Clinical Quiz

The combination of prolonged ischemic chest pain, inferior ST elevation and reciprocal changes is diagnostic of an acute inferior STEMI. Hypotension with clear lungs should raise concern for associated right ventricular infarction.

An irregularly irregular narrow-complex tachycardia with absent organized P waves is classic for atrial fibrillation. The ventricular rate is rapid and explains the symptomatic presentation.

The triad of exertional angina/syncope with a slow-rising pulse and a carotid-radiating ejection systolic murmur strongly indicates severe aortic stenosis.

An opening snap with an apical mid-diastolic rumble is characteristic of mitral stenosis. Atrial fibrillation is a common complication of left atrial enlargement.

Abrupt tearing pain, pulse/BP asymmetry, acute aortic regurgitation and mediastinal widening form a classic high-risk pattern for acute aortic dissection.

Positional pleuritic pain with diffuse concave ST elevation and PR depression favors acute pericarditis rather than territorial myocardial infarction.

A right-sided pansystolic murmur that intensifies with inspiration, giant JVP V waves and pulsatile hepatomegaly strongly support tricuspid regurgitation.

Marked hypertension, orthopnea, hypoxemia, frothy sputum and bilateral crepitations indicate acute cardiogenic pulmonary edema, commonly from abrupt left ventricular filling-pressure elevation.

A regular broad-complex tachycardia with AV dissociation and capture beats in a patient with prior infarction should be considered ventricular tachycardia until proven otherwise.

Independent atrial and ventricular activity with profound bradycardia is diagnostic of complete heart block and is clinically significant because of hemodynamic instability.

Persistent airflow obstruction on spirometry in a symptomatic smoker, together with hyperinflation and prolonged expiration, supports COPD.

Variable respiratory symptoms plus variable expiratory airflow limitation are the key diagnostic features of asthma.

An acute febrile lower-respiratory illness with focal bronchial breathing and lobar consolidation is classic for community-acquired pneumonia.

Basal Velcro-like crackles, clubbing, restrictive physiology and subpleural basal honeycombing strongly indicate fibrotic interstitial lung disease, especially a usual interstitial pneumonia pattern.

Acute unexplained hypoxemic dyspnea with DVT signs and intraluminal filling defects on CTPA establishes pulmonary embolism.

Chronic constitutional symptoms, upper-lobe cavitation and a positive molecular test for M. tuberculosis make pulmonary TB the diagnosis.

Stony dullness, reduced fremitus, absent breath sounds and sonographically visible pleural fluid are characteristic of pleural effusion.

Unilateral absent breath sounds, hyperresonance, contralateral tracheal deviation and obstructive shock after a procedure are diagnostic of tension pneumothorax.

The combination of upper-airway disease, pulmonary nodules/hemorrhage, glomerulonephritis and PR3-ANCA strongly supports granulomatosis with polyangiitis.

Bilateral hilar adenopathy, erythema nodosum and noncaseating granulomas are highly characteristic of sarcoidosis.

Acute cortical deficits with aphasia, gaze deviation and face-arm predominant weakness localize to the left MCA territory; early CT may show no infarct but excludes hemorrhage.

Thunderclap headache with meningism and basal cisternal blood on CT is classic for subarachnoid hemorrhage.

Fatigable ocular and bulbar weakness with preserved pupils is typical of myasthenia gravis.

Progressive ascending weakness with areflexia after infection and albuminocytologic dissociation is characteristic of Guillain–Barré syndrome.

Multifocal CNS demyelinating episodes separated in time and space, with typical periventricular MRI lesions, strongly support multiple sclerosis.

Bradykinesia plus resting tremor and rigidity, especially with asymmetric onset, is the classic syndrome of Parkinson disease.

Symmetric proximal myopathy combined with heliotrope rash, Gottron papules and raised CK is diagnostic of dermatomyositis.

Short, excruciating unilateral orbital attacks with cranial autonomic features and circadian clustering are typical of cluster headache.

Recurrent unilateral pulsatile headache with migrainous associated symptoms preceded by a transient positive visual aura is classic for migraine with aura.

Combined corticospinal and posterior-column dysfunction with low B12 strongly indicates subacute combined degeneration.

Hypovolemia with avid renal sodium retention and a bland sediment supports prerenal AKI rather than intrinsic renal injury.

