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.
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March 10th, 2026
MKSAP 19 Endocrinology & Metabolism, Question 69
A 23-year-old woman is evaluated for persistent hirsutism related to polycystic ovary syndrome (PCOS). She presented for evaluation 6 months ago with irregular menstrual cycles, coarse facial and body hair, and obesity. Diabetes screening was normal. Combined oral contraceptive therapy was prescribed along with weight loss. She has been adherent to this treatment and now has monthly withdrawal vaginal bleeding; she also has lost 4.5 kg (10.0 lb). She has had some improvement in hair growth but is not completely satisfied.
Vital signs are normal. BMI is 30. She has dark, coarse hair over her chin, upper lip, chest, back, pubic area, arms, and legs. No evidence of virilism is noted.
Which of the following is the most appropriate next step?
- Add metformin
- Add spironolactone
- Obtain adrenal CT
- Obtain pelvic ultrasonography
Responses Received from Members (Graph is uploaded on Thursday afternoon):
The Correct Answer is: B. Add spironolactone
Educational Objective: Treat hirsutism in a patient with polycystic ovary syndrome.
The most appropriate next step is to add spironolactone (Option B). Polycystic ovary syndrome (PCOS) is a disorder characterized by hyperandrogenism and ovulatory dysfunction. PCOS affects 6% to 10% of women and is the most common cause of anovulatory infertility in women. It is associated with rapid gonadotropin-releasing hormone pulses, an excess of luteinizing hormone, and insufficient follicle-stimulating hormone secretion, resulting in excessive ovarian androgen production and ovulatory dysfunction. PCOS is accompanied by insulin resistance. Elevated insulin levels in PCOS further enhance ovarian and adrenal androgen production, as well as increase bioavailability of androgens related to a reduction in sex hormone-binding globulin. PCOS is associated with increased incidence of metabolic syndrome, prediabetes, type 2 diabetes mellitus, hypercholesterolemia, and obesity. This patient with PCOS has evidence of ongoing hirsutism (i.e., dark coarse hair on the face, chest, back, arms/legs) and acne despite 6 months of oral contraceptive therapy. The next step is to add an antiandrogen agent to oral contraceptive therapy. Spironolactone is the most commonly used antiandrogen agent and is generally safe and well tolerated. Potential adverse effects include hyperkalemia (rare in patients with normal renal function), gastrointestinal discomfort, and irregular menstrual bleeding. In women prescribed spironolactone, concomitant contraception is mandatory because of teratogenesis in male fetuses.
Metformin (Option A) reduces hyperinsulinemia and androgen levels but has minimal impact on hirsutism and ovulation. Metformin is indicated when impaired glucose tolerance, prediabetes, or type 2 diabetes does not respond adequately to lifestyle modification. This patient has a negative screening test for diabetes and thus has no indication for metformin.
Rapid onset of hirsutism or virilization (voice deepening, clitoromegaly, male pattern baldness, severe acne) occurs only in severe hyperandrogenism and raises concern for ovarian hyperthecosis or an androgen-producing ovarian or adrenal tumor. This patient does not have features of virilization or rapid-onset hirsutism. Because an adrenal or ovarian tumor is unlikely, an adrenal CT (Option C) or pelvic ultrasonography (Option D) is not indicated.
Key Point
- In women with polycystic ovary syndrome and hirsutism, an antiandrogen agent such as spironolactone should be added after 6 months if cosmesis is suboptimal with oral contraceptive agents alone.
- Antiandrogen agents may adversely affect development of the male fetus and therefore should not be used in the treatment for polycystic ovary syndrome without concomitant contraception.
Bibliography
McCartney CR, Marshall JC. Clinical practice. Polycystic ovary syndrome. N Engl J Med. 2016;375:54-
64. PMID: 27406348 doi:10.1056/NEJMcp1514916
Multiple-choice questions reprinted with permission from the American College of Physicians.
MKSAP 19. © Copyright 2021 American College of Physicians.
