Q: Which clinical sign can be graded according to the severity of hypocalcemia? (Select one)

A) Chvostek sign
B) Trousseau sign


Answer: A

Chvostek sign can be demonstrated by briskly tapping the facial nerve at about 2 cm anterior to the external auditory meatus. Depending on the level of hypocalcemia, a response can be graded from mild to severe. Twitching occurs first at the angle of the mouth, then by the nose, the eye, and then the facial muscles. Chvostek sign has high sensitivity but less specificity for hypocalcemia. It can occur without calcium deficiency. 

In contrast, Trousseau sign is less sensitive but highly specific for hypocalcemia. It can be demonstrated by inflating the blood pressure cuff to 20 mm Hg above systolic blood pressure for 3-4 minutes. In hypocalcemia, it will cause a flexion of the wrist and metacarpal phalangeal joints with the extension of the interphalangeal joints and adduction of the thumb, known as carpal spasm. 

Q: What is 'absorptive atelectasis'?

Answer: Absorptive atelectasis is one of the "not very much desired" consequence of high FiO2. Higher oxygen level in lung causes "washout of alveolar nitrogen" which results in alveolar atelectasis. This is probably due to the fact that oxygen diffuses from alveoli to capillaries at faster rate than it gets replenish by inhaled oxygen. Also, particularly in ARDS patients, surfactant abnormalities helps to superimpose the issue. Treatment is applying recruitment maneuver and application of optimum PEEP, followed by FiO2 to keep PaO2 around 65 mm Hg.

Clinical implication: Do not dial more than required FiO2


Reference: 

Santos C, Ferrer M, Roca J, et al. Pulmonary gas exchange response to oxygen breathing in acute lung injury. Am J Respir Crit Care Med 2000; 161:26.

Q; 48 year old male is recovering in your ICU from acute pancreatitis. He asked you his risk of developing any long-term disease from his episode of acute pancreatitis. He is at high risk of developing following long-term disease (select best)

A) End Stage Renal Disease
B) Diabetes 
C) Pancreatic cancer
D) Splenic Vein thrombosis
E) Hepatocellular Carcinoma


Answer: B 

Patient's risk of becoming prediabetic or diabetic just even after first/one episode of acute pancreatitis in one year is around fifteen percent, and instead of decreasing it may increase further in next five years.


Reference: 

Das S, Singh PP, Phillips A, et al. Newly diagnosed diabetes mellitus after acute pancreatitis: A systematic review and meta-analysis. Gut 2014; 63.

Q: How long does it take for hepatic encephalopathy to manifest after Transjugular intrahepatic portosystemic shunt (TIPS)?


Answer: Contrary to popular belief, it takes about two to three weeks for hepatic encephelopathy to fully sits in after TIPS procedure in cirrhotic patients.1 Unfortunately, no prophylaxis (lactulose, rifaximin etc.) prevents it.2 Once encephalopathy sits in after TIPS, all offending causes should be eliminated along with standard of care treatment for hepatic encephalopathy.


Reference:

1. Riggio O, Merlli M, Pedretti G, et al. Hepatic encephalopathy after transjugular intrahepatic portosystemic shunt. Incidence and risk factors. Dig Dis Sci 1996; 41:578.

2. Riggio O, Masini A, Efrati C, et al. Pharmacological prophylaxis of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt: a randomized controlled study. J Hepatol 2005; 42:674.

Q: Folic acid is recommended as an adjuvant therapy in Ethylene Glycol or Methanol poisoning if a patient receives Famipzol as a treatment. What is the dose?


Answer: 

In the situation like above,  the dose of  folic acid is 50 mg IV every six hours till clinical and laboratory parameters normalize. Folinic acid can be used in place of folic acid with similar dosing. The objective of above question is to point the way higher dose of folic acid in toxic alcohol poisonings treatment, than in other clinical situations. 

The evidence is weak but it is a common practice to add thiamine and pyridoxine along with folic acid.


Reference: 

 Barceloux DG, Bond GR, Krenzelok EP, et al. American Academy of Clinical Toxicology practice guidelines on the treatment of methanol poisoning. J Toxicol Clin Toxicol 2002; 40:415.

Q: Which one technique during whole lung lavage for pulmonary alveolar proteinosis increases the chance of recovery of the lipoproteinaceous material?


