Under the Skin
Liver! I Hardly Know Her
Time is Brain
Rheum for IMprovement
Brain Rot
100
55-year-old woman is evaluated in the emergency department for acute onset of fevers and chills and a 3-day history of progressively worsening right-lower-extremity pain, swelling, and erythema. She reports no antecedent trauma or water exposure. Medical history is noncontributory; she takes no medications and has no history of injection drug use.
On physical examination, temperature is 38.9 °C (102.0 °F), blood pressure is 108/62 mm Hg, and pulse rate is 105/min; other vital signs are normal. No focal areas of fluctuance or drainage are noted over the right lower extremity.
Which of the following is the most appropriate treatment?
A. IV Cefazolin
B. IV Vancomycin
C. Oral cephalexin
D. Oral trimethoprim-sulfamethoxazole
What is IV cefazolin
100
A 24-year-old man has a 1-week history of nausea, jaundice, fatigue, and recent confusion. The INR is 2.3, serum AST is 940 U/L, and total bilirubin is 12.6 mg/dL. HBsAg and IgM anti-HBc are both positive. What is the diagnosis?
What is acute liver failure secondary to acute HBV infection?
*Bonus! What are the criteria for acute liver failure?
100
An 18-year-old man is evaluated for a history of daily staring episodes. The episodes occur without warning and last 5 to 10 seconds. He is unaware of the events, as he will continue previous conversations or activities immediately after they end. The episodes are so frequent that he cannot pay attention in his classes, and his academic performance has suffered. Medical history is significant for a single generalized tonic-clonic seizure 6 months ago. He takes no medications.
Physical examination findings, including vital signs, are normal.
Which of the following is the most likely diagnosis?
A. Absence seizures
B. Atonic seizures
C. Focal impaired consciousness seizures
D. Focal preserved consciousness seizures
Answer A: Absence Seizures
The most likely diagnosis is absence seizures (Option A). These seizures are characterized by staring episodes that are typically brief (lasting <15 seconds), occur without an aura or warning, have no postictal confusion, and are frequent (occurring daily or multiple times a day). Absence seizures are generalized seizures; patients do not have awareness during them and may not recall that they are occurring. Absence seizures may also be associated with other generalized seizure types, including generalized tonic-clonic seizures. They may occur as the only seizure type in school-aged children and are often confused with attention-deficit/hyperactivity disorder or focal impaired consciousness seizures, but they are also commonly seen in young adult–onset epilepsies such as juvenile myoclonic epilepsy. This patient has brief staring spells of which he is unaware and that occur without warning and without postictal symptoms. This clinical presentation is most consistent with absence seizures.
Like absence seizures, atonic seizures (Option B) may occur without warning and have no postictal confusion. However, patients with atonic seizures experience a sudden loss of muscle tone that often results in a fall. Additionally, atonic seizures are even more brief than absence seizures, often lasting less than 2 seconds. This patient's symptoms are not consistent with atonic seizures, as atonic seizures would not explain his staring episodes, altered awareness, or abrupt cessation of speech or behavior.
Focal impaired consciousness seizures (Option C) may also present as staring episodes and must be distinguished from absence seizures. In contrast to absence seizures, focal impaired consciousness seizures are longer (>30 seconds in duration), often have a preceding aura or warning, are infrequent (weekly or monthly), and usually include postevent confusion or disorientation (Table: Differentiation of Seizure Types Presenting as Staring Episodes). The shorter duration, frequent occurrence, and lack of warning or postictal confusion of this patient's staring episodes make focal impaired consciousness seizures an unlikely cause.
Focal preserved consciousness seizures (Option D) are localized seizures that have varying symptoms and physical manifestations depending on the site of origin in the brain. By definition, awareness is always preserved in these seizures, so staring and altered awareness should not occur. A diagnosis of focal preserved consciousness seizures would not explain this patient's symptoms.
100
A 75-year-old man is evaluated for a one day of severe left knee pain. He has type 2 diabetes mellitus and well-controlled gout. Medications are metformin and allopurinol.
Physical Exam: 37.8 °C (100.0 °F). The left knee is warm, swollen, and tender, and the overlying skin is erythematous. Aspiration is performed.
