Answer: Choice 2: Brugada Type 2

Explanation:

Type I: Lead V1 has a “coved” ST segment elevation of at least 2 millimeters, followed by a negative T wave.

Type II: There is a “saddleback” appearance of the ST segment in lead V1 with ST segment elevation of at least 2 millimeters; this can be present in normal individuals as well.

Type III: Features of type I (coved) or type II (saddleback) with < 2 mm of ST segment elevation.

These ECG changes can be provoked in the electrophysiology lab by infusing procainamide.

The treatment for Brugada Syndrome is an ICD (implantable cardioverter defibrillator).

Brugada J, Campuzano O, Arbelo E, Sarquella-Brugada G, Brugada R. Present Status of Brugada Syndrome: JACC State-of-the-Art Review. J Am Coll Cardiol. 2018;72(9):1046-1059.

doi:10.1016/j.jacc.2018.06.037

Answer: Cerebral contusions

Explanation:

he patient suffered bifrontal and insular contusional hemorrhages which tend to grow over time.

https://www.henryford.com/physician-directory/m/mayer-stephan

Answer: Idiopathic aplastic anemia

Explanation:

A young man presents with pancytopenia and a hypocellular bone marrow. Since the bone marrow had an aspirate, this is not myelofibrosis (that would be a dry tap).

The normal morphology of hematopoietic cells in the bone marrow and the normal karyotype argue against MDS.

The lack of rash and fever argue against parvovirus B19, especially with this being pancytopenia and not isolated hypoproliferative anemia.

The best diagnosis is idiopathic aplastic anemia (d), especially with no family history to suggest an inherited bone marrow failure state.

Contributed by Lloyd Damon, MD Director of the adult Blood and Marrow Transplant and Hematologic Malignancies Program and Chief of the UCSF Hematology Clinic.

https://www.ucsfhealth.org/lloyd.damon

Answer: Chemotherapy

Explanation:

Up to 10% of patients with SCLC will manifest signs and symptoms of inappropriately elevated anti-diuretic hormone which is secreted by tumor cells.

Osmolarity determination will show decreased serum osmolarity and hyperosmolar urine. Management of hyponatremia due to SIADH is water restriction and treatment of the underlying cause; in this case treatment directed towards SCLC.

Other paraneoplastic symptoms associated with SCLC include Eaton Lambert myasthenia syndrome, ectopic ACTH secretion, sensory neuropathy, and limbic encephalopathy.

Contributed by Scott Gettinger, MD Associate Professor Yale University https://www.yalecancercenter.org/patient/people/scott_gettinger.profile

Answer: A 55-year old inpatient 12 hours post a large anterior myocardial infarction with an ejection fraction of 35% and systolic blood pressure of 88 mmHg on a low dose of dobutamine (2.5 mcg/kg/min).

Explanation:

Initiation of beta-adrenergic receptor blockade for the treatment of heart failure is contraindicated when the patient is hypotensive and receiving treatment with a positive inotropic agent.

Beta-adrenergic receptor blockade should only be initiated or uptitrated in periods of clinical stability.

Potential contraindications to beta-adrenergic receptor blockade include symptomatic hypotension, symptomatic bradycardia, and greater than first degree heart block.

Choice 1 is incorrect as this patient has no described contraindication.

Choice 2 is incorrect as this patient has no described contraindication.

Choice 3 is incorrect as a heart rate of 60 is at the lower limits of the normal range and is not a contraindication to therapy, and first degree heart block is not a contraindication to therapy.

Choice 4 is incorrect as mild orthostatic symptoms are a common side effect of beta blockers, but not a contraindication to therapy.

