Broken Hearts
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Policy Corner and ToC
100
A 70-year-old man presents after a sudden loss of consciousness without warning. He has a history of heart failure and prior MI. EKG shows nonsustained VT, and labs reveal elevated troponin. He reports syncope while walking upstairs. What are high-risk features of syncope requiring hospital admission and urgent cardiac evaluation?
High-Risk Syncope Features Include:
❤️ Structural heart disease or CHF
⚡ Abnormal EKG (VT, AV block, ischemia, QT prolongation)
🚨 Syncope with exertion or no prodrome
🧠 Syncope with chest pain or dyspnea
👴 Older age + comorbidities
🩸 Elevated troponin or anemia
100
A 34-year-old man presents with itchy, scaling skin and fissures between the toes. Exam shows white maceration and erythema in the interdigital spaces. He frequently uses public locker rooms. What is the Diagnosis? (Easy :))
Tinea pedis (athlete’s foot)
100
A 68-year-old man with known BPH on tamsulosin reports persistent urinary urgency, frequency, and urge incontinence. Post-void residual is 45 mL, and there is no evidence of urinary retention. What is the best treatment medication for this patient?
Antimuscarinic agent (e.g., oxybutynin or solifenacin) for overactive bladder symptoms
100
A 72-year-old man presents with fatigue and recurrent infections. Labs show pancytopenia with macrocytic anemia. Peripheral smear reveals dysplastic neutrophils and hypogranulation. Bone marrow biopsy shows hypercellularity with ≥10% dysplasia in multiple cell lines and increased blasts (<20%). What is the most likely diagnosis?
Myelodysplastic syndrome (MDS)
100
According to policy, STAT pages must be answered within this time frame.
Immediately, as soon as possible, <5 minutes.
200
A 26-year-old woman presents with sudden-onset palpitations, dizziness, and mild shortness of breath. Vitals show HR 190 bpm and BP 118/70 mmHg. EKG reveals a regular, narrow-complex tachycardia with no visible P waves. Vagal maneuvers are unsuccessful. What is the next treatment option?
Administering adenosine for acute termination of supraventricular tachycardia (SVT)
200
A 45-year-old man with a history of IV drug use presents with neck pain and fever. MRI shows osteomyelitis of the cervical vertebrae. Blood cultures grow vancomycin-resistant Enterococcus (VRE). Despite appropriate source control, he remains bacteremic. What is the best antibiotic treatment for this patient?
Daptomycin as first-line therapy for VRE osteomyelitis
200
A 58-year-old woman with polymyalgia rheumatica is started on long-term prednisone 20 mg daily. She has no history of fractures, but her DEXA scan shows osteopenia. She has adequate calcium and vitamin D intake and normal renal function. What other medication can be started to prevent glucocorticoid-induced osteoporosis?
Bisphosphonates (risedronate, alendronate) are first-line for steroid-induced bone loss when high dose glucocorticoid use.
Indicated when prednisone ≥5 mg/day for ≥3 months
Use with calcium + vitamin D
Check renal function before starting
200
A hospitalized patient receiving unfractionated heparin for 7 days develops a sudden platelet drop from 240,000 to 95,000. He also has a new DVT. There is no clear alternative cause for thrombocytopenia. What is the score to assess the probability of heparin-induced thrombocytopenia (HIT)?
The 4Ts Score evaluate:
Thrombocytopenia (platelet fall)
Timing of platelet fall
Thrombosis
Tohter causes (other causes)
Score guides next steps:
0–3 = Low → HIT unlikely
4–5 = Intermediate → Test + stop heparin
6–8 = High → Treat as HIT
200
When called activated for backup, residents must report within this window depending on urgency. Missing this is considered a major violation.
Reporting within 60 minutes
300
A 64-year-old man presents with acute chest pain, diaphoresis, and shortness of breath. EKG below, prior EKG was completely normal 3 months ago. Blood pressure is 90/60 mmHg, and he appears diaphoretic. What is the best next action?
Activating Code Heart for suspected STEMI equivalent due to new LBBB
300
A 20-year-old college student presents with severe epistaxis requiring nasal packing. Two days later, she develops high fever, hypotension, diffuse rash, vomiting, and altered mental status. Labs show acute kidney injury and thrombocytopenia, concerning for toxic shock syndrome. What is the best empiric treatment for this patient?