Nephritic syndrome with RBC casts, low complement and a recent infection is typical of post-infectious glomerulonephritis.

Heavy proteinuria, hypoalbuminemia, edema and hyperlipidemia define nephrotic syndrome.

Gradually progressive albuminuric CKD in a patient with long-standing diabetes and retinopathy strongly supports diabetic kidney disease.

Failure to acidify urine in systemic acidosis, hypokalemia and nephrocalcinosis are characteristic of distal RTA.

Hypotonic euvolemic hyponatremia with inappropriately concentrated urine after excluding thyroid and adrenal causes is typical of SIADH.

Marked hyperkalemia accompanied by peaked T waves and QRS widening represents life-threatening hyperkalemia requiring immediate treatment.

Hypertension, hypokalemic metabolic alkalosis and suppressed renin with inappropriate aldosterone excess strongly support primary hyperaldosteronism.

Phosphate retention, reduced calcitriol and compensatory PTH elevation in CKD cause secondary hyperparathyroidism and renal bone disease.

Synpharyngitic hematuria with normal complement and mesangial IgA deposition is classic for IgA nephropathy.

Diffuse hypervascular goiter, orbitopathy and biochemical thyrotoxicosis are characteristic of Graves disease.

Classic hypothyroid symptoms with high TSH and low free T4 indicate primary thyroid failure.

The constellation of proximal myopathy, violaceous striae, bruising and metabolic complications with cortisol excess establishes Cushing syndrome.

Hyperpigmentation, salt loss, hyperkalemia and low cortisol with elevated ACTH indicate primary adrenal failure.

Paroxysmal adrenergic spells with elevated metanephrines and an adrenal lesion strongly indicate pheochromocytoma.

Symptomatic hyperglycemia with ketosis, low endogenous insulin secretion and autoimmune beta-cell markers supports type 1 diabetes.

Length-dependent sensory loss with neuropathic pain in longstanding diabetes is typical of distal symmetric diabetic polyneuropathy.

Hyperglycemia, ketonemia and high-anion-gap metabolic acidosis with Kussmaul respiration define DKA.

Extreme hyperglycemia and hyperosmolality with little ketosis or acidosis is characteristic of HHS.

Progressive acral/facial enlargement with elevated IGF-1 and failure of GH suppression after glucose confirms acromegaly.

Stigmata of chronic liver disease, ascites, splenomegaly and a nodular liver indicate decompensated cirrhosis with portal hypertension.

Typical pancreatic pain plus lipase >3× upper limit establishes acute pancreatitis; gallstones identify the likely cause.

Continuous rectum-based mucosal inflammation with bloody diarrhea and urgency is characteristic of ulcerative colitis.

Malabsorption, dermatitis herpetiformis, positive tTG-IgA and villous atrophy are classic for celiac disease.

Upper GI bleeding in portal hypertension with actively bleeding varices establishes variceal hemorrhage.

Painless obstructive jaundice with a palpable gallbladder and pancreatic head mass is highly suggestive of pancreatic head carcinoma causing distal obstruction.

Skip lesions, transmural inflammation and fistulizing perianal disease are classic for Crohn disease.

Progressive mechanical dysphagia with weight loss and biopsy-proven distal esophageal adenocarcinoma establishes the diagnosis.

Meal-relieved nocturnal epigastric pain with a duodenal ulcer and confirmed H. pylori infection supports H. pylori-associated PUD.

Cholestatic biochemistry, antimitochondrial antibodies and absence of mechanical obstruction in a middle-aged woman strongly indicate primary biliary cholangitis.

Microcytic anemia with low ferritin, high TIBC, pica and chronic menstrual blood loss is diagnostic of iron deficiency anemia.

Marked microcytosis with target cells and elevated HbA2 is characteristic of beta-thalassemia trait.

Isolated severe thrombocytopenia with mucocutaneous bleeding, large platelets and no splenomegaly is typical of ITP after secondary causes are excluded.

Marked granulocytic leukocytosis with basophilia and BCR-ABL1 is diagnostic of CML.

The combination of clonal protein, anemia, renal dysfunction, hypercalcemia and lytic bone disease is classic for multiple myeloma.

Oxidant-triggered hemolysis with bite cells, Heinz bodies and low G6PD activity is diagnostic of G6PD deficiency.

Macrocytosis with neurologic symptoms, low B12 and anti-intrinsic factor antibodies indicates pernicious anemia.