Contributed by Dr Alex Reyentovitch, MD https://nyulangone.org/doctors/1588723662/alex-reyentovich … & Stuart Katz, MD @nyulangone

https://nyulangone.org/doctors/1306834478/stuart-d-katz … @nyuschoolofmed

Answer: Ethylene glycol intoxication

Explanation:

This patient has high anion gap metabolic acidosis with appropriate respiratory compensation (expected pCO2 = 1.5 x HCO3 + 8 = 1.5 × 10 + 8 = 23 ± 2). Additionally, the osmolar gap is increased (24 = measured serum osmolality – calculated serum osmolality = 327- 301).

The conditions that cause high anion gap metabolic acidosis with high osmolar gap include ethylene glycol, methanol, propylene glycol, ethanol, and renal failure.

After accounting for the osmolar contribution of ethanol to the serum osmolality (11= ethanol concentration in mg/dL divided by 4.6), the osmolar gap still remains greater than 10. The presence of calcium oxalate crystals is strongly suggestive of ethylene glycol ingestion.

Mild lactic acidosis likely represents a laboratory artifact. The lactate analyzer mistakenly identifies glycolate as lactate because this metabolite of ethylene glycol bears a close structural resemblance to lactate.

Ketoacidosis is likely from alcoholic ketoacidosis. Modest acute kidney injury seen in this patient is not expected to cause metabolic acidosis of this severity. Furthermore, acute kidney injury does not elevate the osmolar gap.

Salicylate intoxication induces a mixed acid-base disorder with respiratory alkalosis and metabolic acidosis, the latter from lactic acidosis and ketoacidosis. The degree of lactic acidosis does not fully account for the increase in the anion gap.

Contributed by Aldo Peixoto, MD Professor and John J Chang, MD Assistant Professor

https://medicine.yale.edu/intmed/people/aldo_peixoto.profile

Answer: Acute respiratory failure in immunocompromised patients

Explanation:

Studies suggests that NIPPV is associated with decreased ICU mortality, intubation rate, and ICU length of stay among immunocompromised patients with acute respiratory failure, when compared to invasive mechanical ventilation as the first modality of ventilator support. These outcomes are probably a consequence of fewer nosocomial infections among patients given a trial of NIPPV before moving forth with invasive mechanical ventilation. Therefore option A is correct

In a very small study of 30 emergency department patients, the use of NIPPV in severe asthma exacerbation resulted in a favorable outcome. However, this has not been replicated in larger studies, and thus should not be considered standard of care – option B is thus incorrect.

Patients with severe burns and airway involvement typically get worse before they get better, and take a long time to recover. There are no studies to suggest a beneficial outcome with NIPPV use in this population. While there may be special scenarios where NIPPV might be tried, as a group, there are no studies to show that those with ARDS – even those with milder disease – would benefit from NIPPV

Contributed by Dr. Shyoko Honiden, http://M.Sc . M.D., is an Asst Prof of Medicine at the Yale School of Medicine & Dr Dr. Mark David Siegel, the Director of the Traditional Internal Medicine Residency at Yale. @HeartBobH @FutureDocs @StanfordDeptMed @UCSFHospitals

Answer: None of the above

Explanation:

There is no clinical model that accurately predicts disease severity in sleep apnea. Thus objective testing via a sleep study is required to determine disease absence or presence and severity.

The Epworth Sleepiness Scale is an 8 question scale used to measure the degree of daytime sleepiness. It asks subjects to rate, with increasing probability from 0--3 (0 = never, to 3 = very likely) their likelihood of falling asleep in 8 frequently encountered situations. It has been validated in SDB and can be useful to gage treatment response;

The Berlin Questionnaire is a 10-question test used to predict the presence of sleep apnea. The questionnaire refers to BMI, snoring, apneas, daytime sleepiness, drowsy driving frequency, and hypertension.

STOP-BANG, is a questionnaire focused on identifying SDB risk in the peri-operative population. The questionnaire borrows from Berlin, also incorporating information on age, neck circumference, and gender.

