UW (Advanced Editing) Flashcards
Aortic dissection (type A- proximal aorta) can cause what valvular problem?
Aortic regurg
(the intimal tear can cause blood to leak into the aortic valve)
Aortic dissection (type A- proximal aorta) can cause what pericardial problem?
Cardiac tamponade (the intimal tear can cause blood to fill the pericardial sac- if it surrounds the heart and restricts filling it is tamponade)
What is a prolonged PR interval on an EKG suggestive of?
AV block
P wave= atrial contraction
QRS= ventricular contraction
so P->R (PR interval)= the time it takes for the signal from the atria to get sent over to the ventricles for contraction (AV conduction delay- tells us how well the AV node is working)
What is androgenetic alopecia?
“male pattern baldness”
Causes uneven hair loss in a characteristic pattern (different in men vs. women)
What is alopecia areata?
Autoimmune dz–> patches of hair loss
What is seborrheic dermatitis?
Superficial fungus–> scaly, red skin w/ dandruff
(also called seborrheic eczema)
What is trichorrhexis nodosa?
Fragile hair w/ breaking strands (congenital or acquired- from heat, hair dyes, salt water, etc.)
Woman with a recent hx of severe postpardum depression complains of hair loss. Lots of hair comes out when washing or brushing her hair. No redness or scaling of the scalp. When you tug on her hair, >20% of fibers come out. Diagnosis?
Telogen effluvium
- common cause of hair loss where you get widespread thinning of the hair (scalp and hair shafts appear normal)
- normally hair goes through 3 phases: growth-> transform-> rest/ shedding. In this condition, too much hair goes to the rest/ shedding phase
- can be triggered by stress (weight loss, pregnancy, psych issue, etc.)
- **memory trick: when you’re stressed you pull your hair out (hair loss assoc w/ stress) and you want to call a friend (Telogen) and be like eff…(Effluvium)*
What veins are the source of most (>90%) symptomatic PE’s?
Deep veins of the proximal thigh: iliac, femoral, and popliteal
Why do we give ACE inhibitors to diabetic patients? Be specific.
They take pressure off the kidneys to prevent progression to diabetic nephropathy:
There is initial hyperfiltration (high GFR) in DM: lots of glucose in blood-> more reabsorption of glucose and therefore Na+ by the glucose/Na+ co-transporter at the PCT-> macula dense senses it is getting less Na+-> so the kidney responds by dilating the afferent and MAINLY constricting the efferent (preferential involvement of the efferent)-> this raises GFR (hyperfiltration)-> micro-albuminuria (spillage of protein into urine)-> nephrotic syndrome…(ACE inhibitors/ ARBs protect against this all)
ACE inhibitors (and ARBs) decrease renal efferent arteriole vasoconstriction, reducing glomerular hydrostatic pressure and slowing the rate of DM nephropathy progression
What is Choledocholithiasis?
When a gallstone is lodged in the common bile duct
(can present with obstructive jaundice bc bile containing conjugated bilirubin cannot flow through to be excreted)
What is SCD’s (for DVT prophylaxis)?
Sequential compression device
(it is like compression stockings, but better because it applies pressure to squeeze the calf muscles and promote good circulation…when in doubt reg whether or not a patient should get DVT prophylaxis, order SCD. Anticoagulants come with bleeding side effects, this doesn’t.)
What is this? How do you diagnose it? How do you treat it?
Chronic stasis dermatitis
Due to venous insufficiency
- Patient who is old, obese, or hx venous thrombosis (DVT)—> failure of venous valves—> backflow of blood and leakage of fluid, plasma proteins, RBCs—> scaling, weeping, pitting edema, red/ brown discoloration, ulcers*
- **can appear like cellulitis, but it is bilateral & symmetric
Clinical diagnosis, but venous Doppler ultrasonography (way to evaluate blood flow) can confirm
Manage with compression stockings, leg elevation, exercise, avoid standing too long
What is this? What med can you give to treat?
Sustained monomorphic ventricular tachycardia (SMVT)
Amiodarone (class III anti-arrhythmic)
*Ventricular tachy (fast and wide QRS)-> Amiodarone
*SVT’s (fast and narrow QRS)-> Adenosine
*Bradycardia-> Atropine
What is a Watchman procedure/ device?
An implant that is surgically placed in the LA appendage (where clots often from from a-fib and get thrown causing stroke).
This is done in patients with a-fib who need stroke prophylaxis but cannot tolerate anticoagulants (due to bleeding risk).
What is cephalization on x-ray?
Enlarged/ more prominent pulmonary vessels
What is a hydropneumothorax?
Air + fluid in the lung (pleural space)
What does CABG stand for?
Coronary artery bypass grafting (CABG)
*Patients with multiple narrowed coronary arteries may have a better outcome with a CABG as opposed to placement of a stent (PCI)
**Although we learned to load a patient up with Clopidogrel + ASA (2 antiplatelet agents) prior to getting a stent, many doctors in real life do not do this- just use 1. Why? If they go in there (w/ angiogram) and decide a CABG is best for the patient instead of a stent, they wouldn’t be able to do it then and there if the patient was loaded up on antiplatelet agents (bleeding risk)- would have to wait a few weeks. If the patient was just on 1 they could do it.
2 shockable rhythms?
2 non-shockable rhythms?
SHOCKABLE:
1. V-fib (ventricular fibrillation)
2. V-tach (ventricular tachycardia)
**note: Torsades is a subcategory of ventricular tachycardia- shock it.
- *NON-SHOCKABLE:**
1. Asystole
2. Pulseless electrical activity (PEA)- abnormal rhythm (ex: a-fib) is going on where you expect a pulse, but you don’t have one
Rap song: “Defib for V-fib and pulseless V-tach. Don’t defib asystole, you won’t get them back!”
What do the P waves look like in a-fib?
Absent P waves replaced by chaotic fibrillatory waves
(remember P wave= atrial depol, and in a-fib the atria are contracting abnormally)
What anatomic site is the origin of a-fib?
The pulmonary veins
(most common site of the ectopic foci responsible for a-fib)
Lifeguard with multiple sexual partners comes in with this rash. Diagnosis?
Tinea versicolor
(Fungal skin infection that grows in humidity. Causes areas of hypopigmentation or hyperpigmentation. Diagnose by “spaghetti and meatball” appearance of KOH preparation of skin scrapings. Treat with selenium sulfide/ Selsun blue or Ketoconazole.)
Anoscopy vs. Sigmoidoscopy vs. Colonoscopy?
Anoscopy- an anal speculum
Sigmoidoscopy- flexible scope that looks at the sigmoid colon
Colonoscopy- flexible scope that looks at the entire colon
Patient has hyperthyroidism (high T4, low TSH). No obvious signs of Graves’ disease. What test should you do next in your work-up and how do you interpret the results?
- *Radioactive iodine uptake (RAIU) scan**
- If uptake is HIGH—> this means the thyroid gland is actively making TH so it is either Graves’ disease (if it’s diffuse uptake) or nodular disease (if it’s nodular uptake)
-If uptake is LOW—> this means even though you have high TH, the thyroid gland is NOT actively making that excess TH so it is either thyroiditis (preformed TH released) (if Tg is high) or exogenous TH intake (if Tg is low)
What is this?
Ichthyosis vulgaris
(Chronic inherited skin disorder caused by mutations in the filaggrin gene where you get diffuse dermal scaling)
Obese teen girl has a dull ache in her left thigh, worse with activity and better with rest and NSAIDs. Her left hip has decreased range of motion upon internal rotation. Most likely cause of her symptoms?
Slipped capital femoral epiphysis
- Can occur in obese teens who are still growing
- The femoral head is posteriorly displaced (The ball at the head of the femur (thighbone) slips off the neck of the bone in a backwards direction)
- presents with dull pain/ ache of the hip, thigh, or knee
- foot is externally rotated (foot pointed out/ laterally)
- altered gait and internal rotation due to pain
What is this?
Dacryocystitis
(Infection of the lacrimal sac, usually due to staph or strep- presents with tenderness, edema, redness)
What do you do for a patient with an asymptomatic hiatal hernia?
Watch and wait
(If GERD symptoms–> medically manage. If refractory GERD–> consider for surgery.)
ST elevation in leads V4-V6. What artery is occluded?
LCX (left circumflex)
Remember the following:
- II, III, aVF–> RCA occluded (inferior MI)
- V1-V4–> LAD occluded (anterolateral MI)
- I, aVL or V4-V6–> LCX occluded (lateral MI)
*V4 all the way through aVL is LCX territory!
What is this?
Central retinal VEIN occlusion
“Blood and thunder” on fundoscopy exam
-Blood drainage from the eye is blocked off, so the veins going away from the eye get so backed up-> scattered and diffuse hemorrhages
40 year old guy with SLE (on Prednisone) has epigastric burning when lifting boxes at work. Not relieved by antacids. No other symptoms. EKG is normal. Next step?
Stress test (exercise EKG)
*Remember risk-stratifying patients for CAD. He is intermediate risk (atypical chest pain, man of any age)—> stress test!