Answer: Chest percussion

After the desired amount of saline (usually 1 to 1.5 Litre) is flowed in, chest percussion for about  5 minutes, increases the recovery of the lipoproteinaceous material. Usually, it takes about 10 to 15 lavages for each lung.


Reference:

Hammon WE, McCaffree DR, Cucchiara AJ. A comparison of manual to mechanical chest percussion for clearance of alveolar material in patients with pulmonary alveolar proteinosis (phospholipidosis). Chest 1993; 103:1409.

Q: 28 year old male student from Brazil, who visited his family during the months of summer is brought to ER with seizures. CT Head showed multiple cysts consistent with Neurocysticercosis (NCC). The patient was promptly treated with antiepileptics in ER and transferred to ICU. Following of which is recommended prior to the start of treatment for Neurocysticercosis (NCC)?

A) Test for latent Tuberculosis (TB)
B) screen for strongyloidiasis
C) Backup of Neurosurgical service
D) Ophthalmologic exam
E) All of the above



Answer: E

Treatment of NCC is multifacet and carries multiple challenges. Patients from the endemic area for NCC  also have high risks for latent TB and strongyloidiasis. As treatment of NCC also requires treatment with steroid along with antiparasitics, it is recommended to check for latent TB. Also, treatment of NCC may cause dissemination of strongyloidiasis, which may require treatment prior to NCC. Multiple cysts in the brain carry the risk of hydrocephalus with the treatment of NCC and may require ventriculostomy.  Similarly, initiation of the treatment of NCC may cause chorioretinitis, retinal detachment, or vasculitis, due to massive inflammation from the breakdown of cellular walls of parasites. Proper ocular exam is required as surgical intervention may be needed to remove ocular cysts, prior to antiparasitic treatment.

Q; 52 year old male is admitted to ICU with lower GI bleed and have 2 episodes in last 24 hours. GI service wants to do "hydroflush colonoscopy". What is hydroflush colonoscopy?


Answer: Still experimental but in cases where bowel preparation may become a challenge and diagnosis is desired, hydroflush colonoscopy may be an option. Without requiring any bowel preparation, it uses tap-water enema aided by water-jet pumps and mechanical suction devices.



Reference:

Repaka A, Atkinson MR, Faulx AL, et al. Immediate unprepared hydroflush colonoscopy for severe lower GI bleeding: a feasibility study. Gastrointest Endosc 2012; 76:367.

Q; 24 years old female with 31 weeks pregnancy came to ER with mental status change and diligently diagnosed with acquired thrombotic thrombocytopenic purpura (TTP). Your next line of treatment? 

A) Plasma exchange therapy (PEX)
B) Delivery of baby
C) IVIG infusion
D) Continue observation
E) Platelet transfusion


Answer:  A

Objective of above question is to signify the point that delivery of fetus/baby does not resolve TTP and if not treated mortality is almost 90%, so weighing risk vs benefit PEX should be initiated. Delivery should be considered only if there is concern for preeclampsia or HELLP syndrome. 

IVIG may cause increase viscosity issues and platelet transfusion is not recommended in TTP. 


References:

1. Scully M, Thomas M, Underwood M, et al. Thrombotic thrombocytopenic purpura and pregnancy: presentation, management, and subsequent pregnancy outcomes. Blood 2014; 124:211.

2. Ezra Y, Rose M, Eldor A. Therapy and prevention of thrombotic thrombocytopenic purpura during pregnancy: a clinical study of 16 pregnancies. Am J Hematol 1996; 51:1.

Q: 28 year old diabetic female is transferred from OB/Gyn floor with mental status change. 48 hours before, patient had a prolonged labor complicated with bouts of hypotension. On arrival to ICU patient is found to be with blood glucose of 55 mg/dL and sodium of 118 mEq/L. Potassium level was in normal range. Your likely diagnosis?

A) Inadequate nutrition
B) Massive IVF resuscitation
C) post labor diuresis
D) Sheehan's syndrome
E) Overdose of insulin


Answer: D

Pregnancy causes physiological enlargement of pituitary gland and is therefore very sensitive to any kind of hypovolemic shock. Various explanations have been provided of sheehan syndrome presenting as hyponatremia including decrease free-water clearance due to hypothyroidism or from glucocorticoid deficiency or  vasopressin secretion due to hypopituitarism  resulting in inappropriate secretion of antidiuretic hormone. Also, lack of cortisol may cause hypoglycemia. To note, potassium level stays normal as adrenal production of aldosterone is independent of the pituitary gland.


