QUESTION: 1

A 45-year-old male comes to your office for his first annual checkup in the last 10 years. On first impression, he appears overweight but is otherwise healthy and has no specific complaints. He has a brother with diabetes and a sister with high blood pressure. Both of his parents are deceased and his father died of a stroke at age 73. He is a long-standing heavy smoker and only drinks alcohol on special occasions. On physical examination, his blood pressure is 166/90 in the left arm and 164/88 in the right arm. The rest of the examination is unremarkable. He is concerned about his health and does not want to end up on medication, like his siblings. Regarding your initial recommendations, which of the following would be most appropriate?

You should take no action and ask him to return to the clinic in 1 year for a repeat blood pressure check.
You should immediately start him on an oral antihypertensive medication and ask him to return to the clinic in 1 week.
You should advise him to stop smoking, start a strict diet and exercise routine with the goal of losing weight, and return to the clinic in 6 months.
You should consider starting a workup for potential causes of secondary hypertension.
You should screen him for diabetes and evaluate him for other cardiovascular risk factors before proceeding any further.

Answer(s): E

Explanation:

Although this is the first time that your patient has been noted to have an elevated blood pressure reading, given his family history and obesity, it is important to consider the coexistence of other cardiovascular risk factors. His evaluation should include, among other things, screening for DM and dyslipidemia along with an ECG. It is reasonable to ask the patient to submit himself to a strict diet (low in fat and salt) and to increase his exercise and activity, since these lifestyle modifications will likely result in weight loss, decreased blood pressure, and improve his risk profile for cardiovascular disease. Nonetheless, it is rarely enough to normalize blood pressure in all but the earliest stages of hypertension. Provided that no other comorbidities exist, the patient should return to clinic in no more than 2 months for a repeat blood pressure check. There is no need to consider secondary causes of hypertension, given his age and presentation.

You should not start antihypertensive medications until further evaluation is completed, and a second elevated reading confirms your diagnosis of hypertension. In the initial evaluation of hypertension (as per the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure [JNC-7], 2003), it is important to evaluate the patient for end-organ damage. This should include the heart, kidneys, eyes, and nervous system. It is recommended to obtain a urinalysis to assess for proteinuria, glucosuria, or hematuria; to obtain an ECG to evaluate the heart for potential hypertrophy or early signs of cardiovascular disease; to obtain a fasting lipid profile, particularly after the age of 35, to assess the cardiovascular risk profile; and to check the patient's renal function to assess for damage or dysfunction. Thyroid function tests are only indicated in the workup of secondary causes of hypertension. According to the JNC-7, this patient's blood pressure falls into the stage 2 hypertension classification in which either systolic blood pressure (SBP) is at least 160 mmHg or diastolic blood pressure (DBP) is at least 100 mmHg.

Stage 1 hypertension is characterized by a SBP of 140159 mmHg and a DBP of 9099 mmHg. Prehypertension is characterized by a SBP of 120139 mmHg and a DBP of 8089 mmHg. Normal blood pressure is characterized by a SBP of less than 120 mmHg and a DBP of less than 80 mmHg. In classifying a patient's blood pressure and determining appropriate therapy, the higher of the two categories corresponding to the SBP and DBP is the one that is used. Per JNC-7 guidelines, treatment of stage 2 hypertension should involve the consideration of a two-drug regimen initially. The goal blood pressure in patients with diabetes is a SBP less than 130 mmHg and a DBP less than 80 mmHg. An ACE inhibitor should be used as the drug class has been shown to slow the progression of diabetic nephropathy and reduce albuminuria. Thiazide diuretics, betablockers, and calcium channel blockers are appropriate choices to consider in this patient in addition to an ACE inhibitor.

