CHEST PAIN OR HEARTBREAK?
LAB VALUES ARE A VIBE!
PILLS & THRILLS
WHY IS THIS PATIENT YELLOW?
FLUIDS & FEELINGS
100
A 58 y/o M with PMH HTN presents with sudden onset of chest pain. His blood pressure is 178/92 in the right arm and 154/88 in the left arm. His troponin is 80. The senior resident wants to activate the cath lab for NSTEMI.
What is the most likely diagnosis and what is next step?
CT angiography!!!!
the BP difference between arms is a classic giveaway for type A dissection because the dissection flap can extend into o partially block on of the major arteries of that arm. Rushing to anticoagulant for ACS here could be fatal!!
100
24 y/o F comes to your clinic with fatigue. She reports very heavy menstrual bleeding. labs showed hb 9.2, mcv 72, RDW 18%.
What is the most likely diagnosis?
IRON DEFICIENCY ANEMIA!
Low hb, low mcv and low rdw!! next step will be to check her ferritin!!
looses > 80 ml per cycle are considered heavy menstrual bleeding and significantly increase the risk of IDA.
100
78 y/o M is being treated with pna, after two days the serum creatinine rises from 0.9 to 1.6 mg/dl, he feels well, has normal UO and BUN is unchanged, UA is bland
which medications is most likely responsable???
TMP-SMX!!!
Trimethroprim inhibits tubular secreation of creatinine casuing a rise in serum creatinine w/o actually reducing GFR, this is a "FAKE" AKI that can easily cause panic!!
100
52 y/o F presents with fatigue and looking yellowish. Total bili 8.2, AST 1.100, ALT 1350, alk phos 110. she recently returned from a trip where she ate street food.
what is the most likely cause of her jaundice?
ACUTE VIRAL HEPATITIS!
a very high AST/ALT with normal alk phos is usually hepatocellular injury rather than biliary obstruction. Hepatitis A is a classic cause of acute jaundice after travel or contaminated food exposure.
100
Which electrolyte abnormality is classically associated with “stones, bones, groans, thrones, and psychiatric overtones”?
Hypercalcemia!!!!!!!
200
28 y/o woman comes to the ED after learning her fiance called off their wedding. She has sudden crushing chest pain, sob and EKG changes. Her heart cath showed no blocked coronary arteries.
What is the diagnosis and are we going to see on her echocardiogram?
TAKOTSUBO CARDIOMYOPATHY!
hypokinesis or akinesis of the apical and mid ventricular segment with hypercontractile basal segment creating the appearance of a Japanese octopus trap (takotsubo)
200
62 y/o F comes to your clinic with severe constipation and fatigue. Her lab work showed CA 11.8 (8.5-10.5), PO4 2.2 (2.5-4.5), PTH 165 (15-65), creatinine normal.
What is the most likely diagnosis?
PRIMARY HYPERPARATHYRODISM!!!
Classic pattern of high ca, high pth and low po4. Vibe check: if Ca is high PTH should be suppressed. if both ca and pth are elevated think hyperparathyrodism.
Most likely cause >> 80-85% due to solitary parathyroid adenoma! tx: take it out!!
200
54 y/o F admitted for MRSA bacteremia and started on IV antibiotics. 10 Days later she develops worsening shortness of breath, fever and new o2 requirement. chest CT showed bilateral peripheral pulmonary infiltrates. BC are now negative. WBC 14.000, eosinophils 18%.
which medications is the most likely cause???
daptomycin-induced eosinophilic pneumonia!!
usually occurs 2-4 weeks after starting therapy, the classic triad is fever, hypoxemia and peripheral or BAL eosinophilia.
200
24 y/o M comes to the office because his eyes are looking yellowish after he spend a week studying for med school and has been fasting and not eating well, but overall he feels well. His labs showed total bili 3, direct 0.2, AST/ALT normal, HB is normal
What is the diagnosis?
Gilbert syndrome!!!!
causes intermittent unconjugated hyperbilirubinemia triggered by fasting, iLlness, dehydration or stress. liver test are normal!
BONUS* What are the other congenital bilirubin disorders?
200
A 72-year-old woman with CHF is admitted for volume overload. She receives IV furosemide and loses 8 liters over 3 days. On discharge day, bicarbonate is 38, chloride is 88, and potassium is 3.1.
What medication might help her continue diuresing while correcting the acid-base problem?
Acetazolamide!!!
The ADVOR trial (2022) looked at whether adding acetazolamide to IV loop diuretics improves decongestion in patients hospitalized with acute decompensated heart failure and volume overload.
300
75 y/o M comes to the ER after a syncopal episode, patient reports he has been passing out daily for the past week!, His EKG shows:
What is the diagnosis?
COMPLETE HEART BLOCK!
the hallmark of third degree AV block is AV dissociation: the atria and ventricles have both decided to work from home and are no longer communicating.
This is a medical emergency, call EP!!!
300
72 y/o M with PMH HTN on HCTZ, DM on metformin and chronic back pain on percocet comes to your clinic for back pain f/u. Reports his pain is getting worst and his current regimen is not helping. His most recent lab work showed Hb 9.1, Creat 2.3, Ca 12.1, total protein 10.2 and albumin 3.4.
What is the next best test to order on this patient?
SPEP!! with immunofixation and serum free light chains. r/o MM!!
CRAB >> hyperCalcemia, Renal failure, Anemia, Bone pain/lytic lesions.
Patient with high globulin gap (total protein -album) Normal is 2-4. If >4 think: MM, MGUS, Waldenstrom macroglobulinemia, Chronic infections (HIV, hepatitis), autoinmune disease.
300
42 y/o F from group home with pmh bipolar disorder presents with nausea, vomiting, tremor and worsening confusion. The only thing she can tell you is that she wants water.