References:

1.Boulanger E, Pagniez D, Roueff S, et al. Sheehan syndrome presenting as early post-partum hyponatremia. Nephrol Dial Transplant 1999;14:2714-5. 

2. Putterman C, Almog Y, Caraco Y, Gross DJ, Ben-Chetrit E. Inappropriate secretion of antidiuretic hormone in Sheehan's syndrome: a rare cause of postpartum hyponatremia. Am J Obstet Gynecol 1991;165(5 Pt 1):1330-3.

3. Bunch TJ, Dunn WF, Basu A, Gosman RI (October 2002). "Hyponatremia and hypoglycemia in acute Sheehan's syndrome". Gynecol. Endocrinol. 16 (5): 419–23

Q; What is the "6 days rule" for enteral nutrition in very sick critically ill patients?

Answer:  In very sick critically ill patients, enteral nutrition can be started pre or post pyloric with "mucotrophic dose" at a rate of 10 to 30 mL/hour, and to leave it there for about six days and if situation allows start advancing towards the goal rate. This approach gives benefits like decrease residual volumes, less need of  prokinetic agents and better plasma glucose control beside protecting gastrointestinal mucosa. This approach is taken from famous EDEN trial which though failed to show any major difference in overall outcomes between full enteral feed versus nucotrophic feeding for six days (after which both groups were at full enteral feeding), but showed some minor benefits as said above.


References:

1. National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network, Rice TW, Wheeler AP, et al. Initial trophic vs full enteral feeding in patients with acute lung injury: the EDEN randomized trial. JAMA 2012; 307:795. 

2. Needham DM, Dinglas VD, Morris PE, et al. Physical and cognitive performance of patients with acute lung injury 1 year after initial trophic versus full enteral feeding. EDEN trial follow-up. Am J Respir Crit Care Med 2013; 188:567.

Q: Mineralocorticoid administration is mandatory in 'Adrenal crisis' along with Hydrocortisone/Dexamethasone? (Select one)

A) Yes
B) No


Answer: B

In Adrenal Crisis, after ABC (airway, breathing, and circulation), need is to take care of hypovolemia, hypoglycemia and electrolyte imbalance. Hydrocortisone/Dexamethasone is mandatory but fludrocortisone (mineralocorticoid) though desirable is not mandatory. But, it should be added after the crisis is over.

Q: 64 year old male with CHF presented to ER with c/o dizziness. Patient on w/u found to have digoxin toxicity. After due consideration, cardiology service opted not to administer digoxin-specific antibody (Fab) and is admitted to ICU for observation with arrangments of temporary pacemaker at bedside, if needed. While reviewing labs drawn in ER, you found Potassium level of 6.2 mEq/L. Patient since arrival in ER and ICU remained in normal sinus rhythm. Your next step?

A) Give calcium
B) Give dextrose and insulin
C) Try to convince cardiology service to administer digoxin-specific antibody (Fab) 
D) Continue observation
E) Start hemo-dialysis



Answer:  D

Evidence is old but still clinically very relevant. Although hyperkalemia in acute "Dig. Toxicity" corresponds with the risk of death, hyperkalemia itself does not cause death. Once digoxin toxicity resolved/treated, potassium gets back into cells. Actually aggressive treatment of hyperkalemia in dig. toxicity should be avoided as later it may incur life-threatening hypokalemia. In short, hyopkalemia in digoxin toxicity should be treated but extreme caution should be taken in treating hyperkalemia.


Reference:

Bismuth C, Gaultier M, Conso F, Efthymiou ML. Hyperkalemia in acute digitalis poisoning: prognostic significance and therapeutic implications. Clin Toxicol 1973; 6:153.

Q: Osler's nodes can be a clinical finding in (select one)

A) Infective endocarditis
B) Systemic lupus erythematosus 
C) Disseminated gonococcal infection 
D) Distal to infected arterial catheter
E) All of the above



Answer:  E

Osler's nodes in contrast to Janeway's lesion are painful and raised lesions. They are mostly found in hands and feet. They are actually immune complex depositions. Though widely believed to be exclusive of infective endocarditis, they can be found in other conditions like in nonbacterial thrombotic endocarditis (marantic endocarditis), SLE, disseminated gonococcal infection and most importantly to be of note for intensivists, distal to infected arterial catheter.

Q: Which most commonly unpredicted drug interaction of warfarin may go unnoticed and may even without a glance of physicians in ICU, inpatient and outpatient settings?


