Show:
Cardiovascular Trouble
Critical Images
Tricky Diagnostic Studies
Rheumatological Aches
Policy/ToC/History
100

A patient has chest pain at rest with transient ST elevations that resolve with nitroglycerin; coronary angiography shows no obstructive CAD. What is the diagnosis?

Vasospastic (Prinzmetal) angina

100

A patient presents with headache, transient visual obscurations, and pulsatile tinnitus. Funduscopic examination shows this:

What is the funduscopic finding? 

Papilledema is optic disc swelling caused by increased intracranial pressure.

Classic findings:

  • Blurred disc margins
  • Elevated optic disc
  • Venous engorgement
  • Possible hemorrhage
100

A patient with fatigue, weight loss, hypotension, and hyponatremia undergoes cosyntropin stimulation testing.

  • Baseline cortisol: 3 µg/dL
  • 30-minute cortisol: 5 µg/dL
  • 60-minute cortisol: 6 µg/dL

ACTH level is markedly elevated. What is the dx?

Primary adrenal insufficiency

Failure of cortisol to appropriately rise after cosyntropin indicates adrenal insufficiency.

Interpretation

  • Normal response: cortisol rises adequately (commonly ≥18–20 µg/dL depending on assay)
  • Elevated ACTH + abnormal stimulation test → primary adrenal insufficiency
  • Low/inappropriately normal ACTH → secondary adrenal insufficiency
100

A patient taking hydralazine develops fever, arthralgias, and pleuritic chest pain. Labs show positive ANA with negative anti-dsDNA antibodies.

Which antibody is most associated with drug-induced lupus?

Anti-histone antibodies

Explanation

Drug-induced lupus is classically associated with:

  • Hydralazine
  • Procainamide
  • Isoniazid
  • Minocycline

Typical serologies:

  • Positive ANA
  • Positive anti-histone antibodies
  • Usually negative anti-dsDNA
100

A pregnant resident physician asks whether residency programs are required to provide protected parental leave during training.

According to ACGME policy, what is the minimum duration of paid maternity leave residents must receive?

at least 6 weeks of paid maternity leave

200

Patient with dyspnea has a low-flow, low-gradient systolic murmur and EF 30%. Dobutamine stress echo increases valve gradient while valve area remains <1 cm². What will be the treatment? 

Treatment

Aortic valve replacement (AVR) is indicated.

Key Diagnostic Finding

  • Dobutamine increases flow → gradient rises
  • Aortic valve area remains <1 cm²
    → Confirms true severe aortic stenosis rather than pseudo-severe AS.


200

A man with advanced HIV presents with headache, fever, and altered mental status. CSF analysis shows elevated opening pressure, low glucose, elevated protein, and india ink stain as follows:

What is the best treatment for this patient?

Initial treatment of cryptococcal meningitis:

  • Induction: Amphotericin B + flucytosine
  • Followed by consolidation and maintenance fluconazole
  • Serial therapeutic lumbar punctures are often lifesaving


200

A patient is found to have a reactive RPR during routine screening but has no neurologic symptoms, ocular complaints, or cranial nerve deficits.

What is the best next step in the management of this patient? 

RPR and VDRL are nontreponemal screening tests and can produce false positives.

A reactive RPR should be followed by:

  • A treponemal-specific test such as:
    • FTA-ABS
    • TP-PA
    • EIA/CIA
200

A pregnant woman with recurrent first-trimester miscarriages is found to have positive lupus anticoagulant and anticardiolipin antibodies on repeated testing 12 weeks apart.

hat is the recommended treatment during pregnancy for antiphospholipid syndrome?


low-dose aspirin plus prophylactic heparin (LMWH)

Pregnancy management of APS:

  • Low-dose aspirin + prophylactic LMWH/heparin
  • Warfarin is contraindicated during pregnancy
  • Combination therapy reduces pregnancy loss risk significantly
200

A critically ill ventilated patient lacks decision-making capacity. His longtime girlfriend is the legally designated medical power of attorney and requests transition to comfort-focused care. The patient’s estranged wife, from whom he was never legally divorced, demands continuation of full life support.

