Heart, lung, and kidneys, oh my!
MKSAP or Bust
As per my last email
Zebras
"Pop Culture"
100
Increase of serum Creatinine >0.3mg/dL in 48 hours is usually used to diagnose AKI. There are other definitions of AKI. Name one of those definitions.
What is increase in serum Creatinine > 1.5 times baseline within 7 days?
What is urine volume <0.5mL/kg/h for 6 hours
100
40 yo M p/w 5-days of sore throat and fever. He has no cough or nasal congestion. Medical history is otherwise unremarkable. He does not smoke.
On exam, T 38.5 °C, oropharynx is erythematous, with enlarged tonsils with purulent exudate. The anterior cervical lymph nodes are tender and enlarged.
Which of the following is the most appropriate next step in management?
A. Penicillin
B. Rapid Ag detection test for group A strep
C. Throat culture
D. No testing or therapy
B. Acute pharyngitis symptoms typically last less than 1 week. Most cases are viral in etiology, and only 5% to 15% of pharyngitis cases are caused by bacteria, most frequently GAS. The Centor criteria (fever, tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough) can help guide the need for testing for bacterial pharyngitis. The Centor criteria have a low positive predictive value for determining the presence of GAS infection and are best used to exclude infection. Patients with two or fewer Centor criteria are very unlikely to have GAS pharyngitis and do not need to be tested or treated with antibiotics. Patients with three or more Centor criteria should be tested by using a RADT for GAS pharyngitis. This patient presents with four Centor criteria, placing him at risk for streptococcal pharyngitis, and a RADT is needed to guide therapy.
100
This is one cause of an artifactual low HDL-C.
Extremely low HDL-C may be artifactual due to assay interference from paraproteinemia, secondary to drugs or malignancy, or primary resulting from monogenic disorders, namely apoA-I deficiency, Tangier disease, or LCAT deficiency.
100
This patient presents with rapidly progressive crescentic glomerulonephritis. This is the initial treatment (drug name, dosing, and duration).
What is IV methylprednisolone 500-1000mg/day for three days?
100
This reality TV franchise, known for its luxury lifestyles and dramatic personal conflicts, is set in various cities including New York, Beverly Hills, and Atlanta
What is The Real Housewives?
200
This condition causes positive blood on urinalysis, but no hemoglobin is seen on urine microscopy.
What is Rhabdomyolysis?
200
75 yo M p/w SOB + fevers. He underwent transcatheter aortic valve implantation for aortic stenosis 3 years ago. He was admitted to the hospital 1 month ago with diverticulitis and was treated with antibiotic therapy; he developed intermittent fevers 1 week later.
On exam, T 37.6 °C, BP 145/72 mm Hg, and HR 90. Cardiac examination reveals a normal S1 and S2 and no murmurs. There is no evidence of heart failure.
An ECG is normal. A transthoracic echocardiogram shows a left ventricular ejection fraction of 55% with normal right ventricular function. A bioprosthetic aortic valve is evident, with fully mobile and normal-appearing leaflets.
Three sets of blood cultures are negative.
Which of the following is the most appropriate diagnostic test?
A. Cardiac CT
B. Cardiac MRI
C. TEE
D. No further testing
C. The patient's history of intermittent fevers and dyspnea is concerning for infective endocarditis (IE), possibly due to diverticulitis-related episodes of transient bacteremia. Of note, anyone with a bioprosthetic valve is at high risk for endocarditis with any significant episode of bacteremia. This patient has a bioprosthetic valve, symptoms of infection, and a possible source of bacteremia. According to current guidelines, in patients with suspected IE, transthoracic echocardiography (TTE) is recommended to identify vegetations, characterize the hemodynamic severity of valvular lesions, assess ventricular function and pulmonary pressures, and detect complications. In all patients with known or suspected IE and nondiagnostic TTE results, or if complications have developed or are clinically suspected or if intracardiac device leads are present, TEE is recommended.
200
Post-strep reactive arthritis is most often triggered by strep pharyngitis, but can be triggered by other GAS infections. Name the age distribution, typical presenting symptoms/time course, and treatment for it.
What is ages 8-14 and 21-37. Presents with an asymmetric, acute, polyarthritis, typically within 10 days of the initial infection. Treatment is steroids.
