Virtual Diagnosis
Cardiology
Infectious Disease
Pulmonology/Critical Care
Final Jeopardy
100
What abnormality is seen on these frontal and lateral CXR radiographs?
A. RLL atelectasis
B. RLL pneumonia
C. RML atelectasis
D. RML pneumonia
What is C, right middle lobe atelectasis
100
A 45-year-old woman is evaluated during a follow-up visit for breast cancer. She recently underwent surgical removal of a 1.2-cm hormone receptor–negative, HER2-positive invasive cancer of the left breast with positive axillary lymph nodes. Treatment with paclitaxel and adjuvant trastuzumab is planned. Medical history is unremarkable. She has no history or symptoms of cardiovascular disease. She takes no medication.
On physical examination, vital signs are normal. There are healing surgical incisions of the left breast and left axilla. The physical examination is otherwise unremarkable.
An echocardiogram demonstrates normal findings. The left ventricular ejection fraction is 65%.
Which of the following is the most appropriate management of trastuzumab therapy?
A. Initiate prophylactic carvedilol and lisinopril
B. Measure serum troponin I levels before and after each trastuzumab cycle
C. Obtain an exercise stress test before initiating trastuzumab
D. Repeat echocardiography periodically after initiating trastuzumab
What is D, Repeat echocardiography periodically after initiating trastuzumab
100
An 82-year-old woman is hospitalized with hypotension and volume depletion resulting from gastroenteritis. Medical history is noncontributory, and she takes no medications.
On physical examination, temperature is 36.8 °C (98.3 °F), blood pressure is 92/66 mm Hg, pulse rate is 110/min, and respiration rate is 16/min. The remainder of the examination is unremarkable.
Because of difficulty in inserting a peripheral venous access line, an internal jugular central venous catheter will be placed for volume resuscitation.
Which of the following is the most appropriate measure to prevent catheter-related bloodstream infection in this patient?
A. Assess catheter daily for necessity and potential removal
B. Give one dose of vancomycin after catheter insertion
C. Replace catheter every 7 days
D. Use a small sterile drape when inserting the catheter
What is A, Assess catheter daily for necessity and potential removal
100
A 45-year-old woman with hypovolemic shock is evaluated for rapid resuscitation in the ICU. She has sickle cell disease with recurrent pain and hemolytic crises, and osteoporosis.
On physical examination, temperature is 39 °C (102.3 °F), blood pressure is 70/40 mm Hg, pulse rate is 142/min and weak, and respiration rate is 22/min. Oxygen saturation is 99% breathing ambient air. There is a subcutaneous port in the right anterior chest wall.
Which of the following is the most appropriate type of venous access for this patient?
A. Intraosseous port
B. Peripheral wide-bore catheter
C. Subcutaneous intravenous port
D. Triple-lumen central catheter
What is B, peripheral wide-bore catheter
200
Which of the following abnormalities is demonstrated on this electrocardiogram? 
A. Atrial fibrillation
B. Atrial tachycardia
C. AVNRT
D. AV reciprocating tachycardia
E. Multifocal atrial tachycardia
What is E, multifocal atrial tachycardia
200
An 86-year-old woman is hospitalized for acute decompensated heart failure. Her medical history is significant for a stroke 4 years ago, hypertension, severe COPD, and stage 3 chronic kidney disease. She underwent diuresis with furosemide overnight and is now resting comfortably. Her outpatient medications are lisinopril, atorvastatin, low-dose aspirin, tiotropium, and as-needed albuterol.
On physical examination, temperature is normal, blood pressure is 95/65 mm Hg, pulse rate is 80/min, and respiration rate is normal. Oxygen saturation is 90% on 2 L of oxygen by nasal cannula. Bilateral crackles are noted in the bottom quarter of the lung fields. The estimated central venous pressure is elevated. S1 is diminished. A grade 3/6 holosystolic murmur and soft diastolic rumble are present at the apex.
An echocardiogram shows a flail segment involving the posterior leaflet of the mitral valve and severe regurgitation. The left ventricular ejection fraction is 60%.
Cardiac and pulmonary surgical risks are estimated to be high (estimated operative mortality, 10%).
Which of the following is the most appropriate next step in management?
A. Mitral valve replacement
B. Surgical mitral valve repair
C. Transcatheter mitral valve repair
D. Continue current medical therapy
What is C, transcatheter mitral valve repair.