Synovial fluid studies:
Leukocyte count
120,000/µL (120 × 109/L) with 80% polymorphonuclear cells
Analysis shows opaque fluid; extracellular negatively birefringent needle-shaped crystals are present. Gram stain is negative. Culture is pending.
A. Canakinumab
B. Low-dose colchicine
C. Intra-articular methylprednisolone injection
D. Vancyomycin
D. Vancomycin
New-onset monoarthritis in a patient with well-controlled inflammatory arthritis should prompt urgent arthrocentesis.
In the absence of positive findings on Gram stain, initial empiric antibiotic therapy for infectious arthritis is guided by risk factors and expected common pathogens.
100
Which recently released movie tells the story of a man's 10 year journey returning home from war?
The Odyssey
200
A 50-year-old woman is evaluated for fever, malaise, and the acute onset of the facial skin rash shown, which is associated with regional lymphadenopathy.
What is the most likely diagnosis?
A. Disseminated herpes simplex infection
B. Erysipelas
C. Staphylocaoccal scalded skin syndrome
D. Toxic shock syndrome
What is erysipelas?
200
65 year old male with alcohol associated liver cirrhosis undergoes upper endoscopy for variceal screening and is found to have Grade II esophageal varicies. What is the preferred treatment for primary prophylaxis of variceal bleeding?
What is carvedilol (preferred). Also accept propranolol or nadolol
200
A 22-year-old man is evaluated 3 days after experiencing a single event of suddenly falling to the ground and stiffening, followed by shaking of all limbs, loss of consciousness, and urinary incontinence. He reports that the shaking lasted 2 minutes; afterward, he was sleepy and slow to respond, with deep, slow breathing. He took a 1-hour nap afterward and then gradually awakened and returned to normal consciousness. He did not seek care at the time of the event. He has had no past episodes. Medical history is otherwise unremarkable; he has no history of head trauma, meningitis, or developmental problems. He takes no medications and does not drink alcohol or use other drugs.
On physical examination, vital signs are normal. He is awake. He reports only mild diffuse body pains and having bitten his tongue.
Which of the following is the most appropriate management?
A. Perform CT of the head
B. Perform LP
C. Perform MRI of the brain
D. Start levetiracetam
Answer: C
The most appropriate management is to perform a brain MRI (Option C). In patients with a first seizure, the recurrence risk must be determined to establish the likelihood that the patient has epilepsy and whether antiseizure medications (ASMs) are warranted. To make this determination, neuroimaging and electroencephalography (EEG) are indicated. MRI with contrast is the preferred neuroimaging test, as it is more sensitive than CT for finding abnormalities that suggest epilepsy. The use of contrast with MRI may be deferred unless infection, tumor, or vascular lesions are suspected. Because temporal lobe epilepsy is common, MRI sequences focusing on the hippocampus and temporal lobes are also useful. This patient has had a generalized tonic-clonic seizure and should undergo MRI of the brain.
After a patient's first seizure, MRI and electroencephalography are needed to determine the patient's risk for recurrent seizures.
Antiseizure medication therapy is not indicated after a first seizure in patients with no seizure or epilepsy risk factors or past events concerning for seizures.
200
An 18-year-old man is evaluated in the ER for 3 days of worsening abdominal and knee pain, as well as a rash. He completed antibiotics for strep pharyngitis 2 weeks ago. No other medical history or medications.
Physical Exam: Vitals WNL. Petechiae and palpable purpura present over the buttocks and on both lower extremities. There is diffuse abdominal tenderness without peritoneal signs. Warmth and swelling in both knees are present; knees are tender along the joint lines. Remainder of exam is normal.
Labs: Normal CBC with differential, CMP, lactate, PT, and PTT.
CT scan of the abdomen shows multifocal areas of bowel wall thickening and mesenteric lymphadenopathy.
A. Antinuclear antibody measurement
B. CT angiography
C. Rapid streptococcal antigen test
D. Urinalysis microscopy
D) Urinalysis microscopy
IgA vasculitis is characterized by palpable purpura, abdominal pain or gastrointestinal bleeding, and arthritis and arthralgias.
IgA vasculitis involves the kidney in one third of adults, and patients suspected of having IgA vasculitis should be evaluated with urinalysis with microscopy and urine protein measurement.
