A 27-year-old medical student undergoes an ECG as part of a class demonstration. The results are depicted in Figure below. He has no history of hypertension, diabetes, transient ischemic attacks, syncope, or heart failure. He does not smoke. He is currently not experiencing any symptoms.
What is the best next step in management?
Echocardiogram, complete blood count, and basic metabolic panel. Given the patient’s young age, asymptomatic status, and lack of risk factors, it is likely that he has lone atrial fibrillation. However, structural heart disease, electrolyte abnormalities, and hyperthyroidism must be ruled out first. (A) If the patient were symptomatic, TEE to rule out a blood clot (given the unknown duration of fibrillation) and cardioversion would be the appropriate next steps. (B) Anticoagulation may be used prior to cardioversion if that decision is made. Given the patient’s CHADS2 score of 0, long-term anticoagulation is not necessary. (C) Exercise testing can be used to determine if ischemic heart disease is contributing to the atrial fibrillation (unlikely in this patient) or to evaluate rhythm response in asymptomatic athletes who cannot use β-blockers for sports eligibility. However, this would not be the next step in evaluation of this patient. (D) Thyroid function testing alone would be inadequate.
A 38-year-old woman with past medical history of HIV infection presents with an inability to ambulate, urinary and fecal incontinence, and selective mutism. She is not currently taking any medications. On examination, her pupils are equal, round, and reactive with no papilledema noted. Extraocular movements are intact. She is able to plantarflex her left foot but not her right foot. Skin examination is notable for extensive seborrheic dermatitis at her hairline. An MRI reveals peripherally enhancing lesions of her basal ganglia, frontal lobe, and cerebellum.
Which of the following is the most likely cause of her neural deficits?
Toxoplasma gondii encephalitis. Toxoplasma encephalitis is an opportunistic infection in AIDS patients. It usually presents as multiple ring-enhancing lesions affecting the basal ganglia. (A) CNS lymphoma also can present with ring-enhancing lesions, but solitary lesions and whole tumor enhancement is more common. (C, D) Herpes encephalitis and progressive multifocal leukoencephalopathy do not present as ring-enhancing lesions. (E) Pneumocystis jirovecii brain abscesses can also present as multiple ringenhancing lesions and be difficult to distinguish from Toxoplasma encephalitis, but CNS Pneumocystis jirovecii infection is extremely rare.
A 52-year-old woman with a history of asthma since childhood presents to the Emergency Department with severe shortness of breath and wheezing. When speaking to the intake nurse, she is only able to say one to two words at a time due to her difficulty breathing. She has been using her albuterol rescue inhaler without any improvement in her symptoms. On physical examination, she appears very anxious with rapid shallow breaths and diffuse inspiratory wheezes. Vital signs are: blood pressure 118/68 mmHg, heart rate 120 beats per minute, respiratory rate 32 breaths per minute, and oxygen saturation of 81% on 6 L supplemental O2 from a nonrebreather mask. A stat ABG is sent and shows a PaO2 of 54 mmHg.
Emergent intubation. This patient is in respiratory distress due to an asthma exacerbation. Her critically low pO2 on ABG and her low O2 saturation despite supplemental oxygen indicate that she is not sufficiently oxygenating on her own and has respiratory muscle fatigue. The best next step is thus emergency intubation. (A, C) Intubation should not be delayed by a chest x-ray or repeat ABG. (D) Hypoxemia would not be seen in panic disorder. (E) Ipratropium and albuterol are treatments of an acute asthma exacerbation; however, intubation should be the first priority.
A 69-year-old woman with metastatic breast cancer is brought in by her family with severe back pain. She states that her pain is 10/10 and that her current goals of care are to be comfortable and to enjoy time at home with her husband and children. She is alert and oriented and has full understanding of her condition and prognosis. Her eldest son, who is her durable power of attorney (DOA), is demanding that she continues radiation and chemotherapy for her metastatic cancer.
Which of the following is the best action in this situation?
Give morphine intravenously and consult the palliative care team. The patient in this vignette is still competent and able to make decisions. (B) Even though her son is the DOA, her wishes should still be followed. (A) Most answer choices that shift the responsibility to another physician or group (such as an ethics committee) is likely to be wrong on the test. (D) The patient desires to be at home with her family and therefore surgery is not a good answer choice.
A 77-year-old man is admitted to the hospital after an acute change in mental status during the previous day, which was following a mild upper respiratory infection. He has a longstanding history of type 2 diabetes and sometimes forgets to take his medications. Blood glucose on admission is 670 mg/dL, and over the course of the first hospital day his urine output is 3 L.
What additional finding would you expect to see in this patient?
Severe volume depletion. This patient is experiencing hyperosmolar hyperglycemic state (also called nonketotic hyperglycemia), a dangerous complication of type 2. It is defined as having a glucose >600 mg/dL and a serum osmolality >320 mOsm/kg. Patients will eventually progress to oliguria and prerenal azotemia, which is particularly concerning because many of these patients have underlying diabetic nephropathy. (A) The serum osmolarity would be increased, not decreased, due to the loss of free water caused by osmotic diuresis associated with hyperglycemia and glycosuria. (B, C, E) Arterial pH is usually normal, serum ketones are few or absent, and reflexes are depressed. Mortality for this condition is up to 20%, and early fluid resuscitation is crucial.
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