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{{WBRQuestion
{{WBRQuestion
|QuestionAuthor={{Rim}}
|QuestionAuthor=Mahmoud Sakr M.D.
|ExamType=USMLE Step 1
|ExamType=USMLE Step 2 CK
|MainCategory=Pathology
|MainCategory=Internal medicine
|SubCategory=Renal
|SubCategory=Cardiovascular
|MainCategory=Pathology
|MainCategory=Internal medicine
|SubCategory=Renal
|SubCategory=Cardiovascular
|MainCategory=Pathology
|MainCategory=Internal medicine
|SubCategory=Renal
|SubCategory=Cardiovascular
|MainCategory=Pathology
|MainCategory=Internal medicine
|MainCategory=Pathology
|MainCategory=Internal medicine
|SubCategory=Renal
|SubCategory=Cardiovascular
|MainCategory=Pathology
|MainCategory=Internal medicine
|SubCategory=Renal
|SubCategory=Cardiovascular
|MainCategory=Pathology
|MainCategory=Internal medicine
|SubCategory=Renal
|SubCategory=Cardiovascular
|MainCategory=Pathology
|MainCategory=Internal medicine
|SubCategory=Renal
|SubCategory=Cardiovascular
|MainCategory=Pathology
|MainCategory=Internal medicine
|MainCategory=Pathology
|MainCategory=Internal medicine
|SubCategory=Renal
|SubCategory=Cardiovascular
|Prompt=A 23 year old Caucasian female patient presents to the emergency department with a one day history of confusion and altered level of consciousness. Appropriate history could not be taken due to the patient’s condition. Patient’s vital signs are immediately taken. Her temperature is 39.5 degrees C (103.1 degrees F). Her heart rate is 102 beats per minute and her blood pressure is 90/50 mmHg. On physical examination, the patient has a petechial rash and nuchal rigidity. Blood cultures are taken and appropriate antibiotic therapy is immediately initiated. Blood cultures reveal group B Neisseria meningitidis. Patient’s condition gradually improves. Despite fluid resuscitation, the patient remains anuric. Abdominal computed tomography (CT) scan will reveal which of the following findings in this patient?
|Prompt=47 y/o African American male patient comes to the emergency department with severe chest pain radiating to his left jaw for 45 minutes. He describes his pain as constant, and dull in nature. It is accompanied by diaphoresis and nausea. He admits to smoking 2 packs of cigarettes per day. His Blood pressure is 145/92, Pulse is 103, RR 18, and temperature is 96.7. He received oxygen, aspirin and IV morphine upon arrival. His EKG only shows ST segment depression in leads 2,3,AVF.  His cardiac markers are normal. What is the most appropriate next step in management.
|Explanation=Bilateral renal cortical necrosis is a rare phenomenon characterized by bilateral renal infarcts. It is a complication of vascular insult to the arteries that supply the renal cortex. Sepsis and disseminated intravascular coagulation (DIC) are typical inciting events. Pregnancy-related complications are frequently implicated in renal cortical necrosis as well. Other causes include drugs and trauma.  
|Explanation=This patient is likely having a non-STEMI given the presentation and EKG changes. He would benefit from the medical therapy mentioned and also from anticoagulation. Therefore, a dose of SC low molecular weight heparin would be the most important next step in management. Cardiac markers should be obtained, if they are positive, then a definite diagnosis of MI will be made and consultation with a cardiologist is warranted for further intervention.  
|AnswerA=IV benzodiazepines


Contrast-enhanced computed tomography (CT) is the imaging of choice to diagnose renal cortical necrosis.  CT scan reveals acutely hypo-dense areas in the renal cortex bilaterally. Renal replacement therapy is an effective therapy for many patients who suffer from renal cortical necrosis, but partial recovery is also possible.


Educational Objective: Bilateral renal cortical necrosis is a rare complication of pregnancy-related medical conditions and sepsis. Contrast-enhanced CT scan is the imaging reveals bilateral renal infarcts that confirms the diagnosis.
|AnswerAExp=IV benzodiazepines are reasonable in a case of cocaine induced MI or significant anxiety. No such history of here.
|AnswerB=IV alteplase