200
Which movie tells the origin story of a group of superheroes banding together to stop an alien invasion of Earth?
The Avengers
300
A 33-year-old woman is admitted to the hospital for fever and excruciating left arm pain at the site of a recent insect bite, which she had been continuously scratching.
On physical examination, temperature is 39.0 °C (102.0 °F), blood pressure is 88/60 mm Hg, pulse rate is 105/min, and respiration rate is 24/min. The left biceps is exquisitely tender, with associated warmth, edema, and violaceous hue. The skin surrounding the insect bite is excoriated, and crepitus is present.
A plain radiograph of the left biceps area shows gas.
Empiric meropenem, vancomycin, and clindamycin are initiated. Surgical debridement confirms necrotizing fasciitis. Bacteria are visualized on blood and intraoperative tissue cultures as shown.
Which of the following is the most likely causative organism?
A. Clostridium perfringens
B. Staphylococcus aureus
C. Streptococcus pyogenes
D. Vibrio vulnificus
What is Streptococcus pyogenes?
300
A 55-year-old man with alcohol-associated cirrhosis is admitted to the hospital with fever and abdominal pain. Paracentesis is performed. The ascitic fluid granulocyte count is 650/μL and serum creatinine is 1.6 mg/dL. You diagnose spontaneous bacterial peritonitis. What is the most appropriate management?
What is cefotaxime and albumin infusion?
300
A 37-year-old man is evaluated in the hospital for a first-time generalized tonic-clonic seizure. He was hospitalized 3 days ago for severe pneumonia with sepsis in the setting of chronic immunosuppression for SLE. Cefepime, azithromycin, intravenous fluids, and stress-dose hydrocortisone were initiated at hospitalization. Over the initial 72 hours, his fever resolved, and his blood pressure stabilized. Earlier this evening, however, he became confused and agitated and was given haloperidol. His mental status improved, but the seizure occurred 6 hours later. Medical history is significant for systemic lupus erythematosus, end-stage kidney disease treated with hemodialysis, and opioid use disorder. His usual outpatient medications are prednisone, sevelamer, calcium carbonate, and buprenorphine, all of which are being continued in the hospital.
On physical examination, vital signs are within normal limits. He is somnolent and opens his eyes to voices but does not follow commands. He moves his limbs spontaneously against gravity and withdraws from noxious stimuli in all limbs. Deep tendon reflexes are reduced throughout. Labs are significant for creatinine of 5.4. Head CT is normal.
A. Discontinue buprenorphine
B. Discontinue cefepime
C. Discontinue haloperidol
D. Start methylprednisolone
Answer B: Discontinue cefepime
Cefepime should be discontinued and replaced with another antibiotic (Option B). Cefepime, like other fourth-generation cephalosporins, is increasingly recognized as a cause of encephalopathy and decreased seizure threshold, especially in patients with kidney dysfunction. In a patient with a seizure, attention should be paid to the patient's medications, and drugs that lower seizure threshold should be avoided. In addition to discontinuing the offending medication, evaluating patients for seizure recurrence risk (i.e., underlying epilepsy) with electroencephalography and brain MRI should be considered. If that testing is negative, then the episode would likely be considered a provoked seizure and not an indicator of epilepsy. This patient with chronic kidney disease developed encephalopathy and seizure shortly after starting cefepime. Cefepime should be discontinued.
Buprenorphine is not associated with causing significant delirium or encephalopathy or with lowering seizure threshold and is unlikely to have provoked this patient's seizure. Discontinuing buprenorphine (Option A) in this patient may lead to opioid withdrawal or increase the likelihood of recurrent opioid use.
Atypical antipsychotics (e.g., clozapine, quetiapine, risperidone, ziprasidone) are implicated in lowering seizure threshold, but this is not the case for typical antipsychotics, like haloperidol (Option C).
Starting methylprednisolone (Option D) is not necessary in this patient with a seizure likely secondary to a medication. High-dose glucocorticoids may be appropriate if lupus cerebritis were a likely cause of the seizure and mental status changes, but the temporal association with the administration of a medication with known neurotoxicity makes a medication effect far more likely.