Answer:  Warfarin and acetaminophen

INR may go dangerously high if a patient use or get prescribe 3 or 4 extra-strength acetaminophen per day, which is a common practice in ICU and other health care settings. Also to add, it is the most commonly used over the counter medicine. This interaction has no linear association and can be very unpredictable. 


For further reading/list of references:

Renato D. Lopes, John D. Horowitz, David A. Garcia, Mark A. Crowther, Elaine M. Hylek - Warfarin and acetaminophen interaction: a summary of the evidence and biologic plausibility - Blood 2011 118:6269-6273

Q; Aspiration of the amebic liver abscess is usually not recommended but may require under few conditions like danger of the rupture or if diagnosis remains doubtful. What characteristic of amebic liver abscess should be kept in mind while aspirating or draining it? 


Answer:  It is very hard to recover amebae from the aspirate as they tend to present only in the peripheral areas of the abscess, busy invading and destroying adjacent tissue. Usually aspiration of amebic liver abscess is discouraged as they may increase the risk of amebic peritonitis, bleeding and others.


References/further reading: 

1. Bammigatti C, Ramasubramanian N, Kadhiravan T, Das AK. Percutaneous needle aspiration in uncomplicated amebic liver abscess: a randomized trial. Trop Doct. 2013 Jan. 43(1):19-22. 

2. Khanna S, Chaudhary D, Kumar A, et al. Experience with aspiration in cases of amebic liver abscess in an endemic area. Eur J Clin Microbiol Infect Dis. 2005 Jun. 24(6):428-30.

Q: CXR finding of tuberculous pleural effusions is mostly?

A) Bilateral and small to moderate
B) Tend to be unilateral on left and large
C) Tend to be unilateral on right and small to moderate
D) Loculated on right upper
E) Loculated on left upper



Answer:  C

Interestingly, 2 studies 1,2 looked into this 5 decades apart and found that tuberculous pleural effusions are mostly unilateral and tends to occur on the right side. Effusions are usually small to moderate - and famously quote to occupy less than one-third of the hemithorax. On side note, Tuberculous pleurisy is more common in AIDS than in non-AIDS patients 3.


References:


1. SIBLEY JC. A study of 200 cases of tuberculous pleurisy with effusion. Am Rev Tuberc 1950; 62:314.

2. Valdés L, Alvarez D, San José E, et al. Tuberculous pleurisy: a study of 254 patients. Arch Intern Med 1998; 158:2017. Frye MD, Pozsik CJ, Sahn SA. 

3. Tuberculous pleurisy is more common in AIDS than in non-AIDS patients with tuberculosis. Chest 1997; 112:393. 

Q: 32 year  old male from South Africa and with history of tuberculosis in his teen who migrated to USA 5 years back presented with  chest pain and shortness of breath. Patient was initially admitted to ICU with concern of cardiac tamponade due to clinical finding of  pulsus paradoxus. STAT ECHO showed  mild pericardial effusion, and patient continue to have clinical signs consistent with pericarditis and pericardial effusion?


Answer: Effusive constrictive pericarditis

Commonly found in southern Africa and presents frequently in patients with history of tuberculous pericarditis  is difficult to distinguish from constrictive pericarditis. Despite little effusion and despite lowering the pericardial pressure to normal, elevated right atrial pressure persists with Y dominance and impaired respiratory variation. This is due to the fact that the pericardial cavity is  obliterated, and very little coexisting pericardial effusion can manifest cardiac tamponade physiology, despite lowering the pericardial pressure to normal. It is hard to diagnose due to mix findings. 


 Reference: 

 Sagristà-Sauleda J, Angel J, Sánchez A, et al. Effusive-constrictive pericarditis. N Engl J Med 2004; 350:469.

Q: What is the implication of using D-5 instead of D-20 as a purge solution in cardiac device Impella? 


Answer:  Impella is a percutaneously inserted ventricular assist device (VAD) to support heart in cardiogenic shock. (video here). Purge refers to the solution which flows through the Impella® Catheter in the opposite direction of the patient’s blood being drawn into the catheter during device support. The purge solution creates a pressure barrier that prevents blood from entering the Impella ® motor. The recommended solution is the dextrose and its concentration determines the viscosity and flow rate of the purge fluid. Makers of the Impella device recommend solutions from D-5 to D-20. Higher concentration of dextrose i.e. D-20 provides higher barrier pressure but on the down side requires replacement of Impella® purge cassette daily. On the other hand, purge solution of 5% dextrose provides lesser barrier but the purge cassette can be used for 5 days. As a standard practice, heparin is added in the purge solution for anticoagulation. A purge solution of D5 increases flow rate by 40% compared to D20. As a result, patients receive a higher infusion of heparin, so close monitoring of PTT may be required.