Vancomycin, cefepime, and clindamycin for STSS.
Clindamycin suppresses toxin production
Vancomycin covers MRSA
Cefepime provides broad gram-negative coverage
Early broad-spectrum therapy + source control is critical in TSS
300
A patient recently diagnosed with multiple myeloma presents with polyuria, muscle weakness, and bone pain. Labs show hypophosphatemia, metabolic acidosis with normal anion gap, glucosuria despite normal serum glucose, and aminoaciduria. What renal tubular disorder is most likely?
Fanconi syndrome
Fanconi = Proximal Tubule Failure (“Pee Loses Everything”)
Common causes:
Multiple myeloma (light chains)
Tenofovir
Ifosfamide
Heavy metals (lead)
Cystinosis (kids)
300
A 54 yo Male with Hx of prior strokes, HLD, CAD, PAD, PE on anticoagulation, comes to the ED with sudden painless vision loss has the following finding on fundus exam.
What is the diagnosis?
Central retinal artery occlusion
300
Discharge summaries must be completed within this time frame to avoid remediation.
72 hrs
400
A 74-year-old patient with nonvalvular atrial fibrillation, CHA₂DS₂-VASc score of 4, and prior intracranial hemorrhage is unable to tolerate long-term anticoagulation. Which procedure can reduce stroke risk?
Watchman device implantation
400
A 62-year-old man with recent dental work presents with altered mental status and is found to have a frontal brain abscess. CT shows septic emboli. TTE reveals a 7-mm mobile aortic valve vegetation with EF 45%. He develops pulmonary edema on chest X-ray, peripheral edema, and requires intubation. which is the strongest and most urgent indication for surgery in infective endocarditis in this case?
Decompensated acute heart failure (Pulmonary edema on CXR + peripheral edema + EF 45%)
400
A mechanically ventilated patient with severe ARDS is placed on high PEEP. Shortly after, they develop hypotension and decreased cardiac output but its not hypoxic. CXR is showing no change compared to prior.
What is the most likely cause of this complication?
Decreased venous return due to increased intrathoracic pressure
400
A 45-year-old patient presents with fatigue, recurrent infections, easy bruising, and marked gingival hypertrophy on exam. CBC shows anemia, thrombocytopenia, and circulating blasts.
Which hematologic malignancy is most likely?
Acute myelogenous leukemia (especially the monocytic subtype, AML M5)
400
Accessing your own, writing your own notes, prescribing yourself medications or accessing patient charts outside of direct patient care triggers immediate disciplinary review under this policy.
HIPAA violation
500
A patient presents 5 days after an anterior MI with cardiogenic shock, acute heart failure, and a new harsh holosystolic murmur at the left sternal border. Echo reveals a left-to-right shunt.
What is the most likely diagnosis?
Ventricular septal rupture
500
A 55-year-old patient presents with pruritic, purple, polygonal papules on the wrists and oral mucosa with white lacy streaks (Wickham striae).
Which chronic viral infection should be screened for due to its strong association with this condition?
Hepatitis C antibody.
Lichen planus = Think Hep C
Important extrahepatic association → always consider screening.
500
(From Grand Rounds) A patient with a history of short bowel syndrome presents with episodic confusion, slurred speech, and ataxia after high-carbohydrate meals. Labs show metabolic acidosis with normal L-lactate levels. What is the most likely diagnosis?
D-lactic acidosis
D-Lactic Acidosis = Short Gut + Neuro Symptoms
Caused by bacterial fermentation of carbs
Produces D-lactate (not detected on standard lactate tests)
Triggers: High-carb intake
Tx: Carb restriction + antibiotics (e.g., metronidazole)
500
A 60-year-old man has recurrent blistering on sun-exposed skin, hyperpigmentation, and scarring.
Which abnormality on porphyrin testing is most diagnostic of porphyria cutanea tarda?
Increased uroporphyrin and heptacarboxyl porphyrin levels in urine (porphyria cutanea tarda)
500
During evening sign-out, a resident states:
“Mr. Lopez is stable, he is full code. He’s here for pneumonia. On antibiotics Azithro and Ceftriaxone. Let me know if anything comes up.”
No contingency plans, pending labs, or overnight tasks are mentioned. Which is the most critical component of the I-PASS handoff is missing?
Situation awareness and contingency planning (Action list)