300
A 30-year-old woman is evaluated for 2 days of worsening abdominal pain. She also has a rash on her feet, thighs, and buttocks and achiness in the joints and muscles. She reports no diarrhea, vomiting, or nausea.
Vital are normal. Abdominal palpation elicits periumbilical tenderness. Palpable purpura are noted on the feet, legs, and buttocks.
Labs:
ESR: 70
Creatinine: 1.1 mg/dL
Urinalysis with microscopy: 1+ protein, 10-15 erythrocytes/hpf
CBC with differential is normal; ANCA is negative. Abdominal CT scan shows a short segment of small bowel thickening and edema.
A. Kidney Biopsy
B. Mesenteric angiography
C. Serum IgA level measurement
D. Skin biopsy
D. Skin biopsy
The classic triad for IgA vasculitis (Henoch-Schönlein purpura) is purpura, abdominal pain, and arthralgia; diagnosis is established with biopsy of the most accessible affected organ.
300
Which science fiction movie follows Paul Atreides as he joins the Fremen to seek revenge against the forces that destroyed his family?
Dune: Part Two
400
A 58-year-old patient is evaluated for an ulcer on their left foot. They report no injuries but report “breaking in” a new pair of shoes for the past couple of weeks. They are sure the wound was not present 2 weeks ago. They have no fever or chills and have not noticed drainage on their socks. Medical history is significant for type 2 diabetes mellitus, diabetic neuropathy, and hypertension. Medications are metformin, dulaglutide, gabapentin, rosuvastatin, and lisinopril.
On physical examination, vital signs are normal. A shallow ulcer approximately 1 cm in diameter is noted on the plantar surface of the left central forefoot without drainage, warmth, erythema, or induration. They have decreased sensation to pinprick below the ankles bilaterally.
Which of the following is the most appropriate diagnostic test to perform next?
A. ESR
B. Plain radiography of the foot
C. Wound culture
D. No further testing
What is no further testing?
400
A 55-year-old man with liver cirrhosis presents with lethargy, confusion, and disorientation consistent with hepatic encephalopathy. This medication helps reduce serum ammonia levels by acidifying the colon, converting ammonia (NH₃) to ammonium (NH₄⁺) that is trapped and excreted, while also increasing stool frequency to eliminate nitrogenous waste.
What is the mechanism of action of lactulose?
400
A 21-year-old man is evaluated in the emergency department for persistent convulsive status epilepticus that began 30 minutes before arrival. Upon arrival, his airway was secured, and he received thiamine, intravenous glucose, and lorazepam. The patient continues to shake 5 minutes after receiving a second dose of lorazepam. Medical history is relevant for epilepsy diagnosed 8 years ago. His only medication is levetiracetam. He is allergic to phenytoin.
On physical examination, temperature and blood pressure are normal, and respiration rate is 16/min. The pupils are reactive, but the patient remains comatose.
Which of the following is the most appropriate next step in management?
A. Brain MRI
B. EEG
C. Fosphenytoin
D. Valproate
Answer D: Valproate
This patient is in generalized convulsive status epilepticus (CSE) and should now receive intravenous valproate (Option D). CSE, a medical emergency that can lead to significant morbidity and mortality, is defined as a generalized tonic-clonic seizure (GTCS) lasting more than 5 minutes or two such seizures within 5 minutes without return to baseline in between. Initial CSE management requires rapidly assessing airways, breathing, circulation, and the blood glucose level. These steps should be performed simultaneously with initiation of drug treatment. According to an American Epilepsy Society guideline, intramuscular midazolam, intravenous lorazepam, and intravenous diazepam are the first-line agents for the initial treatment of CSE and have been judged to be equivalent. If CSE has not ceased after one dose of midazolam or two doses of lorazepam or diazepam, second-line therapy is initiated. Fosphenytoin (Option C), a prodrug of phenytoin, is preferred over phenytoin because it can be administered faster and does not carry the risk for thrombophlebitis or skin necrosis that is associated with phenytoin extravasation. Valproate, levetiracetam, and lacosamide are alternatives to phenytoin or fosphenytoin, particularly in patients who are allergic to phenytoin or have primary generalized epilepsy. This patient continues to have CSE 5 minutes after a second dose of lorazepam and requires second-line therapy. He is allergic to phenytoin; therefore, he should receive valproate.
