Cardiology Nightmares
GI and Liver Zebras
Call a Rapid Response
Who knows renal knows it all
Rare Bugs and Skin Rashes
History and Policy Corner
100
A patient is on aspirin and clopidogrel after DES placement. He requires urgent non-cardiac surgery at 2 months. Which medication should be continued perioperatively if possible?
Aspirin
100
A 54-year-old woman presents with fatigue, pruritus, and dark urine. Two weeks ago, she completed a course of amoxicillin-clavulanate for sinusitis. She drinks alcohol socially and has no history of liver disease.
Laboratory studies show:
AST: 110 U/L, ALT: 140 U/L, Alkaline phosphatase: 520 U/L, Total bilirubin: 4.2 mg/dL, INR: normal
Hepatitis serologies and autoimmune markers are negative. What is the most likely diagnosis?
Drug-induced liver injury (cholestatic pattern) due to amoxicillin-clavulanate
100
A 67-year-old man is admitted due to pneumonia. Rapid response called due to hypotension. He has received 30 mL/kg of IV crystalloids.Despite fluid resuscitation, his MAP remains 58 mmHg. He is tachycardic and requires supplemental oxygen. CXR shown below.
What is the next step in the management?
Start norepinephrine
100
A 70-year-old woman with small-cell lung cancer presents with confusion.
Labs: Na⁺ 118 mmol/L, Serum osmolality 255 mOsm/kg, Urine osmolality 520 mOsm/kg, Urine Na⁺ 62 mmol/L
She has received normal saline without improvement.
What is the next best treatment?
fluid restriction
100
A 58-year-old man presents with fever, confusion, diarrhea, and pneumonia. Labs show hyponatremia and elevated transaminases. He recently stayed at an old hotel in Philadelphia.
What is the most likely pathogen?
Legionella pneumophila
100
During the 1952 polio epidemic, this country became the first in history to use positive-pressure mechanical ventilation, dramatically reducing mortality and laying the foundation for modern ICUs. The first modern mechanical ventilator was used in this Country:
Blegdam Hospital in Copenhagen, Denmark
200
A 72-year-old man with a history of hypertension and heart failure presents with palpitations and mild dyspnea.
Vital signs: HR 150 bpm, BP 132/78 mmHg, RR 18, SpO₂ 97% on room air. EKG shown below.
What is the diagnosis of this rhythm abnormality?
Atrial Flutter
200
A 27-year-old man presents with 3 months of bloody diarrhea, urgency, and tenesmus. He reports 6–8 bowel movements per day and unintentional weight loss. He has no recent travel or antibiotic exposure.
Laboratory studies show: Mild anemia and Elevated CRP
Colonoscopy demonstrates these findings:
What is the diagnosis?
Ulcerative colitis
200
A 64-year-old man admitted for NSTEMI suddenly becomes unresponsive.
He has no pulse and no spontaneous respirations.
The monitor shows:
What is the most immediate next step in management?
Immediate defibrillation
200
A 58-year-old man develops rising creatinine 10 days after starting TMP-SMX.
He has fever, a maculopapular rash, and peripheral eosinophilia.
Urinalysis shows sterile pyuria.
What is the most likely diagnosis?
Acute interstitial nephritis (AIN)
200
A veterinarian develops a slowly progressive ulcerative lesion on the hand after a cat bite. The lesion spreads along lymphatic channels as seen below:
What is the organism causing this disease?
Francisella tularensis
200
According to ACGME duty hour requirements, how often must residents receive a full day off from all clinical and educational duties?
At least 1 day off in 7, averaged over 4 weeks
300
A 62-year-old man with coronary artery disease underwent drug-eluting stent (DES) placement to the LAD 10 days ago for NSTEMI. He was discharged on aspirin and clopidogrel but stopped taking clopidogrel after 3 days due to bruising. He now presents with sudden-onset crushing chest pain, diaphoresis, and nausea. EKG shown below
What is the most likely diagnosis?
Acute stent thrombosis
300
A 63-year-old man with progressive abdominal distension presents for evaluation of ascites. He has no known history of cirrhosis. Vital signs are stable. Exam reveals jugular venous distention, hepatomegaly, and bilateral lower-extremity edema.
Diagnostic paracentesis reveals: SAAG: 1.6 g/dL, Ascitic total protein: 3.8 g/dL, Cell count: low PMNs (4)
What is the most likely cause of this patient’s ascites?
Cardiac ascites due to right-sided heart failure (congestive hepatopathy)
300
A 58-year-old man with type 2 diabetes on insulin and sulfonylurea is found actively seizing on the hospital floor.
He is diaphoretic and unresponsive.
Vital signs: HR 118 bpm, BP 146/88 mmHg, RR 20, SpO₂ 98% on room air, Point-of-care glucose: 34 mg/dL
What is the most immediate next step in management?
IV dextrose (D50 bolus)
300
Patient has chronic diarrhea. Has the following ABG and BMP.