**SLE is a risk-factor for accelerated atherosclerosis and premature CAD.
What X-ray findings would you expect to see in a patient with thoracic aortic aneurysm (TAA)?
Widened mediastinum, enlarged aortic knob, tracheal deviation
*TAA usually happens due to long-standing HTN, age-related degenerative changes (breakdown of collagen, elastic), and/or connective tissue dz (Marfan, Ehlers-Danlos) that disrupt the medial layer of the aortic wall-> aortic dilation
What is the main mitral valve abnormality in patients with HOCM?
Systolic anterior motion of the mitral valve
(the mitral valve leaflet shifts toward the aortic valve/ interventricular septum)
Contact between the mitral valve and thickened septum during systole leads to ventricular outflow obstruction.
Stepwise treatment approach for asthma?
- Start with SABA (short-acting beta agonist= Albuterol rescue inhaler)
- Add on a ICS (inhaled corticosteroid)
- Add on a LABA (long-acting beta agonist)
- Worse case: Add on oral corticosteroid and omalizumab if allergies
*Treatment should depend on the severity of the asthma:
- Intermittent- symptoms 2 or less days/ week (step 1 treatment)*
- Mild persistent- symptoms >2 days/ week but not daily (step 2 treatment)*
- Moderate persistent- symptoms daily (step 3 treatment)*
- Severe persistent- symptoms throughout the day (step 4 treatment)*
Patient comes in with this rash that has been present for several months and slowly enlarging. It is not itchy. Topical corticosteroids have not helped. Next step?
Punch biopsy it
- This is suspicious for squamous cell carcinoma (SCC) in Situ (Bowen disease) of the skin
- scaly, erythematous
- not responding to corticosteroids
*you need to biopsy to confirm—it is confined to the epidermis by definition, but over time can develop foci of invasive SCC (needs to be removed)
Patient presents with this rash that occasionally seeps clear, yellow fluid. Has dogs at home. Diagnosis?
Nummular eczema
- pruritic, scaly, fissured plaque with intermittent exudate seeping from it
- idiopathic inflammatory disorder of the skin (usually extremities)
- nummum= “coin lesions”
- *1st line treatment is topical glucocorticoids (betamethasone dipropionate)
Lady with recent MI and stenting complains of vague abdominal pain on day 3 of hospitalization. Her toe is blue and leg looks like this. Labs are significant for elevated Creatinine. Diagnosis?
Cholesterol embolism
- A complication of cardiac cath/ vascular procedures (atherosclerotic plaque disrupted-> chol plaque/ debris are showered into circulation). Can cause:
- Skin manifestations
- Blue toe syndrome
- Livedo Reticularis (this lacy looking leg rash)
- Hollenhorst plaques (cholesterol plaque seen in retinal artery)
- Tissue ischemia (incl stroke if it were to embolism to brain), AKI
Patient comes in for work-up of hypercalcemia of 11 found in routine labs. She’s a smoker with asthma, otherwise no significant med hx. Next step to determine cause of hypercalcemia (assuming you already corrected for albumin concentration to confirm hypercalcemia)?
Get a serum PTH level
- PTH-independent hypercalcemia (high calcium-> low PTH) is usually due to cancer
-
PTH-dependent hypercalcemia (high PTH-> high calcium) is usually due to primary hyperparathyroidism
- This is most likely the case for her bc cancer (like squamous cell with PTHrP release) usually causes a higher calcium level >14 and may lead to symptoms from it (“stones, bones, abdominal moans, psychiatric groans”)
20 year old guy has a bad headache for a week. He had an insect bite on his cheek and now both his eyes are swollen. He vomited. Has impaired EO eye movements on exam. Diagnosis?
Cavernous sinus thrombosis
-The facial/ophthalmic venous system is valveless, so uncontrolled skin infection can cause cavernous sinus thrombosis. Red-flag symptoms= severe headache, bilateral periorbital edema, CN 3-6 deficits.
Would the following levels be high, low, or normal in a patient with hypothyroidism?
TSH
Prolactin
FSH
- TSH- HIGH (neg feedback from low T4)
- Prolactin- HIGH (hypOthyroid-> hypERprolactinemia)
- FSH- LOW (high prolactin will block GnRH, which will lead to less production of FSH)
Guy is brought to the ED due to a car accident. He is hypotensive and tachy. Has bruising across the anterior chest w/ an imprint of the steering wheel. His extremities are cool to touch. CXR shows rib fractures, opacification of the left hemithorax, and widened mediastinum. Diagnosis?
Thoracic aortic injury
- Patients who undergo rapid deceleration (car crash, fall) are at risk for blunt aortic injury (full rupture-> sudden death. incomplete rupture w/ at least the adventitia layer intact-> can survive to hospital)
- CXR: widened mediastinum, enlarged aortic contour (shadow), left-sided hemothorax (effusion w/ blood)
- Requires emergency surgery
Boy presents with right knee pain, worse after basketball practice. Anterior and posterior drawer tests are negative. Range of motion of the right hip is limited, and the knee points laterally upon passive hip flexion. Diagnosis?
Slipped capital femoral epiphysis (SCFE)
- anterolateral and superior displacement of the proximal femur along the physio (growth plate)
- foot points laterally due to limited internal rotation
- most common among obese adolescents!
What do the following mean? What information do they tell you in regards to where the problem is at in the urinary tract?
- Initial gross hematuria
- Terminal gross hematuria
- Total gross hematuria
-
Initial gross hematuria- blood seen at the beginning of the urinary stream
* Means problem is in the urethra
-
Initial gross hematuria- blood seen at the beginning of the urinary stream
-
Terminal gross hematuria- blood seen at end of the urinary stream
* Means problem is in the prostate, bladder neck (bottom part), or posterior urethra
-
Terminal gross hematuria- blood seen at end of the urinary stream
-
Total gross hematuria- blood seen during the entire urinary stream
* Means bleeding could be anywhere in urinary tract (kidneys, bladder, etc.)
-
Total gross hematuria- blood seen during the entire urinary stream
75 year old guy has right hip pain for 5 mo. He can’t walk much anymore or reach down to tie his shoes. Diagnosis?
Osteoarthritis (also called “degenerative joint disease”)
- wear and tear of the hip (he’s old, worse with activity/ weight bearing)
- X-ray shows narrowed joint space (degeneration of cartilage-> bone rubbing against bone) and osteophytes (bone spurs/ bony outgrowths)
Man with HIV presents with SOB, left-sided chest pain, fever/ chills, cough productive of green sputum for 1 week. CXR looks like this. Most likely diagnosis?
Empyema
Collection of pus in the pleural space—a complication of PNA
*a complicated parapneumonic effusion would not be this bad looking, would be a cavity on CXR
What is tanometry?
Procedure to determine the intraocular pressure (IOP) of the eye to evaluate risk for glaucoma
What is a fluorescein eye stain exam?
Eyedrop dye applied to the surface of the eye to inspect the cornea
(in patients with foreign body, corneal abrasion, keratitis) *would present as eye pain, irritation, tearing, or redness
What would an X-ray of SBO (small bowel obstruction) show?
A transition point (the obstruction) and dilated small bowel proximal/ leading up to that point
What would X-ray of a post-op ileus show?
Uniformly dilated bowel loops
Patient presents with eye pain and swelling after a bar fight. He has double vision when he looks up and cannot look up with his left eye. CT shows this. Diagnosis?
Inferior rectus muscle entrapment
(Orbital floor fracture-> entrapment of inferior rectus muscle-> vertical diplopia and restriction of upward eye movement)
20 year old man has a nose bleed from basketball. Bleeding goes on for 10 min. Now it stopped, but he can’t breathe through his nose. There’s bruising across the nose and swelling of the nasal septum on both sides. Next step?
Incise and drain the nasal septum
This is a septal hematoma!
(accumulation of blood between the perichondrium and septal cartilage)
-nasal trauma-> swelling and obstruction
*If not treated/ drained, can get septal abscess (from infection) or avascular necrosis of the septal cartilage (since the septal cartilage doesn’t have its own blood supply and gets nutrients by diffusion from the perichondrium), which can further cause septal perforation, nasal deformity, or internal nasal valve collapse/ nasal obstruction
When is weight loss medication indicated?
BMI >30 (obese) or BMI 25-29 (overweight) w/ weight-related complications
med options:
- Orlistat: blocks intestinal fat absorption, GI side effects
- Lorcaserin: serotonin receptor agonist believed to promote satiety by activating anorexigenic neurons in the hypothalamus
- Naltrexone/ Buproprion: opioid antagonist that happens to have a side effect of weight loss/ atypical antidepressant that blocks NE and Dopamine reuptake that happens to have a side effect of weight loss
- Phentermine/ Topiramate: sympathomimetic that stimulates the CNS and inc BP and happens to have a side effect of weight loss/ antiepileptic that happens to have a side effect of weight loss
- Liraglutide: GLP-1 receptor agonist that inc insulin release and happens to act on receptors in the brain leading to early satiety and weight loss
Pick based on the patient’s comorbidities and med list, taking into consideration the side effect profiles
80 year old woman with PMH of DM, HTN, MVP, gallstones, and diverticulitis presents with severe abdominal pain and vomiting. She thought she had a “stomach virus” brewing over the last week. Abdomen is distended with hyperactive bowel sounds. Labs show high WBC count and mild transaminitis. X-ray shows dilated loops of small bowel and air in the intrahepatic bile ducts. Diagnosis?
