Free Questions and Answers for All Medical Students all over the World
USMLE Clinical Cases: Alcoholic Cardiomyopathy, Granulomatosis with Polyangiitis and Spinal Metastases
These 3 detailed USMLE clinical case questions walk through how to reach the diagnosis step by step: dilated cardiomyopathy from chronic alcohol use, granulomatosis with polyangiitis (Wegener) and vertebral metastases from lung cancer. Each case has a full explanation of why the correct answer is right and why the others are wrong.
Written by Dr. Ray Makar, MD, author of the Repeated USMLE Questions eBook series.
How to use this page: read the question, pick your answer, then tap Show Answer and Explanation.
Questions
Question 1. A 65-year-old farmer presents to your clinic complaining of shortness of breath for 6 months. Last 2 weeks he noticed that he must get up several times during the night to be able to breathe. He proudly tells you that he had never visited a doctor before although he smokes and drinks every night. On physical examination, there is a displaced point of his maximum impulse, rales over both lungs, and an enlarged liver. Echo shows both right and left ventricular dilation and EF 30%. Laboratory tests are normal except for high bilirubin, AST 245, and ALT 180. What is the initial cause of this patient presentation?
This man’s symptoms are due to heart failure caused by long-term alcohol use. He has been drinking every night for years, and alcohol can slowly damage the heart muscle. Over time, the heart becomes weak and enlarged, which makes it unable to pump blood properly. That explains his shortness of breath, the need to sit up at night to breathe, the crackles heard in his lungs, and the enlarged liver caused by blood backing up. His echocardiogram shows both sides of the heart are dilated with a low ejection fraction of 30%, which means poor pumping ability. The elevated liver tests, including AST, ALT, and bilirubin, also support alcohol-related injury.
Smoking mainly affects the lungs and arteries, Lyme disease does not cause this chronic pattern, high blood pressure makes the heart thick rather than weak, and high cholesterol leads to blocked arteries, not this type of heart failure.
In summary, his condition is best explained by chronic alcohol use that weakened his heart muscle and led to dilated cardiomyopathy.
The correct answer is B
Question 2. A 55-year-old man presents to his physician complaining of sinusitis, chest pain, and productive cough for 2 weeks. His sputum is mixed with blood. He also has had pain and swelling of his hands and feet for 3 months. On examination, he has synovitis of the proximal interphalangeal joints of both hands. His laboratory tests reveal anemia, elevated ESR, elevated creatinine, and positive c-ANCA. Urinalysis shows red blood casts and proteinuria. Chest x-ray shows multiple nodules in both lungs. What is the most likely diagnosis?
The constellation of symptoms and findings described suggests a systemic autoimmune condition with involvement of multiple organs.
The presence of sinusitis, chest pain, productive cough with hemoptysis, and multiple nodules in both lungs on chest x-ray suggests pulmonary involvement, which could be due to granulomatous inflammation seen in certain autoimmune diseases.
The pain and swelling of hands and feet along with synovitis of the proximal interphalangeal joints are suggestive of an inflammatory arthritis, which can be seen in various autoimmune diseases.
The laboratory findings of anemia, elevated ESR (erythrocyte sedimentation rate), elevated creatinine, positive c-ANCA (anti-neutrophil cytoplasmic antibody), red blood casts, and proteinuria indicate renal involvement, likely secondary to Wegener granulomatosis.
Wegener granulomatosis, now known as granulomatosis with polyangiitis (GPA), is a systemic autoimmune disorder characterized by necrotizing granulomatous inflammation affecting the upper and lower respiratory tract, as well as small- to medium-sized blood vessels (vasculitis). It commonly presents with sinusitis, pulmonary nodules, hemoptysis, and renal involvement (glomerulonephritis). The presence of c-ANCA is a characteristic serologic finding in GPA. Additionally, joint involvement can occur in GPA, manifesting as arthritis or synovitis.
The correct answer is C
Question 3. A 54-year-old man visits his physician for evaluation of low back pain. He has a history of lung cancer and he receives a combination of radiation and chemotherapy. His back pain started 3 months ago and now he complains of numbness and tingling in his lower limbs. What is the most likely cause of this patient’s back pain?
A- Paraneoplastic disease
B- Metastases to the vertebral column
C- Muscular spasm of paravertebral muscles
D- Primary osteosarcoma
Given the patient’s history of lung cancer and the development of low back pain along with numbness and tingling in the lower limbs, the most likely cause of his symptoms is metastases to the vertebral column.
Lung cancer commonly metastasizes to the spine, and vertebral metastases can cause back pain, nerve compression leading to radicular symptoms (such as numbness and tingling), and potentially spinal cord compression symptoms if the metastases are extensive.
Paraneoplastic syndromes associated with lung cancer can present with various neurological symptoms, but they are less likely to cause isolated low back pain with numbness and tingling in the lower limbs.
Muscular spasm of paravertebral muscles could cause low back pain, but it wouldn’t typically lead to numbness and tingling in the lower limbs.
Primary osteosarcoma of the spine is rare, and it would be less common compared to metastases from lung cancer in a patient with a known history of lung cancer.
The correct answer is B
High-yield points from this set
Chronic heavy alcohol use is a classic cause of dilated cardiomyopathy (both ventricles dilated, low ejection fraction).
Sinusitis + hemoptysis + lung nodules + red blood cell casts + c-ANCA = granulomatosis with polyangiitis.
New back pain with leg numbness in a patient with cancer = vertebral metastasis until proven otherwise; watch for spinal cord compression.