NYACP Board Review Question of the Week
Every other Tuesday, NYACP members are sent a Board Review Question from ACP's MKSAP 18 to test professional knowledge and help prepare for the exam. Participant totals and answer percentages are distributed on the first Thursday of the month in IM Connected, the Chapter's eNewsletter, and are also published on this page.
If you are interested in receiving these questions bi-weekly, join us as a member!
If you are a member who needs to receive the questions and newsletter via email, let us know!
June 30th, 2026
MKSAP 19 Nephrology, Question 56
A 44-year-old woman is evaluated during a follow-up visit for chronic hypertension. Over the past month, her average blood pressure measured with home blood pressure monitoring was 145/90 mm Hg. There is no family history of hypertension. She has no other medical problems. The patient adheres to a low sodium diet. Medications are maximum doses of amlodipine and lisinopril.
On physical examination, blood pressure is 148/96 mm Hg, and pulse rate is 64/min; other vital signs are normal. BMI is 26. The remainder of the examination is unremarkable.
Laboratory studies show a serum creatinine level of 0.8 mg/dL (70.7 µmol/L) and normal electrolyte levels. Urinalysis shows no blood, protein, or leukocyte esterase.
Which of the following is the most appropriate next step in management?
A. Add chlorthalidone
B. Measure plasma aldosterone concentration/plasma renin activity ratio
C. Measure plasma fractionated metanephrines
D. Obtain renal artery imaging
Responses Received from Members (Graph is uploaded on Thursday afternoon):
The Correct Answer is: A. Add chlorthalidone
Educational Objective: Treat difficult-to-control hypertension by adding a diuretic.
The most appropriate next step in management is to add chlorthalidone, a thiazide diuretic (Option A). Resistant hypertension is defined as blood pressure (BP) that remains above goal despite concurrent use of three antihypertensive agents of different classes, or BP at goal but requiring four or more medications. One of these medications must be a diuretic. Suboptimal antihypertensive therapy in patients with difficult-to-control hypertension is frequently the result of not including a diuretic agent, which ensures that extracellular volume expansion is prevented or treated.
Therefore, before a diagnosis of resistant hypertension is made or evaluation is initiated for secondary causes of hypertension, the patient should be treated with an appropriate diuretic medication, with attention to effective dose and dosing frequency. Although hydrochlorothiazide is the most commonly used thiazide diuretic, chlorthalidone has a longer half-life, which allows once-daily dosing; some evidence from trials suggests efficacy in reducing cardiovascular events.
Obtaining a plasma aldosterone concentration/plasma renin activity ratio (Option B) is not indicated at this time, as there is no clinical suspicion for primary hyperaldosteronism. Primary hyperaldosteronism should be suspected in patients with sustained hypertension of >150/100 mm Hg on three separate measurements, resistant hypertension (uncontrolled hypertension on a three-drug regimen inclusive of a diuretic), controlled blood pressure on four or more antihypertensives (one of which is a diuretic), hypertension with hypokalemia (either spontaneous or diuretic induced), hypertension and an incidentally discovered adrenal mass, or a family history of early-onset hypertension or stroke at age <40 years. If adding a diuretic does not lead to improved blood pressure control, a subsequent work-up for primary hyperaldosteronism would be appropriate.
Testing for plasma fractionated metanephrines (Option C), which screens for a pheochromocytoma, is not indicated. The following characteristics raise clinical suspicion for pheochromocytoma: resistant hypertension; new-onset hypertension or onset at a young age; paroxysmal hypertension; episodic tachycardia, headaches, and sweating; history of familial syndromes; adrenal adenoma found incidentally on imaging with or without hypertension; or pressor response during invasive procedures or anesthesia. The patient has none of these indications for testing.
Obtaining renal artery imaging (Option D) is not indicated, as there is no clinical suspicion for renal artery stenosis, which includes the onset of severe hypertension in patients >55 years of age, recurrent flash pulmonary edema, refractory heart failure, or acute kidney injury after initiation of an ACE inhibitor or angiotensin receptor blocker.
