Case Files 13-18 (C) Flashcards
A closed pocket containing pus
Abscess
A blister greater than 0.5 cm in diameter
Bulla (plural: bullae)
A closed, saclike, membranous capsule containing a liquid or semisolid material
Cyst
A discoloration on the skin that is neither raised nor depressed
Macule (large: patch)
A small mass of rounded or irregular shape that is greater than 1.0 cm
Nodule
A small, circumscribed elevated lesion of the skin that is less than 1.0 cm
Papule
A plateaulike, raised, solid area on the skin that covers a large surface area in relation to its height above the skin
Plaque
A lesion through the skin or mucous membrane resulting from loss of tissue
Ulcer
A small blister less than 0.5 cm in diameter
Vesicle
The single most important risk factor for the development of skin cancer is…
exposure to UV radiation
What are the 4 basic types of melanoma?
- Superficial Spreading Melanoma
- Lentigo Maligna
- Acral Lentiginous Melanoma
- Nodular Melanoma
The most common type of melanoma is…
Superficial Spreading Melanoma
Spreads superficially before penetrating (radial growth phase is slower than the vertical phase)
Common clinical features: raised borders and brown lesion with pink, whites, grays, or blues
Least common type of melanoma
Often found in the elderly (commonly diagnosed in the seventh decade of life)
*Most common form of melanoma found in Hawaii
Lentigo Maligna
Clinicaly characterized as tan to brown lesions with very irregular borders (found on sun-damaged skin such as the face, ears, arms, and upper trunk)
Most common melanoma found in African Americans and Asians
Acral Lentiginous Melanoma (think the one that starts with an “A”)
Usually found under the nails, on the soles of feet, and on the palms of the hands. Common clinical features include: flat, irregular, dark brown to black lesions
Most aggressive form of melanoma
Nodular Melanoma
Usually invasive at the time of diagnosis. Clinically characterized as brown to black lesions that arise from nevi or normal skin
ABCDE of Melanoma
Asymmetry
Borders
Color
Diameter (>6 mm)
Elevation/Evolving
What is the next step for any new pigmented lesion that exhibits any of the ABCDE signs or any preexisting nevus that has changed?
Excision with 2-3 mm margin
*If pathology indicates a malignancy, the lesion should then be completely excised with 5 mm margins
The single most important piece of information for prognosis in melanoma is…
thickness of the tumor (Breslow measurement)
Melanomas less than 1 mm thick have a low rate of metastasis and a high cure rate with excision
Nevus in a patient with a history of actinic keratoses and HPV raises the risk of…
Squamous cell carcinomas
Have a higher rate of metastasis than BCC, but the risk is still low
Most common skin cancer
Basal cell carcinoma
Typically appear as pearly papules, often with a central ulceration or with multiple telangiectasias (bleeds and itches)
Which studies image the upper urinary tract?
i.e., the kidneys and ureters
Intravenous pyelogram (IVP)
or
CT
What study images the lower urinary tract?
i.e., the urinary bladder and urethra
Cystoscopy
The incidence of cancer presenting as asymptomatic microscopic hematuria is…
low
Define microscopic hematuria
The presence of three or more RBCs per HPF on two or more properly collected urinalyses
Urine samples showing significant proteinuria, erythrocyte casts, and dysmorphic RBCs
Likely glomerular hematuria
*Renal hematuria is also associated with proteinuria, but not with erythrocyte casts or dysmorphic RBCs
*Urologic hematuria is not associated with any of the three mentioned above
Routine screening for hematuria is
not recommended
The initial finding of hematuria by the dipstick method should be…
confirmed by microscopic evaluation of urinary sediment.
*the dipstick has limited specificity because it lacks the ability to distinguish RBCs from myoglobin or hemoglobin
How do you distinguish glomerular disease from interstitial nephritis?
RBC casts + dysmorphic RBCs = renal glomerular
Eosinophils = interstitial nephritis (often caused by analgesics or other drugs)
What medications can be given to reduce the risk of contrast nephropathy during an IVP or CT urography?
N-acetylcysteine or IV sodium bicarbonate
*Remember to take a CT scan without contrast first to detect calculi
What study can you give a patient with renal insufficiency to evaluate their upper urinary tract?
Retrograde pyelography combined with a renal ultrasound
What is the next step for a patient who had microscopic hematuria, but a negative workup?
Follow-up blood pressure measurements, urinalyses, and voided urine cytology studies at 6, 12, 24, and 36 months
A 24-year-old male bodybuilder with no significant medical history presents with gross hematuria? He was told by his trainer that exercise can induce hematuria and that this is nothing to worry about. He comes to you for a second opinion. What is the appropriate management?
