{"id":1065,"date":"2024-03-13T18:15:00","date_gmt":"2024-03-13T18:15:00","guid":{"rendered":"https:\/\/www.osmosis.org\/blog\/?p=1065"},"modified":"2025-10-01T11:39:31","modified_gmt":"2025-10-01T19:39:31","slug":"usmle-step-2-question-of-the-day-sinus-tachycardia","status":"publish","type":"post","link":"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-sinus-tachycardia","title":{"rendered":"USMLE\u00ae Step 2 Question of the Day: Sinus tachycardia"},"content":{"rendered":"<div id=\"ez-toc-container\" class=\"ez-toc-v2_0_80 ez-toc-wrap-center counter-hierarchy ez-toc-counter ez-toc-custom ez-toc-container-direction\">\n<div class=\"ez-toc-title-container\">\n<p class=\"ez-toc-title\" style=\"cursor:inherit\">In This Article<\/p>\n<span class=\"ez-toc-title-toggle\"><a href=\"#\" class=\"ez-toc-pull-right ez-toc-btn ez-toc-btn-xs ez-toc-btn-default ez-toc-toggle\" aria-label=\"Toggle Table of Content\"><span class=\"ez-toc-js-icon-con\"><span class=\"\"><span class=\"eztoc-hide\" style=\"display:none;\">Toggle<\/span><span class=\"ez-toc-icon-toggle-span\"><svg style=\"fill: #999;color:#999\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" class=\"list-377408\" width=\"20px\" height=\"20px\" viewBox=\"0 0 24 24\" fill=\"none\"><path d=\"M6 6H4v2h2V6zm14 0H8v2h12V6zM4 11h2v2H4v-2zm16 0H8v2h12v-2zM4 16h2v2H4v-2zm16 0H8v2h12v-2z\" fill=\"currentColor\"><\/path><\/svg><svg style=\"fill: #999;color:#999\" class=\"arrow-unsorted-368013\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"10px\" height=\"10px\" viewBox=\"0 0 24 24\" version=\"1.2\" baseProfile=\"tiny\"><path d=\"M18.2 9.3l-6.2-6.3-6.2 6.3c-.2.2-.3.4-.3.7s.1.5.3.7c.2.2.4.3.7.3h11c.3 0 .5-.1.7-.3.2-.2.3-.5.3-.7s-.1-.5-.3-.7zM5.8 14.7l6.2 6.3 6.2-6.3c.2-.2.3-.5.3-.7s-.1-.5-.3-.7c-.2-.2-.4-.3-.7-.3h-11c-.3 0-.5.1-.7.3-.2.2-.3.5-.3.7s.1.5.3.7z\"\/><\/svg><\/span><\/span><\/span><\/a><\/span><\/div>\n<nav><ul class='ez-toc-list ez-toc-list-level-1 ' ><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-1\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-sinus-tachycardia\/#The_correct_answer_to_todays_USMLE%C2%AE_Step_2_CK_Question_is%E2%80%A6\" >The correct answer to today&#8217;s USMLE\u00ae Step 2 CK Question is&#8230;<\/a><ul class='ez-toc-list-level-3' ><li class='ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-2\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-sinus-tachycardia\/#A_Intravenous_phentolamine\" >A.&nbsp;Intravenous phentolamine<\/a><\/li><\/ul><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-3\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-sinus-tachycardia\/#Incorrect_answer_explanations\" >Incorrect answer explanations<\/a><ul class='ez-toc-list-level-3' ><li class='ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-4\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-sinus-tachycardia\/#B_Intravenous_labetalol\" >B.&nbsp;Intravenous labetalol<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-5\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-sinus-tachycardia\/#D_MRI_of_the_abdomen_and_pelvis\" >D.&nbsp;MRI of the abdomen and pelvis<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-6\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-sinus-tachycardia\/#E_CT_scan_of_the_head\" >E.&nbsp;CT scan of the head<\/a><\/li><\/ul><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-7\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-sinus-tachycardia\/#Main_Explanation\" >Main Explanation<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-8\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-sinus-tachycardia\/#Major_Takeaway\" >Major Takeaway<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-9\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-sinus-tachycardia\/#References\" >References<\/a><\/li><\/ul><\/nav><\/div>\n\n<p class=\"wp-block-paragraph\"><em><strong>This USMLE\u00ae Step 2 Question of the Day focuses on sinus tachycardia and its association with conditions like pheochromocytoma and hypertensive emergencies. Understand the role of alpha-blockers in management.<\/strong><\/em><em><strong><br><\/strong><\/em><br>A 54-year-old woman presents to the emergency department with the abrupt onset of severe headache, palpitations, and diaphoresis. She reports similar episodes over the past two months. Past medical history includes uncontrolled hypertension despite adherence to a three-medication antihypertensive regimen, including a diuretic, calcium channel blocker, and ACE inhibitor. The patient\u2019s sister was diagnosed with a paraganglioma two years ago. Temperature is 37.2\u00b0C (99\u00b0F), blood pressure is 210\/125 mmHg, pulse is 130\/min, respiratory rate is 22\/min, and O2&nbsp;saturation is 97% on room air. Physical examination reveals an anxious-appearing woman. Her skin is cool and clammy. A cardiac exam reveals tachycardia without murmurs. Neurologic examination shows no focal abnormalities. Laboratory results are significant for a creatinine of 2.2 mg\/dL. An ECG is significant for sinus tachycardia. Which of the following is the best next step in management?&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A.&nbsp;Intravenous phentolamine<\/strong><strong>B.&nbsp;Intravenous labetalol<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C.&nbsp;Oral ramipril<br><\/strong><br><strong>D.&nbsp;MRI of the abdomen and pelvis<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E.