Key Point
- Resistant hypertension is blood pressure that remains above goal despite concurrent use of three antihypertensive agents of different classes, or blood pressure at goal but requiring four or more medications; one of these medications must be a diuretic.
Bibliography
Braam B, Taler SJ, Rahman M, et al. Recognition and management of resistant hypertension. Clin J Am Soc Nephrol. 2017;12:524-535. PMID: 27895136 doi:10.2215/CJN.06180616
Multiple-choice questions reprinted with permission from the American College of Physicians.
MKSAP 19. © Copyright 2021 American College of Physicians.
ACP MKSAP. © Copyright 2025 American College of Physicians. All Rights Reserved All Rights Reserved.
June 16th, 2026
MKSAP 19 Oncology, Question 55
A 66-year-old woman is evaluated following completion of therapy for locally advanced squamous cell carcinoma of the hypopharynx. She was treated with combined cisplatin chemotherapy and irradiation. One month ago, imaging with PET/CT revealed a complete response. She is a former smoker with a 40-pack-year history who quit 7 years ago. She takes no medications.
On physical examination, vital signs are normal. She has dry oral mucosa and post-irradiation induration to the right of the neck. No cervical adenopathy is noted.
Which of the following imaging tests is most appropriate?
A. Low-dose CT of the chest in 1 year
B. MRI of the neck in 3 months
C. PET/CT in 3 months
D. No additional imaging is required
Responses Received from Members (645 Responses):
The Correct Answer is: A. Low-dose CT of the chest in 1 year
Educational Objective: Screen for lung cancer in a former smoker diagnosed with head and neck cancer.
This patient should have a low-dose CT of the chest in 1 year (Option A). She was diagnosed with locally advanced hypopharynx cancer. As is common in this type of cancer, treatment with combined chemotherapy and irradiation was recommended. She completed this treatment and achieved complete remission. Surveillance for recurrence is now indicated. Standard surveillance consists of physical examination and assessment for symptoms suggestive of recurrence. Physical examination includes in-office laryngoscopy to evaluate the upper aerodigestive tract for both local recurrence and development of second primary cancers. Following an imaging study identifying no active disease after completion of treatment, further imaging studies for surveillance purposes are not indicated. Such testing has not been shown to improve outcomes. Rather, imaging to look for recurrence is based on clinical suspicion of recurrence as directed by signs and symptoms. However, patients diagnosed with head and neck cancer are at risk for second cancers, most notably non–small cell lung cancer. This is especially true in patients aged 50 to 80 years who are current smokers or have quit less than 15 years ago and who have at least a 20-pack-year smoking history. All patients who meet criteria for lung cancer screening should be offered screening with a low-dose CT on an annual basis.
PET/CT (Option C) is not indicated in this patient for surveillance purposes because it does not improve outcomes. The same is true for MRI of the neck (Option B). Advanced imaging is reserved for patients with signs or symptoms suggestive of recurrence.
Up to 20% of head and neck cancer survivors develop a second primary cancer related to smoking and alcohol exposure. In addition to lifestyle modification, screening for lung cancer should be implemented in individuals at increased risk, rather than no additional imaging (Option D).
Key Point
- Following an imaging study identifying no active disease after completion of treatment for head and neck cancer, further imaging studies for surveillance purposes are not indicated.
- Patients with head and neck cancer, especially current or former smokers, should be screened for lung cancer.
Bibliography
Chow LQM. Head and neck cancer. N Engl J Med. 2020;382:60-72. PMID: 31893516 doi:10.1056/NEJMra1715715
Multiple-choice questions reprinted with permission from the American College of Physicians.
MKSAP 19. © Copyright 2021 American College of Physicians.
ACP MKSAP. © Copyright 2025 American College of Physicians. All Rights Reserved All Rights Reserved.