Recurrent vaso-occlusive pain, hemolysis, functional asplenia and predominant HbS establish sickle cell disease.

Thrombocytopenia plus microangiopathic hemolytic anemia with neurologic involvement and relatively preserved coagulation tests strongly suggests TTP.

Consumptive coagulopathy with thrombocytopenia, prolonged clotting times, low fibrinogen and high fibrin degradation products is diagnostic of DIC in the appropriate setting.

Persistent symmetric inflammatory small-joint polyarthritis with anti-CCP positivity and erosions is typical of rheumatoid arthritis.

Multisystem autoimmune features plus anti-dsDNA, hypocomplementemia and nephritic urine strongly support SLE with renal involvement.

Young-onset inflammatory back pain with sacroiliitis and reduced spinal mobility is characteristic of axial spondyloarthritis.

Objective sicca features with anti-Ro antibodies and parotid enlargement strongly suggest Sjögren syndrome.

Acute podagra with negatively birefringent needle-shaped monosodium urate crystals confirms gout.

Bilateral shoulder/hip girdle pain and stiffness with elevated inflammatory markers and preserved strength in an older adult is typical of polymyalgia rheumatica.

New headache, jaw claudication and visual symptoms with a markedly elevated ESR in an older adult is a high-probability presentation of giant cell arteritis.

Raynaud phenomenon, sclerodactyly, nailfold changes and anticentromere antibodies are typical of limited cutaneous systemic sclerosis.

Recurrent oral/genital ulceration with uveitis, vascular involvement and pathergy strongly supports Behçet disease.

Thrombosis and pregnancy morbidity with persistent antiphospholipid antibodies is diagnostic of antiphospholipid syndrome.

A febrile illness with hemolysis/thrombocytopenia and parasitologic evidence of P. falciparum establishes falciparum malaria.

Typical dengue symptoms with thrombocytopenia and a rising hematocrit indicate hemoconcentration from plasma leakage and warrant close monitoring for severe dengue.

The CSF pattern is bacterial meningitis; gram-positive diplococci strongly suggest Streptococcus pneumoniae.

Encephalopathy with seizures, thalamic MRI lesions and JE IgM positivity in an endemic setting strongly supports Japanese encephalitis.

Prolonged systemic febrile illness with splenomegaly, leukopenia and S. Typhi bacteremia establishes enteric fever.

Conjunctival suffusion, jaundice, renal injury and compatible exposure are classic for severe leptospirosis.

Diabetes, soil exposure, multifocal abscesses and B. pseudomallei culture identify disseminated melioidosis.

Matted nodes, sinus formation and caseating AFB-positive granulomas are characteristic of tuberculous lymphadenitis.

Acute febrile illness with eschar, lymphadenopathy, thrombocytopenia and transaminitis in an endemic exposure setting is highly suggestive of scrub typhus.

A febrile exanthem involving palms/soles after tick exposure with thrombocytopenia and confirmatory testing supports spotted fever rickettsiosis.

Persistent vasopressor-dependent hypotension with elevated lactate after adequate fluid resuscitation is consistent with septic shock.

Acute bilateral noncardiogenic pulmonary edema with a P/F ratio of 101–200 on adequate PEEP meets criteria for moderate ARDS.

Acidemic hypercapnia with increased work of breathing in COPD indicates acute hypercapnic respiratory failure; if no contraindication exists, NIV is typically the initial ventilatory strategy.

A silent chest, very low PEF and a rising/normalizing PaCO₂ in a severely distressed asthmatic are ominous features of impending ventilatory failure.

Shock with acute right-ventricular pressure overload and DVT in the absence of pulmonary edema strongly suggests high-risk PE causing obstructive shock.

Acute MI with tissue hypoperfusion, low cardiac output and elevated filling pressures represents cardiogenic shock.

Major blood loss with hypotension, tachycardia and tissue hypoperfusion in the absence of another shock mechanism indicates hemorrhagic shock.

Recent dopamine-antagonist exposure with hyperthermia, severe rigidity, autonomic instability and CK elevation is classic for neuroleptic malignant syndrome.

Serotonergic drug exposure plus clonus, hyperreflexia, autonomic activation and gastrointestinal symptoms strongly indicates serotonin syndrome.

Descending cranial and bulbar paralysis with preserved consciousness after a snake bite is typical of neurotoxic envenomation.