&nbsp;<\/strong><strong>CT scan of the head<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Scroll down for the correct answer!<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"The_correct_answer_to_todays_USMLE%C2%AE_Step_2_CK_Question_is%E2%80%A6\"><\/span>The correct answer to today&#8217;s USMLE\u00ae Step 2 CK Question is&#8230;<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"A_Intravenous_phentolamine\"><\/span><strong>A.&nbsp;Intravenous phentolamine<\/strong><span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Before we get to the&nbsp;<strong>Main Explanation<\/strong>, let&#8217;s see why the answer wasn&#8217;t B, C, D, or E. Skip to the bottom if you want to see the correct answer right away!<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Incorrect_answer_explanations\"><\/span>Incorrect answer explanations<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Today&#8217;s incorrect answers are&#8230;<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"B_Intravenous_labetalol\"><\/span><strong>B.&nbsp;Intravenous labetalol<\/strong><span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:&nbsp;<\/strong>Labetalol is a combined alpha- and beta-blocker used in the management of hypertensive emergencies. However, in patients with suspected pheochromocytomas, alpha-blockade must be established before beta-blockade. Starting a beta-blocker before an alpha-blocker can lead to worsened hypertension due to unopposed alpha-adrenergic stimulation.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C.&nbsp;Oral ramipril<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:&nbsp;<\/strong>ACE inhibitors like ramipril are often used for chronic management of hypertension, but they are not appropriate for the management of hypertensive emergencies.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"D_MRI_of_the_abdomen_and_pelvis\"><\/span><strong>D.&nbsp;MRI of the abdomen and pelvis<\/strong><span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:&nbsp;<\/strong>An MRI of the abdomen and pelvis can assist in tumor localization once the diagnosis of pheochromocytoma has been biochemically confirmed. It is not the first step in management for a patient with a hypertensive emergency.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"E_CT_scan_of_the_head\"><\/span><strong>E.&nbsp;CT scan of the head<\/strong><span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:&nbsp;<\/strong>CT scan of the head would be useful for evaluating the cause of a headache if there was suspicion of CNS pathology. This patient has no focal neurologic findings and other symptoms and signs suggestive of a pheochromocytoma.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Main_Explanation\"><\/span>Main Explanation<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">This patient is presenting with an abrupt and severe headache, palpitations, diaphoresis, severe hypertension, elevated creatinine, and a history of uncontrolled hypertension and familial history of paraganglioma; he likely has a pheochromocytoma presenting as a hypertensive emergency. An alpha-adrenergic receptor blocker, like intravenous phentolamine, can be used as an initial treatment.&nbsp;It decreases blood pressure by&nbsp;counteracting the vasoconstrictive&nbsp;effects of the&nbsp;catecholamines&nbsp;secreted by the pheochromocytoma.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Pheochromocytomas are catecholamine-secreting tumors that can cause paroxysmal hypertension and precipitate hypertensive emergencies. The immediate goal of treatment is to control blood pressure and reduce the risk of serious complications, such as stroke, myocardial infarction, and aortic dissection. An alpha-adrenergic receptor blocker such as phentolamine can be used to lower blood pressure quickly in a hypertensive emergency caused by a pheochromocytoma. Alpha-blockade must be initiated before beta-blockade to prevent a paradoxical hypertensive crisis from unopposed alpha stimulation. Nitroprusside, which is a&nbsp;<a href=\"https:\/\/www.osmosis.org\/learn\/Vasodilator_Therapy\" target=\"_blank\" rel=\"noreferrer noopener\">vasodilator<\/a>, can also be used, as well as nicardipine. &nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Following the acute management of hypertension, the next step in management is to confirm the diagnosis with biochemical testing, typically with a plasma-free metanephrines test or a 24-hour urine collection for catecholamines, metanephrines, and creatinine. Once the diagnosis of&nbsp;<a href=\"https:\/\/www.osmosis.org\/learn\/Pheochromocytoma\" target=\"_blank\" rel=\"noreferrer noopener\">pheochromocytoma<\/a>&nbsp;is confirmed, definitive treatment is surgical removal of the tumor. Before surgery can be performed, the patient must undergo a period of preoperative alpha-blockade (and then possibly beta-blockade) to prevent intraoperative hypertensive crises.