BLUF: gross hematuria always deserves a full workup
Urinalysis, urine culture, and imaging of the upper urinary tract by CT scanning
A 78-year-old man with multiple medical problems presents with dysuria and is found to have microscopic hematuria. His examination is only positive for a very tender and boggy prostate. What is the next step?
Tender/boggy prostate = prostatitis
Treat the prostatitis with 1 month of antibiotics and reevaluate the patient with a follow-up urinalysis and culture posttreatment
A 45-year-old woman with a history of cancer, currently receiving radiation therapy, presents as a new patient. On a routine urinalysis, you discover 2 RBCs per HPF, 15-20 WBCs per HPF, nitrites, and leukocyte esterase. What is the appropriate next step?
Repeat a clean-catch midstream specimen, send for culture, and treat the UTI. Repeat urinalysis after UTI treatment.
The most common cause of noniatrogenic hyperthyroidism is…
Graves disease
Treatment of Graves disease
The definitive treatment is radioactive iodine (40% of patients eventually become hypothyroid)
Can also treat with antithyroid drugs (propylthiouracil and methimazole) and/or β-blockers
What treatment can a pregnant woman with Graves disease receive?
Surgical removal or PTU
*Radioactive iodine can cross the placenta and cause fetal thryoid ablation
Graves disease and acute thyroiditis can both lead to a medical emergency called…
Thyroid storm
Treat with high doses of PTU/methimazole and β-blockers. Hydrocortisone is given to prevent possible adrenal crisis
50% of patients with Graves disease also have…
exopthalmos (the “thyroid stare”)
How do you distinguish Graves disease from thyroiditis?
Radionucleotide imaging (technetium-99 or iodine-123)
Graves = diffuse hyperactivity with large amounts of uptake
Thryoiditis = patchy uptake (reflecting the release of exisiting hormone rather than the overproduction of new thyroxine)
*serum thyroid-receptor antibodies is a specific diagnostic test for Graves
The second most common cause of hyperthyroidism?
autonomous thyroid nodule
Propylthiouracil
Methimazole
Carbimazole
Antithyroid drugs
Work by inhibiting the organification of iodine, and PTU also prevents the peripheral converstion of T4 to T3
What is the “black box” warning for PTU?
Hepatotoxicity
Methimazole is considered the first-line agent except when the patient is pregnant
In older patients with suspected Alzheimer disease, what else should be considered for a differential?
Hypothyroidism and Depression
Most common noniatrogenic condition causing hypothyroidism in the US
Hashimoto thyroiditis
Primary hypothyroidism is diagnosed by TSH elevation and low free thyroid levels
For secondary hypothyroidism, how do you determine whether the cause is a hypothalamic or pituitary problem?
TRH test
A normal functioning pituitary will result in an increase of TSH that can be measured in 30 minutes
Further workup of identified nodules is indicated, as the incidence of malignancy in solitary nodules is estimated at….
5-6%
Incidence of malignancy is higher in children, adults younger than 30 or older than 60, and patients with a history of head/neck irradiation
Nonfunctioning nodules measuring greater than 1 cm by exam or ultrasound require…
biopsy (FNA)
*Functional adenomas that present with hyperthyroidism are rarely malignant
Why is FNA a limited test?
Follicular cell malignancy cannot be distinguished cytologically from its benign equivalent
Papillary, medullary, and anaplastic thyroid carcinomas can be diagnosed accurately
A 24 year-old woman who is 8 weeks pregnant is found to have a thyroid nodule. Biopsy is performed and malignancy of the thyroid is diagnosed. What is the most appropriate management?
Thyroid cancer detected during pregnancy can usually be observed until after the pregnancy is complete. If needed, thyroid surgery can be performed safely in the second and third trimesters.
Signs that could confirm the rupture of membranes
- Visualization of amniotic fluid leaking from the cervix
- Presence of pooling in the posterior fornix
- pH above 6.5 in the fluid collected from the vagina using Nitrazine paper
- Visualization of “ferning”
Cutoff for preterm and postterm
preterm = labor > 3 weeks from EDC
postterm = labor > 2 weeks from EDC
EDC is estimated date of confinement (280 days after the first day of the LMP)
Late preterm = 34 to 36w6
What can cause a false-positive Nitrazine test?
The presence of semen, blood, or bacterial vaginosis can all cause elevated pH in vaginal secretions
The most common cause of fetal tachycardia
Maternal fever
What is shoulder dystocia and how do you treat it?
