,Answer: C. Order a complete blood count (CBC) and thyroid-stimulating hormone (TSH).
The most appropriate next step is to order a complete blood count (CBC) and thyroid-
stimulating hormone (TSH) level because this 68-year-old woman presents with progressive
fatigue and occasional shortness of breath with exertion, which are common but nonspecific
symptoms in older adults. The initial approach in primary care should focus on identifying
common, reversible causes before initiating treatment or ordering more advanced diagnostic
tests. A CBC can detect anemia, infection, or hematologic abnormalities, while a TSH test
evaluates for hypothyroidism, another frequent cause of fatigue, weakness, and reduced
exercise tolerance in older adults. Although a chest X-ray may be appropriate if pulmonary
disease is suspected, there are no symptoms such as cough, fever, chest pain, or abnormal lung
,findings to justify imaging as the first step. Increasing the lisinopril dosage is inappropriate
because there is no evidence that her blood pressure is uncontrolled, and doing so could
worsen fatigue or cause hypotension. Likewise, recommending an exercise program without
first determining the cause of her symptoms could delay diagnosis and potentially worsen an
underlying condition. Therefore, obtaining a CBC and TSH is the most appropriate evidence-
based initial evaluation to identify common medical causes of fatigue and exertional dyspnea
before considering further diagnostic testing or treatment.
A 78-year-old male with a 45-pack-year smoking history and a diagnosis of
COPD (GOLD Stage 3) presents with a 4-week history of progressive hoarseness,
a sensation of a "lump" in his throat, and occasional hemoptysis. He denies
fever, night sweats, or weight loss. A recent chest X-ray was read as normal. On
examination, you note no cervical lymphadenopathy, but a fiberoptic
nasopharyngoscopy performed in the office reveals a lesion on his left true vocal
cord. What is the most appropriate next step in the management of this patient?
A. Reassure the patient and schedule a repeat chest X-ray in 6 months, as this is
likely benign vocal cord polyps from chronic coughing.
B. Prescribe a 6-week course of a proton pump inhibitor (PPI) for suspected
laryngopharyngeal reflux (LPR) and schedule a follow-up.
C. Arrange for an urgent direct laryngoscopy and biopsy under anesthesia to
evaluate for laryngeal malignancy.
D. Order a CT scan of the neck with contrast and a positron emission tomography
(PET) scan to stage the lesion before any biopsy.
Correct Answer: C. Arrange for an urgent direct laryngoscopy and biopsy under
anesthesia to evaluate for laryngeal malignancy.
Rationale: Hoarseness persisting for more than 3 weeks in a patient with a
significant smoking history is a red flag for laryngeal cancer, regardless of a normal
chest X-ray. Direct laryngoscopy with biopsy is the gold standard for definitive
diagnosis and must not be delayed. While laryngopharyngeal reflux (LPR) can
cause hoarseness, it would not typically present with a visible lesion on
nasopharyngoscopy or hemoptysis. A CT/PET scan is useful for staging once a
, tissue diagnosis is confirmed, but it should not delay the biopsy. Reassurance or a
PPI trial would delay a potential cancer diagnosis and is unsafe.
2. An 82-year-old female with a history of hypertension, type 2 diabetes (HbA1c
7.5%), and stage 3b chronic kidney disease (eGFR 38 mL/min) presents with a 2-
week history of progressive, bilateral lower extremity weakness, difficulty rising
from a chair, and a waddling gait. She reports that she has been feeling more
fatigued than usual. On exam, you note proximal muscle weakness in her hips
and shoulders, and she has a positive Trendelenburg sign bilaterally. Her serum
creatine kinase (CK) is 250 U/L, and her aldolase is elevated. What is the most
likely diagnosis and the most appropriate next diagnostic test?
A. Polymyalgia rheumatica (PMR); order an erythrocyte sedimentation rate (ESR)
and C-reactive protein (CRP).
B. Diabetic amyotrophy; order a nerve conduction study and electromyography
(NCS/EMG).
C. Polymyositis; order a muscle biopsy and anti-Jo-1 antibody testing.
D. Osteoarthritis of the hips; order a plain X-ray of the pelvis and hips.
Correct Answer: C. Polymyositis; order a muscle biopsy and anti-Jo-1 antibody
testing.
Rationale: This patient has classic signs of an inflammatory myopathy
(polymyositis), including symmetric proximal muscle weakness, a waddling gait,
and elevated muscle enzymes (CK, aldolase). Polymyalgia rheumatica (PMR)
presents with pain and stiffness without true muscle weakness and does not
elevate CK. Diabetic amyotrophy is a rare, asymmetric neuropathy that typically
presents with severe pain and unilateral thigh wasting. A muscle biopsy is the gold
standard for confirming polymyositis, and anti-Jo-1 antibodies are a specific
marker for the condition.
