Matters of the Heart
A 24-year-old has exertional presyncope. The systolic murmur becomes louder with Valsalva and softer with squatting.
What is hypertrophic obstructive cardiomyopathy?
Teaching Point: Reduced preload intensifies dynamic LV outflow obstruction; increased preload or afterload usually softens the murmur.
An older adult with meningitis has CSF neutrophilic pleocytosis. Which additional empiric antibiotic covers the age-specific pathogen?
What is ampicillin?
Teaching Point: Add ampicillin for Listeria coverage in older or immunocompromised adults with suspected bacterial meningitis.
Metabolic alkalosis with urine chloride 8 mEq/L is most likely to improve with this therapy.
What is isotonic saline with potassium repletion?
Teaching Point: Low urine chloride suggests chloride-responsive alkalosis, commonly from vomiting or remote diuretic exposure.
An intubated patient with COPD becomes hypotensive; peak pressure rises, plateau pressure is unchanged, and expiratory flow never reaches zero.
What is dynamic hyperinflation (auto-PEEP)?
Teaching Point: Disconnect briefly if crashing, reduce respiratory rate or tidal volume, increase expiratory time, and treat airflow obstruction.
Fever, agitation, diaphoresis, hyperreflexia, and inducible clonus after a serotonergic medication change.
What is serotonin syndrome?
Teaching Point: Clonus and hyperreflexia distinguish serotonin toxicity from many mimics; stop serotonergic agents and provide supportive care.
A stable patient has a regular narrow-complex tachycardia at 190/min. Vagal maneuvers fail. Name the next acute therapy.
What is rapid IV adenosine?
Teaching Point: For stable regular narrow-complex SVT, adenosine is first-line after vagal maneuvers. Synchronize cardioversion if unstable.
A patient with AIDS, CD4 count 35/µL, has multiple ring-enhancing brain lesions and positive Toxoplasma IgG.
What is cerebral toxoplasmosis?
Teaching Point: Multiple basal-ganglia lesions favor toxoplasmosis; begin empiric therapy and reassess clinically and radiographically.
Diabetes, mild CKD, potassium 6.0 mEq/L, bicarbonate 17 mEq/L, and urine pH 5.0 suggest this renal tubular disorder.
What is type 4 renal tubular acidosis?
Teaching Point: Hypoaldosteronism or aldosterone resistance causes hyperkalemic non–anion-gap acidosis; urine can still acidify below pH 5.5.
An immunocompromised patient has diffuse ground-glass opacities, elevated LDH, and exertional hypoxemia.
What is Pneumocystis jirovecii pneumonia?
Teaching Point: Confirm with induced sputum or BAL testing; use TMP-SMX and add corticosteroids for substantial hypoxemia.
Recurrent abdominal pain, neuropathy, psychiatric symptoms, and darkening urine without peritoneal findings.
What is acute intermittent porphyria?
Teaching Point: Check urine porphobilinogen during an attack; treat severe attacks with hemin and carbohydrate support.
Syncope, polymorphic VT that twists around the baseline, QTc 560 ms, and no pulse. Name the drug given while defibrillation proceeds.
What is IV magnesium sulfate?
Teaching Point: Pulseless torsades requires defibrillation plus magnesium; correct potassium and remove QT-prolonging triggers.
Profound neutropenia, fever, right-lower-quadrant pain, and bowel-wall thickening of the cecum identify this emergency.
What is neutropenic enterocolitis (typhlitis)?
Teaching Point: Treat promptly with bowel rest and broad antipseudomonal therapy including anaerobic coverage; involve surgery for complications.
High-anion-gap acidosis, acute kidney injury, hypocalcemia, and envelope-shaped crystals identify this ingestion.
What is ethylene glycol poisoning?
Teaching Point: Calcium oxalate crystalluria supports ethylene glycol toxicity; give fomepizole and consider hemodialysis when severe.
A patient with confirmed pulmonary embolism has persistent hypotension and no major bleeding contraindication.
What is systemic thrombolysis?
Teaching Point: Hemodynamic instability defines high-risk PE; reperfusion therapy is indicated unless contraindicated.
Heart failure with preserved ejection fraction, increased ventricular wall thickness, low ECG voltage, and bilateral carpal tunnel syndrome.
What is transthyretin cardiac amyloidosis?
Teaching Point: Exclude a monoclonal protein first; bone-avid tracer scintigraphy can establish ATTR cardiomyopathy noninvasively in the right context.
Three days after an inferior MI, a patient develops shock and a new harsh holosystolic murmur at the left lower sternal border.
What is post-infarction ventricular septal rupture?
Teaching Point: A mechanical complication 3–5 days after MI causes an acute left-to-right shunt; confirm urgently with echocardiography and obtain surgical consultation.
Persistent Staphylococcus aureus bacteremia plus a new regurgitant murmur demands this diagnostic study even if the transthoracic study is unrevealing.
What is transesophageal echocardiography?
Teaching Point: Persistent bacteremia and high-risk features warrant TEE to evaluate infective endocarditis and perivalvular complications.
Measured sodium is 124 mEq/L and glucose is 1,000 mg/dL. Using 1.6 mEq/L per 100 mg/dL above normal, estimate corrected sodium.
What is approximately 138 mEq/L?
Teaching Point: Correction: 124 + 1.6 × 9 = 138.4 mEq/L. This is hypertonic hyponatremia, not true hypotonic hyponatremia.
In ARDS, this ventilator target should generally remain at or below 30 cm H₂O.
What is plateau pressure?
Teaching Point: Use lung-protective ventilation with low tidal volume based on predicted body weight and limit plateau pressure.
Recurrent thrombosis, pregnancy morbidity, thrombocytopenia, and a prolonged PTT that does not correct on mixing.
What is antiphospholipid syndrome?
Teaching Point: A lupus anticoagulant prolongs phospholipid-dependent clotting tests yet is associated clinically with thrombosis.
A patient with atrial fibrillation and moderate rheumatic mitral stenosis needs stroke prevention. Choose the anticoagulant class.
What is a vitamin K antagonist (warfarin)?
Teaching Point: Direct oral anticoagulants are not preferred for AF with moderate-to-severe rheumatic mitral stenosis; use warfarin.
Culture-negative endocarditis, weight loss, arthralgias, diarrhea, and PAS-positive foamy macrophages point to this organism.
What is Tropheryma whipplei?
Teaching Point: Whipple disease can cause blood-culture-negative endocarditis; diagnosis uses tissue histology and organism-specific PCR.
Thrombocytopenia, microangiopathic hemolysis, neurologic symptoms, fever, and renal injury require immediate treatment before the confirmatory assay returns.
What is plasma exchange plus glucocorticoids for suspected TTP?
Teaching Point: Do not wait for ADAMTS13 results when clinical suspicion is high; add caplacizumab where available and appropriate.
Asthma, eosinophilia, chronic sinusitis, mononeuritis multiplex, and pulmonary infiltrates identify this vasculitis.
What is eosinophilic granulomatosis with polyangiitis?
Teaching Point: EGPA is an eosinophilic small-to-medium-vessel vasculitis; ANCA may be absent, especially with cardiac-predominant disease.
Fever, splenomegaly, cytopenias, hepatitis, ferritin 28,000 ng/mL, and low fibrinogen.
What is hemophagocytic lymphohistiocytosis?
Teaching Point: HLH is a hyperinflammatory syndrome; calculate an HScore or apply HLH criteria while urgently searching for triggers