🎆 Final Final Jeopardy 2026 🎆

Chemo Chaos 🧪

100

What is the classic cardiotoxicity of anthracyclines and its mechanism?

Dilated cardiomyopathy; free radical-mediated oxidative damage to cardiomyocytes — dose-dependent and largely irreversible

200

Trastuzumab cardiotoxicity differs from anthracyclines in what two key ways?

largely reversible with drug discontinuation

not dose-dependent — mechanism is HER2 receptor blockade impairing cardiomyocyte repair rather than direct toxic injury

300

Fluorouracil cardiotoxicity — mechanism and which patients are highest risk?

Coronary vasospasm causing demand ischemia

highest risk in patients with pre-existing CAD or prior chest radiation — occurs in up to 10% of patients

400

Per ACC cardio-oncology guidelines, when should cardioprotective therapy be started during anthracycline treatment?

ACE inhibitor/ARB + beta-blocker initiated when EF drops ≥10% or GLS declines >15% — some centers start prophylactically in high-risk patients (prior cardiac disease, high cumulative dose.

500

Clonal hematopoiesis of indeterminate potential (CHIP) — why is it relevant to cardio-oncology?

CHIP mutations (TET2, DNMT3A) independently increase cardiovascular risk — accelerate atherosclerosis and heart failure; also increases risk of chemotherapy cardiotoxicity; emerging screening target in cardio-oncology

Big Kid Hearts 🐣

100

What shunt direction occurs in an uncorrected VSD and what murmur does it produce?

Left-to-right shunt; harsh holosystolic murmur at left lower sternal border

200

Eisenmenger syndrome — define it and name two absolute contraindications once established?

Reversal of left-to-right to right-to-left shunt due to pulmonary hypertension; contraindications: defect closure (fatal) and pregnancy (maternal mortality up to 50%)

300

In repaired TOF, what is the most common cause of late sudden death and its substrate?

Ventricular tachycardia via scar-mediated reentry at RVOT surgical scar (ventriculotomy or transannular patch); QRS duration >180ms is the strongest non-invasive risk marker — distinct from overall late mortality which is dominated by RV failure from chronic pulmonary regurgitation

400

Scimitar syndrome — describe the anatomy and its hemodynamic consequence?

Partial anomalous pulmonary venous return of right lung to IVC — left-to-right shunt; scimitar sign on CXR (curved vessel shadow); associated with right lung hypoplasia and dextroposition of heart

500

Name four specific long-term complications of Fontan circulation and their mechanisms?

Protein-losing enteropathy (elevated venous pressure → gut lymphatic leak)
Fontan-associated liver disease (hepatic venous congestion → fibrosis → HCC)
plastic bronchitis (lymphatic casts in airways)
atrial arrhythmias (massively dilated atria from chronic high pressure)

Aorta Anxiety 😰

100

Type A vs Type B aortic dissection — define and first-line management of each?

Type A: involves ascending aorta → emergent surgery. Type B: descending only → medical management (beta-blocker, BP control) unless complicated

200

What genetic syndrome has hypertelorism, bifid uvula/cleft palate, arterial tortuosity — TGFBR1/2 mutation?

Loeys-Dietz syndrome

300

Complicated vs uncomplicated Type B dissection — name three complications mandating intervention?

malperfusion (renal, mesenteric, spinal)
rupture or impending rupture
rapid expansion >1cm/year
refractory pain
hypertension despite maximal medical therapy

400

Loeys-Dietz syndrome vs Marfan — which has more aggressive aortic disease and why?

Loeys-Dietz — TGFBR1/2 mutation causes more diffuse arterial tortuosity and aneurysms throughout entire arterial tree (not just aorta); dissection occurs at smaller diameters than Marfan; surgical threshold 4.0–4.5 cm vs 4.5–5.0 cm in Marfan; also intracranial aneurysms, cervical spine instability — requires whole-body MRA surveillance annually

500

Ehlers-Danlos Type IV — why is surgical mortality so high and what is the management strategy?

COL3A1 mutation causes Type III collagen deficiency — arterial walls extremely fragile, tear with minimal manipulation; sutures pull through tissue; surgical mortality 5–10x higher than standard aortic surgery;

Management: avoid elective surgery, angiography only if absolutely necessary, conservative management of dissection/rupture when possible — most patients die from spontaneous arterial rupture not amenable to repair

Sweat & Stress 🏃‍♀️

100

What ECG finding in an athlete is normal and does not require further workup?