CSE is usually diagnosed clinically. Obtaining a brain MRI (Option A) is an unnecessary, time-consuming process and would delay treatment. Once CSE is controlled, imaging with head CT or brain MRI may be considered. Similarly, electroencephalography (Option B) could eventually be considered but should not delay treatment; it would not be appropriate to obtain at this point.
According to American Epilepsy Society guidelines, valproate, levetiracetam, and lacosamide are appropriate second-line therapy for convulsive status epilepticus for patients allergic to phenytoin.
400
A 52-year-old woman is hospitalized for a 3-week history of fatigue, decreased exercise tolerance, and hemoptysis. She has had recurrent sinus infections during the past 3 years, treated with several courses of antibiotics. She currently has periodic epistaxis and foul-smelling nasal discharge. Her only outpatient medication is amoxicillin-clavulanate.
Physical Exam: 37.9 °C (100.2 °F), HR 100. There is tenderness over the maxillary and frontal sinuses. Stridor is noted, and palpation of the trachea elicits pain. Lungs are clear to auscultation. There is 1+ pitting edema of the ankles. Remainder of the exam is normal.
Labs:
Hgb: 8.7 g/dL
WBC: 6200/μL
Platelets: 480,000/μL
Creatinine: 2.1 mg/dL
ANCA: Positive (c-ANCA pattern)
Urinalysis: 2+ blood, 2+ protein; 10-20 erythrocytes/hpf
Urine protein-creatinine ratio: 2400 mg/g
Sinus CT scan reveals erosive changes and opacification of the maxillary sinuses. Chest CT scan demonstrates scattered nodules bilaterally and a 4-cm cavitary lesion in the right lower lobe.
Kidney biopsy specimen shows pauci-immune necrotizing glomerulonephritis.
A. Eosinophilic granulomatosis with polyangiitis
B. Granulomatosis with polyangiitis
C. Microscopic polyangiitis
D. Relapsing polychondritis
B. Granulomatosis with polyangiitis
Granulomatosis with polyangiitis is a systemic vasculitis characterized by sinonasal, upper airway, lung, and kidney involvement; it is highly associated with c-ANCA/anti–proteinase 3 antibodies.
400
Which upcoming animated movie follows an adult Aang and his friends as they search for an ancient power that could help restore the Air Nomad culture?
Avatar Aang: The Last Airbender
500
A 48-year-old man is evaluated in the emergency department for fever and pain at the site of right forearm lacerations sustained in a lake 2 days ago. Medical history is remarkable for alcoholic cirrhosis. He takes no medications.
On physical examination, temperature is 39.1 °C (102.4 °F), blood pressure is 100/70 mm Hg, pulse rate is 120/min, and respiration rate is 25/min. The right forearm is tender and warm, with several hemorrhagic bullae noted.
Surgical exploration and debridement confirm necrotizing fasciitis; intraoperative tissue cultures grow Aeromonas hydrophila.
Which of the following is the most appropriate treatment?
A. Ciprofloxacin plus doxycycline
B. Linezolid plus metronidazole
C. Nafcillin plus rifampin
D. Vancomycin plus clindamycin
What is ciprofloxacin plus doxycycline
500
A 58-year-old woman is hospitalized for dyspnea due to recurrent right-sided pleural effusion. She has autoimmune hepatitis with cirrhosis. Findings on previous thoracenteses during the past 3 months were consistent with hepatic hydrothorax. She has received escalating doses of diuretics for the past year and adhered to a sodium-restricted diet. Medications are furosemide, spironolactone, carvedilol, and azathioprine.
On physical examination, blood pressure is 100/65 mm Hg, pulse rate is 60/min, and respiration rate is 20/min. Oxygen saturation is 92% with the patient breathing ambient air. She is alert and oriented. There are no signs of asterixis. She has decreased breath sounds on the right side. Her abdomen is soft and nondistended.
Ultrasound shows a nodular liver surface with a round edge and hypoechoic nodules in the liver parenchyma, as well as slight perihepatic ascites. Echocardiogram shows normal cardiac function.
Which of the following is the most appropriate next step in management?
A. Fluid restriction
B. Indwelling chest tube
C. Large volume paracentesis
D. Transjugular intrahepatic portosystemic shunt
What is TIPS?