Overnight oximetry can be considered for screening of high risk patient groups. The test is not diagnostic for SDB and can be quite limited by false negative and false positive results.

https://www.bidmc.org/centers-and-departments/neurology/programs-and-services/sleep-disorders-clinic/meet-our-team

Answer: This is likely to be secondary to drug-drug interaction. A careful review of the medication list and the method of intake are essential for the identification of the cause.

Explanation:

This is a common scenario seen in the office management of hypothyroidism. A careful review of medical history and medication list can sometimes identify the causes responsible for the increasing demand of Levothyroxine dose. In this case, the patient has added Calcium Carbonate tablets in the morning. Unfortunately, calcium carbonate has extensive interaction with Levothyroxine and can severely compromise the absorption of the later. Therefore, the best next step of action will be to change the morning calcium carbonate to be at least one hour after Levothyroxine to minimize the compromised absorption of the thyroid hormone. There is no need to change the dose of Levothyroxine as yet since an obvious underlying cause can be identified and should be removed. As a follow up, TSH should be re-checked in ~6 to 8 weeks with the aim to correct it into normal reference range. It should be noted that T4 monotherapy is the preferred treatment for hypothyroidism. Levothyroxine is known to have extensive drug-drug and drug-food interaction. Therefore, it is recommended that it should be taken in early morning in empty stomach with water only. It should be separated from any other oral medications or food for ~1 hour. In addition, the bioavailability of different preparations of thyroid hormone is different and whenever a brand is changed, TSH should be re-measured in 6 to 8 weeks to ensure the stability of thyroid function

Choice a is incorrect. Patient is known to have Hashimoto’s thyroiditis, which is the most likely cause for her hypothyroidism. Her TPO and thyroglobulin antibodies are all likely to be positive. Repeated measurements of these antibodies are likely to be low yield in the work up of her worsening hypothyroidism. In addition, RAIU and thyroid scan are unlikely to identify the cause of her increasing demand of Levothyroxine.

Choice c is incorrect. There is no indication that patient is having a gastrointestinal issue at this time that warrants an investigation.

Choice d is incorrect. All the obvious underlying cause should be addressed before simply increasing the dose of the medication.

Choice e is incorrect. The weight gain of the patient is likely secondary to the worsening hypothyroidism. Simply increasing Levothyroxine dose may or may not be able to correct her hypothyroidism unless the underlying cause was corrected. Besides, the estimation of Levothyroxine dose is based on body lean mass instead of the actual weight. Increasing her Levothyroxine from 125 to 130 µg daily is unlikely to be the best choice.

James V. Hennessey, MD is Director of Clinical Endocrinology at Beth Israel Deaconess Medical Center in Boston, MA. He is an Associate Professor of Medicine at the Harvard medical School.

https://findadoc.bidmc.org/details/622/james-hennessey-endocrinology_diabetes__metabolism-boston-needham

Answer: No additional testing indicated

Explanation:

The skin lesion has an area of central erythema with clearing, suggestive of a target or bulls-eye appearance. This, coupled with the recent tick bite at the site and the history of enlarging size is diagnostic of an erythema migrans skin lesion, which may be seen either with Lyme disease or with Southern tick associated rash illness (STARI).

Although the skin findings for these two diseases are identical, they occur in distinct geographic regions. B. burgdorferi, the etiologic agent of Lyme disease, is found in ticks endemic to the Northeast and upper Midwest United States.

The etiologic agent of STARI is not known, but the disease is transmitted by the lone star tick, with is found through the Southeast and South Central regions, including Missouri. Regardless, laboratory confirmation is not needed for Lyme disease when a classic erythema migrans rash is present, as antibodies may not yet have developed at this early stage

While human monocytic ehrlichiois (HME), caused by E chaffeensis, and Rocky Mountain spotted fever (RMSF), caused by R. rickettsii have both been reported in patients from Missouri, neither disease is associated with an erythema migrans skin lesion.