Gallstone ileus
causing mechanical small bowel obstruction (SBO)
- Inflammation breaks down gallbladder wall-> forms a fistula w/ duodenum-> stone moves into iliocecal valve
- pneumobilia= air (from intestines) in gallbladder*
*as the stone advances, it may cause a tumbling obstruction before ultimately causing complete obstruction
*treat by surgical removal of stone + cholecystectomy
Boy presents with a left neck mass. Last month he has a fever and URI. A week later, he noticed a painful lump on the side of his neck (anterior to sternocleidomastoid), which leaks fluid. Diagnosis?
Branchial cleft cyst
*The branchial apparatus is an embryo structure that develops into face and neck structures
What is a thoracotomy?
Thoracotomy= A surgical procedure where you’re completely opening up the chest in order to gain access to the pleural space (heart, lungs, esophagus, etc.)
**vs. Thoracostomy= Small incision in chest wall to place a chest tube (usually to treat pneumothorax)
What is a thoracostomy?
Thoracostomy= Small incision in chest wall to place a chest tube (usually to treat pneumothorax)
**vs. Thoracotomy= A surgical procedure where you’re completely opening up the chest in order to gain access to the pleural space (heart, lungs, esophagus, etc.)
What is the mediastinum?
*note: lots of things cause a widened mediastinum seen on CXR (tumor, vascular shadown from aortic aneurysm or aortic dissection, enlarged lymphoid mass, etc.)
Young pregnant lady has a thyroid nodule. She denies hot/ cold intolerance and skin changes. TSH is normal. Ultrasound of her thyroid reveals a hypoechoic nodule with irregular margins, microcalcifications, and internal vascularity. Next step?
Get a FNA (fine-needle aspiration) to biopsy the nodule
*Following the Online MedEd algorithm: TSH is normal, meaning T4 is NOT high, so it’s NOT a hot nodule. Cold nodules are higher-risk, more likely to be cancer. You do the ultrasound and if it’s large (>1 cm) or suspicious for cancer, you go onto FNA biopsy.
*U/S report is hypoechoic (means more dense/ solid), irregular margins, micro calcifications, internal vascular it’s (tumors hog blood supply)–all point to thyroid cancer
When do you do a radioactive nucleotide scan for a thyroid nodule?
In the setting of low TSH (hyperthyroid) because these nodules are often ‘hot’ (overactive) and less likely to be cancer
*if radioactive uptake scan shows it is indeed hot, you treat the hyperthyroid/ resect
*if radioactive uptake scan shows it is not hot (non-functioning), you cannot r/o cancer so must move onto ultrasound and [if U/S shows large (>1 cm) or suspicious] FNA
**never do radioactive anything if the patient is pregnant!
40 year old guy with PMH of T1DM (on insulin) has worsening RLQ abdominal pain radiating to the groin. 2 weeks ago he was treated for furunculosis of the right thigh (infected hair follicle with abscess). He has a fever and leukocytosis and extension of the right hip increases pain. Next step?
CT abdomen and pelvis
- Patient with recent skin infection presenting with fever + abdominal pain is suspicious for psoas abscess
- Positive “psoas sign” (abd pain with hip extension/ bringing the straight leg of the patient back as they lay on their side)
*psoas abscess can occur from hematologic seeding (spread through blood) of a distant infection or from direct extension of an intraabdominal infection (diverticulitis, vertebral osteomyelitis)
**risk factors: HIV, IV drug use, DM, Crohn’s dz
CT to confirm and drainage + antibiotics to treat
25 year old who underwent difficult rhinoplasty 2 months ago presents with an annoying whistling noise during respiration. Diagnosis?
Nasal septal perforation (hole in nasal septum)
*Rhinoplasty= a “nose job” (plastic surgery for correcting and reconstructing the nose)
-this is a complication of the surgery, usually resulting from a septal hematoma (complications are common in rhinoplasty- 25%)
**other causes of nasal septal perforation: Cocaine, nose picking, Syphilis, TB, sarcoidosis, granulomatosis with polyangiitis (Wegener’s)
Crohn’s disease patient comes in due to a painful leg ulcer that has been expanding over the last 2 months. The patient works as a gardener. Diagnosis?
Pyoderma gangrenosum
-rare inflammatory skin disease that involves growing ulcers
-associated with IBD (inflammatory bowel disease: Crohn’s and ulcerative colitis) as well as RA (rheumatoid arthritic) and malignancy
**may or may not be triggered by local trauma
Lady presents with severe, diffuse headache and nuchal rigidity. Babinski is present bilaterally. CT head w/o contrast shows hyperintense signals within basal cisterns and sulci. Diagnosis?
Subarachnoid hemorrhage
(“worst headache of my life”/ thunderclap, due to rupture of berry aneurysms, hyperintese signals= blood, basal cisterns= areas within the subarachnoid space)
20 year old guy has severe sore throat, pain and difficulty swallowing, and SOB. Was treated for pharyngitis 3 days ago. He has a fever of 104, BP 90/60, HR 115. Exam shows erythema of oropharynx and tonsils, crackles over lungs. Labs show leukocytosis. U/S shows internal jugular vein thrombosis. CXR shows lung nodules w/ cavitation. Diagnosis?
Lemierre syndrome
Caused by the gram negative bug Fusobacterium necrophorum (Fusoform bacteria), which is part of the normal oral flora
- Life-threatening infection that affects young immunocompetent patients
- Starts out as an oropharyngeal infection (pharyngitis, tonsillitis, dental infection, etc.)
- Bacteria invades the lymphatics-> spread to soft tissues (deep space neck infection of parapharyngeal space, specifically carotid space)-> endotoxins promote platelet aggregation in the adjacent internal jugular vein (IJ)-> IJ thrombosis-> throws off septic emboli to body, esp lungs! (explains SOB, lung nodules)
- Consider this in a toxic-appearing patient with SOB/ cough and neck swelling/ tenderness following an oropharyngeal infection
- Culture blood or pus to diagnose, do U/S of IJ and CXR
- Treat with supportive airway management, IV antibiotics (anaerobic coverage), surgery (I and D or vein excision) if not responding to Abx
**YouTube video “EM in 5”
What is the formula for SAAG (serum ascites albumin gradient)? If SAAG is greater than 1, that means the ascites is due to what?
SAAG= (serum albumin)- (ascites fluid albumin)
>1.1 means portal HTN from cirrhosis
Man has persistent abdominal pain with vomiting, appetite loss, and low-grade fever. He is being treated for a seizure disorder. CT shows this. Diagnosis?
Acute pancreatitis
(drug-induced from anti-seizure medication)
*would get labs to show high lipase
*note the CT shows swelling of the pancreas with peripancreatic fluid and fat-stranding (red arrow)
Guy presents with swelling of his left hand and redness extending to his forearm after getting burned from grease splattering as he was flipping burgers at work. Medical history includes “abnormal liver tests” and multiple sexual partners. He has a fever and WBC count with left shift. Hand x-ray shows soft tissue edema. Diagnosis?
Lymphangitis
-inflammation/ infection of the lymphatic channels secondary to infection or burn
*most commonly due to the bacteria group A strep. If fungal, due to Sporothrix.
Lady has a thyroid nodule but no symptoms. It is non-tender and firm. Next step?
Get a serum TSH
- TSH is the first step.
- If TSH is normal-high (meaning TH is prob low= cold nodule= more likely to be cancer)—> this is high-risk. You do an U/S and follow-up U/S if it’s small or FNA if it’s >1cm.
- If TSH is low (meaning TH is prob high= hot nodule= not likely to be cancer)—> this is low-risk. You do a RAIU scan to confirm it’s a hot nodule and treat hyperthyroidism from there (if it were cold, you’d go to U/S and FNA).
How does non-traumatic subarachnoid hemorrhage usually present?
Thunderclap headache (maximal intensity “worst headache of my life” reached in <1 min) + symptoms of meningeal irritation (nuchal rigidity, photophobia, nausea)
*due to ruptured saccular (berry) aneurysms
*noncontrast CT shows bleeding around brainstem and basal cisterns (in subarachnoid space)
Which Parkinson’s medications can cause hallucinations as a side effect?
Dopamine agonists and (less so) Levodopa (L-DOPA)
*The basic idea is more peripheral dopamine-> GI side effects, arrhythmia, orthostatic hypotension. We want to get the dopamine to the brain (since Parkinson’s is a problem with low dopamine). But too much central dopamine in the brain-> neuro side effects like psychosis, hallucinations.
Lady presents with fatigue, anxiety, sleep disturbance for 2 months. She takes OCP’s and smokes marijuana. Thyroid gland is normal sized without nodules. TSH is normal, T4 is high. Explanation for these labs?