Her labs showed Na 151, serum osm 315, urine osm 90, urine specific gravity of 1.002.
Which medication is the most likely cause of her presentation?
LITHIUM induced nephrogenic DI!!
Lithium enters the collecting ducts cells and interferes with ADH signaling producing nephrogenic DI. so patients has polyuri, polydipsia, hypernatremia, dilute urine despite hydration.
key >> high serum osm with inappropriately dilute urine
300
A 68-year-old man presents with progressive jaundice, dark urine, pale stools, and a 20-pound unintentional weight loss over 3 months. He has no abdominal pain. Labs show predominantly direct hyperbilirubinemia and elevated alkaline phosphatase.
whats the diagnosis?
Obstructive jaundice from pancreatic head cancer.
Painless jaundice + weight loss = pancreatic cancer until proven otherwise.
300
A patient with cirrhosis and tense ascites is admitted for AKI. Urine sodium is <10, FeNa is 0.2%, and the kidneys look normal on ultrasound. Two liters of saline produce no improvement.
What is going on?????
Hepatorenal syndrome!!
HRS is severe renal vasoconstriction caused by advanced cirrhosis and splanchnic vasodilation, leading to functional kidney failure despite structurally normal kidneys.
400
76 y/o M admitted for cellulitis, during rounds the medical studen with a brand new stethoscope hears a harsh crescendo-decrescendo systolic murmur at the right upper sternal border radiating to the carotids. Echo shows AS with aortic valve 1.2 cm, mean gradient of 30 and peak velocity 3.5.
What is the most appropriate management?
NO valve replacement at this time, continue with surveillance and cardiology follow up.
MILD VA >1.5, MG <20, PV 2-2.9
MOD VA 1-1.5, MG 20-39, PV 3.39
SEV A <1, MG >40, PV >4
400
72 y/o F comes to the ER for bloody nose. Her labs showed WBC 9.8, hb 13, platelets 850, Na 140, K 8, co2 24, creat 0.8.
EKG is shown:
What is the next step in treatment:
REPEAT BMP!!!!!!
Pseudohyperkalemia!! during clotting in the collection tube platelets release K causing falsely elevated serum potassium. Also seen with severe leukocytosis!!
400
58 y/o F with RA presents with progressive SOB and dry cough. wbc 7.8, eosinophils 18%, ESR is elevated. She was started on a new med for RA 6 months ago. CT is bellow:
Which medication is the most likely culprit?
methotrexate induced pneumonitis.
-can occur weeks to years after starting therapy and is not dose dependent.
-peripheral eosinophilia might be present.
-pt have dry cough, sob, fever and diffuse interstitial or ground glass infiltrates on imaging.
400
A 45-year-old woman is admitted for fatigue and jaundice. Labs show: Total bilirubin: 6.8 mg/dL. Direct bilirubin: 0.4 mg/dL, AST 28 U/L, ALT 31 U/L, Alkaline phosphatase 82 U/L, Hemoglobin 9.1 g/dL, LDH 1,200 U/L, Haptoglobin undetectable, Creatinine 1.8 mg/dL
what enzyme deficiency causes this condition????
TTP caused by Adams13 deficiency!!!!
Pentade: MAHA, thrombocytopenia, neurological sx, renal dysfunctionand fever
500
42 y/o F comes with chest pain and palpitations. She has had several episodes over the last months. EKG during sx showed transient ST segment elevations in the inferior leads. Troponin is negative. LHC reveals no significant obstructive coronary disease.
Her symptoms occur most often between midnight and 6 AM and improve rapidly after receiving nitro.
What is the diagnosis?
VASOSPASTIC (PRINZMETAL) ANGINA!!!!
is caused by transient coronary artery vasospam leading to myocardial ischemia. Pt have st elevations that mimic STEMI but coronary arteries are often normal.
TX >> CCB!!! nitrates
500
38 y/o M presents with 3 month of progressive fatigue, dyspnea, pruritus and 15 pound weight loss.
wbc 38.000, eosinophils 58%, hb 10.8, platelets 210.000, troponin 80. EKG non specific st-t changes. CT chest with patchy pulmonary infiltrates.
What organ complication are you most worried about?
EOSINOPHILIS MYOCARDITIS!!
marked eosinophilia > 1500 can cause end organ damage but cardiac involvement is the major cause of morbi/mortality. it can also affect lungs, skin and cns.
500
54 y/o M with gout presents with fever, diffuse rash, facial edema and malaise 4 weeks after starting a new medication. AST 320, ALT 410, Creat 2.Eosinophils 22%. He has a widespread morbilliform rash involving over 50% of his body surface area.
What medications is the most likely culprit?
ALLOPURINOL INDUCED DRESS SYNDROME!
Drug reaction with eosinophilia and systemic symptoms. typically occurs 2-8 weeks after starting a medication. we have a rash, eosinophilia, facial edema, hepatitis, nephritis, fever and LAD.
common offenders: allopurinol (classic), carbamazepine, phenytoin, lamotrigine, sulfas, vanc. in certain population we order HLA-B58:01 before starting allopurinol
500
A 34-year-old woman presents with jaundice, fatigue, and itching. Labs show: Total bilirubin: 8.1 mg/dL, Direct bilirubin: 6.7 mg/dL, AST 78 U/L, ALT 65 U/L, Alkaline phosphatase 620 U/L
RUQ ultrasound shows no gallstones and no biliary dilation. She has a history of ulcerative colitis.
What condition she has and what cancer is associated with it?
Primary sclerosing cholangitis!!! the us might be normal because The disease affects intrahepatic and extrahepatic ducts diffusely; early disease may not cause a single obstructing lesion or ductal dilation.associated with UC and is highly associated with cholangiocarcinoma
- Cholangiocarcinoma