Hematologic abnormalities are frequent with both HME and RMSF, but are not present with STARI.

https://medicine.mc.vanderbilt.edu/person/karen-c-bloch-mdmph-fidsa

Answer: Peroneal nerve

Explanation:

The pattern of weakness and sensory loss fits best with injury to the peroneal nerve.

A peroneal neuropathy should be distinguished from a L5 radiculopathy by testing foot inversion. Foot inversion is performed by the posterior tibialis muscle which is supplied by the tibial nerve through the L5 root. Thus, an L5 radiculopathy will cause weakness of foot inversion in addition to foot dorsiflexion, but a peroneal neuropathy will have weakness in foot dorsiflexion, but spare foot inversion.

The peroneal nerve has both a deep and superficial branch.

The deep peroneal nerve supplies the tibialis anterior, extensor hallucis longus and supplies sensation in the webspace between the first and second toe.

The superficial peroneal nerve supplies the foot evertors (peroneus) and sensation to the dorsal aspect of the foot.

The sciatic nerve divides into both the tibial and peroneal nerve.

The femoral nerve supplies the quadriceps and iliopsoas muscles.

https://weillcornell.org/josafdieh

Answer: Common variable immunodeficiency syndrome

Explanation:

Common variable immunodeficiency syndrome is characterized by frequent sinus infections and diarrhea, in the setting of normal celiac serology and absent quantitative immunoglobulins.

Duodenal biopsies will show villous atrophy and a lack of plasma cells.

Patients with celiac disease can have a false negative TTG test in the setting of immunoglobulin deficiency, but an absence of plasma cells is not a feature of celiac disease on biopsy.

Lymphoma would have characteristics features on histology, and

Burton's agammaglubulinemia will not have duodenal abnormalities.

Contributed by Drs Maggie Ham, MD and Alan C Moss, MD, Harvard Medical School

Answer: This exudative effusion is likely due to metastatic lung cancer.

Explanation:

This is an exudative effusion as determined by Light's criteria. Although only 1 criteria is required, this patient's pleural fluid LDH to serum LDH ratio is >0.6 and the pleural fluid protein to serum protein ratio is > 0.5. She also has a lung mass and history of tobacco use. All of these suggest a malignant pleural effusion and advanced lung cancer

Contributed by Dr Jonathan Puchlaski, MD

Associate Professor of Internal Medicine (Pulmonary, Critical Care and Sleep Medicine)

Director, Interventional Pulmonology

Director, Interventional Pulmonary Fellowship

https://medicine.yale.edu/intmed/people/jonathan_puchalski.profile

Answer: Blood Glucose

Explanation:

DKA is an acute, major, life-threatening complication of diabetes, which leads to profound dehydration, acidosis, and electrolyte disturbances.

Prompt diagnosis and treatment is lifesaving. The clinician can perform a fingerstick glucose test while waiting for the serum chemistry panel.

It is typically characterized by hyperglycemia over 300 mg/dL. Approximately 8,000 eyes become blind yearly because of diabetes.

from: Galor A, Goldhardt R. Ophthalmology for the Internist in Baliga's Textbook of Internal Medicine: An Intensive Board Review Book with 1480 Multiple Choice Questions

https://doctors.umiamihealth.org/provider/Anat+Galor/525537 https://doctors.umiamihealth.org/provider/Raquel+Goldhardt/525680

Answer: Nominal

Explanation:

Since the variable in question is broken into three naming categories that do not have any rank or order associated with them, the variable would be a nominal variable.

Contributed by Donna Windish, MD, Associate Professor of Medicine, Department of Internal Medicine at Yale University School of Medicine.

https://medicine.yale.edu/intmed/people/donna_windish.profile

Answer: Neomycin

Explanation:

The eczematous eruption limited to the surgical site suggests a focal or local cause of the rash.

Typical systemic drug eruptions are characterized by a morbilliform eruption, consisting of erythematous blanching macules and fine papules, usually on the trunk, flanks, upper inner arms, or accentuated at sites of pressure, such as the lower back in supine patients and around the elastic bands of clothing or pads.