Increased thyroid hormone-binding protein (TBG)
*pregnancy or OCP’s (more estrogen)-> increased TBG-> more TBG binds more TH, so TH production increases to maintain the same level of free TH
Patient has a PE. How may this affect serum calcium levels?
Can cause hypOcalcemia
PE-> hyperventilation (blow of more CO2-> low CO2)= respiratory alkalosis (high pH, low H+)-> albumin, which binds up both H+ and Ca2+, will bind less/ release more H+ into serum to try to help with the pH imbalance…this means it will bind MORE calcium-> hypocalcemia (crampy pain, paresthesias
Diagnosis?
Cherry angioma (aka senile hemangiomas)
Most common benign vascular tumor in older adults. They are superficial and do not require treatment (but they don’t go away, so can remove for cosmetic reasons).
**vs. strawberry hemangiomas- also bright red, but bigger and in BABIES
Lady is brought to the hospital from Denny’s after becoming suddenly short of breath. Flow volume loop shows this. Most likely cause?
Fixed upper airway obstruction (obstruction limiting airflow during inspiration and expiration-> flatter curve from the top and bottom)
*since this all started at Denny’s, she probably ate something she was allergic to-> laryngeal edema (give epi! Then antihistamines and corticosteroids)
What is the red flow volume curve?
Obstructive lung disease (like COPD, asthma)
- problem getting air out, so functioning at larger lung volumes (more air left behind in lungs-> air trapping)*
- *Restrictive lung dz (problem getting air in) would have a curve shifted right (less air in= less air out)*
Patient has chronic low back pain. What kind of presentation would make you think it’s due to radiculopathy (compression of spinal nerve root/ “pinched nerve” such as from herniated disc)?
- It radiates below knee (sciatica)
- Positive straight-leg test
- Neurologic deficits
Patient has chronic low back pain. What kind of presentation would make you think it’s due to spinal stenosis?
- Pseudoclaudication (in legs, buttocks when standing)
- Relief with leaning forward
Patient has chronic low back pain. What kind of presentation would make you think it’s due to an inflammatory problem (ex: spondyloarthropathy)?
- Improves with activity
- Sacroilitis (inflammation of sacroiliac joints)
Patient has chronic low back pain. What kind of presentation would make you think it’s due to metastatic cancer?
- Old patient (>50)
- Pain is worse at night
- Pain is NOT relieved with rest
Patient has chronic low back pain. What kind of presentation would make you think it’s due to a mechanical problem (muscles strain, disk degeneration)?
- Normal neuro exam
- Paraspinal tenderness
Patient has chronic low back pain. What kind of presentation would make you think it’s due to an infectious cause (osteomyelitis, discitis)?
- Recent infection or history of IV drug use
- Fever
- Focal spine tenderness
Patient comes into the ED with this red eye. He has no symptoms, just woke up and saw this. Diagnosis and management?
Subconjunctival hemorrhage
Do nothing!
-This is a benign condition due to simple trauma like rubbing the eyes vigorously, violent coughing spells, HTN episodes, or coagulopathy. It is usually from minor bruising and requires zero work-up or treatment (can tell the patient it will go away in 1-2 days, observe it).
It’s itchy. It’s red. It’s so flakey. What is it?
Tinea pedis (“athlete’s foot”)
- caused by dermatophyte fungi
- confirm diagnosis in more severe cases (this patient) with KOH skin prep (showing branched, segmented hyphae) (*if mild, just treat it- if other hyperkeratosic disorders are not on the ddx)
- treat with antifungals (miconazole, terbinafine, tolnaftate)
29 year old has left anterior knee pain, worse when walking up or down stairs. Exam of left leg shows mild quadriceps atrophy. Most likely diagnosis?
Patellofemoral pain syndrome (also called: anterior knee pain syndrome, “runners knee”)
*pain is reproducible with quadriceps contraction w/ a flexed knee (when sitting, squatting)
*treat with physical therapy (strengthen quads and hip aBductors)
40 year old man has fever, sore throat, headache, and a rash. The rash is maculopapular and began on his trunk, but is now all over his body. Grey mucosal patches are seen in his mouth. He is sexually active with 3 partners and denies recent travel or outdoor activities. Diagnosis?
Secondary Syphilis
*Primary-> painless genital chancre
*Secondary-> systemic symptoms (fever, sore throat, headache), widespread lymphadenopathy, grey mucosal patches, raised grey genital papules (condylomata lata), and diffuse maculopapular rash involving the palms and soles
*Treat with one dose of IM Penicillin G benzathine
Man is coming in for follow-up on HTN (on ASA, Lisinopril, Hydrochlorothiazide). His BP today is 160/95. Labs show low K+, low renin. Most likely problem?
Primary hyperaldosteronism
-most common cause of secondary hypertension (usually due to adrenal adenoma or bilateral adrenal hyperplasia)
(High aldosterone-> low renin by neg feedback, also HTN, hypokalemia, met alkalosis)
Patient comes in during summer with this itchy foot lesion. What likely caused this?
Walking barefoot on a sandy beach
-This is Cutaneous Larva Migrans (dog or cat hookworm)
*walk barefoot on sandy beach-> hookworm penetrates epidermis only-> itchy lesion
*give Ivermectin to speed up resolution
25 year old guy has a single non-painful ulcer on his penile shaft and non-tender inguinal lymphadenopathy. He’s sexually active with a new partner. HIV and VDRL testing is negative. What test should you do next to most likely yield the diagnosis?
FTA-ABS (Fluorescent Treponemal Antibody Absorption)
-You can screen for Syphilis with VDRL or FTA-ABS, but FTA-ABS is more sensitive. So, if VDRL comes back negative but the clinical picture fits Syphilis, follow-up with FTA-ABS.
Boy comes in for an eye injury. He was mowing the lawn when an object struck his left eye and now he feels a foreign body sensation but can’t see any object in his eye. His eye is painful, teary, and red. What finding would be most suggestive of acute globe perforation?
A fixed teardrop pupil
- he had a high-velocity projectile injury to the eye, but can’t see an object in his eye, which is concerning for open globe laceration (object penetrated through his eye)
- penetration of the globe usually occurs at the cornea-> stretches the iris-> teardrop pupil
- *get an immediate ophthalmologist consult for surgical repair!
What is hypopyon (an eye finding) and what is it suggestive of?
Layering of inflammatory cells in the anterior chamber of the eye
Suggestive of an inflammatory condition like uveitis or infection like keratitis
(*often seen with ciliary flush, dilation of the vasculature at the junction fo the sclera and cornea)
What does periorbital ecchymosis (raccoon eyes) suggest?
Orbital/ skull fracture
Obese 50 year old man has right-sided hip pain that makes it difficult for him to lie on that side while sleeping. He describes the pain at burning on the outer surface of the thigh. On exam, there’s tenderness over the lateral aspect of the right hip and buttock with deep palpation. Neuro exam is normal. Diagnosis?
- *Trochanteria** bursitis aka
- *Greater trochanteric pain syndrome**
- inflammation of the bursa over the joint
- presents with lateral hip pain, tenderness over greater trochanter during flexion (*X-ray is commonly done to r/o other hip disorders)
*treat with NSAIDs and PT (corticosteroid injections if refractory)
**not stress fracture of the femoral neck (this is more common in an athlete)
**not hip osteoarthritis (usually affects medial joint)
45 year old man fell down a flight of stairs from missing a step. He has neck and shoulder pain afterward and complains of numbness/ weakness in the left upper extremity. On exam, he has left-sided weakness with elbow extension and wrist flexion and decreased pain sensation in the index and middle finger. CT spine shows this. Most likely diagnosis?
Facet dislocation (of C6)
- (Facet joints link vertebrae together)
- falling onto a flexed neck
- C6/C7 vertebral bodies affected-> C7 radiculoapthy (pinched nerve root)-> weakness of triceps extension and wrist flexion + numbness of index and middle finger
- *treat with neck stabilization (spinal precautions) and surgery
40 year old man presents with dysphasia to solids and liquids and weight loss. Standing upright makes swallowing easier. Barium esophagogram is shown. Diagnosis?
Achalasia
-chronic dysphasia (difficulty swallowing) solids and liquids, difficulty belching, weight loss (due to not eating much bc it’s hard to swallow)
*note that barium esophagram can be helpful in diagnosis, but manometry (tube down esophagus and you get a recording of esophageal motility) is the most sensitive test for diagnosis
(Absent myenteric plexus-> impaired esophageal motility and relaxation of LES-> “bird-beak esophagus”)
Man with PMH of HTN and DM has dizziness with N/V when playing tennis. He’s had prior episodes of dizziness when working with his arms. His left arm feels heavy with exertion. BP is 140/90 on the right arm, 100/70 on the left arm. Exams reveals a left bruit above the clavicle and S4 heart sound. Diagnosis?