Q: What is vasodilator-stimulated phosphoprotein (VASP) Index? 


 Answer: Vasodilator-stimulated phosphoprotein (VASP) Index, accurately detect biological clopidogrel resistance. Studies have shown that there is a strong correlation between stent thrombosis and a VASP index higher than 48%- 50%. 


Reference:

1. Barragan P, Bouvier JL, Roquebert PO, et al. Resistance to thienopyridines: clinical detection of coronary stent thrombosis by monitoring of vasodilator-stimulated phosphoprotein phosphorylation. Catheter Cardiovasc Interv 2003;59:295–302.

2. Cuisset T, Frere C, Quilici J, et al. Benefit of a 600-mg loading dose of clopidogrel on platelet reactivity and clinical outcomes in patients with non–ST-segment elevation acute coronary syndrome undergoing coronary stenting. J Am Coll Cardiol 2006;48:1339–45. 

 3. Blindt B, Stellbrink K, de Taeye A, et al. The significance of vasodilator-stimulated phosphoprotein for risk stratification of stent thrombosis. Thromb Haemost 2007;98:1329–34.

Q: The third most common aneurysm within the abdomen after aortic and iliac arteries is of? 

A) Renal artery 
B) Splenic artery 
C) Superior mesenteric artery 
D) Pancreaticoduodenal artery 
E) Common hepatic artery 


Answer: B 

Splenic artery aneurysms are the third most common aneurysms within the abdomen followed after the aortic aneurysm and iliac arteries aneurysm. This is an important clinical pearl as rupture of splenic artery carries a high mortality rate. Particular attention should be paid if a patient with portal hypertension c/o Left upper quadrant pain. Also, pregnant patients with an underlying liver disease are also prone to splenic artery aneurysm.


References: 

1. Čolović R, Čolović N, Grubor N, Kaitović M. - [Symptomatic calcified splenic artery aneurysm: case report]. Srp Arh Celok Lek 2010; 138:760. 

2.Rahmoune FC, Aya G, Biard M, et al.  Splenic artery aneurysm rupture in late pregnancy: a case report and review of the literature. Ann Fr Anesth Reanim 2011; 30:156.

Q: Why Ampicillin remains the first line of treatment for listeriosis? 

Answer: Listeria is universally resistant to cephalosporins. Listeria also remains universally resistant to clindamycin. Trimethoprim/sulfamethoxazole (Bactrim) is the second line of treatment. Vancomycin can be used as a third line of therapy but although active in vitro, it does not have good penetration in vivo.

Q: 47-year-old male is admitted to ICU with hypertensive crisis. On examination, patient appears to be of tall stature. ENT exam showed a rounded surgical scar on the neck (which he attributed to his previous thyroid tumor) and protruded tongue exam is shown below. your diagnosis?

Answer: MEN 2B

Multiple endocrine neoplasia (MEN) are combinations of various tumors of endocrine glands. They are autosomal dominant. It is not possible to describe them in detail here but in nutshell they are grouped as

MEN I - Pituitary adenoma, Parathyroid hyperplasia and Pancreatic tumors 
MEN 2a - Medullary Thyroid Cancer, Parathyroid hyperplasia and Pheochromocytoma 
MEN 2b - Medullary Thyroid Cancer, Marfanoid habitus, mucosal neuromas and Pheochromocytoma

Q: What does FFP/RBC ratio mean in massive transfusion?

Answer:  Trauma literature  regarding  Massive Transfusion Protocol (MTP) lean towards higher FFP:RBC ratio. The thought process behind this approach is that the body's physiologic response to major trauma results in the triad of acidosis, hypothermia and coagulopathy, which eventually results in further massive blood loss. Replacement of coagulation factors may result in better control of bleeding.


References: 

1. Borgman MA, Spinella PC, Perkins JG, et al. The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma. 2007;63:805–813. 

