WhizKids
A 9-month-old infant presents in January with cough, rhinorrhea, low-grade fever, and expiratory wheezing. This is her first episode. She attends daycare. Oxygen saturation is 95% on room air.
Based on the article, what is the most likely cause of wheezing in this age group, and what epidemiologic fact supports this?
Brief Answer:
Bronchiolitis (most commonly RSV). Up to 90% of infants and children are affected by bronchiolitis by age 2 years.
Teaching Pearl:
In infants younger than 2 years — especially during winter — bronchiolitis is far more common than asthma. Age and season are powerful diagnostic clues.
A healthy 23-year-old patient with no prior abnormal results presents for routine preventive care. She is sexually active and asks what cervical cancer screening she needs.
According to the 2024 USPSTF draft recommendation, what is the appropriate screening strategy?
Brief Answer:
Cytology alone every 3 years (ages 21–29).
Teaching Pearl:
HPV testing is not recommended in patients younger than 25–29 (depending on guideline) due to high rates of transient HPV infection and low cancer risk.
A 68-year-old man presents with 5 days of fever, malaise, and chills. He has a history of degenerative mitral valve disease. Blood pressure is stable. On exam, you detect a new systolic murmur.
According to the article, what diagnosis must be strongly considered and what is the most common presenting feature?
Brief Answer:
Infective endocarditis; fever is the most common presenting feature in acute cases.
Teaching Pearl:
Any patient with fever of unclear origin plus a new or worsening murmur should trigger evaluation for endocarditis — even before classic peripheral stigmata appear.
A 45-year-old patient with obesity asks about starting semaglutide for weight loss. She wants to know what degree of weight loss is realistic.
According to the article, what average total body weight loss is seen with GLP-1–based injectable medications?
Brief Answer:
Approximately 15% to 25% total body weight loss.
Teaching Pearl:
These medications produce unprecedented weight loss compared with prior pharmacologic options, but expectations must include discussion of long-term adherence and discontinuation challenges.
A 64-year-old man with established coronary artery disease is on atorvastatin 40 mg daily. His LDL-C is 82 mg/dL.
Based on the evidence summarized in the article, what LDL-C goal is supported for patients with established ASCVD?
Brief Answer:
Target LDL-C < 70 mg/dL.
Teaching Pearl:
Meta-analyses and RCTs support treating to a specific LDL-C target (<70 mg/dL) rather than relying solely on fixed-dose statin intensity.
A 3-year-old child presents with recurrent wheezing episodes triggered by viral illnesses. Between illnesses, the child is asymptomatic. The mother has asthma and allergic rhinitis, and the child has eczema.
How does this family and atopic history change the probability of asthma, and how should this influence your clinical suspicion?
Parental asthma, allergies, or eczema significantly increase asthma risk (OR ≈ 4.2). This history raises suspicion for early childhood asthma rather than transient viral wheeze.
Teaching Pearl:
Recurrent wheeze + atopy + family history strongly shifts the differential toward asthma, even in children younger than 5 years where diagnosis is clinical.
A 32-year-old average-risk patient presents for screening. Your clinic now has access to FDA-approved primary HPV testing.
What is the preferred screening method and interval for this patient?
Brief Answer:
Primary HPV testing every 5 years.
Teaching Pearl:
Primary HPV screening is now the preferred strategy for ages 30–65 because it has higher sensitivity (>90%) for precancer compared with cytology (50–70%).
A 55-year-old woman with persistent bacteremia due to Staphylococcus aureus is being evaluated for endocarditis. You plan imaging.
What is the recommended first-line imaging modality, and what is the next step if it is negative but suspicion remains high?
Brief Answer:
Transthoracic echocardiography (TTE) first; if negative or equivocal, perform transesophageal echocardiography (TEE).
Teaching Pearl:
TTE is first-line but misses up to 40% of cases. TEE has higher sensitivity (≈92–96%) and is required when suspicion persists.
A patient who lost 18% of body weight on tirzepatide discontinues therapy due to cost. Within months, weight begins to return.
Why does weight regain after discontinuation often worsen cardiovascular risk?
Brief Answer:
Because up to 40% of initial weight loss is lean mass, and weight regain predominantly involves fat mass.