Sinus bradycardia, first-degree AV block, early repolarization, incomplete RBBB, voltage criteria for LVH — all training-related normal variants

200

Athlete's heart vs HCM — what wall thickness is the gray zone where differentiation is difficult?

13–15mm — below this is almost always athlete's heart; above 16mm is almost always pathologic

300

What is the physiologic explanation for athlete's bradycardia and high vagal tone?

Enhanced parasympathetic tone + increased stroke volume from cardiac remodeling → lower resting HR required to meet cardiac output needs; intrinsic SA node rate also decreases with sustained training

400

In exercise-induced hypertension, what is the SBP definition (men and women), and significance?

SBP >210 mmHg in men or >190 mmHg in women at peak exercise — associated with increased risk of future resting hypertension and LVH; consider antihypertensive therapy if exaggerated response with normal resting BP

500

Wolff-Parkinson-White in an asymptomatic athlete — when is ablation recommended per current guidelines?

Electrophysiology study recommended to risk-stratify; ablation recommended if SPERRI <250ms or ERP <250ms during EP study — asymptomatic WPW with high-risk EP findings warrants ablation before competitive sport clearance

Poison Control ☠️

100

Digoxin toxicity classic ECG finding?

Scooped ST depression ("Salvador Dali" sign) — also bradyarrhythmias, heart block, bidirectional VT in severe toxicity

200

QT prolonging drugs — name the four drug classes most commonly responsible for drug-induced torsades?

antiarrhythmics (sotalol, dofetilide, amiodarone), 

antipsychotics (haloperidol, quetiapine)

antibiotics (azithromycin, fluoroquinolones), 

antiemetics (ondansetron, metoclopramide)

300

Tricyclic antidepressant overdose — mechanism of cardiotoxicity and ECG finding?

Sodium channel blockade → wide QRS; also alpha blockade (hypotension) and anticholinergic effects (tachycardia); terminal R wave in aVR >3mm predicts arrhythmia risk

400

Clozapine cardiac toxicity — what life-threatening complication occurs and when in treatment course?

Myocarditis — occurs in first 4–8 weeks of treatment; also cardiomyopathy with chronic use; monitor troponin and CRP weekly for first month; discontinue immediately if myocarditis suspected

500

Chloroquine/hydroxychloroquine overdose — ECG findings and how do you treat it? 

Wide QRS, QT prolongation, ventricular arrhythmias — sodium channel blockade similar to TCA; sodium bicarbonate alkalinizes serum, reduces drug-channel binding, narrows QRS; also treat hypokalemia aggressively

The Attendings' Lounge 💼

100

A physician has no federal taxes withheld on 1099 moonlighting income until April — what IRS penalty applies?

Underpayment penalty — quarterly estimated taxes required; safe harbor is paying 100% of prior year tax liability quarterly, otherwise 8% penalty on underpayment amount

200

What is the self-employment tax rate?

Bonus: what income does it apply to?

15.3%

• Social Security portion (12.4%) only applies up to the wage base — $176,100 for 2025
• Medicare (2.9%) applies to all net SE income, no cap
• An additional 0.9% Medicare surtax kicks in above $200K (single) / $250K (married filing jointly) in combined wages + SE income

300

What is the difference between a revocable and irrevocable trust and why would a high-earning physician choose the latter?

Revocable: you control it, can change it, assets still in your estate for tax purposes. 

Irrevocable: you give up control, assets removed from your taxable estate — used for asset protection from malpractice, Medicaid planning, and reducing estate tax exposure above the $13.6M federal exemption (2024)

400

Name the two most important disability optional riders and why each matters?

(1) Future increase option (FIO) — locks in ability to increase coverage as attending income grows without new medical underwriting; critical before any health changes occur.
(2) Own-occupation rider — ensures benefit pays if you can't perform subspecialty specifically even if you can still practice general medicine; without it, policy may deny claim if you can see office patients

500

Explain how S-corp election reduces self-employment tax, the IRS reasonable salary requirement, and the risk of underpaying salary.

S-corp splits income into W2 salary (subject to FICA 15.3%) and distributions (not subject to FICA); IRS requires "reasonable compensation" for services — typically 40–60% of net profit; underpaying salary triggers IRS audit, back FICA taxes, penalties; savings of $10,000-$30,000/year at high income levels if structured correctly