200
A 33-year-old woman is evaluated 4 days after removing an embedded tick from her left arm. She reports that the tick was attached for less than 12 hours. She noticed itching at the site of tick attachment 2 days ago but otherwise has been asymptomatic. She preserved the tick in a bottle, and it is confirmed visually to be an adult black-legged deer tick (Ixodes scapularis).
On physical examination, vital signs are normal. A small area of induration is noted on the left arm, with no erythema, tenderness, or warmth. All other physical examination findings are unremarkable.
Which of the following is the most appropriate initial management?
A. Borrelia burgdorferi polymerase chain reaction testing of the tick
B. Borrelia burgdorferi serologies
C. Doxycycline
D. Reassurance that the risk of Lyme disease is low
What is D, Reassurance that the risk of Lyme disease is low
200
A 42-year-old man is evaluated in the office for chronic cough. He first developed a cough 3 years ago. It is productive of clear to yellow sputum that is occasionally blood-tinged. He has taken antibiotics when his sputum production increases, after which his cough improves but never completely resolves. He has no dyspnea. He does not smoke cigarettes. He currently is taking no medications.
On physical examination, vital signs are normal. Oxygen saturation is 96% breathing ambient air. BMI is normal. Pulmonary examination reveals scattered inspiratory squeaks.
A chest radiograph shows ill-defined linear atelectasis and irregular peripheral opacities in the right and left lower lobes. A CT scan of the chest with contrast is shown below.
Which of the following is the most likely diagnosis?
A. Bronchiectasis
B. Centrilobular emphysema
C. Chronic bronchitis
D. Pulmonary Langerhans cell histiocytosis
What is A, Bronchiectasis
300
For a patient with arthralgia, positivity for anti-Ro/SSA and anti-La/SSB antibodies, which of the following is the most likely diagnosis for the rash shown?
A. Acute cutaneous lupus erythematosus
B. Chronic discoid lupus erythematosus
C. Polymorphous light eruption
D. Subacute cutaneous lupus erythematosus
What is D, subacute cutaneous lupus erythematosus
300
A 61-year-old man is seen in the office for follow-up evaluation 5 weeks after an ischemic stroke. At that time, an electrocardiogram in the emergency department was normal, and a subsequent transthoracic echocardiogram showed normal systolic and diastolic function and no valvular disease. Evaluation for patent foramen ovale was negative. A carotid artery ultrasound showed no significant stenosis. Telemetry findings during hospitalization showed occasional premature atrial contractions. An MRI of the brain and subsequent magnetic resonance angiogram of the head were compatible with a cardioembolic cause of the stroke. Thirty days of ambulatory electrocardiographic monitoring showed frequent premature atrial contractions and infrequent premature ventricular contractions. His medical history includes hypertension and hyperlipidemia. Current medications are lisinopril, chlorthalidone, atorvastatin, and aspirin.
On physical examination, vital signs are normal. Cardiovascular examination is normal. On neurologic examination, increased tone in the left leg and weakness below the left knee are noted; the patient ambulates with a cane.
Which of the following is the most appropriate next step in management?
A. Implantation of a cardiac monitor
B. Initiation of long-term aspirin and clopidogrel
C. Initiation of long-term warfarin
D. Referral for percutaneous left atrial appendage occlusion
What is A, implantation of a cardiac monitor
300
A 24-year-old woman is evaluated for cystitis symptoms of 4 days' duration. She reports no fever, chills, flank pain, or vaginal discharge. She has had similar symptoms three times within the past 10 months. She has been treated each time with trimethoprim-sulfamethoxazole at an urgent care center. The last episode was 5 weeks ago. She has sexual intercourse infrequently. Her only medication is an oral contraceptive.
On physical examination, vital signs and other findings are unremarkable.
On microscopic urinalysis, leukocytes are too numerous to count, erythrocyte count is 10/hpf, 4+ bacteria are present, and rare squamous epithelial cells are seen.
Which of the following is the most appropriate management?
A. Nitrofurantoin
B. Trimethoprim-sulfamethoxazole
C. Urine culture plus ampicillin
D. Urine culture plus cefpodoxime
E. Urine culture plus ciprofloxacin
What is E, Urine culture plus ciprofloxacin
300
A 38-year-old man is evaluated for a 6-month history of dyspnea on exertion. He has gastroesophageal reflux disease and Raynaud phenomenon. He does not smoke and has no cough or wheezing. Current medications are lansoprazole and amlodipine.
On physical examination, vital signs are normal. Oxygen saturation is 91% breathing ambient air. He has scattered telangiectasias on the face and trunk and sclerodactyly. Lung fields are clear on auscultation.
The only abnormality on pulmonary function testing is a DLCO of 43% of predicted.