Teaching Pearl:
GLP-1–associated weight loss can include substantial lean mass loss (sarcopenia risk). Regain is metabolically unfavorable if lifestyle measures are not reinforced.
A patient with ASCVD reduces LDL-C by 38.7 mg/dL on therapy.
What relative risk reduction in major vascular events is expected per this LDL-C reduction?
Brief Answer:
Approximately 22% relative risk reduction per 38.7 mg/dL LDL-C decrease.
Teaching Pearl:
Cardiovascular risk reduction is proportional to the magnitude of LDL-C lowering — not simply the drug class used.
A 2-month-old infant has persistent wheezing since birth. The wheeze is not associated with viral symptoms. The infant also has difficulty feeding and poor weight gain. Bronchodilators provide no improvement.
What category of pathology should be suspected, and what specific conditions are highlighted in the article?
Brief Answer:
Congenital structural abnormalities — such as congenital heart disease, congenital airway disease, cystic fibrosis, or vascular rings.
Teaching Pearl:
Wheezing present from birth is not asthma until proven otherwise. Persistent symptoms independent of viral triggers demand evaluation for structural disease.
A 40-year-old patient with a history of trauma strongly prefers to avoid speculum examination. She is asymptomatic and average risk.
Is self-collected primary HPV screening acceptable, and what is the recommended interval if negative?
Brief Answer:
Yes, self-collected primary HPV screening is acceptable; repeat in 3 years if negative.
Teaching Pearl:
Self-collection improves screening uptake and has similar accuracy to clinician-collected samples, but requires reflex follow-up if HPV positive.
A patient has positive blood cultures for Enterococcus species and echocardiography shows a mobile vegetation on the mitral valve.
Under the 2023 Duke Criteria, how would this case be classified?
Brief Answer:
Definite infective endocarditis (meets major microbiologic + major imaging criteria).
Teaching Pearl:
The 2023 Duke Criteria integrate clinical, microbiologic, and imaging findings and classify cases as definite, possible, or rejected — do not diagnose IE without applying structured criteria.
A patient has reached her weight loss goal and wants to stop semaglutide but fears rebound appetite. You propose gradually lowering the dose monthly rather than stopping abruptly.
Which discontinuation strategy is this, and what is the rationale?
Brief Answer:
Dose de-escalation (microdosing); gradual tapering reduces abrupt appetite rebound and weight regain.
Teaching Pearl:
Although guidelines are lacking, reversing the original dose-escalation schedule is a rational clinical strategy supported by preliminary real-world data.
A patient hospitalized for acute coronary syndrome remains at LDL-C 72 mg/dL on moderate-intensity statin therapy.
What evidence supports adding ezetimibe, and what is the approximate number needed to treat (NNT)?
Brief Answer:
The IMPROVE-IT trial showed a 2% absolute risk reduction (NNT ≈ 50 over ~6 years) when ezetimibe was added.
Teaching Pearl:
Combination therapy can improve outcomes even when LDL-C is already near 70 mg/dL — incremental lowering still matters.
A 4-year-old child presents with recurrent wheezing over the past year. Symptoms are not clearly linked to viral illness, and there is no clear diagnosis. Physical exam today shows mild expiratory wheeze without distress.
According to the article, what is the recommended initial imaging modality, and what is its purpose?
Chest radiography; to evaluate for structural abnormalities, cardiomegaly, hyperinflation, or foreign body aspiration.
Teaching Pearl:
Chest radiography is not routine for every wheeze — it is indicated in recurrent or persistent cases without a clear cause.
A 66-year-old patient with no history of CIN2+ has had:
Negative primary HPV tests at ages 60 and 65
No abnormal results in the past 25 years
Should screening continue?
Brief Answer:
No. Screening can be discontinued.
Teaching Pearl:
Exit criteria require adequate negative prior screening and no history of CIN2+ in the past 25 years. Documentation matters.
A 60-year-old patient is diagnosed with native valve endocarditis due to penicillin-susceptible Streptococcus.
What is the minimum duration of therapy, and under what circumstances can a shorter regimen be considered?
Brief Answer:
Standard minimum duration is 4 weeks; a 2-week regimen of penicillin G or ceftriaxone plus gentamicin may be considered in select native valve cases.