200
Name the HACEK organisms.
- Haemophilus: Includes Haemophilus parainfluenza and Haemophilus aphrophilus
- Aggregatibacter: Includes Aggregatibacter actinomycetemcomitans
- Cardiobacterium: Includes Cardiobacterium hominis
- Eikenella: Includes Eikenella species
- Kingella: Includes Kingella species
200
This "Real Housewives" star from New Jersey was known for her dramatic feud with her sister-in-law, Teresa Giudice, and her involvement in various legal troubles related to her business.
Who is Melissa Gorga?
300
Diagnosis of Diffuse Alveolar Hemorrhage is clinical; however, it can be supported by these two findings.
What are progressively bloodier serial BALs and hemosiderin laden macrophages on cytopathology
300
A 24-year-old man is evaluated for fever of 6 weeks' duration. He also has joint pain, myalgia, and occasional sore throat. The fever begins in the early evening and resolves by morning. His most recent temperature in the evening was 39.5 °C (103.1 °F). The fever is accompanied by a salmon-pink macular rash on the trunk and arms, which resolves with the fever. He has no history of travel. Current medication is acetaminophen.
On physical examination, temperature is 37.5 °C (99.6°F). The remaining vital signs are normal. There is bilateral cervical lymphadenopathy. A friction rub is heard bilaterally at the lung bases. Abdomen is tender without guarding. The knees have effusions. Cardiac examination is normal.
Laboratory studies:
Erythrocyte sedimentation rate
125 mm/h
Leukocyte count
22,000/μL (22 × 109/L)
Hemoglobin
11.5 g/dL (115 g/L)
Ferritin
5200 ng/mL (5200 μg/L)
Blood cultures are pending.
A chest CT scan shows small pleural effusions bilaterally with moderate pleural thickening. An abdominal CT scan shows a small amount of ascitic fluid with evidence of peritoneal thickening.
Which of the following is the most likely diagnosis?
A. Adult onset Still disease
B. Familial Mediterranean fever
C. Infectious endocarditis
D. SLE
A. The patient's symptoms (daily evening fevers accompanied by salmon-pink rash, inflammatory arthritis, sore throat, and serositis) and laboratory evidence of high inflammatory markers and leukocytosis are most consistent with AOSD, a condition of unknown cause. His high serum ferritin level, although not specific, is fairly characteristic of AOSD. Because no specific test exists for AOSD, it remains a diagnosis of exclusion, and other causes should be considered.
300
These are two TTE findings that have been found in patients with COVID19.
What is RV dilatation and dysfunction as well as LV diastolic/systolic dysfunction?
300
Name a type of acute sarcoidosis that presents with the triad of erythema nodosum, bilateral hilar lymphadenopathy and joint pain.
What is Lofgren syndrome?
300
This Bravo executive producer is the host of the late-night talk show Watch What Happens Live, where he interviews celebrities and reality stars.
Who is Andy Cohen?
400
When hypoxemia is caused by these two causes, it is less responsive to supplemental oxygen.
What are hypoventilation and shunt?
400
62 yo F is evaluated in the emergency department for fatigue, headaches, confusion, and weakness that have progressed over the past 6 weeks. She has an 11.3 kg (25 lb) unintentional weight loss over the past month. She has an 85-pack-year history of smoking and quit smoking 3 months ago.
On physical examination, blood pressure is 125/75 mm Hg, pulse rate is 92/min, respiration rate is 21/min, and oxygen saturation is 89% with the patient breathing ambient air. BMI is 17. An expiratory wheeze is noted on the left side. The remainder of the examination is normal.
Laboratory evaluation reveals a serum sodium level of 123 mEq/L (123 mmol/L).
CT scan of the chest shows a 4-cm mediastinal mass compressing the left upper lobe bronchus with associated bulky mediastinal lymphadenopathy.
Which of the following is the most likely diagnosis?