ABG: pH 7.31, PaCO₂ 28 mmHg, HCO₃⁻ 14 mEq/L
BMP:Na⁺ 138, Cl⁻ 112, HCO₃⁻ 14
What acid–base disorder is present?
Non-anion gap metabolic acidosis with appropriate respiratory compensation
300
45 years old female coming for PCP eval. Has been seen by multiple specialists for management of lip herpes simplex with no improvement despite high doses of Acyclovir. Lesions in the skin are shown.
What is the real diagnosis of this lady?
Rosacea
300
This Swedish radiologist is credited with inventing central venous catheterization in 1929 by advancing a catheter from his own arm vein into the right atrium under fluoroscopy. Who was this physician?
Werner Forssmann
400
A 34-year-old man with no significant past medical history presents with sudden onset palpitations and lightheadedness. Vital signs: HR 274 bpm, BP 128/76 mmHg, RR 16, SpO₂ 99% on room air. EKG shown below.
Pt feels palpitations but no chest pain. Next conduct in the management should be:
6 mg IV Adenosine
400
A 78-year-old man with known severe aortic stenosis presents with recurrent episodes of painless lower GI bleeding and iron-deficiency anemia. Colonoscopy reveals angiodysplasia in the cecum. Routine coagulation studies are normal.
What syndrome explains this patient’s presentation?
Heyde syndrome
400
A 69-year-old man with severe COPD (GOLD IV) is admitted for community-acquired pneumonia. He is on high-flow oxygen. Nursing calls a rapid response for progressive somnolence and now patient unresponsive. Pt has pulse and is ventilated with 15L NRB. HR 140, BP 120/85, RR 4, Spo2 78%.
ABG shown below:
What is the next best step to do now?
Endotracheal intubation and place a high RR in MV.
400
A 55-year-old man with acute leukemia is admitted for induction chemotherapy. On hospital day 2 he develops oliguria and flank discomfort.Urine microscopy reveals these findings:
The composition of these crystals is likely:
Uric Acid (Pt most likely has TLS)
400
A 32-year-old man presents with recurrent, painful nodules and draining sinus tracts in the axillae and groin for several years. He is obese and smokes cigarettes. He has been treated with topical clindamycin, oral doxycycline, and intralesional steroids with minimal improvement. On exam, there are multiple interconnected sinus tracts and scarring in both axillae, chest and groins.
What is the most appropriate next step in management?
Initiation of a TNF-α inhibitor (adalimumab)
400
A resident starts a 24-hour in-house call at 8:00 AM.
At 8:00 AM the next day, he is presenting during rounds the new admissions and finishes presenting at 10:00 AM. No new admissions or active patient care is given after 8 AM. According to ACGME policy, is this resident compliant with duty hours?
Yes he is compliant.
24 hours = maximum time for direct patient care
+4 hours = allowed only for Transitions of care
Handoffs, Educational debriefing
500
A 68-year-old man with ischemic cardiomyopathy (LVEF 30%) and a prior anterior MI presents with recurrent syncope. Telemetry reveals runs of polymorphic ventricular tachycardia occurring shortly after long–short RR sequences. Baseline ECG shows QT prolongation.
He was recently started on a new medication by EP. Labs: K⁺ 3.6 mmol/L, Mg²⁺ 1.7 mg/dL. Interns have not replaced the electrolytes in the am.
Which medication is the most likely trigger?
Sotalol
500
A 29-year-old man presents with intermittent solid-food dysphagia and several episodes of food impaction requiring emergency evaluation. He has a history of asthma and seasonal allergies.
Upper endoscopy shown below.
What is the most likely diagnosis?
Eosinophilic esophagitis
500
A 62-year-old man, postoperative day 3 after hip surgery, suddenly develops acute dyspnea and chest pain.
On arrival of the rapid response team: HR 132 bpm, BP 78/46 mmHg, RR 32, SpO₂ 86% on non-rebreather currently on distress. Exam reveals distended neck veins and cool extremities. Labs with elevated Troponins and Pro-BNP for the age.
POCUS reveals this:
What is the most appropriate immediate treatment?
Thrombolysis with alteplase (tPA)
500
A 46-year-old woman with Sjögren syndrome presents with fatigue and muscle weakness.
Labs show: Na⁺ 140 mmol/L, K⁺ 3.1 mmol/L, Cl⁻ 114 mmol/L, HCO₃⁻ 15 mmol/L
ABG:pH 7.30, PaCO₂ 30 mmHg
Urinalysis: Urine pH 6.2, No protein or glucose
What is the most likely diagnosis?
Distal (type 1) renal tubular acidosis
500
Which antobody testing you will order after seeing this patient in clinic?
Anti-Mi-2, Anti-Jo-1
500
Dr. Hood is transitioning to PGY-3 and will become a MICU senior in the next week. When does he need to update the MICU census log?
As soon as Dr. Hood completes his shifts.