Subclavian artery occlusion
(subclavian steal)
-atherosclerosis of left subclavian (bruit above left clavicle, lower BP on left arm)-> when using arm, there’s inc demand for blood flow-> blood flow goes in opposite direction through vertebral artery to meet the high demand (subclavian is “stealing” blood from vertebral artery)-> vertebrobasillar ischemia (since blood is getting re-routed away from the brain, patient’s who already have atherosclerosis of the circle of Willis can develop dizziness)
50 year old woman with PMH of HTN, recent URI, and smoking hx presents with severe dizziness and nausea, which began when her head was tilted back and to the left while getting her hair washed at the salon. BP is 140/90. She has nystagmus and impaired pain sensation on the left face and right upper/ lower extremities. Diagnosis?
Lateral medullary (Wallenberg) syndrome
Due to dissection of the left vertebral artery
- ipsilateral loss of pain/ temp in face
- controlateral loss of pain/ temp in the body
- nystagmus
- Horner syndrome
Are LH and TSH high, low, or normal in prolactinoma?
LH- low
TSH- normal
- Prolactin inhibits GnRH-> decreased release of LH
- It goes (hypothal) TRH-> (ant pituitary) prolactin. And (hypothal) TRH-> (ant pituitary) TSH-> (thyroid glands) TH. Both share the TRH precursor. So, high prolactin-> dec TRH-> dec TSH and TH.
Teenager presents with hair loss for 2 mo. She had mild itching before loss of hair, otherwise no symptoms. She takes OCPs, no other meds. Diagnosis and next step?
Alopecia areata (autoimmune attack of hair cells)
Give topical corticosteroids (ex: intralesional triamcinolone)
*recurrence is common, but the condition doesn’t cause permanent damage to hair follicles, so usually hair grows back
35 year old woman has worsening leg swelling for 2 mo. She also has had fatigue, achy pain in her hands, and respiratory illness. Exam shows bilateral lower extremity edema, mildly swollen and tender finger and wrist joints, and decreased breath sounds at the left lung base. Labs show low Hb, low platelet count, and high Cr. U/A is positive for protein and blood in the urine. Diagnosis?
SLE (lupus)
*anti-DNA immune complexes-> renal dz
Lady presents with fatigue. Rest of history and physical is unremarkable. Labs show normal Mg, normal albumin, low calcium, high PTH. Next step?
Get a serum 25-Vit D level
-This sounds like Vitamin D deficiency (due to inadequate dietary Vit D intake, inadequate sunlight, or a malabsorption disorder)
*it’s important to note that Mg adn albumin levels are normal. If Mg is low, that can be why Ca2+ is low (low Mg-> low Ca, P, K). If albumin is low, you have to correct for the calcium–might not truly be low.
What empiric treatment for bacterial meningitis do you give a patient that is age 2-50?
Vancomycin + 3rd gen Cephalosporin (Ceftriaxone or Cefotaximine)
*Vanco will cover cephalosporin-resistant pneumococci.
What empiric treatment for bacterial meningitis do you give a patient that is age >50?
Vancomycin + 3rd gen Cephalosporin (Ceftriaxone or Cefotaximine) + Ampicillin (or Bactrim)
Also consider giving empiric Dexamethasone (steroids) to prevent neuro complications (deafness, focal deficits) in case it is strep pneumo meningitis.
*Vanco will cover cephalosporin-resistant pneumococci. Ampicillin will cover Listeria.
What empiric treatment for bacterial meningitis do you give a patient that is immunocomprimised?
Vancomycin + Cefepime (4th gen cephalosporin) (or Ceftazidime or Meropenem) + Ampicillin (or Bactrim)
Also consider giving empiric Dexamethasone (steroids) to prevent neuro complications (deafness, focal deficits) in case it is strep pneumo meningitis.
*Vanco will cover cephalosporin-resistant pneumococci. Ampicillin will cover Listeria.
What empiric treatment for bacterial meningitis do you give a patient that had a neurosurgery or penetrating skull trauma?
Vancomycin + Cefepime (4th gen cephalosporin) (or Ceftazidime or Meropenem)
Also consider giving empiric Dexamethasone (steroids) to prevent neuro complications (deafness, focal deficits) in case it is strep pneumo meningitis.
*Vanco will cover cephalosporin-resistant pneumococci.
25 year old female presents with skin rash and pain in her wrists, ankles, and elbows for 4 days. She also has fever and sweats. She recently went on vacation and had unprotected sex with her new boyfriend. Exam is notable for pain along the tendon sheaths with active and passive movement. Diagnosis?
Disseminated gonococcal infection
TRIAD:
- Polyarthralgias (pain in multiple joints)
- Tenosynovitis (inflammation of the flexor tendon sheath in the wrist)
- Vesiculopustular skin lesions (2-10 of them)
*occurs in 1-2% of Gonorrhea cases
75 year old lady has hyperthyroid symptoms. T4 is elevated at 4.7 (normal= 0.9-1.7) and TSH is low (<0.001). Radioactive iodine uptake is significantly increased and diffuse. She is started on a beta-blocker. Best next step?
Start Methimazole
*In patients with mod-severe hyperthyroidism (TH >2-3x the normal) and in elderly patients/ multiple comorbidities (high risk of complications with radioactive ablation due to the transient hyperthyroidism it causes) it is recommended to stabilize them with a beta-blocker + antithyroid med (Methimazole, PTU) first. THEN you can do definitive treatment (radioactive ablation or thyroidectomy).
Man comes in with this rash on his lower back/ buttocks. He said it was burning and itching in the area, and then the red rash developed. Diagnosis?
Herpes Zoster (Shingles)
*treat with an antiviral agent like Acyclovir (best if given within 72 hrs)
60 year old lady with PMH of breast cancer s/p lumpectomy and radiation complains of low back pain for 2 wks, worse with bending over while gardening. It wakes her from her sleep. She has no other symptoms or physical exam findings. Next best step?
Lumbosacral spine imaging
*most cases of lower back pain are benign and do NOT need imaging for work-up, but if there are red flags you need to do imaging (sudden onset pain w/ spinal tenderness, history of cancer, constitutional symptoms, trauma, neuro deficits, risk of spinal infection like recent infection or immunosuppression or IV drug use)
*she has a hx of breast CA and pain so bad it’s waking her from her sleep- this is suspicious for bony metastasis so get an x-ray and inflammatory markers (ESR)!
What physical exam finding would you expect in this patient?
Right hemi-ataxia
*This CT is showing the part of the brain at the level of the nose…the cerebellum
*Notice the bleed (hemorrhagic stroke) on the RIGHT side
*Cerebellar strokes cause deficit on the same ipsilateral side (vs. cortex strokes cause ipsilateral facial problems + controlateral body problems)
30 year old woman has right shoulder pain and weakness after returning from her backpacking trip. She has weakness on right shoulder aBduction and external rotation. Most likely cause?
Suprascapular nerve injury
*the suprascapular nerve innervates the supraspinatus and infraspinatus muscles
*heavy backpacks can compress this nerve-> tenderness
*give NSAIDs and avoid use of backpacks
85 year old lady with Alzheimer’s disease, chronic a-fib, and HTN has had progressive confusion and lethargy for the past several hours. BP is 170/100, HR is 70 and irregularly irregular. EKG shows a-fib. On exam, she’s somnolent (drowsy) but arousable and has diminished pain sensation not he left side. CT head shows this. Diagnosis?
Amyloid angiopathy
-Beta-amyloid deposition in the walls of small-med sized cerebral arteries-> weakening of the cerebral arteries-> lobular hemorrhage
*this is the most common cause of spontaneous lobular hemorrhage, particularly in the elderly and is associated with Alzheimer’s disease (remember, in Alzheimer’s you get A-beta amyloid misfolded protein deposits in the brain)
What tests do you do for work-up of suspected acromegaly (in order)?
- IGF-1 level
- Oral glucose suppression
- MRI brain looking for pituitary mass (somatotroph adenoma)
Young female runner presents with pain in the right forefoot. When the 3rd and 4th metatarsal heads are squeezed together on exam, she feels a clicking sensation and burning pain over the plantar surface of the foot. Diagnosis?
Morton (interdigital) neuroma
-mechanically induced degeneration of the interdigital nerves (thickening of the tissue around one of the nerves leading to your toes)
*lateral compression of metatarsal heads reproduces pain
*palpation may reveal crepitus (Mulder sign)
*treatment is supportive: metatarsal support or _padded shoe insert_s
40 year old man presents with worsening joint pain and deformity. Hands look like this. Diagnosis?
Tophaceous Gout
(these are tophi from monosodium urate crystals in the synovial fluid of the joint space)
21 year old complains of sore throat, extreme fatigue, myalgias, and headaches for a week after returning from a Jamaica trip. She has a fever of 100.4, tonsils with exudates, and generalized lymphadenopathy and splenomegaly. CBC shows leukocytosis. Peripheral blood smear shows this. Rapid strep antigen and heterophile antibody tests are negative. Most likely diagnosis?
Infectious mononucleosis (EBV)
*negative heterophile antibody (Monospot) test does NOT r/o mono. It is specific for EBV and detects EBV antibodies that agglutinate to horse RBCs, but you can get false negatives early in the disease course.