High-resolution CT of the chest shows no evidence of parenchymal lung disease.
Which of the following is the most likely diagnosis?
A. Cryptogenic organizing pneumonia
B. Lymphangioleiomyomatosis
C. Lymphoid interstitial pneumonia
D. Pulmonary arterial hypertension
What is D, pulmonary arterial hypertension
300
Which of the following is the most likely diagnosis? 
What is uremia
400
Which of the following is the most likely diagnosis?
A. Cerebral hemorrhage
B. Embolic stroke
C. HSV encephalitis
D. MS
E. Progressive multifocal leukoencephalopathy
What is C, herpes simplex encephalitis
400
A 64-year-old man is hospitalized for persistent low-grade fever, chest discomfort, and lower extremity edema. He underwent triple coronary artery bypass graft surgery 6 weeks ago. His medical history is otherwise notable for hypertension, hyperlipidemia, and previous smoking. His current medications are aspirin, metoprolol succinate, atorvastatin, lisinopril, and furosemide.
On physical examination, temperature is 37.7 °C (99.8 °F), blood pressure is 136/84 mm Hg, pulse rate is 96/min, and respiration rate is 14/min. Jugular venous distention is noted to the angle of the mandible. Decreased breath sounds and dullness to percussion are noted at the left base. No crackles are noted. A pericardial rub is present. There is no gallop. The liver is enlarged. There is bilateral pitting edema to the mid shin.
Laboratory studies:
Erythrocyte sedimentation rate:76 mm/h
Leukocyte count/: 12,000/µL (12 × 109/L)
Serum creatinine: 1.4 mg/dL (123.8 µmol/L)
Troponin (two samples): Normal
B-type natriuretic peptide: 105 pg/mL (105 ng/L)
A 12-lead electrocardiogram demonstrates normal sinus rhythm with nonspecific ST-T–wave abnormalities. A chest radiograph demonstrates bilateral small pleural effusions. An echocardiogram shows no pericardial effusion. A Doppler echocardiogram shows enhanced ventricular interdependence and dilation of the inferior vena cava. Right heart catheterization demonstrates equalization of diastolic pressures in all heart chambers. Gadolinium-enhanced cardiac magnetic resonance imaging demonstrates increased pericardial thickness and evidence of active pericardial inflammation and edema.
Which of the following is the most likely diagnosis?
A. Heart failure with preserved ejection fraction
B. Perioperative graft failure with infarction
C. Restrictive cardiomyopathy
D. Transient constrictive pericarditis
What is D, Transient constrictive pericarditis
400
A 25-year-old man is evaluated in the emergency department for fever, productive cough, dyspnea, and pleuritic chest pain that began several days ago. He reports no other symptoms. Intravenous ceftriaxone and oral azithromycin are initiated, and he is hospitalized. Medical history is significant for a recent diagnosis of HIV infection, for which he began antiretroviral therapy 1 month ago. Other medications are lamivudine, abacavir, and dolutegravir.
On physical examination, temperature is 39.2 °C (102.6 °F), blood pressure is 136/84 mm Hg, pulse rate is 110/min, and respiration rate is 20/min. Oxygen saturation is 90% breathing ambient air. Cardiac examination is normal, and the lungs are clear bilaterally.
Laboratory studies at the time of HIV diagnosis showed a viral load of 95,420 copies/mL and CD4 cell count of 256/µL. The interferon-γ release assay for tuberculosis was indeterminate because of inadequate response to the positive control. One week ago, HIV viral load was 1077 copies/mL and CD4 cell count was 313/µL.
A chest radiograph shows an infiltrate in the right middle lobe and bilateral hilar enlargement.
Sputum acid-fast bacilli smear shows acid-fast bacilli; culture results are pending.
What does this patient have and which of the following is the most appropriate management?
A. Await culture results
B. Pause antiretroviral therapy
C. Start prednisone
D. Start rifabutin, isoniazid, ethambutol, and pyrazinamide
What is immune reconstitution inflammatory syndrome with TB and D, start rifabutin, isoniazid, ethambutol, and pyrazinamide
400
A 19-year-old man is brought to the emergency department after he attended a party with friends. He is anxious and tremulous. He has a history of depression. His only medication is fluoxetine.
On physical examination, he is alert and oriented. Temperature is 38.9 °C (102 °F), blood pressure is 136/79 mm Hg, pulse rate is 112/min, and respiration rate is 20/min. Oxygen saturation is 98% breathing ambient air. Physical examination is notable for slow, continuous, horizontal eye movements, tremor of extremities, hyperreflexia, and sustained ankle clonus and spontaneous myoclonus. The physical examination is otherwise normal.
