Podcast Ep 50: Acute Mitral Regurgitation & More

A hero is someone who has given his or her life to something bigger than oneself.

–Joseph Campbell

Welcome back to RoshCast for Episode 50! Wow!! We can’t believe we’re already at Episode 50. It’s been a real journey building this podcast from the original concept two years ago. And in the last year, we have seen some pretty big changes, including Megha joining the team. We are excited to see how RoshCast continues to evolve over the next fifty episodes and two years.

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None of this would be possible without you, our listeners. Your listenership and feedback is what drives us to keep delivering high-quality content! We value every moment you give your attention to us, and we try our best to design the episode to maximize your learning. We have a pretty involved process for choosing questions to present to you and for how we manipulate and deliver the content before we get it to your ears.

With that, let’s kick off a great episode!

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Question 1

A 70-year-old woman with history of coronary artery disease, hypertension, and diabetes presents to the emergency department with chest pressure and shortness of breath. Her exam is notable for a new holosystolic murmur best heard over the midaxillary line as well as diffuse bilateral rales. Which of the following is most likely to be seen on this patient’s ECG?

A. Biventricular tachycardia

B. S1Q3T3 pattern

C. ST-depressions in I, V6, and aVL without ST-elevations

D. ST elevations in II, III, aVF

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Question 2

A 26-year-old woman with no medical history presents with bleeding gums after brushing her teeth for the last three days. Her complaint was preceded two weeks ago by a URI. Her examination is unremarkable except for oozing from the gums. Labs show a platelet count of 23,000. Which of the following is the most appropriate next step in management?

A. IV immunoglobulin

B. Platelet transfusion

C. Steroids, IV immunoglobulin

D. Steroids, IV immunoglobulin, and platelet transfusion

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Question 3

Which of the following is most suggestive of measles infection?

A. A prodrome of fever, lymphadenopathy, and conjunctivitis followed by a maculopapular rash that starts on the face and spreads to the trunk and limbs

B. Diffuse maculopapular rash with white spots on the buccal mucosa

C. High fever for three days followed by the appearance of a pink maculopapular rash after defervescence

D. Presence of shallow ulcers on oral mucosa and vesicular lesions on the palms and soles

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Question 4

A 23-year-old man who has unprotected, receptive anal intercourse presents to the ED with two weeks of worsening rectal pain and dyschezia. On exam, he has numerous ulcers in the anorectal area and a crop of grouped vesicles containing clear fluid on an erythematous base. The surrounding skin shows no sign of cellulitis or abscess. Which of the following is the most appropriate next step?

A. Refer the patient to a surgeon for operative intervention

B. Send a serology test

C. Send a Tzanck smear

D. Treat with acyclovir

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Question 5

A 5-year-old boy with von Willebrand disease presents with persistent bleeding after he lost a tooth 4 hours ago. Vital signs are unremarkable. Physical exam reveals oozing at the site of the tooth which persists despite pressure. Which of the following is the most appropriate treatment?

A. Desmopressin

B. Factor VIII concentrate

C. Fresh frozen plasma

D. Vitamin K

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Question 6

A 70-year-old man with a history of chronic neck pain presents after a fall. On physical examination, he has a laceration on his chin. Motor strength is 2/5 in his upper extremities and 4/5 in his lower extremities. He has decreased sensation to soft touch in both legs. Which of the following is the most likely diagnosis?

A. Anterior cord syndrome

B. Brown-Sequard syndrome

C. Cauda equina syndrome

D. Central cord syndrome

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• A new holosystolic murmur over the midaxillary line, with signs of heart failure, is consistent with acute mitral valve regurgitation. Think of inferior stemi as a possible cause here.
• Immune thrombocytopenia presents with bleeding that is often preceded by a viral illness. It is treated with steroids and IVIG in most cases. For those with severe or life-threatening bleeding, platelet transfusion should be considered as well.
• Measles presents with a prodrome of fever and three Cs (coryza, cough, and conjunctivitis) followed by a diffuse maculopapular rash and Koplik spots.
• A painful vesicular rash on an erythematous base in the anorectal area is consistent with herpes simplex proctitis. Diagnosis is clinical. Treat with antivirals.
• von Willebrand disease presents with mucosal bleeding, and the first-line treatment is desmopressin.
• Central cord syndrome is often the result of a hyperextension injury to the cervical spine. It presents with bilateral motor dysfunction that is greater in the upper extremities than the lower extremities.

That wraps up RoshCast Episode 50! Be sure to also check out the rest of the Rosh Review Blog for questions from prior episodes, related images and tables, and bonus teaching points. There are also tons of other great free resources to help prepare you for the boards and the wards. Don’t forget to follow us on twitter @RoshCast. And you can always email us at RoshCast@RoshReview.com with any feedback, corrections, or suggestions. 

You can also help us pick questions by identifying ones you would like us to review. Write “RoshCast” in the submit feedback box as you go through the question bank. Lastly, if you have a minute, make sure to rate us and leave comments on iTunes to help spread the word about RoshCast.

Megha and Nachi