An eczematous eruption, localized to a single site, is suggestive of a topical culprit. In this case, the patient is receiving neomycin to the surgical wound; neomycin is a common cause of allergic contact dermatitis, and in this case is the most likely culprit.

Rosenbach M, Micheletti R. A Practical Approach To The Diagnosis And Treatment Of Urticaria in Baliga's Textbook of Internal Medicine: An Intensive Board Review Book with 1480 Multiple Choice Questions

Answer: Pimecrolimus

Explanation:

This patient likely has allergic contact dermatitis. Of the available answers, pimecrolimus is the best one because it shares anti-inflammatory properties with topical corticosteroids but without the concerns regarding atrophy and hypopigmentation.

Fluocinonide is a potent topical corticosteroid and its use in intertriginous areas should be avoided.

While the topical neuromodulators capsaicin and pramoxine sometimes improve localized pruritus, neither one will affect the inflammation present in allergic contact dermatitis.

Brett King, MD, PhD > Dermatology | Yale School of Medicine > https://medicine.yale.edu/dermatology/education/fellowships/brett_king.profile

Answer: New complaint of dyspnea and a finding of a third heart sound

Explanation:

Patients should not undergo elective surgery if they have severe or decompensated cardiac disease that requires immediate evaluation and treatment regardless of the upcoming operation. The findings of dyspnea and a third heart sound suggest decompensated heart failure, which should be addressed prior to surgery. Atrial ectopy on ECG, remote myocardial infarction, rate-controlled atrial fibrillation, and stable chronic kidney disease do not require urgent management and are not contraindications to surgery.

Cheng HQ. Perioperative Medicine. in Baliga RR (editor). Baliga's Textbook of Internal Medicine: An Intensive Board Review Book with 1480 Multiple Choice Questions, Blendon-Miller, An imprint of MasterMedFacts LLC

Answer: Urine toxicology

Explanation:

The patient described has severe retiform (angulated) purpura associated with purpura and necrosis of the skin of the ears. This is a typical presentation of thrombotic vasculopathy caused by levamisole-adulterated cocaine. This diagnosis would be suggested by the presence of cocaine in the urine. Antineutrophil cytoplasmic antibodies and ANA are commonly positive in this condition. The treatment is to discontinue cocaine and institute supportive measures. A plastic surgery consult should be obtained.

From Chismar LA, Rudikoff D. Approach to a Patient with Dermatologic Disease in Baliga RR (editor). Textbook of Internal Medicine:An Intensive Board Review Book with 1480 Multiple Choice Questions.

Answer: Choice 1: Lower Lung Zone Predominance

Explanation:

Asbestosis is a fibrotic lung disease caused by the inhalation of asbestos. It is characterized by reticular radiographic abnormalities and stacked cysts (“honeycombing”) in a sub-pleural distribution, typically involving the lower lobes of the lung initially.

Exposure settings associated with asbestosis have included asbestos mining, ship building, and asbestos textile manufacturing. A latency period of approximately 20 years or more between initial exposure and the development of clinically significant disease is typical. Individuals who develop malignant pleural mesothelioma do not necessarily exhibit asbestosis.

Silicosis is a diffuse parenchymal nodular lung disease that results from the inhalation of silicon dioxide (silica). The most common form of silicosis is chronic simple silicosis, which typically presents after 10 years of exposure to silica dust and results in small nodules, typically affecting the upper lung zones first. A subset of patients with silicosis will exhibit calcification of hilar lymph nodes - “egg shell calcification”.

Answer: Choice 4: Repeat prolactin level

Explanation:

Prolactin level can be elevated by the stress of phlebotomy, recent breast or nipple manipulation (i.e. after a physical exam of breast tissue), medications, or sleep.

