. His current medications include hydrochlorothiazide, metformin (Glucophage), pantoprazole (Protonix), and lovastatin. He currently feels well. He has not had any visual symptoms, erythromelalgia, headache, or weakness. Basic laboratory studies reveal a platelet count of 670,000/μL. Which of the following treatments would be best for reducing this man&#8217;s risk of thrombotic events?

A. Daily low-dose aspirin

B. Weekly clopidogrel (Plavix)

C. No change in his current regimen

D. Hydroxyurea (Hydrea)

E. Anagrelide (Agrylin)

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