A. Adenocarcinoma of lung
B. Fibrosing mediastinitis
C. Large cell lung cancer
D. Small cell lung cancer
D. There are two major classes of lung cancer: non–small cell lung cancer (NSCLC) and small cell lung cancer (SCLC). Small cell lung cancer typically presents as bulky symptomatic masses with mediastinal involvement. It originates from neuroendocrine cell precursors and is characterized by rapid growth and early metastases. Extrathoracic spread is present in 75% to 80% of patients at initial diagnosis. Symptom onset is rapid (typically <8-12 weeks) and includes cough, wheezing, dyspnea, hemoptysis, weight loss, fatigue, anorexia, and manifestations of paraneoplastic syndromes. The most frequent paraneoplastic syndrome is the syndrome of inappropriate antidiuretic hormone secretion (SIADH). This syndrome results from production of antidiuretic hormone by malignant cells. Other paraneoplastic syndromes associated with SCLC include Cushing syndrome, Lambert-Eaton syndrome, encephalomyelitis, and sensory neuropathy. This patient has a lung mass with bulky mediastinal lymphadenopathy and hyponatremia (secondary to SIADH), making small cell lung cancer the most likely diagnosis.
400
The Duke Criteria for endocarditis have been updated! Name the new additions to the 2023 criteria.
What is evidence of vegetation on cardiac CT or PET-CT as major imaging criteria, and inclusion of history of IE and presence of CIED as minor criteria.
400
This is the treatment for myxedema coma.
What is glucocorticoids (hydrocortisone 100 mg IV q8h) prior to starting IV levothyroxine 200-400 mcg IV if you cannot rule out underlying adrenal insufficiency.
400
Pittsburgh is famously called the "City of Bridges" for having more than this number of bridges, surpassing cities like Venice.
>446
500
Name the surgical indications for infective endocarditis.
(1) IE-associated valve dysfunction (usually aortic or mitral regurgitation) or valve dehiscence causing symptoms or signs of HF, (2) paravalvular extension of infection with abscess, fistula and/or heart block, (3) difficult-to-treat pathogen (e.g. MDR organisms, fungal endocarditis), (4) persistent infection (persistent bacteremia/fever lasting >5d after abx). Veg >10mm are associated with increased risk of embolization BUT the available data have not established that surgical management improves outcomes in patients with large vegetations without other indication for valve surgery
500
A 26-year-old man is evaluated for a 1-week history of pain and swelling in the left ankle, along with pain in the toes and tenderness in the left heel. Three weeks ago, he returned from a vacation in Central America. Before returning home, he experienced 4 days of diarrhea that spontaneously resolved. Current medication is acetaminophen as needed.
On physical examination, vital signs are normal. The left ankle is swollen, with reduced range of motion. Several toes are swollen, as shown, and the Achilles insertion on the left is swollen and tender.
Laboratory evaluation reveals a blood C-reactive protein level of 3.5 mg/dL (35 mg/L).
Which of the following is the most appropriate management?
A. Azithromycin
B. HLA-B27 testing
C. Piroxicam
D. Stool cultures for enteric pathogens
The most appropriate management is an NSAID, such as piroxicam (Option C). The patient has post–enteric infection reactive arthritis, with asymmetric pauci-arthritis involving the lower extremities, enthesitis involving the Achilles tendon, and dactylitis of the right fourth toe and left third and fourth toes. Reactive arthritis is the least common form of spondyloarthritis (2% of cases). Reactive arthritis typically entails arthritis/enthesitis in the lower extremities 2 to 3 weeks after an enteric infection or a bout of nongonococcal urethritis or cervicitis. Joint inflammation can be intense, with high leukocyte counts in the synovial fluid.
500
For diagnosing Wernicke’s encephalopathy, the four-item Caine criteria are more sensitive and specific than the full classic triad of encephalopathy, oculomotor dysfunction, and ataxia. Name two of the four Caine criteria.
To make the diagnosis, you need only two of the four Caine criteria: nutritional deficiency, encephalopathy, oculomotor dysfunction, and ataxia.
500
To satisfy one of the major clinical criteria for infective endocarditis (modified Duke's criteria), you typically need typical microorganisms from two separate blood cultures. However, you only need a single positive blood culture for this bacterium.
What is Coxiella Burnetii?
500
This Pittsburgh bridge, completed in 1928 and named after a U.S. Navy Commodore, was the first in the city to use a self-anchored suspension design and is a key link between downtown and the North Shore.
What is the Andy Warhol Bridge (formerly the Seventh Street Bridge)?