【Nejm】Painful Blue Toes

Front 1

ECG finding of acute pericarditis？

Back 1

Diffuse ST elevation and PR segment depression initially. With T wave depression later

Front 2

Brugada syndrome？

Back 2

Sudden cardiac death in Asian young man with RBBB and ST elevation in V1-V3

Front 3

ECG finding of cocaine use？

Back 3

ST elevation with early repolarization. Use of cocaine may lead to coronary thrombosis, vasospasm, arrhythmia, aortic dissection and accelerated atherosclerosis

Front 4

ECG finding of major pulmonary embolism？

Back 4

sinus tachycardia, RBBB, S wave in lead I, Q wave in lead III, or T wave inversion in lead III

Front 5

Skin changes of amyloidosis？

Back 5

Purpura & ecchymoses. Factor X binding by amyloid fibrils may be partly responsible

Front 6

Common finding of antiphosholipid syndrome？

Back 6

Stroke, recurrent pregnancy loss, livedo recitularis, purpura, thrombocytopenia, pulmonary embolism

Front 7

Common finding of cryoglobulinemia?

Back 7

Palpable purpura, Raynaud phenomenon, digital ischemia. Type I is associated with hyperviscosity and thrombosis

Front 8

Common finding of hereditary hemorrhagic telangiectasia?

Back 8

Mucosal and pulmonary AV malformation lead to epistaxis and GI bleeding, paradoxical embolism with stroke and brain abscess

Front 9

Common finding of thrombotic thrombocytopenic purpura?

Back 9

Anemia, hemolysis, thrombocytopenia, confusion, fever, renal involvement, myocardial infarction

Front 10

What is the common cause of multifocal vascular lesion?

Back 10

Vasculitis, e.g. cryoglobulinemia. SLE. Hypercoagulable state, e.g. antiphosholipid syndrome. Endocarditis and cholesterol emboli

Front 11

How to manage suspected subacute endocarditis?

Back 11

Culture three blood samples, drawn 1hr apart at separate sites. Start empirical board spectrum antibiotics once all blood sample have been obtained

Front 12

What should be tested for culture-negative endocarditis?

Back 12

Coxiella, Bartonella, Legionella, Clamydia species. HACEK bacteria (Haemophilus aphrophilus; Actinobacillus, cardiobacterium, Eikenella, Kingella)

Front 13

Causes of painful purple toes?

Back 13

Peripheral arterial disease; Cellulitis; Cryoglobulinemia Phlegmasia cerulae dolens

Front 14

Classification of cryoglobulinemia?

Back 14

Type I: monoclonal IgG or IgM, occurs in the presence of multiple myeloma or Waldenstrom's macroglobulinemia Type II: polyclonal IgG bound to monoclonal IgM. Associated with hepatitis C Type III: polyclonal IgG bound to polyclonal IgM. occurs in SLE, Sjogren's syndrome and other autoimmune diseases

Front 15

What is cryoglobulinemia?

Back 15

Condition caused by immunoglobulins precipitate out of serum at the temperature below 37C

Front 16

What is the common association of cryoglobulinemia?

Back 16

MembranoProliferative GlomeruloNephritis; fever; arthralgias, neuropathy;

Front 17

What is the manifestation of Phlegmasia cerulea dolens

Back 17

Severe leg pain, edema, bluish discoloration of the toes

Front 18

What is the cause of phlegmasia cerulea dolens?

Back 18

Cancer, heparin-induced thrombocytopenia, pregnancy, antiphospholipid syndrome

Front 19

Management of phlegmasia cerulea dolens?

Back 19

anticoagulation, aggressive management with thrombolysis or thrombectomy

Front 20

Risk factor: prosthetic heart valve. Casual organism for culture negative endocarditis?

Back 20

Aspergillus species

Front 21

Management in preventing recurrent thromboembolism in patient with active cancer and thrombosis?

Back 21

Low-Molecular-Weight-Heparin. LMWH is superior than warfarin in preventing thrombosis (CLOT trial) Malnutrition, drug interactions, and vomiting from chemotherapy may make dosing warfarin more problematic.

Front 22

What is the cause of hypercoagulability of cancer patient?

Back 22

1. Tissue factor driven thrombosis 2. Mucin-producing tumors 3. Chemotherapy 4. Immobility 5. Deep venous compression by tumor or lymph nodes

Front 23

Risk factor: exposure to kitten. Casual organism for culture negative endocarditis?

Back 23

Bartonella henselae

Front 24

Risk factor: homeless and body lice. Casual organism for culture negative endocarditis?

Back 24

Bartonella quintana (urban trench fever)

Front 25

Risk factor: consumption of unpasteurized dairy product. Casual organism for culture negative endocarditis?

Back 25

Brucella melintensis

Front 26

Risk factor: exposure to birthing animals Casual organism for culture negative endocarditis?

Back 26

Coxiella burnetii (Q fever)

Front 27

Risk factor: poor dentition. Casual organism for culture negative endocarditis?

Back 27

HACEK bacteria

Front 28

What is the alternative anticoagulation in heparin-induced thrombocytopenia patient?

Back 28

Argatroban. Direct thrombin inhibitor

Front 29

What is the diagnosis

Back 29

Cryoglobulinemia

Front 30

What is the diagnosis?

Back 30

Phlegmasia cerulea dolens

Front 31

What is the diagnosis?

Back 31

Peripheral arterial disease
Become red when hanging down, and resolve when elevated.
Because low arterial flow and chronic venous dilation

Front 32

What is the diagnosis?

Back 32

Cellulitis
Caused by group A streptococcus or Staphylococcus aureus

Front 33

What are the risk factors for cellulitis?

Back 33

Trauma and wound (including interdigital tinea pedis), diabetes mellitus, IV drug use, lymphedema, saphenous vein harvesting