3. A 79-year-old male with a history of heart failure with reduced ejection
fraction (HFrEF, EF 25%), hypertension, and iron deficiency anemia presents with
The most appropriate next step is to order a complete blood count (CBC) and thyroid-
stimulating hormone (TSH) level because this 68-year-old woman presents with progressive
fatigue and occasional shortness of breath with exertion, which are common but nonspecific
symptoms in older adults. The initial approach in primary care should focus on identifying
common, reversible causes before initiating treatment or ordering more advanced diagnostic
tests. A CBC can detect anemia, infection, or hematologic abnormalities, while a TSH test
evaluates for hypothyroidism, another frequent cause of fatigue, weakness, and reduced
exercise tolerance in older adults. Although a chest X-ray may be appropriate if pulmonary
disease is suspected, there are no symptoms such as cough, fever, chest pain, or abnormal lung
,findings to justify imaging as the first step. Increasing the lisinopril dosage is inappropriate
because there is no evidence that her blood pressure is uncontrolled, and doing so could
worsen fatigue or cause hypotension. Likewise, recommending an exercise program without
first determining the cause of her symptoms could delay diagnosis and potentially worsen an
underlying condition. Therefore, obtaining a CBC and TSH is the most appropriate evidence-
based initial evaluation to identify common medical causes of fatigue and exertional dyspnea
before considering further diagnostic testing or treatment.
A 78-year-old male with a 45-pack-year smoking history and a diagnosis of
COPD (GOLD Stage 3) presents with a 4-week history of progressive hoarseness,
a sensation of a "lump" in his throat, and occasional hemoptysis. He denies
fever, night sweats, or weight loss. A recent chest X-ray was read as normal. On
examination, you note no cervical lymphadenopathy, but a fiberoptic
nasopharyngoscopy performed in the office reveals a lesion on his left true vocal
cord. What is the most appropriate next step in the management of this patient?
A. Reassure the patient and schedule a repeat chest X-ray in 6 months, as this is
likely benign vocal cord polyps from chronic coughing.
B. Prescribe a 6-week course of a proton pump inhibitor (PPI) for suspected
laryngopharyngeal reflux (LPR) and schedule a follow-up.
C. Arrange for an urgent direct laryngoscopy and biopsy under anesthesia to
evaluate for laryngeal malignancy.
D. Order a CT scan of the neck with contrast and a positron emission tomography
(PET) scan to stage the lesion before any biopsy.
Correct Answer: C. Arrange for an urgent direct laryngoscopy and biopsy under
anesthesia to evaluate for laryngeal malignancy.
Rationale: Hoarseness persisting for more than 3 weeks in a patient with a
significant smoking history is a red flag for laryngeal cancer, regardless of a normal
chest X-ray. Direct laryngoscopy with biopsy is the gold standard for definitive
diagnosis and must not be delayed. While laryngopharyngeal reflux (LPR) can
cause hoarseness, it would not typically present with a visible lesion on
nasopharyngoscopy or hemoptysis. A CT/PET scan is useful for staging once a
, tissue diagnosis is confirmed, but it should not delay the biopsy. Reassurance or a
PPI trial would delay a potential cancer diagnosis and is unsafe.
2. An 82-year-old female with a history of hypertension, type 2 diabetes (HbA1c
7.5%), and stage 3b chronic kidney disease (eGFR 38 mL/min) presents with a 2-
week history of progressive, bilateral lower extremity weakness, difficulty rising
from a chair, and a waddling gait. She reports that she has been feeling more
fatigued than usual. On exam, you note proximal muscle weakness in her hips
and shoulders, and she has a positive Trendelenburg sign bilaterally. Her serum
creatine kinase (CK) is 250 U/L, and her aldolase is elevated. What is the most
likely diagnosis and the most appropriate next diagnostic test?
A. Polymyalgia rheumatica (PMR); order an erythrocyte sedimentation rate (ESR)
and C-reactive protein (CRP).
B. Diabetic amyotrophy; order a nerve conduction study and electromyography
(NCS/EMG).
C. Polymyositis; order a muscle biopsy and anti-Jo-1 antibody testing.
D. Osteoarthritis of the hips; order a plain X-ray of the pelvis and hips.
Correct Answer: C. Polymyositis; order a muscle biopsy and anti-Jo-1 antibody
testing.
Rationale: This patient has classic signs of an inflammatory myopathy
(polymyositis), including symmetric proximal muscle weakness, a waddling gait,
and elevated muscle enzymes (CK, aldolase). Polymyalgia rheumatica (PMR)
presents with pain and stiffness without true muscle weakness and does not
elevate CK. Diabetic amyotrophy is a rare, asymmetric neuropathy that typically
presents with severe pain and unilateral thigh wasting. A muscle biopsy is the gold
standard for confirming polymyositis, and anti-Jo-1 antibodies are a specific
marker for the condition.
3. A 79-year-old male with a history of heart failure with reduced ejection
fraction (HFrEF, EF 25%), hypertension, and iron deficiency anemia presents with