Urine toxicology screening is pending.
Which of the following is the most likely diagnosis and how do you treat it?
A. Anticholinergic toxicity
B. Malignant hyperthermia
C. Neuroleptic malignant syndrome
D. Serotonin syndrome
What is D, serotonin syndrome. Treatment is supportive and benzodiazepines
500
Which of the following diagnoses is most compatible with this isolated skin finding?
A. Acute cutaneous lupus erythematosus
B. Chronic cutaneous lupus erythematosus
C. Neurogibromatosis
D. Sarcoidosis
E. Subacute cutaneous lupus erythematosus
What is D, sarcoidosis.
500
A 43-year-old woman is evaluated during a follow-up visit. Six months ago, she was diagnosed with heart failure and pulmonary sarcoidosis. Cardiac magnetic resonance imaging suggested possible cardiac sarcoidosis. She is feeling better after initiation of therapy, but she still has exertional dyspnea when walking up one flight of stairs. An echocardiogram obtained 1 week ago showed a left ventricular ejection fraction of 30%. Medications are candesartan, carvedilol, and spironolactone. She has also been taking prednisone for cardiac sarcoidosis for the past 6 months.
On physical examination, temperature is normal, blood pressure is 98/60 mm Hg, and pulse rate is 58/min. There is no jugular venous distention. Lungs are clear to auscultation. Cardiac examination is normal. No edema is noted.
An electrocardiogram shows a QRS duration of 158 ms, left bundle branch block, and first-degree atrioventricular block.
Which of the following is the most appropriate management?
A. Add furosemide
B. Increase carvedilol
C. Perform endomyocardial biopsy
D. Refer for placement of an implantable cardioverter-defibrillator with cardiac resynchronization therapy
What is D, Refer for placement of an implantable cardioverter-defibrillator with cardiac resynchronization therapy
500
A 19-year-old man is evaluated in the emergency department for fever, cough producing blood-tinged sputum, shortness of breath, and headache. He attended a political rally on his college campus 4 days ago. Six other people have been hospitalized with similar symptoms. Medical history is unremarkable, and he takes no medications.
On physical examination, the patient is alert and oriented. Temperature is 39.1 °C (102.4 °F), blood pressure is 98/58 mm Hg, pulse rate is 110/min, and respiration rate is 24/min. Oxygen saturation is 92% breathing oxygen 2 L/min by nasal cannula. Neurologic examination is nonfocal, and no meningeal signs are present. Dyspnea, bilateral pulmonary rhonchi, and tubular breath sounds are noted on pulmonary examination. No rash is present, and the abdomen is nontender.
Sputum Gram stain reveals many polymorphonuclear cells and abundant gram-negative coccobacilli demonstrating bipolar staining.
A chest radiograph shows bilateral patchy infiltrates.
What does the patient have and which of the following is the most appropriate treatment?
A. Ceftriaxone and azithromycin
B. Ciprofloxacin
C. Gentamicin
D. Piperacillin-tazobactam and levofloxacin
What is the pneumonic plaque (Yersinia pestis) and D, Gentamicin
500
A 30-year-old woman is evaluated in the emergency department after she was rescued from her home where her vinyl sofa caught fire. She is intubated and unconscious.
On physical examination, blood pressure is 108/78 mm Hg, pulse rate is 100/min, and respiration rate is 24/min. Oxygen saturation by pulse oximetry is 100% on mechanical ventilation using 50% oxygen. She is unresponsive. She has no visible burns on her skin, and her airway secretions are clear. Brainstem reflexes are all intact.
Laboratory studies:
Serum electrolytes :
Sodium 140 mEq/L (140 mmol/L)
Potassium 4.4 mEq/L (4.4 mmol/L)
Chloride 99 mEq/L (99 mmol/L)
Bicarbonate 13.1 mEq/L (13.1 mmol/L)
Arterial blood gas studies:
pH 7.29
Pco2 28 mm Hg (3.7 kPa)
PO2 233 mm Hg (31 kPa)
Carboxyhemoglobin 5%
Methemoglobin 2%
Lactate 11 mEq/L (11 mmol/L)
The oxygen is increased to 100%.
What does the patient have and which of the following is the most appropriate treatment?
A. Hydroxocobalamin
B. Hyperbaric oxygen therapy
C. Methylene blue
D. Sodium nitrite
What is cyanide poisoning and A, hydroxocobalamin