A 62-year-old woman with a history of alcoholism and homelessness presents to the Emergency Department because of abdominal pain. She has not been to the doctor in years and does not take any medications, herbs, or supplements. She is afebrile but is jaundiced with abdominal distention, pitting edema of the lower extremities, and palmar erythema. Her laboratory values are significant for the following.
An ultrasound shows a small, nodular liver. IV fluids are given to the patient but her renal function does not improve.
Which of the following is the underlying mechanism of this patient’s renal failure?
Splanchnic vasodilation. The patient has physical examination findings, laboratory values, and an ultrasound consistent with cirrhosis of the liver, likely from alcohol abuse. She also has poor renal function, which is called hepatorenal syndrome and portends a poor prognosis. The mechanism of renal failure in liver cirrhosis is caused by splanchnic vasodilation in response to portal hypertension. This produces a decrease in systemic vascular resistance and blood pressure, leading to decreased effective circulating volume and an increase in angiotensin II and norepinephrine, leading to renal afferent arteriole vasoconstriction and renal ischemia. (D) Afferent arteriole vasodilation would increase renal blood flow and be beneficial. (A) Cirrhosis does not cause bilateral urinary tract obstructions. (B) Patients with cirrhosis are at an increased risk of hepatocellular carcinoma; however, there are no further clues in the vignette that this patient has cancer. (C) The patient denied any medications, herbs, or supplements.
A 41-year-old man presents for a routine health maintenance examination. The patient has no complaints other than a “nagging cough” for the past 2 weeks. He has a history of hypertension and diabetes and has smoked one pack of cigarettes per day for the last 15 years. His mother was diagnosed with colon cancer at the age of 52. Physical examination and routine laboratory values are all within normal limits.
Which of the following is the most appropriate step for this patient?
Colonoscopy now. This patient is considered high risk for colorectal cancer as he has a first-degree relative with colorectal cancer (mother) before the age of 60. Two or more first-degree relatives with colorectal cancer at any age is also considered high risk. High-risk patients should be screened for colon cancer at the age of 40 or 10 years before the relative’s diagnosis (choose the one that comes first). In this patient, his mother was diagnosed with colon cancer at the age of 52, and since the patient is 41 years old, he should be screened today instead of 1 year at the age of 42. Of note, it is helpful to remember that in the outpatient setting, the most common causes of a chronic cough are asthma, GERD, and postnasal drip.
A 39-year-old man with a history of HSV encephalitis is brought into the hospital after experiencing a seizure that lasted several minutes. Further history reveals that this has happened several times previously. He is started on a medication and discharged. Several months later, the patient follows up and has the findings shown below.
Which of the following medications is most likely responsible?
Phenytoin. This patient has gingival hyperplasia, a wellknown side effect of phenytoin. (B, D) Many anticonvulsants are also associated with gingival hyperplasia; however, the risk is greatest with phenytoin. Other medications that can cause this are cyclosporine and calcium channel blockers. (A) Lorazepam is a benzodiazepine that is used in the treatment of status epilepticus; however, it is not used for chronic seizure prophylaxis.
A 23-year-old college student is brought in by police to the Emergency Department in the middle of the night. He was found running down the street screaming, and is now extremely irritable and holding his chest. A full history cannot be obtained due to the patient’s altered mental status. On examination, he is hyperactive and diaphoretic, and old needle tracks are seen on his arms. His vitals show a temperature of 38.1°C, blood pressure of 154/92 mmHg, heart rate of 154 beats per minute, and respiratory rate of 18 breaths per minute. He has marked mydriasis. An ECG shows ST depression and T wave inversions in multiple leads. Urine toxicology screen and initial laboratory values are ordered.
Which of the following should NOT be given to the patient at this time?
Metoprolol. This patient is acutely intoxicated with cocaine (sympathetic hyperactivity, dilated pupils) and there is concern for cocaine-induced myocardial ischemia given that the patient was holding his chest and an ECG was consistent with ischemia. Cocaine blocks dopamine reuptake in the central nervous system, causing euphoria, but also blocks norepinephrine reuptake in sympathetic neurons and produces many of the sympathomimetic signs seen in this patient. The cardiovascular effects include myocardial infarction and arrhythmias and therefore it is important to consider these life-threatening consequences in patients who abuse cocaine. All of the options above are appropriate for a patient presenting with chest pain after cocaine use, except for metoprolol. Theoretically, β-blockers should be avoided while cocaine is still present in the body, since β-blockade can result in unopposed α-receptor activation leading to worsening hypertension and coronary vasospasm. Though the clinical significance of this problem is debated (recent data suggests that β-blockers are likely safe in this setting), it is a widely taught principle and may still show up on the shelf examination. This is also important to remember for other conditions that cause very elevated sympathetic activity (e.g., pheochromocytoma).
A 60-year-old woman with a longstanding history of rheumatoid arthritis presents to the Emergency Department with shortness of breath, productive cough, and fever. Chest x-ray shows right lower lobe consolidation, consistent with pneumonia, along with numerous rheumatoid nodules that are unchanged from prior x-rays. Her medical record shows that this is her third hospitalization this year. Laboratory values show a leukocyte count of 1,200/mm3 , and a diagnosis of Felty syndrome is made.
What additional finding would you expect in this patient?
Splenomegaly. Felty syndrome is characterized by the triad of rheumatoid arthritis, neutropenia, and splenomegaly. It may go misdiagnosed as simply rheumatoid arthritis for many years before laboratory values reveal neutropenia, often found after admission for one of their frequent infections. (A) Rheumatoid factor will be markedly elevated. (C) Patients will also be anemic and thrombocytopenic due to splenic consumption of blood cells and platelets. (D) Patients with Felty syndrome respond well to treatment of the underlying rheumatologic disease.
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