ACP MKSAP. © Copyright 2026 American College of Physicians. All Rights Reserved All Rights Reserved.
February 24th, 2026
MKSAP 19 Cardiovascular Medicine, Question 58
A 74-year-old man is evaluated in the hospital for a 6-month history of progressive fatigue and exertional dyspnea, along with increasing peripheral edema and abdominal girth over the past 3 months. He also has coronary artery disease, for which he had a coronary artery bypass graft at age 62 years. Medications are metoprolol, low-dose aspirin, and atorvastatin.
On physical examination, vital signs are normal. Jugular venous distention with prominent waveforms is noted. There is no discernable fall in the central venous pressure during inspiration. An early diastolic sound is present. The liver is enlarged and pulsatile. Ascites is present, and peripheral edema extends to the knees bilaterally.
On chest radiograph, sternotomy wires and vascular clips are seen, and small bilateral pleural effusions are present.
Which of the following is the most likely diagnosis?
A. Cardiac tamponade
B. Chronic liver disease
C. Constrictive pericarditis
D. Restrictive cardiomyopathy
Responses Received from Members (503 Responses):
The Correct Answer is: C. Constrictive pericarditis
Educational Objective: Diagnose constrictive pericarditis.
The diagnostic findings are consistent with constrictive pericarditis (Option C), which typically presents with indolent, progressive signs and symptoms of right heart failure, including fatigue and exertional dyspnea. On physical examination, the central venous pressure is elevated in nearly all patients, with prominent x and y descents. The height of the waveform does not fall or may increase during inspiration (Kussmaul sign), reflecting the fixed diastolic volume of the right heart. Early diastolic filling is unimpaired or even accentuated and is followed by sudden cessation when total acceptable volume is met, resulting in a high-frequency early diastolic sound (pericardial knock, heard in <50% of patients). Pulsus paradoxus is less frequent (<20% of patients) in constrictive pericarditis than in cardiac tamponade. Peripheral edema, ascites, hepatomegaly, and pleural effusions are common. Diagnosis of constrictive pericarditis is made with imaging studies and hemodynamic evaluation. Transthoracic echocardiography reveals normal right and left ventricular size and systolic function despite prominent symptoms and findings suggestive of heart failure. Dilatation of the inferior vena cava reflects elevated right-sided filling (right atrial) pressure. Doppler echocardiography and tissue Doppler velocity are required to differentiate constrictive pericarditis from restrictive cardiomyopathy. Although an underlying cause of constrictive pericarditis is not always identified, previous pericarditis, cardiac surgery, chest irradiation, connective tissue disorders, and uremia are common precipitants.
Cardiac tamponade (Option A) can easily be confused with constrictive pericarditis. However, cardiac tamponade is typically associated with pulsus paradoxus and not associated with Kussmaul sign.
A not uncommon misdiagnosis in patients with constrictive pericarditis is cirrhosis. Like patients with constrictive pericarditis, those with cirrhosis may have a palpable liver, ascites, pleural effusions, and peripheral edema. Patients with chronic liver disease (Option B) do not have jugular venous distention, Kussmaul sign, or a pericardial knock, as detected in this patient.
In most cases, clinically differentiating restrictive cardiomyopathy (Option D) from constrictive pericarditis is impossible. Restrictive cardiomyopathy is more likely in a patient with a predisposing systemic disease, such as diabetes mellitus or amyloidosis. In this case, constrictive pericarditis is suggested by the previous coronary artery bypass surgery. Restrictive cardiomyopathy is not associated with a pericardial knock, but this finding is sometimes difficult to distinguish from an S3.
Key Point
- Kussmaul sign and pericardial knock, if present, are helpful clues to the presence of constrictive pericarditis.
Bibliography
Geske JB, Anavekar NS, Nishimura RA, et al. Differentiation of constriction and restriction: complex cardiovascular hemodynamics. J Am Coll Cardiol. 2016;68:2329-47. PMID:
27884252 doi:10.1016/j.jacc.2016.08.
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.