*repeating the Monospot test after several days or checking the anti-EBV IgM or IgG antibodies can help establish the diagnosis.
Man presents with intermittent upper abdominal pain and nausea for 6 months, worse after meals. He lost weight and has occasional diarrhea. Past history is significant for heavy alcohol consumption and hospitalization 5 years ago due to acute abdominal pain. Diagnosis and what test will establish this diagnosis?
- *Chronic pancreatitis**
- *CT abdomen** (looking for pancreatic calcifications)
*this is a chronic issue (hospitalized with what sounds like acute pancreatitis in the past, drinks alcohol, fits the symptoms, going on for 6 months)
70 year old female with PMH of HTN and a-fib is brought in due to sudden-onset weakness and numbness. Her symptoms got worse over several minutes and she later also had nausea/ vomiting. Her meds are Amlodipine, Metorpolol, Warfarin, and over-the-counter cold meds recently. BP is 170/90. Labs show prolonged PTT (30 sec) and INR of 5. CT head shows this. Diagnosis and immediate treatment?
Warfarin-associated intracerebral hemorrhage
- notice INR of 5 (too much bleeding, as the therapeutic range is 2-3)
- likely provoked by use of over-the-counter cold meds, which often contain acetaminophen (makes effects of warfarin stronger) and decongestants like phenylephrine (alpha-1 agonist, so vasoconstricts and raises BP)
- symptoms of inc ICP (headache, N/V, altered mental status) can develop as the hemorrhage expands
IV Vitamin K + Prothrombin Complex Concentrate (PCC)
- Vit K reverses Warfarin by promoting clotting factor synthesis in the liver, but takes 12-24 hrs
- PCC contains the Vit K-dependent clotting factors (2, 7, 9, 10) for quick short-term reversal
- Fresh frozen plasma (FFP) is not really used unless PCC is not available—it takes longer to prepare/ administer
What MD Calc tool do you use to make a diagnois of infective endocarditis?
Duke’s criteria
What is this?
Melanocytic nevus
Dentist comes in complaining of itchy, dry skin on the hands. Diagnosis?
Contact dermatitis
(likely 2/2 frequent hand washing)
Man is stabbed in the back. He now has no motor function in the right lower extremity. Patellar reflex, Achilles reflex, and Babinski sign are absent on the right. There is loss of light touch and proprioception below the right costal margin. Pinprick is lost on the left at and below the umbilicus. Most likely location of injury?
Right hemisection at T8
This is spinal cord hemisection (entire half of spinal cord affected) aka Brown Sequard syndrome
Right hemisection-> loss of motor (CST) on right, loss of proprioception/ vibration (DC-ML) on right, and loss of pain/ temp (STT) on LEFT
**all ipsilateral except pain/ temp bc the STT tract crosses at the spinal cord and note that some fibers cross 2 levels below
Patient in a car crash has a displaced fracture of the right C5 lamina, with slight subluxation (dislocation) of the right C5-C6 facet joint (connecting the vertebrae). On exam, the patient has weakness of right wrist extension + loss of pinprick sensation in the right thumb. What study should you get?
CT of the thoracic and lumbar spine
*lamina fractures occur with neck hyperextension (car crash)
*subluxation (partial dislocation) can affect the associated spinal nerve root-> monoradiculopathy
*weakness on right wrist extension + loss of pinprick sensation on right thumb= C6 radiculopathy (compression of spinal nerve root)
The presence of a single vertebral fracture in a patient with blunt trauma is an indication to image the entire spine!
80 year old patient is brought in due to unsteadiness and recurrent falls. There is hyperreflexia of the lower extremities and wide-based gait. CT shows this. Diagnosis and initial step to confirm diagnosis and treat?
Normal pressure hydrocephalus (NPH)
High-volume lumbar puncture
(LP confirms opening pressure is normal + if that improves gait you got your diagnosis and initial treatment. *ventricular shunt placement to divert away excess CSF is the definitive treatment)
- CSF accumulation-> increased ventricular size (ventriculomegaly) w/o persistent elevations in intracranial pressure
- “wet, wobbly, and wacky” (triad of urinary incontinence, gait dysfunction, and cognitive impairment), but all 3 are not required!
How can you tell the difference between acute vs subacute cardiac tamponade by the CXR?
Acute cardiac tamponade-> normal cardiac silhouette (blood rapidly accumulated like in trauma, so heart didn’t have time to adapt)
Subacute cardiac tamponade-> globular cardiac silhouette as shown in this picture (blood gradually accumulated like in cancer or renal failure, so heart had time to adapt by stretching out)
What is this?
Torus palatinus (TP)
A benign bony growth (can be congenital or develop later in life)
*surgery is done to remove it if it becomes symptomatic, interferes with speech or eating, or causes problems with dentures
Lady fell on her outstretched hand and injured her right wrist. She developed paresthesia in her right hand. Diagnosis and what problems may this cause?
Colles fracture of the distal radius
- > pain, swelling, dinner-fork deformity
- dorsal displacement of the radius compresses the median nerve-> acute carpal tunnel symptoms-> paresthesia, impaired thumb aBduction (*may also get reduced sensation over anterolateral hand)
What is this?
Subdural hematoma (from tearing of bridging veins)
Nursing home paitent with diabetes and HTN is evalutated for a food ulcer. What is this?
Pressure (decubitus) ulcer
*risk factors: impaired motility, malnutrition, abnormal mental status, decreased skin perfusion, reduced sensation
*most common over bonds prominences
*manage with repositioning of the patient to reduce pressure, pain control, and nutritional support
What will most likely establish the diagnosis?
Colonoscopy
- Notice there are multiple liver lesions on the CT scan–this suggests metastasis to the liver rather than primary liver cancer
- Most common cancer to metastasize to the liver is colon cancer (also think of lung and breast cancers, but not as common to met to the liver as colon ca)
A pregnancy in the cornual area of the uterus is what type of pregnancy?
Ectopic pregnancy
Paitent has neck pain and numbness over her ring and little fingers. Exam shows weakness of all intrinsic hand muscles, but no loss of reflexes. What nerve root is likely to be involved?
C8
- Ulnar nerve (root C8) innervates intrinsic hand muscles and is responsible for sensation in the pinky and ring fingers (*median nerve provides sensation to other digits)
- Intact reflexes: biceps (C5, C6) and triceps (C7, C8) (“1, 2 buckle my shoe. 3, 4 shut the door. 5, 6 pick up sticks. 7, 8 lay them straight.”)
What is this? What’s the treatment?
Subdural hematoma
(torn bridging veins)
Minutes after removal of an internal jugular venous catheter, a patient develops acute-onset SOB and cough and is in respiratory distress. O2 sat is 85%, jugular veins are distended, breath sounds normal and equal on both sides. In addition to high-flow oxygen supplementation, what position should you put the patient in?
Left lateral decubitus position (roll patient on left side)
- This is Venous air emboli, a complication of removing a central line catheter (when pulling out, there’s a moment where it’s open to air and an air bubble can form)
- You want pt on their left side bc air rises—so this will push the air bubble to the highest point/ lateral wall of the RV out of the way (if pt were on right side, air bubble would be on intraventricular septum/ outflow tract in the way)
- *Patient is presenting with SOB here bc the bubble was momentarily blocking the RV outflow tract, but did not yet get to the lungs-> PE (intervene with this placement in this position until high-flow oxygen or hyperbaric oxygen can dissolve it)
Diagnosis?
Mobitz type I 2nd-degree AV block (Wenckebach)
- “Longer, longer, longer, drop- this is how you Wenckebach” (PR interval elongates before it drops vs. Mobitz type II where QRS beats randomly drop w/o a change in PR interval length)*
- *When deciding between Mobitz I or II: always look at PR interval and ask yourself is it getting longer? If yes-> type I/ Wenckeback**
Guy comes in due to ankle pain after jumping in the air and landing on his friend’s foot. The lateral aspect of his right ankle is swollen and tender to palpation over the lateral malleolus. He can plantar flex and dorsiflex and sensation is normal. Next step?
X-ray the ankle
*based on Ottawa ankle rules, x-ray is indicated to check for fracture if there is pain in the malleolar region + bony tenderness at the lateral/ medial malleolus or inability to bear weight/ walk 4 steps.
What is it?
Ganglion cyst
Lady with PMH of GERD during pregnancy presents with substernal discomfort and nausea for several months. She gets these episodes after eating and sometimes makes herself throw up to relieve her symptoms. 2 weeks ago, she also felt like food was stuck in her chest. Chest imaging shows a retrocardiac air-fluid level. Underlying diagnosis?
Paraesophageal Hiatal hernia
- most hiatal hernias (90%) are sliding hiatal hernias- the proximal stomach herniates into the chest-> GERD/ heartburn symptoms
- managed medically
-
paraesophag_eal_ hiatal hernias- the fundus of the stomach herniates into the chest through a diaphragmatic membrane defect-> compression of stomach and surrounding organs (esophagus, lungs)-> abdominal fullness, dysphagia (difficulty swallowing), epigastric or chest pain, N/V
- managed surgically
- retrocardiac air-fluid level (stomach bubble up in thoracic cavity/ chest) suggests paraesophageal hiatal hernia (but can be seen in sliding too). Confirm w/ barium swallow or upper GI endoscopy!