Who is the legally authorized decision-maker and what is the next step?


the designated medical power of attorney

A validly appointed MPOA/surrogate decision-maker has authority over medical decisions when the patient lacks capacity, even if another family member disagrees.

Confirm validity of MPOA documentation

300

A patient in cardiogenic shock supported with an Impella suddenly develops recurrent suction alarms, hemolysis, hypotension, and loss of pulsatile flow. Monitor seen below: 

What do you expect to see in bedside echo?

Echo: Impella displacement into the ascending aorta at level of aortic valve.

The Impella outlet is malpositioned near the aortic valve. The aortic waveform appears plausibly arterial, but the trough is lower, indicating the fiber-optic sensor is sitting across the aortic valve.

300

A patient presents with severe headache, confusion, and altered mental status. ECG shows these findings: 

What is the most likely cause of the EKG changes?

Intracranial hemorrhage causing cerebral T waves

Massive CNS injury (especially subarachnoid hemorrhage) can produce:

  • Deep symmetric T-wave inversions (“cerebral T waves”)
  • QT prolongation
  • Bradyarrhythmias or other repolarization abnormalities



300

A critically ill ICU patient with sepsis due to severe UTI has:

  • Low T3
  • Low FT4
  • Normal TSH
  • Cortisol 8 AM: 19
  • Still using Norepi at 8 mcg/min

The team considers starting levothyroxine. What is the best next step in the management? 


Euthyroid sick syndrome (nonthyroidal illness syndrome) occurs during severe systemic illness due to altered peripheral thyroid hormone metabolism.

Typical Pattern

  • ↓ T3 (earliest finding)
  • Normal or ↓ T4
  • Normal or ↓ TSH

Do NOT diagnose hypothyroidism during acute critical illness unless there is strong evidence of primary thyroid disease.


Management is treatment of the underlying illness, not routine thyroid hormone replacement.

300

A woman with chronic dry eyes and dry mouth presents with recurrent nephrolithiasis and muscle weakness. Labs show:

  • Non-anion gap metabolic acidosis
  • Hypokalemia
  • Urine pH 6.5

Which renal disorder is associated with Sjögren syndrome?


distal (type 1) renal tubular acidosis

Sjögren syndrome is strongly associated with distal (type 1) RTA due to autoimmune tubulointerstitial injury impairing hydrogen ion secretion.

Features of type 1 RTA:

  • Non-anion gap metabolic acidosis
  • Inappropriately high urine pH (>5.5)
  • Hypokalemia
  • Calcium phosphate kidney stones/nephrocalcinosis

Think of Sjögren syndrome when sicca symptoms occur with unexplained hypokalemia or nephrolithiasis.



300

A physician investigated the 1854 London cholera outbreak by mapping cases around the Broad Street water pump, helping establish modern epidemiology.

Which physician is considered the father of modern epidemiology?


John Snow is considered one of the founders of modern epidemiology for tracing the 1854 London cholera outbreak to the Broad Street water pump.

400

A patient with inferior STEMI develops hypotension and worsening renal function. Swan-Ganz catheterization shows:

  • CVP: 18 mmHg
  • PCWP: 8 mmHg
  • Cardiac index: 1.7 L/min/m²
  • SVR: elevated

Lungs are clear on exam. What is the most likely diagnosis?

This hemodynamic profile is classic for right ventricular (RV) cardiogenic shock, most commonly due to an inferior MI involving the RV.

Key Swan-Ganz Findings

  • High CVP (18 mmHg) → elevated right-sided filling pressures from RV failure
  • Low PCWP (8 mmHg) → left-sided filling pressures are normal/low because the RV cannot effectively deliver blood to the LV
  • Low cardiac index (1.7 L/min/m²) → reduced forward flow/cardiogenic shock
  • High SVR → compensatory vasoconstriction in shock
400

A patient presents with progressive cognitive decline, gait instability, diplopia, and pupils that accommodate but do not react to light. 