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QUESTION: 2

A 45-year-old male comes to your office for his first annual checkup in the last 10 years. On first impression, he appears overweight but is otherwise healthy and has no specific complaints. He has a brother with diabetes and a sister with high blood pressure. Both of his parents are deceased and his father died of a stroke at age 73. He is a long-standing heavy smoker and only drinks alcohol on special occasions. On physical examination, his blood pressure is 166/90 in the left arm and 164/88 in the right arm. The rest of the examination is unremarkable. He is concerned about his health and does not want to end up on medication, like his siblings

In the initial evaluation of a patient such as this, which of the following should be routinely recommended?

a urine microalbumin/creatinine ratio
an echocardiogram
thyroid function tests
renal function tests (serum creatinine and blood urea nitrogen [BUN])
an exercise stress test

Answer(s): D

Explanation:

Although this is the first time that your patient has been noted to have an elevated blood pressure reading, given his family history and obesity, it is important to consider the coexistence of other cardiovascular risk factors. His evaluation should include, among other things, screening for DM and dyslipidemia along with an ECG. It is reasonable to ask the patient to submit himself to a strict diet (low in fat and salt) and to increase his exercise and activity, since these lifestyle modifications will likely result in weight loss, decreased blood pressure, and improve his risk profile for cardiovascular disease. Nonetheless, it is rarely enough to normalize blood pressure in all but the earliest stages of hypertension. Provided that no other comorbidities exist, the patient should return to clinic in no more than 2 months for a repeat blood pressure check. There is no need to consider secondary causes of hypertension, given his age and presentation.

You should not start antihypertensive medications until further evaluation is completed, and a second elevated reading confirms your diagnosis of hypertension. In the initial evaluation of hypertension (as per the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure [JNC-7], 2003), it is important to evaluate the patient for end-organ damage. This should include the heart, kidneys, eyes, and nervous system. It is recommended to obtain a urinalysis to assess for proteinuria, glucosuria, or hematuria; to obtain an ECG to evaluate the heart for potential hypertrophy or early signs of cardiovascular disease; to obtain a fasting lipid profile, particularly after the age of 35, to assess the cardiovascular risk profile; and to check the patient's renal function to assess for damage or dysfunction. Thyroid function tests are only indicated in the workup of secondary causes of hypertension. According to the JNC-7, this patient's blood pressure falls into the stage 2 hypertension classification in which either systolic blood pressure (SBP) is at least 160 mmHg or diastolic blood pressure (DBP) is at least 100 mmHg.

Stage 1 hypertension is characterized by a SBP of 140159 mmHg and a DBP of 9099 mmHg. Prehypertension is characterized by a SBP of 120139 mmHg and a DBP of 8089 mmHg. Normal blood pressure is characterized by a SBP of less than 120 mmHg and a DBP of less than 80 mmHg. In classifying a patient's blood pressure and determining appropriate therapy, the higher of the two categories corresponding to the SBP and DBP is the one that is used. Per JNC-7 guidelines, treatment of stage 2 hypertension should involve the consideration of a two-drug regimen initially. The goal blood pressure in patients with diabetes is a SBP less than 130 mmHg and a DBP less than 80 mmHg. An ACE inhibitor should be used as the drug class has been shown to slow the progression of diabetic nephropathy and reduce albuminuria. Thiazide diuretics, betablockers, and calcium channel blockers are appropriate choices to consider in this patient in addition to an ACE inhibitor.

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QUESTION: 3

A42-year-old man without prior significant medical history comes to your office for evaluation of chronic diarrhea of 12 months duration, although the patient states he has had loose stools for many years. During this time he has lost 25 lbs. The diarrhea is large volume, occasionally greasy, and nonbloody. In addition, the patient has mild abdominal pain for much of the day. He has been smoking a pack of cigarettes a day for 20 years and drinks approximately five beers per day. His physical examination reveals a thin male with temporal wasting and generalized muscle loss. He has glossitis and angular cheilosis. He has excoriations on his elbows and knees and scattered papulovesicular lesions in these regions as well Which of the following is the best test to confirm the suspected diagnosis?

