CARDIO
A 59 year old man with hypertension and hyperlipidemia develops substernal chest pressure while walking uphill. The discomfort resolves within 5 minutes of resting. ECG at rest is normal. He has no symptoms at rest. What is the most likely diagnosis?
Stable angina
why: predictable exertional chest pain relieved by rest= stable ischemic heart disease.
A 23 year old woman has recurrent epsiodes of wheezing, cough and chest tightness. Symptoms occur after exercise and improve with an inhaled bronchodilator.
Most likely diagnosis?
answer: asthma.
A 45 year old man has had severe vomiting and diarrhea for 3 days. Creatinine increased from 0.9 to 2.1 mg/dL. BUN is 56 mg/dL.
Urine sodium is low and fractional excretion of sodium is <1%. What is the most likely diagnosis?
answer: prerenal AKI.
a 22 year old woman develops periumbilical abdominal pain that migrates to the right lower quadrant. She has anorexia, nausea and low-grade fever. What is most likely the diagnosis?
answer: acute appendicitis.
35 year old woman at 34 weeks' gestation presents with painless bright red vaginal bleeding. Her abdomen is soft and nontender. What is most likely the diagnosis?
answer: Placentia previa.
A 68 year old woman presents with palpitations and dyspnea. ECG shows atrial fibrillation with a ventricular rate of 170/min. BP is 78/46 mm Hg, and she is confused.
What is the next best step?
Immediate synchronized cardioversion.
why: this is unstable tachyarrhythmia. Don't waste time with rate control medication.
a 67 year old man with COPD presents with increased dyspnea and sputum production. His sputum has become purulent. Which treatment should be added to bronchodilator therapy?
answer: antibiotics.
why: COPD exacerbation with increased sputum production purulence is an indication for antibiotics.
a hospitalized patient develops AKI after several days of septic shock. Urinalysis shows muddy granular casts. What's the diagnosis?
Answer: acute tubular necrosis.
key: muddy brown casts = ATN.
A 48 year old man develops severe epigastric pain radiating to the back. Lipase is > 3 times the upper limit of normal. What is the diagnosis?
answer: acute pancreatitis
a 32 year old woman at 37 weeks develops sudden painful vaginal bleeding with uterine tenderness and frequent contractions. fetal heart rate shows recurrent late decelerations. What's the diagnosis?
answer: placental abruption.
remember: painful bleeding + uterine tenderness --> abruption.
A 64 year old man presents with crushing chest pain. ECG demonstrates ST-segment elevation in leads ll, lll and aVF. He becomes hypotensive after receiving nitroglycerin. Examination reveals clear lungs and elevated jugular venous pressure.
Which coronary artery is most likely occluded?
Bonus question (5 pts): What medication should you be cautious about?
Right coronary artery.
why: Inferior MI + Hypotension + JVD + clear lungs --> right ventricular infarction, usually RCA.
bonus question answer: nitroglycerin because RV infraction is preload dependent.
a 56 year old woman develops sudden dyspnea and pleuritic chest pain 5 days after hip placement. HR is 118/min and oxygen saturation is 89%. She has unilateral calf swelling. What is the most likely diagnosis?
Bonus (5 pts) if she hemodynamically stable, what imaging test is generally used?
Answer: pulmonary embolism.
Bonus answer: CT pulmonary angiography.
A 62 year old man with small cell lung cancer develops confusion. Sodium is 188 mEq/L. Serum osmolality is low, urine osmolality is high, and he appears euvolemic. what is the diagnosis?
answer: SIADH.
a 59 year old man with cirrhosis presents with large-volume hematemesis. BP is 85/50 mmHg. Along with resuscitation and urgent endoscopy, which medication should be started?
answer: octreotide.
more info: suspected variceal bleeding --> vasoactive therapy
a 2 month old infant has progressively worsening projectile nonbilious vomiting after feeds. the infant remains hungry after vomiting. Examination reveals a small, firm, mobile mass in the upper abdomen. What's the diagnosis?
answer: hypertrophic pyloric stenosis.
remember: projectile nonbilious vomiting + hungry afterward + palpable "olive."
a 72 year old man with HFrEF has an EF of 30%. He takes sacubitril/valsartan and carvedilol. He remains symptomatic but has normal renal function and potassium. What additional medication provides a mortality benefit?
A. Furosemide B. Digoxin C. Spironolactone D. Diltiazem E. hydrochlorothiazide
C. Sprionolactone.
key: mineralocorticoid receptor antagonist reduce mortality in appropriate HRrEF patients.
a 35 year old man with asthma has severe wheezing despite repeated inhaled albuterol and ipratropium. He is using accessory muscles. His PaCO2, previously low, is now 45 mm Hg. Why is this finding concerning?
answer: It suggest impending respiratory failure due to respiratory muscle fatigue.
High yield: in severe asthma, patients initially hyperventilate --> low CO2. A rising/normalizing CO2 can be a bad sign.
more info: calcium doesn't lower potassium- it stabilizes the myocardium while definitive potassium lowering measures are initiated.
a 51 year old woman presents with fever, jaundice and RUQ pain. She becomes hypotensive and confused. What is the diagnosis and definitive treatment?
more info: this is Reynolds pentad. Charcot traid + hypotension altered mental status.
a 3 year old boy develops a barking cough, hoarseness and inspiratory stridor that worsens at night. He has no drooling and appears nontoxic. most appropriate treatment is?
answer: dexamethasone.
key: croup. add nebulized epinephrine if moderate/severe.
a 74 year old man develops sudden severe chest pain radiating to his back. BP is 210/110 mm Hg in the right arm and 175/95 mm Hg in the left arm. There is a new diastolic murmur. CTA confirms an acute asending aortic dissention.
What is the definitive management?
answer: emergent surgical repair.
why: ascending/type A--> surgery.
descending/type B--> usually medical management unless complicated.
a 29 year old woman presents with sudden dyspnea and chest pain. She is hypotensive with BP 78/50 mmHg. Echocardiography demonstrates severe right ventricular dilation and dysfunction. She has no major contraindication to thrombolysis. What is the best next treatment?
More info: massive/high-risk PE + hemodynamic instability --> thrombolysis.
a 26-year-old man develops hemoptysis and rapidly progressive renal failure. Urinalysis shows RBC casts. Serum testing reveals antibodies against the glomerular basement membrane. What is the diagnosis?
answer: Anti-GBM Disease (Goodpasture syndrome)
more info: pulmonary hemorrhage + rapidly progressive glomerulonephritis + anti-GBM antibodies.
a 31 year old man with ulcerative colitis presents with severe bloody diarrhea, fever, and abdominal distention. Abdominal radiograph demonstrates colic dilation. What is the diagnosis?
bonus 5 pts: what should you avoid?
answer: toxic megacolon.
bonus pts answer: colonoscopy, because increased perforation risk.
a 29 year old woman at 35 weeks gestation has BP 168/112 mmHg on two measurements. She reports severe headache and visual disturbances. Labs who elevated AST/ALT and platelets of 85,000/uL. what is the next best step?
answer: stabilize the mother with magnesium sulfate for seizure prophylaxis and proceed with delivery after stabilization.
remember: severe preeclampsia with HELLP features at 35 weeks --> maternal stabilization followed by delivery.