Step3 41

Question 1

Etiology of Acute mitral regurge

Answer 1

ACUTE ONSET OF LEFT AND RIGHT HEART FAILURE

A- Corda tendinae rupture
Mitral valve prolapse (Marfan and Ehler-Danlos)
Infective endocarditis
Rhematic fever
Trauma

B- Papillary muscle rupture
In the setting of a Myocardial infarction

Question 2

Main difference between Marfan and Ehler-Danlos

Skin

Answer 2

Skin:
Ehler-Danlos: Hyperelasticity, rugae, easy bruising, poor healing, scars

Marfan: striae only

Question 3

Main difference between Marfan and Ehler-Danlos

Musculoskeletal

Answer 3

Both have scoliosis, joint hypermotility, pectus excavatum

Ehler-Danlos: high, arched palate

Marfan: also pectum carinatum, tall with long extremities

Question 4

Main difference between Marfan and Ehler-Danlos

Cardiac

Answer 4

Both: Mitral valve prolapse

Marfan: aortic root dilatation

Question 5

Main difference between Marfan and Ehler-Danlos

Gene

Answer 5

Both autosomal dominant

Ehler-Danlos:COL5A1 / COL5A2

Marfan: FBN1 mutation

Question 6

Patient on anticoagulation for DVT starts bleeding on the GI. What do you do next?

Answer 6

Stop anticoagulation

Place vena cava filter

Question 7

Takotsubo (stress-induced) Cardiomyopathy

Risk factor
Presentation
Physiopathology

Answer 7

Catecholamine surge

Risk factor:
Postmenopausal women
Recent physical or emotional stress

Presentation:
Myocardial infarction-like pain
Decompensated HF
Mild troponin elevation
EKG: changes in precordial leads

Question 8

Takotsubo (stress-induced) Cardiomyopathy

Diagnosis and treatment

Answer 8

Cath: no obstructive CAD

Echo: LV hypokinesis, basilar hypokinesis
ballon-shape heart that resembles octopus trap

Question 9

Sentinel event

Answer 9

Unanticipated event in a medical setting that results in harm (physical, emotional) to a patient

Eg.: in-hospital suicide, child kidnapping, discharge of baby with the wrong family, surgery performed on the wrong side

Not necessarily due to medical error

Question 10

Near miss

Answer 10

An error caught on time before it reached the patient

Needs to be reported to hospital administration, disclosure to the patient is not necessary

Question 11

Approach to a patient with TIA

Risk of stroke
Workup

Answer 11

Symptoms resolved, negative CT?
Risk of stroke is 5% in the <48% and 12% in the next 30 days

Hospitalize
MRI: to localize smaller lesions
Angiography: MRI or CT of the head and neck to evaluate cerebral vascular patency
Look for embolic source: EKG for rhythms, echocardiography, carotid doppler

Initiate appropriate treatment: eg. antiplatelet

Question 12

The false-positive and false-negative rate

Answer 12

False-positive rate:
1-sensibility
eg. a test with high sensitivity has high TP and low TN.

False-negative rate:
1-specificity
eg. a test with high sensitivity has high TN and low TP

Question 13

Extramuscular findings in dermatomyositis

Answer 13

Interstitial lung disease
Dysphagia
Myocarditis

Perform PFTs in patients with respiratory symptoms

Maybe a paraneoplastic syndrome. Screen for cancer

Question 14

Serologic markers for dermatomyositis

Answer 14

ANA (positive in 80%)

Anti Jo-1

Anti Mi2

Elevated CK, aldolase, LDH, ESR/CRP

Diagnostic uncertainty: skin or muscle biopsy, EMG/MRI

Question 15

Rash of dermatomyositis

Answer 15

Heliotrope rash: rash around the eyes

Gottron sing, papules: dorsa of the hands

Shawl sing: rash in the shoulder and upper chest

Question 16

Approach to dyspepsia

Answer 16

Epigastric pain ("burning)
\+/- nausea, vomiting, fullness, heartburn

> 60: Upper endoscopy
<60:
Test and treat for H. pylori
Upper endoscopy if alarm symptoms

Question 17

Neuroblastoma vs. Nephroblastoma

Answer 17

Both can present as a renal mass that causes hypertension

Neuroblastoma presents with flushing and diaphoresis and can cross the middle line. Opsoclonus/myoclonus

Question 18

Presentation of Neuroblastoma

Answer 18

Median age <2 (vs. nephroblastoma <5)
Abdominal mass
Periorbital ecchymosis
Spinal cord compression (invasion)
Onsuclonus/myoclonus

Hypertension (compression of the renal artery causes RAAS activation)
Flushing and sweating: catecholamine (manilvandellic and homovanilic)