abdominal CT scan with contrast
small bowel x-ray
esophagogastroduodenoscopy with small bowel biopsy
colonoscopy with colonic biopsy
72-hour fecal fat quantification

Answer(s): C

Explanation:

The patient has chronic diarrhea superimposed on a long history of loose stools, steatorrhea, and significant weight loss. While these features could be seen in several diseases, the presence of the pruritic vesiculopapular lesions on his extensor surfaces makes the diagnosis highly likely to be celiac sprue, with its frequently accompanying skin manifestation dermatitis herpetiformis. Crohn's disease is not usually associated with steatorrhea, and ulcerative colitis is often associated with bloody stools. Chronic pancreatitis and Whipple disease could cause a similar clinical picture but would not have the associated skin findings. A small bowel biopsy would confirm histopathologic features consistent with celiac sprue, such as villous atrophy and crypt hyperplasia. A small bowel biopsy could also diagnose or rule out Whipple disease by looking for the pathognomonic PAS (periodic acid-Schiff) positive organism Tropheryma whippelii. Colonic biopsies would be unhelpful in celiac sprue. A fecal fat quantification would likely confirm and assess the degree of steatorrhea, but would offer little other diagnostic information. A small bowel x-ray is too nonspecific to confirm the diagnosis and an abdominal CT scan would likely be normal unless the patient had developed a complication of advanced sprue, such as intestinal lymphoma. Patients with celiac sprue are at increased risk for malignancies of the small bowel with adenocarcinoma and lymphoma being the two most commonly encountered. Patients with celiac sprue are not at greatly increased risk of the other malignancies listed. Limited data suggest that strict adherence to a glutenfree diet may decrease the incidence of malignancy in these patients.

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QUESTION: 4

A42-year-old man without prior significant medical history comes to your office for evaluation of chronic diarrhea of 12 months duration, although the patient states he has had loose stools for many years. During this time he has lost 25 lbs. The diarrhea is large volume, occasionally greasy, and nonbloody. In addition, the patient has mild abdominal pain for much of the day. He has been smoking a pack of cigarettes a day for 20 years and drinks approximately five beers per day. His physical examination reveals a thin male with temporal wasting and generalized muscle loss. He has glossitis and angular cheilosis. He has excoriations on his elbows and knees and scattered papulovesicular lesions in these regions as well What is the most serious long-term complication this patient could face?

pancreatic cancer
small bowel cancer
gastric cancer
colon cancer
rectal cancer

Answer(s): B

Explanation:

The patient has chronic diarrhea superimposed on a long history of loose stools, steatorrhea, and significant weight loss. While these features could be seen in several diseases, the presence of the pruritic vesiculopapular lesions on his extensor surfaces makes the diagnosis highly likely to be celiac sprue, with its frequently accompanying skin manifestation dermatitis herpetiformis. Crohn's disease is not usually associated with steatorrhea, and ulcerative colitis is often associated with bloody stools. Chronic pancreatitis and Whipple disease could cause a similar clinical picture but would not have the associated skin findings. A small bowel biopsy would confirm histopathologic features consistent with celiac sprue, such as villous atrophy and crypt hyperplasia. A small bowel biopsy could also diagnose or rule out Whipple disease by looking for the pathognomonic PAS (periodic acid-Schiff) positive organism Tropheryma whippelii. Colonic biopsies would be unhelpful in celiac sprue. A fecal fat quantification would likely confirm and assess the degree of steatorrhea, but would offer little other diagnostic information. A small bowel x-ray is too nonspecific to confirm the diagnosis and an abdominal CT scan would likely be normal unless the patient had developed a complication of advanced sprue, such as intestinal lymphoma. Patients with celiac sprue are at increased risk for malignancies of the small bowel with adenocarcinoma and lymphoma being the two most commonly encountered. Patients with celiac sprue are not at greatly increased risk of the other malignancies listed. Limited data suggest that strict adherence to a glutenfree diet may decrease the incidence of malignancy in these patients.

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