Sliding hiatal hernia vs. paraesophageal hernia?
-
Sliding hiatal hernia- proximal stomach herniates into the chest-> GERD/ heartburn symptoms
- managed medically
-
Paraesophageal**** hiatal hernia- fundus of the stomach herniates into the chest through a diaphragmatic membrane defect-> compression of stomach and surrounding organs (esophagus, lungs)-> abdominal fullness, dysphagia (difficulty swallowing), epigastric or chest pain, N/V
- managed surgically
40 year old woman with recent URI complains of SOB and fatigue for 2 weeks. BP is 98/55, HR 105. Jugular veins are distended, lungs clear. CXR shows this. Diagnosis?
Large pericardial effusion-> Cardiac tamponade
- recent URI (pericardial effusions are often idiopathic, but can be triggered by viral illness), SOB, elevated JVP (fluid around the heart is restricting it from filling/ pumping, so blood backs up), clear lungs, large cardiac silhouette on CXR
- Beck’s triad: (1) hypotension, (2) elevated JVP, (3) muffled heart sounds
- “water bottle” shaped heart
Is lateral hip pain more likely due to osteoarthritis or greater trochanteric pain syndrome (trochanteric bursitis)?
trochanteric pain syndrome (trochanteric bursitis)
Obese lady complains of lateral hip pain for 2 months. It is burning and worse with rising from chairs or going up stairs. Exam shows point tenderness over the greater trochanter and worsened pain with passive leg aBduction. Diagnosis and management?
Greater trochanteric pain syndrome
(trochanteric bursitis)
NSAIDs. If that doesn’t work, local corticosteroid injection
- overuse syndrome involving gluteus medius + minimus tendons, which run over the greater trochanter
- presents with chronic lateral hip pain worse with repetitive hip flexion (climbing stairs, walking uphill, lying on affected side)
65 year old smoker man comes in due to sudden-onset chest pain followed by syncope. BP is 190/110, pulse is 100 and regular. There is a S4 and EKG shows LV hypertrophy. Troponin is normal, D-dimer elevated. CT chest shows this. Diagnosis and management?
Acute ascending aortic dissection
*syncope likely due to the fact that some blood is leaking into the aortic wall rather than perfusing organs- the brain
*CT here is showing both ascending and descending parts of the aorta (cut at a level where both are in the picture)- notice the intimal flap
Man presents with painful nodular lesions associated with foul odor. He’s had this for 1 year, but it has been worse the last few months. The lesions are in both axillae bilaterally. Diagnosis?
Hidradenitis suppurativa (aka acne inversa)
- most commonly occurs in intertriginous areas (skin folds where skin rubs against skin—axilla, inguinal, perineal areas)
- risk factors: family hx, smoking, obesity, DM, mechanical stress on the skin
- due to chronic inflammatory blockage of folliculopilosebaceous units-> prevents keratinocytes from properly shedding from the follicular epithelium
What is this?
A furuncle
- skin abscess, usually due to staph a.
- painful pustule/ nodule, usually draining pus
What is this?
Intertrigo
- due to infection with Candida
- well-defined erythematous plaques with vesicles/ pustules in intertiginous (skin fold areas) and occluded skin areas
60 year old lady comes in for acute leg pain. She recently started an exercise program and felt right knee and calf pain. She then developed swelling of her right calf and ankle. Exam shows tenderness and induration at the medial head of the gastrocnemius (calf), pitting edema at the ankle, and a crescent-shaped patch of ecchymoses at the medial malleolus (of the ankle). Most likely cause?
Ruptured popliteal (Baker) cyst
- excessive synovial fluid formation (due to osteoarthritis or RA) + pressure on knee during extension-> passage of fluid into bursa and cyst enlargement (*popliteal cysts are usually asymptomatic and present as a chronic, painless bulge behind the knee most noticeable with knee extension)
- rupture of popliteal cyst (following strenuous exercise)-> posterior knee and calf pain and tenderness w/ swelling of the calf resembling a DVT
- how do you confirm? Ultrasound to r/o DVT and confirm popliteal cyst rupture (*also look out for “crescent sign”)
60 year old lady with CKD has right knee pain + swelling. She fell on her knee and heard a popping sound. Exam shows a right knee effusion with bruising. The patella is midline. Range of motion is limited by pain. X-ray is shown. Diagnosis?
Patella tendon rupture
- X-ray shows a high-riding patella bone
- rupture of the quadriceps-patellar tendon complex can occur with sudden, forceful contraction fo the quads (such as in deceleration from a fall)
*CKD patients have more fragile tendons (so this medical hx put her at increased risk)
45 year old patient has low-grade fever, abdominal pain, and bloody diarrhea for 2 months, worse today. She lost 10 lbs. On exam, she appears dry and has diffuse abdominal tenderness. Labs show anemia and leukocytosis. Diagnosis?
Toxic megacolon
- fever, 2 mo bloody diarrhea, weight loss (due to chronic diarrhea)-> ulcerative colitis (UC)
- this presentation + imaging suggest toxic megacolon, a complication from inflammation extending to the smooth muscle layer-> muscle paralysis and colonic dilation
- **medical emergency because it can lead to colonic perforation. Treat with IV fluids, broad-spectrum antibiotics, bowel rest (NG tube decompression), and IV corticosteroids for IBD-induced
60 year old woman with PMH of CAD and T2DM has RUQ pain, N/V, and fever for 1 day. Labs show leukocytosis, blood glucose of 350, and mildly elevated total bili, alk phos, ALT, and AST. Imaging shows distended gallbladder with gas in the gallbladder wall and lumen. Diagnosis?
Emphysematous cholecystitis
-life-threatening form of acute cholecystitis (gallstone lodged in cystic duct, causing inflammation) caused by gas-forming bacteria (Clostridium p., E. Coli strains)
*may feel crepitus in abdominal wall
*confirm with imaging showing gas in gallbladder (air-fluid levels)
**more common in patient with immunosuppression (including DM) or vascular disease
Lady comes in with fever and this. She’s a dishwasher and wears rubber shoes all day. It’s been itchy between her toes for 6 months and skin there is flakey. Exam shows erythema and edema and her foot feels warm. Right inguinal lymph nodes are mildly tender. Diagnosis?
Cellulitis
- bacterial infection involving the deep dermis or subcutaneous fat
- breaks in skin (trauma, insect bite, preexisting skin condition—in her likely due to tines pedis/ athletes foot, explaining the itching and flaking)-> gram (+) bacteria (staph, strep) gains entry
80 year old man has fever, productive cough, and SOB for 3 days. His wife reports he coughs, chokes, and has nasal regurgitation when swallowing solids or liquids. He says food “gets stuck” in his throat. Lung exam shows crackles in the lower lung and CXR confirms PNA. Next step in evaluating his dysphagia?
Videofluoroscopic modified barium swallow
- This is oropharyngeal dysphagia (vs. esophageal dysphagia)
- Trouble initiating swallowing (can’t properly transfer food from the mouth to the pharynx due to underlying stroke, dementia, oropharyngeal malignancy, or neuromuscular disorders like MG)
- Aspiration PNA is a complication
When evaluating dysphagia (trouble swallowing), what do you need to distinguish between?
- *Oropharyngeal dysphagia** (trouble initiating swallowing, cough/ choking, nasal regurg)
vs. Esophageal dysphagia
Soccer player comes in due to buckling of her right knee when her foot was planted. She heard an audible pop and limped off the field with assistance. Exam shows swelling and limited range of motion due to pain. There is increased anterior translation of the tibia on the femur compared to the good side. Diagnosis?
ACL injury
- common in young athletes with pivoting (soccer, b-ball, tennis)
- rapid onset “popping” sensation-> swelling (due to hemarthrosis/ bleeding into the joint space)
- laxity of tibia relative to the femur= positive anterior drawer test
60 year old lady comes in for a routine exam. You palpate a firm, nontender mass in her RUQ. CT shows this. What does she have and what’s she at risk for?
- *Porcelain gallbladder**
- inc risk for gallbladder adenocarcinoma
*means the gallbladder is calcified and brittle (thought to be due to chronic inflammation from gallstones-> deposition of calcium salts)
*do a cholecystectomy to get it out
70 year old man has worsening RUQ pain, fever/ chills, and anorexia for 2 days. He was treated for acute diverticulitis 4 wks ago. Labs show leukocytosis and elevated alk phos and LFTs. CT abdomen is shown. You get blood cultures. What’s your next step?
Percutaneous aspiration
-this is a pyogenic liver abscess
*can result from direct spreads from the biliary tract or from hematogenous seeding of distal infection, esp in the portal system (diverticulitis got into the bloodstream and resulted in this liver abscess)
*get blood cultures, give antibiotics, and aspirate/ drain it
30 year old man is brought in after a vehicle accident. He has ecchymoses and tenderness in the distribution of his seat belt. CXR shows fracture of the left 6th rib w/o pneumothorax. FAST exam is negative. CT abdomen shows a thick proximal small bowel and small mesenteric hematoma. Over the next day of hospitalization, his abdominal pain gets worse with N/V. Repeat CT shows this. What’s going on and what’s your next step?