Serum RPR and FTA-ABS are positive. What next study you will perform? 

lumbar puncture to evaluate neurosyphilis (VDRL in CSF)

Argyll Robertson pupils (“accommodates but does not react”) are classic for neurosyphilis.

Patients with:

  • Neurologic symptoms
  • Cognitive changes
  • Cranial nerve abnormalities
  • Tabes dorsalis findings
  • Ocular findings


400

A patient hospitalized with severe pneumonia is started empirically on vancomycin and cefepime. Nasal MRSA PCR screening later returns negative, and blood cultures remain negative on day 4 of admission. Pt is now afebrile. 

What is the best next step in the management of this patient? 

As per the Gupta et al trial. 

A negative nasal MRSA PCR has a very high negative predictive value for MRSA pneumonia and can help safely discontinue empiric vancomycin in appropriate patients.

  • Negative MRSA screen → strong evidence AGAINST MRSA pneumonia
  • Useful antimicrobial stewardship tool
  • Positive screen is less specific and does not confirm infection
400

A patient with diffuse systemic sclerosis develops abrupt severe hypertension, headache, oliguria, and acute kidney injury. Labs show:

  • Hemoglobin: 8.2 g/dL
  • Platelets: 78,000/µL
  • Elevated LDH
  • Low haptoglobin
  • Peripheral smear with schistocytes

What is the best next step in the management of this patient? 

ACE inhibitor therapy for scleroderma renal crisis

Explanation

This patient has scleroderma renal crisis complicated by microangiopathic hemolytic anemia (MAHA).

Evidence of MAHA

Schistocytes

Elevated LDH

Low haptoglobin

Thrombocytopenia

ABIM Pearl

Despite worsening creatinine, ACE inhibitors remain first-line therapy and improve survival.

Do not confuse with TTP/HUS; the key clue is severe hypertension in diffuse systemic sclerosis

400

How many lumbar punctures are required to be completed by residents before graduation? 

5 LPs

500

A 58-year-old man presents with recurrent syncope during exertion. ECG shows below. T


Telemetry later demonstrates the following findings: 


What is the treatment?

Treatment is pacemaker placement

High-grade AV block with symptoms (syncope) is a Class I indication for permanent pacemaker implantation.
ABIM pearl:

  • Mobitz II and third-degree AV block are usually infranodal and can rapidly deteriorate.
  • Syncope + conduction disease = think pacemaker.
500

A 42-year-old woman with fatigue, dry cough, and bilateral hilar lymphadenopathy develops edema and nephrotic-range proteinuria. She has a rash in the eyelid:

What is the most likely diagnosis?

Renal sarcoidosis presenting with nephrotic syndrome

500

Tell at least 3 microorganisms that if growing in blood cultures SHOULD NEVER been considered contaminants. 


ABIM Pearl — “Never Contaminants”

  • Staphylococcus aureus
  • Candida species
  • Streptococcus pneumoniae
  • Group A Streptococcus
  • Pseudomonas aeruginosa
  • Enterobacterales (e.g., E. coli, Klebsiella)

These organisms warrant:

  • Repeat blood cultures
  • Source evaluation
  • Appropriate antimicrobial therapy
  • Consideration of endocarditis evaluation when appropriate.
500

A patient presents with hemoptysis, hypoxemia, and rapidly progressive acute kidney injury. Urinalysis shows dysmorphic RBCs and red blood cell casts. Chest imaging demonstrates diffuse alveolar infiltrates.

Which antibody is most associated with this disease?


This patient has Goodpasture syndrome (anti-GBM disease) causing:

Diffuse alveolar hemorrhage (DAH)

Rapidly progressive glomerulonephritis

ABIM Pearl

Classic findings:

Hemoptysis + AKI

RBC casts

Anti-GBM antibodies

Linear IgG deposition on kidney biopsy immunofluorescence

Treatment:

Plasmapheresis

High-dose glucocorticoids

Cyclophosphamide

500

The first residency program established in El Paso was ________________ in 1975. 

Family Medicine