When the anterior shoulder will not readily pass below the pubic symphysis (obstetrical emergency)
McRoberts maneuver (hyperflexion of the hips)
Suprapubic pressure
Episiotomy
Rotation of the fetal body
The presence of accelerations on fetal heart tracing is very reassuring and consistent with a fetal pH of…
7.2 or more
Primary vs Secondary vs Tertiary Hyperparathyroidism
1º = excessive production by the parathyroid glands
2º = overproduction of PTH in response to low serum Ca
3º = elevated PTH in patients who have renal failure
Most of the calcium in the body is found in the…
skeleton (approximately 98%)
the remaining calcium is found in circulation (half bound to albumin/other proteins and half free/ionized)
*only ionized calcium has physiologic effects
When is a “corrected” serum calcium helpful?
With patients found to have a concomitant hypoalbuminemia
corrected = [0.8 x (normal albumin) - (patient’s albumin)] + serum calcium
What is the difference between PTH and calcitonin in regards to phosphate
PTH increases calcium in the blood (via promotion of osteoclast activation, resorption at the kidneys, and increased calcitriol levels) and decreases serum phosphate levels (counterintuitive because phosphate follows calcium when excreted)
Calcitonin responds to elevated calcium levels by promoting renal excretion (resulting in phosphate excretion) and opposing osteoclast activation
The most common cause of hypercalcemia in the ambulatory patient is…
hyperparathyroidism (cancer ranks as the second leading cause)
helpful to categorize the etiologies of hypercalcemia into into five main area: PTH related, malignancy, renal failure, high bone turnover, and vitamin D
Physical manifestation of hypercalcemia
Stones
Bones
Psychic groans
Abdominal moans
The vast majority of primary hyperparathyroidism is caused by…
an adenoma of one of the four parathyroid glands
Patient with hypocalcemia, hyperphosphatemia, and low vitamin D levels
Most likely secondary to renal failure
If left untreated, it leads to hyperplasia of the parathyroid gland, an increased PTH secretion, and subsequent hypercalcemia (3º)
Famililial Hypocalciuric Hypercalcemia (FHH)
Inappropriately high PTH levels unrelated to the parathyroid production (a genetic disorder related to a defect in a gene that codes for a calcium-sensing receptor)
Can be confused with 1º hyperparathyroidism. Use a 24-hr urinary calcium level to distinguish (FHH is assocatied with low urinary calcium)
What produces PTH-rP (parathyroid hormone-related peptide)
Lung cancer, SCC of the head and neck, and renal cell cancer
PTH-rP effectively takes the parathyroid gland out of the loop in calcium homestasis
*Malignancies can also cause hypercalcemia via direct osteoclastic bone resorption (multiple myeloma, granulomatous disease such as TB, sarcoidosis, Hodgkin lymphoma, and breast cancer)
A 60-year-old man comes into your office with the complaint of fatigue and constipation. He has had no dietary changes recently. A history reveals that he has HTN, treated with medications, and an inguinal hernia that was repaired 10 years earlier. The exam was nonspecific. You decide to obtain an electrolyte panel and find that the calcium level is elevated at 11.5 mg/dL. What is your next step?
Ask him about what medication he is taking to treat his HTN. HCTZ is a commonly used antihypertensive medication that may contribute to elevated calcium levels
A 48-year-old man presents for follow-up of an elevated calcium level of 12.3 mg/dL found on routine screening at his last well-man visit. He takes no medications. He recently started smoking a half-pack of cigarettes per day. He was prompted to attend his well-man visit by his wife who claims that he has become forgetful, has a decreased appetite, and has had a 10-lb weight loss over the past 2 months. As part of his follow-up lab tests, you obtain a serum PTH, which comes back within the normal range. What is the next step?
Measurement of urinary calcium excretion
He has sypmtomatic hypercalcemia. He also has an inappropriately normal PTH level. A 24-hr urinary calcium will determine if this condition represents 1º hyperparathyroidism (most common) or FHH (rare)
Presbycusis
Age-related sensorineural hearing loss typically associated with both selective high-frequency loss and difficulty with speech discrimination
Leading cause of severe vision loss in the elderly
Age-related macular degeneration (AMD)
Characterized by atrophy of cells in the central macular region of the retinal pigment epithelium, resulting in the lose of central vision
Common causes of geriatric hearing impairments
Presbycusis
Noise-induced hearing loss
Cerumen impaction
Otosclerosis
Central auditory processing disorder
Leading cause of nonfatal injuries in the elderly
Falls
The combination of the “clock draw” and the “three-item recall” is a rapid and fairly reliable office-based screening test for…
dementia
when patients fail either of these screening tests, furthing testing with Folstein Mini-Mental State questionnaire should be performed
Protein undernutrition is associated with an increased risk of…
infections, anemia, orthostatic hypotension, and decubitus ulcer
combination of serial weight measurements and inquiry about changing appetite are the most useful methods of assessing nutritional status
Differential for vision loss in the elderly
Presbyopia, macular degeneration, glaucoma, cataracts, and diabetic retinopathy