500
A 42-year-old woman is evaluated for new-onset focal impaired consciousness seizures that began 2 months ago. She has had a total of three seizures, none of which was associated with clear provoking factors. Medical history is significant for bipolar disorder with psychotic features, including two psychiatric hospitalizations in the past 6 months for suicidal and homicidal ideation. Her only medication is risperidone.
Physical examination findings, including vital signs, are normal.
Electroencephalogram shows focal epileptiform discharges with focal sharp waves arising from the right temporal region. Brain MRI without contrast is normal.
Which of the following is the most appropriate treatment?
A. Lamotrigine
B. Levetiracetam
C. Perampanel
D. Topiramate
Answer A: Lamotrigine
Lamotrigine (Option A) is the most appropriate treatment in this patient with more than two unprovoked seizures and psychiatric comorbidity. Antiseizure medications (ASMs) are generally started after two or more unprovoked seizures because the risk for recurrence in this scenario is about 50%. Treatment is usually guided by the seizure type (focal versus generalized) rather than ASM mechanism or epilepsy cause. Additionally, the potential adverse and beneficial side effects of ASMs and patient childbearing status and comorbidities must be carefully considered when selecting an ASM. Lamotrigine is a first-line, broad-spectrum ASM for both focal and generalized seizures with an overall excellent safety and efficacy profile. It is also a mood stabilizer, and it is a good choice for initial therapy in patients with psychiatric comorbidities. It is usually well-tolerated, although rapid titration of lamotrigine has been associated with the development of Stevens-Johnson syndrome, toxic epidermal necrolysis, drug-induced hypersensitivity syndrome (also known as drug reaction with eosinophilia and systemic symptoms [DRESS]), and hemophagocytic lymphohistiocytosis. Other ASMs with mood-stabilizing properties include oxcarbazepine and valproate, but adverse effects are common with valproate use. Lamotrigine is the best treatment option in this patient with recurrent unprovoked seizures and psychiatric comorbidities.
Levetiracetam (Option B) is generally considered a first-line treatment option for patients with focal seizures. Although all ASMs carry a warning about worsening depression and suicidality and all patients must be screened and monitored for these symptoms, levetiracetam in particular may cause depression, anxiety, anger, or agitation. It would be an inappropriate choice in this patient with psychiatric comorbidities.
Perampanel (Option C) can cause homicidal ideation and would not be the most appropriate treatment for this patient.
Topiramate (Option D) is a second-line treatment option for patients with focal seizures but can cause acute psychosis; it would not be an appropriate treatment for this patient with psychiatric comorbidities.
500
A 69-year-old patient is evaluated in the ER for 1 day of progressive pain and swelling of the left knee. They have HTN treated with HCTZ.
Physical Exam: 37.3 °C (99.2 °F); other vitals WNL. The left knee is warm, red, tender, and swollen. The joint has limited range of motion due to pain. Remainder of the exam is normal.
Labs:
ESR: 62 mm/h
WBC: 12,300/μL
Urate: 8.3 mg/dL
The left knee is aspirated, and 20 mL of cloudy yellow fluid is removed. Synovial fluid analysis shows a leukocyte count of 22,000/μL (22 × 109/L), with 83% neutrophils, and rhomboid-shaped, positively birefringent crystals under polarizing microscopy, including intracellularly in neutrophils. Gram stain is negative; culture is pending.
Radiographs of the knees show mild medial compartment narrowing, with small osteophytes and faint calcification in the menisci bilaterally.
A. Acute calcium pyrophosphate crystal arthritis
B. Basic calcium phosphate deposition
C. Gout flare
D. Osteoarthritis
A. Acute calcium pyrophosphate crystal arthritis
Acute calcium pyrophosphate crystal arthritis (pseudogout) typically presents as a monoarticular or oligoarticular inflammatory arthritis characterized by rapid onset of swelling, pain, loss of function, tenderness, and warmth of the affected joint (commonly a knee or wrist), and inflammatory synovial fluid with rhomboid-shaped, positively birefringent crystals.
500
Which movie tells the story of a lone science teacher who wakes up on a spaceship with no memory and must save humanity from a dying sun?
Project Hail Mary