&nbsp;<\/p>\n\n\n\n<figure class=\"wp-block-image size-large\"><img loading=\"lazy\" decoding=\"async\" width=\"934\" height=\"518\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/paroxysmal-hypertension-and-treatment.jpg?w=934\" alt=\"paroxysmal hypertension crisis and treatment\" class=\"wp-image-1067\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/paroxysmal-hypertension-and-treatment.jpg 934w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/paroxysmal-hypertension-and-treatment.jpg?resize=300,166 300w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/paroxysmal-hypertension-and-treatment.jpg?resize=768,426 768w\" sizes=\"auto, (max-width: 934px) 100vw, 934px\" \/><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Major_Takeaway\"><\/span><strong>Major Takeaway<\/strong><span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Acute management of a hypertensive crisis secondary to a pheochromocytoma involves rapid blood pressure reduction with intravenous alpha-blockers like phentolamine or with other agents like nitroprusside or nicardipine. Treatment with alpha-blockers should precede treatment with beta-blockers to prevent worsening hypertension.&nbsp;&nbsp;<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"References\"><\/span><strong>References<\/strong><span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Lenders JW, Duh QY, Eisenhofer G, et al. Pheochromocytoma and paraganglioma: an endocrine society clinical practice guideline [published correction appears in J Clin Endocrinol Metab. 2023 Apr 13;108(5):e200]. J Clin Endocrinol Metab. 2014;99(6):1915-1942. doi:10.1210\/jc.2014-1498\u00a0<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; \u2013\u2013\u2013\u2013\u2013\u2013\u2013\u2013\u2013\u2013\u2013\u2013<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><em><strong>Want more &nbsp;USMLE\u00ae Step 2 CK practice questions?&nbsp;<\/strong><\/em><em><strong>Try Osmosis by Elsevier today! Access your&nbsp;<a href=\"https:\/\/www.osmosis.org\/login?type=create\" target=\"_blank\" rel=\"noreferrer noopener\">free trial<\/a>&nbsp;and find out why millions of current and future clinicians and caregivers love learning with us.<\/strong><\/em><\/p>\n\n\n\n<figure class=\"wp-block-image size-large\"><a href=\"https:\/\/www.osmosis.org\/plans\" target=\"_blank\" rel=\"noreferrer noopener\"><img loading=\"lazy\" decoding=\"async\" width=\"700\" height=\"250\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/ace-your-clerkship-banner-2.png?w=700\" alt=\"Ace your clerkships with clinical practice videos on Osmosis. Watch now.\" class=\"wp-image-544\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/ace-your-clerkship-banner-2.png 700w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/ace-your-clerkship-banner-2.png?resize=300,107 300w\" sizes=\"auto, (max-width: 700px) 100vw, 700px\" \/><\/a><\/figure>\n","protected":false},"excerpt":{"rendered":"<p>This USMLE\u00ae Step 2 Question of the Day focuses on sinus tachycardia and its association with conditions like pheochromocytoma and hypertensive emergencies. Understand the role of alpha-blockers in management.A 54-year-old woman presents to the emergency department with the abrupt onset of severe headache, palpitations, and diaphoresis. She reports similar episodes over the past two months. [&hellip;]<\/p>\n","protected":false},"author":202,"featured_media":1066,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_feature_clip_id":0,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_post_was_ever_published":false},"categories":[27,20,1370,45],"tags":[],"class_list":["post-1065","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-medicine","category-exam-prep","category-step-2-questions","category-step-2"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.6 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>USMLE\u00ae Step 2 Question of the Day: Sinus tachycardia - Osmosis Blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-sinus-tachycardia\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"USMLE\u00ae Step 2 Question of the Day: Sinus tachycardia - Osmosis Blog\" \/>\n<meta property=\"og:description\" content=\"This USMLE\u00ae Step 2 Question of the Day focuses on sinus tachycardia and its association with conditions like pheochromocytoma and hypertensive emergencies. Understand the role of alpha-blockers in management.A 54-year-old woman presents to the emergency department with the abrupt onset of severe headache, palpitations, and diaphoresis. She reports similar episodes over the past two months. 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Can you identify\u2026","rel":"","context":"In &quot;Allopathic Medicine (MD)&quot;","block_context":{"text":"Allopathic Medicine (MD)","link":"https:\/\/www.osmosis.org\/blog\/category\/medicine"},"img":{"alt_text":"","src":"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/usmle-double-vision.webp","width":350,"height":200,"srcset":"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/usmle-double-vision.webp 1x, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/usmle-double-vision.webp 1.5x, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/usmle-double-vision.webp 2x"},"classes":[]},{"id":681,"url":"https:\/\/www.osmosis.org\/blog\/usmle-step-2-ck-question-of-the-day-second-degree-mobitz-type-ii-av-block","url_meta":{"origin":1065,"position":4},"title":"USMLE\u00ae Step 2 CK Question of the Day: Second Degree Mobitz type II AV block","author":"Marina Horiates Kerekes, MD &amp; Team","date":"May 4, 2022","format":false,"excerpt":"Enhance your USMLE\u00ae Step 2 CK exam prep with this clinical case involving a 66-year-old woman with left-sided weakness and symptoms suggestive of cardiac issues. 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