Teaching Pearl:
Duration depends on organism and valve type. Prosthetic valves require ≥6 weeks, and Enterococcus requires at least 6 weeks regardless of valve type.
A patient with stable weight loss on weekly semaglutide asks whether extending injections to every 14 to 21 days is reasonable due to cost concerns.
What discontinuation strategy is this, and what pharmacologic principle supports it?
Brief Answer:
Interval dosing; supported by the long half-life of GLP-1 receptor agonists, allowing continued appetite regulation with less frequent dosing.
Teaching Pearl:
Interval dosing may reduce cost, adverse effects, and treatment fatigue while maintaining weight control — though long-term RCT data are limited.
A patient with stable coronary artery disease asks whether it is better to aim for LDL-C 50–70 mg/dL or simply stay on high-intensity statin therapy regardless of LDL level.
What did the 2023 noninferiority trial demonstrate?
Brief Answer:
Treat-to-target (LDL 50–70 mg/dL) was noninferior to fixed high-intensity statin therapy, with similar cardiovascular outcomes and fewer safety events.
Teaching Pearl:
Treat-to-target may allow lower high-intensity statin exposure while maintaining outcomes and reducing adverse effects such as new-onset diabetes.
A 2-year-old presents with chronic wheezing that worsens when lying supine and improves when upright. The wheeze is not responsive to bronchodilators. There is no fever. The child has normal growth.
What diagnosis should be suspected, what is the pathophysiology, and what is the preferred diagnostic test?
Brief Answer:
Tracheomalacia or tracheobronchomalacia; flaccid large airways collapse during expiration; diagnosed with flexible bronchoscopy.
Teaching Pearl:
Positional worsening and bronchodilator nonresponse point away from asthma and toward dynamic airway collapse — a classic board trap.
A 35-year-old patient undergoes primary HPV screening. Results show HPV 16 positive. Cytology is negative for intraepithelial lesion or malignancy.
What is the next step in management and why?
Brief Answer:
Colposcopy.
Teaching Pearl:
HPV 16 and 18 carry the highest cancer risk. Under ASCCP risk-based guidelines, HPV 16 positivity warrants colposcopy even if cytology is normal.
A patient with infective endocarditis has persistent fever and bacteremia after 6 days of appropriate antibiotic therapy. Echocardiography shows a 1.5-cm vegetation and worsening mitral regurgitation.
What is the next management consideration, and why?
Brief Answer:
Urgent evaluation for surgical valve replacement.
Teaching Pearl:
Indications for surgery include persistent bacteremia >5 days, heart failure from valvular damage, recurrent emboli, abscess, heart block, or large vegetations (≥1 cm). Early surgery can reduce embolic risk and mortality.
A 52-year-old patient with obesity, type 2 diabetes in remission after 20% weight loss, and prior severe rebound weight gain after lifestyle-only attempts asks to discontinue tirzepatide due to GI side effects.
How should discontinuation be approached, and in which patients might continuation be preferable?
Brief Answer:
Use shared decision-making. Consider dose de-escalation, interval dosing, or add-on oral agents while reinforcing lifestyle therapy. Patients with multiple comorbidities or history of significant rebound weight gain may require ongoing treatment.
Teaching Pearl:
Discontinuation is not purely pharmacologic — it is behavioral, metabolic, financial, and psychosocial. High-risk patients may benefit from long-term therapy rather than complete withdrawal.
A 66-year-old patient with chronic coronary disease has LDL-C 74 mg/dL on maximally tolerated statin therapy. You are considering whether to intensify treatment.
How do evidence and guidelines differ in their recommendations, and how should this influence your decision?
Brief Answer:
Evidence from meta-analyses and RCTs supports treating to LDL-C <70 mg/dL (SOR A). However, 2023 AHA/ACC guidelines recommend a fixed-dose, risk-based approach and adding nonstatin therapy if LDL-C remains ≥70 mg/dL. Shared decision-making is appropriate.
Teaching Pearl:
Exams often test this nuance: strong outcome data support LDL-C targets, but some guidelines prioritize simplified fixed-dose strategies. Knowing both positions is critical.