Reference: Chervu I, Koss M, Campese VM. Bilateral renal cortical necrosis in two patients with Neisseria meningitidis sepsis. Am J Nephrol. 1991;11(5):411-5
|AnswerBExp=PCI have been proven superior to IV thrombolytics and are now rarely used unless PCI is not available or arrival to a PCI lab would not be timely. Therefore it would not be the next step in management here.
|AnswerC=SC low molecular weight heparin


|AnswerA=Bilateral renal infarcts
|AnswerCExp=Correct!
|AnswerAExp=Bilateral renal cortical necrosis is characterized by renal infarcts. In is a rare complication of DIC, pregnancy, and sepsis, trauma, and drugs.
This patient is likely having a non-STEMI given the presentation and EKG changes. He would benefit from the medical therapy mentioned and also from anticoagulation. Therefore, a dose of SC low molecular weight heparin would be the most important next step in management.  
|AnswerB=Adrenal hemorrhage
|AnswerD=Cardiac catheterization
|AnswerBExp=Adrenal hemorrhage followed by adrenal gland failure is characteristic of “Waterhouse-Friderichsen” syndrome. Although the syndrome is also commonly due to N. meningitidis, symptoms of adrenal insufficiency would be prevalent, such as abdominal pain, hypotension, hyponatremia, and hyperkalemia. The patient’s general status improvement without additional intervention and urinary findings favor bilateral renal cortical necrosis in this case.
 
|AnswerC=Shrunken kidney size bilaterally
|AnswerDExp=If the patient was having a STEMI, then this answer would be correct, however no signs of ST elevation mentioned, therefore anticoagulation and further cardiac workup is reasonable here.
|AnswerCExp=Shrunken kidney size bilaterally is a characteristic finding of chronic kidney disease (CKD). Given the patient’s acute history, shrunken kidneys are unlikely to be present on CT scan.
|AnswerE=Cardiology consultation
|AnswerD=Tubular eosinophilic casts that look like thyroid tissue
|AnswerEExp=Cardiology consultation may eventually be needed, however it is not the next step in management.
|AnswerDExp=Thyroidization of the kidney is a finding on renal biopsy that is commonly found in several chronic renal diseases. The process is characterized by renal tissue that resembles that of thyroid on renal biopsy under light microscopy.
|RightAnswer=C
|AnswerE=Dilation of renal pelvis and calyces
|Approved=Yes
|AnswerEExp=Hydronephrosis is characterized by the dilation of renal pelvis and calyces. The patient’s presentation is not compatible with hydronephrosis
|RightAnswer=A
|Approved=No
}}
}}

Latest revision as of 00:20, 28 October 2020
Author PageAuthor::Mahmoud Sakr M.D.
Exam Type ExamType::USMLE Step 2 CK
Main Category MainCategory::Internal medicine
Sub Category SubCategory::Cardiovascular
Prompt [[Prompt::47 y/o African American male patient comes to the emergency department with severe chest pain radiating to his left jaw for 45 minutes. He describes his pain as constant, and dull in nature. It is accompanied by diaphoresis and nausea. He admits to smoking 2 packs of cigarettes per day. His Blood pressure is 145/92, Pulse is 103, RR 18, and temperature is 96.7. He received oxygen, aspirin and IV morphine upon arrival. His EKG only shows ST segment depression in leads 2,3,AVF. His cardiac markers are normal. What is the most appropriate next step in management.]]
Answer A AnswerA::IV benzodiazepines
Answer A Explanation AnswerAExp::IV benzodiazepines are reasonable in a case of cocaine induced MI or significant anxiety. No such history of here.
Answer B AnswerB::IV alteplase
Answer B Explanation AnswerBExp::PCI have been proven superior to IV thrombolytics and are now rarely used unless PCI is not available or arrival to a PCI lab would not be timely. Therefore it would not be the next step in management here.
Answer C AnswerC::SC low molecular weight heparin
Answer C Explanation [[AnswerCExp::Correct!

This patient is likely having a non-STEMI given the presentation and EKG changes. He would benefit from the medical therapy mentioned and also from anticoagulation. Therefore, a dose of SC low molecular weight heparin would be the most important next step in management.]]

Answer D AnswerD::Cardiac catheterization
Answer D Explanation AnswerDExp::If the patient was having a STEMI, then this answer would be correct, however no signs of ST elevation mentioned, therefore anticoagulation and further cardiac workup is reasonable here.
Answer E AnswerE::Cardiology consultation
Answer E Explanation AnswerEExp::Cardiology consultation may eventually be needed, however it is not the next step in management.
Right Answer RightAnswer::C
Explanation [[Explanation::This patient is likely having a non-STEMI given the presentation and EKG changes. He would benefit from the medical therapy mentioned and also from anticoagulation. Therefore, a dose of SC low molecular weight heparin would be the most important next step in management. Cardiac markers should be obtained, if they are positive, then a definite diagnosis of MI will be made and consultation with a cardiologist is warranted for further intervention.

Educational Objective:
References: ]]

Approved Approved::Yes
Keyword
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