Verification of the elevation in prolactin should occur prior to proceeding with imaging. If fear of phlebotomy is severe, the stress of phlebotomy can be diminished by inserting an indwelling catheter, waiting 15–30 minutes, and then drawing the blood off the catheter

Answer: Choice 3

Explanation:

Self-administration of antibiotics or steroids during acute exacerbations has been shown to increase mortality (Annals of Internal Medicine 2012;156(10):673-683). No benefit has been shown with co-management between COPD specialists and primary care physicians (Cochrane Database Syst Rev. 2007;3:CD004910). Low-dose theophylline, compared with placebo, has no effect of reducing the mean number of exacerbations among patients with COPD (JAMA 2018;320(15):1548-1559). A recent study from Johns Hopkins has demonstrated that a combination of transitional care support by COPD nurses (during hospital stay and 3-months after discharge) and long-term management can improve outcomes in COPD patients ( Rinne ST, Lindenauer PK, Au DH. Intensive Intervention to Improve Outcomes for Patients With COPD. JAMA 2018;320:2335-2343).

Answer: 3: The patient's gastrointestinal bleed

Explanation:

Though the patient suffered from a UTI and delirium, from the details in the case these are not related to specific actions or processes of care. The gastrointestinal bleed is harm that she has suffered as a result of a supratherapeuticINR. Choice d is not correct as it does not describe harm per se. Contributed by Dr. Anjala V. Tess, MD is an Associate Chair for Education in the Department of Medicine at Beth Israel Deaconess Medical Center (BIDMC), Director of QI and Safety for GME at BIDMC, and an Associate Professor in Medicine at Harvard Medical School and Dr. Eric J. Alper, MD, FACP, SFHM is Professor of Medicine, UMass Medical School.

Answer: C

Explanation:

Liver stiffness measurements (LSM) of 21 kPa suggests cirrhosis—it is greater than diagnostic threshold for cirrhosis which is 12.5 kPa (where the specificity is >94%) [1]. Area under the receiver operating curves, for cirrhosis, range from 0.93 to 0.99. VTCE is better at diagnosing cirrhosis than staging cirrhosis. The most common cause of cirrhosis and end-stage liver disease among adults awaiting hepatic transplantation, in the US, is chronic hepatitis C (35%), followed by alcoholic liver disease (18%) and non-alcoholic fatty liver disease (16%) [2]. He drinks in moderation so it is unlikely to cause alcoholic liver disease 1. Mueller S, Sandrin L. Liver stiffness: a novel parameter for the diagnosis of liver disease. Hepat Med 2010; 2: 49-67. 2. Wong RJ, Aguilar M, Cheung R, et al. Nonalcoholic steatohepatitis is the second leading etiology of liver disease among adults awaiting liver transplantation in the United States. Gastroenterology 2015; 148(3): 547-55.

Answer: Choice 2

Explanation:

The most likely reason for this patient’s hypoxemia is alveolar hypoventilation. Working thorough the alveolar gas equation, the PAO2 = FIO2(Patm-PH2O) – PaCO2/0.8. Assuming that the patient is on room air at sea level, PAO2 = 0.21(760–47) –65/0.8, which works out to be ~68.5mmHg. If you then subtract the measured PaO2 of 60mmHg, the alveolar to arterial (A-a) oxygen gradient comes out at 8.5 mmHg which is NORMAL. Hypoxemia related to V/Q mismatch, diffusion impairment, as well as shunts result in an elevated A-a gradient. Thus, alveolar hypoventilation, in this case most likely due to drug overdose, is the likely explanation. Contributed by Drs Shyoko Honiden and Mark Siegel, MD, Yale University https://medicine.yale.edu/intmed/pulmonary/about/mark_siegel.profile

Answer: Choice 2

Explanation:

Since the question is assessing a change (difference) in score, any confidence interval that contains the value of “0” would not be considered statistically significant. This leaves answer “2” as the only statistically significant result. (more details in the book chapter)