2. Holcomb JB, Wade CE, Michalek JE, et al. Increased plasma and platelet to red blood cell ratios improve outcome in 466 massively transfused civilian trauma patients [published correction appears in Ann Surg. 2011;253:392 

3. Zink KA, Sambasivan CN, Holcomb JB, et al. A high ratio of plasma and platelets to packed red blood cells in the first 6 hours of massive transfusion improves outcomes in a large multicenter study. Am J Surg. 2009;197:565–570.

Q: 34-year-old male with a known history of Ulcerative Colitis (UC) is admitted to ICU with severe abdominal pain and hypovolemic shock. Following is noted on his leg. Your diagnosis?

Answer: Pyoderma gangrenosum

Pyoderma gangrenosum is an ulcerative cutaneous condition and is a diagnosis of exclusion. It is found to be associated with malignancy, vasculitis, collagen vascular diseases, diabetes, trauma and others. The pitfall is to treat it as an infective process. Rather it requires anti-inflammatory agents including steroids, immunosuppressive agents, and biologic agents. Antibiotics are required only on superimposed infections.

Q: Why it is important to quickly reverse metabolic acidosis in methanol poisoning?


Answer: Ingested methanol is metabolized first to formaldehyde and then to formic acid. Treating acidosis with sodium bicarbonate in methanol poisoning converts formic acid to it anion form formate. Formate, unlike formic acid cannot penetrate and diffuse across cell membranes of end-organ tissues particularly retina, a major danger of methanol toxicity. 


Reference: 

Barceloux, D. G.; Bond, G. R.; Krenzelok, E. P.; Cooper, H; Vale, J. A.;  "American Academy of Clinical Toxicology practice guidelines on the treatment of methanol poisoning". Journal of toxicology. Clinical toxicology. 2002: 40 (4): 415–46.

Q: In factitious hypoglycemia caused by sulfonylureas or meglitinides ingestion 

A) Plasma Insulin will be high
B) Plasma insulin will be low
C) Plasma C-peptide will be low
D) Plasma proinsulin will be low


Answer: A

Factitious hypoglycemia from sulfonylureas or meglitinides is very hard to detect as they mimic like insulinoma as they work by stimulating insulin secretion. Levels of all three i.e plasma insulin, C-peptide, and proinsulin will be high. The most accurate test would be to directly measure plasma sulfonylureas or meglitinides. 

Picture Diagnosis

Q: Following picture with 2 hints 

1) solid nodule lying in the periphery of the lung and 
2) linked to a bronchus (bronchus positive sign)

Answer:  Adenocarcinoma 

Adenocarcinoma of lungs tends to occur in peripheries in contrast to squamous or small cell lung cancers which tend to occur in the central locations. The 'positive bronchus' (also called 'bronchus positive') sign is also highly suspicious for lung cancer.


Reference: 

 Zacharopoulos G1, Adam A, Ind PW. - The positive bronchus sign in patients with known lung cancer - Eur J Radiol. 1990 Mar-Apr;10(2):130-3.

Q: 54-year-old male is transferred from oncology floor to ICU due to high suspicion of Tumor Lysis Syndrome (TLS). Patient has been started on IV fluid, prescribed rasburicase and close electrolyte and uric acid measurement has been planned. What one precaution should be taken while checking the uric acid level in a patient who has been receiving rasburicase?


Answer:  Blood samples drawn for the uric acid level in patients who are getting treated with rasburicase should be collected in a pre-chilled tube, immediately placed on ice as soon as blood is drawn, and lab should be instructed to run the test without delay. This is due to the reason the rasburicase present in the sample may interfere with the serum uric acid measurements.

Q: What is the famous "CRAB" for Multiple Myeloma (MM)?

Answer: CRAB symptoms are considered to be diagnostic of MM with evidence of proliferation of monoclonal plasma cells in the bone marrow.

C = HyperCalcium
R = Renal failure
A = Anemia
B = Bony lesions


Reference: 

International Myeloma Working Group (2003). "Criteria for the classification of monoclonal gammopathies, multiple myeloma and related disorders: a report of the International Myeloma Working Group". Br. J. Haematol. 121 (5): 749–57.

Q: What is Sneddon syndrome?

Answer:  When patient develop CVA and found to have widespread livedo reticularis on physical exam, it is known as Sneddon syndrome.

Clinical significance: Patient probably has Anti-Phospholipid Syndrome proved otherwise.


Reference:

Francès C, Piette JC. The mystery of Sneddon syndrome: relationship with antiphospholipid syndrome and systemic lupus erythematosus. J Autoimmun 2000; 15:139.