- *Perforated viscus** (there is intraperitoneal free air)
- do surgery!
*GI perforation is more often associated with penetrating abdominal injury, but it can also occur with blunt abdominal injury (car crash)
*A perforation can be acute or delayed (his was delayed 1 day—initial CT showed a thick small bowel + hematoma. The bowel may ruptured due to the fact it was already thick/ edematous or due to the injured vasculature causing hematoma-> ischemia and necrosis.)
Lady goes into labor. A few days later, she develops fever/ chills, lower abdominal pain, and hypotension thought to be due to postpartum endometritis. She is given NS for hypotension. The next day, she develops SOB, has bilateral crackles, pulse ox is 80%. She is intubated and the new CXR is shown on the right. After intubation, ABG shows PaO2 of 60 while receiving 100% O2, PaCO2 of 25. Diagnosis?
ARDS
- has sepsis 2/2 postpartum endometritis
- bilateral lung infiltrates
- P/F (PaO2/FiO2) ratio is 60/100 (FiO2= 100% oxygen she received)= 60
- In ARDS, the P/F ratio is <300
55 year old man with PMH of GERD (on Omeprazole for years) presents with tingling in both legs. Lower extremity muscle strength is intact, but sensation to light touch and vibration are reduced. Next step?
Serum vitamin B-12 level
-chronic PPI use-> decreased stomach acid-> can’t dissociate B12 to bind to R-binder (normally released by salivary glands and binds in the stomach)-> can’t bind IF in the duodenum-> can’t absorb vitamin B-12
PERNICIOUS ANEMIA 2/2 PPI USE
Man is brought in due to motorcycle trauma. BP is 85/50, HR 130. Airway- intact, Breath sounds- normal, Circulation- heart sounds normal. There is bruising over the chest and abdomen and left flank. The abdomen is tender with no rebound tenderness. The pelvis is unstable to gentle downward pressure. There is blood at the urethral meatus. CXR shows rib fractures w/o pneumothorax. FAST exam is negative. Pelvic x-ray is shown. You give IV fluids and/or blood products. Next step?
Placement of a pelvic binder
-Since there is blood at the urethral meatus indicating pelvic fracture-> urethral and/or bladder injury, you need to do a retrograde cyst o urethrogram! But, 1st step is to stabilize the patient! He has shock in the setting of severe pelvic fracture, so you need to stabilize the hip to prevent further bleeding while working on the patient.
30 year old lady presents with hearing loss in her right ear. She had nasal congestion, rhinorrhea, and cough for 1 week. Was on a plane 3 days ago when she developed hearing loss and severe pain in her right ear and noticed a drop of blood on her finger when scratching her ear canal. Symptoms resolved except the hearing loss. Diagnosis and next step?
Barotrauma of the ear complicated by rupture of the tympanic membrane (TM)/ eardrum
Reassurance (will heal spontaneously in a few weeks) and follow-up exam
Normally, the Eustachian tube opens intermittently (during swallowing, yawning, etc.). URI-> Eustachian tube doesn’t open adequately (clogged)-> pressure difference between the middle ear and outside environment. Get on a plane-> makes the pressure difference greater-> stretches the TM-> ear pain + hearing loss. In severe cases you get TM rupture to equalize pressures-> bleeding.
Diagnosis?
A-flutter
(*treat like A-fib)
35 year old man comes in due to right knee pain after jumping and landing on his planted foot with a partially bent knee on the football field. He heard a loud popping sound, felt immediate pain, and hasn’t been able to walk since. There’s a large effusion over his right knee with low-lying patella and he can’t straighten it or bear weight on it. Diagnosis?
Quadriceps tendon rupture
- sudden, forceful contraction such as in deceleration from a fall can rupture the quadriceps-patellar tendon complex (loud pop, inability to do knee extension)
- key: “low-riding patella”
- (vs. if the patella ligament tore, that would cause a high-riding patella bone)
- risk factors: CKD, hyperPTH, steroid abuse, fluoroquinolones
- dx with MRI
- surgery to repair full tears
Diagnosis?
Multifocal atrial tachycardia (MAT)
Diagnosis?
A-fib
Surfer comes in with this skin lesion. Diagnosis?
Nodular malignant melanoma
- grows vertically rather than horizontally (as in most superficially spread cases of melanoma), so has few of the ABCDE melanoma criteria
- suspicious for this if 1+ of these criteria:
- ugly duckling sign (a lesion that looks different from all the rest of the pigmented nevi)
- elevation from the skin (nodular, pedunculated/ on a stalk)
- firm to palpation
- continuous growth over a month
Diagnosis?
Cherry hemangioma
Benign vascular skin lesion of capillaries
Diagnosis?
Angiosarcoma
Rare tumor of blood vessels. Usually occurs in pts with past radiation exposure
Diagnosis?
Basal cell carcinoma
Diagnosis?
Seborrheic keratosis
pigmented “stuck-on” skin lesions
Man has this skin bump on his lower back for 2 months. He had a similar bump here months ago that resolved on its own. It is painless, firm, and mobile. Diagnosis?
Epidermal inclusion cyst
-benign nodule lined w/ squamous epithelium with core of keratin + lipid
(aka epidermal cyst)
Diagnosis?
Basal cell carcinoma
Diagnosis?
Squamous cell carcinoma
Dermatofibroma
Benign fibroblast proliferation (has center dimpling/ “button-hole sign”)
Diagnosis
Lipoma
Benign fat tumor
70 year old man with PMH of DM, diabetic nephropathy, HTN, a-fib (on Warfarin), and chronic leg cellulitis presents with weakness, dizziness, and back pain. BP is 120/70, HR 110. Labs show mild leukocytosis and Hb of 7. CT is shown. Diagnosis?
Retroperitoneal hematoma
- on anticoagulation, weakness/ dizziness, anemia, tachycardia-> internal hemorrhage
- back pain and CT suggest hematoma at the right retroperitoneum
Basketball player injured his right shoulder. His aBducted and externally rotated arm was forced back by an opposing player. There is asymmetry of the right shoulder compared to the left, and the right arm is held in slight aBduction and external rotation. Pulses are intact. What’s the most likely injury and deficit he will have if left untreated?
Anterior shoulder dislocation
If untreated-> weakened shoulder aBduction and decreased sensation over the lateral shoulder
- anterior dislocations happen due to a blow to an externally rotated and aBducted arm
- anterior dislocations may cause injury to the axillary nerve (remember the ARM mnemonic)
- axillary nerve innervates the teres minor and deltoid-> shoulder aBduction and sensation over the lateral shoulder
4 year old boy comes in due to vague chest discomfort. 2 months ago, he was involved in a car accident and sustained minor injuries. Lungs have decreased air entry into the left lower base. X-ray is shown. Next step?
CT chest and abdomen
*then you are going to do surgery
- this is a diaphragmatic rupture-> herniation of abdominal convents into the thoracic cavity!
- can occur after blunt trauma and be asymptomatic…until the tear in the diaphragm expands in the kiddo overtime and bowel pushes through
*more common in the left diaphragm (right diaphragms got the liver securing it)
Lady comes in due to worsening fever and sore throat. She accidentally swallowed a fish bone that scratched her throat 4 days ago and ever since has had a sore throat and difficulty swallowing. Exam shows stiff neck, pooling of saliva in the hypopharynx, and a red posterior pharynx. Lateral radiographs of the neck show increased thickening of the soft tissues and an air-fluid level. Due to spread, what is the patient at risk for developing?
Acute necrotizing mediastinitis
-fish bone cut back of throat-> infection seeps into prevertebral “danger zone” space-> continuous with the mediastinum, so can progress to mediastinitis
*air-fluid level in this context= (retropharnygeal) abscess (pus + air, or a gas-producing organism)
55 year old smoker presents with new-onset SOB 3 days after undergoing a right hemicolectomy. Pulse ox is 88%. Lung exam shows dullness to percussion and absent breath sounds on the left. CXR is shown. Diagnosis?
Severe atelectasis (all over his left lung)
-due to left mainstem bronchus mucus plug
(Just had surgery + a smoker, so gets mucus built up in airways-> mucus plugging prevents alveoli from filling with air-> collapse)
- dullness to percussion= fluid/ blood in lungs or lack of air in lungs from collapse (more dense)
- absent breath sounds= not moving air
- *notice the mediastinal shift to the left (atelectasis pulls it toward that side)
- **NOT ARDS, as this would be a white-out/ infiltrates of BOTH lungs—not just one side
What medications can you give for neuropathic pain (such as in diabetic neuropathy)?
TCAs (amitriptyline, nortriptyline) AND Gabapentin, Pregabalin
*others listed on this chart
*CAUTION: avoid TCAs in old patients (anticholinergic affects) and avoid opioids if possible (dependence)
60 year old man with T1DM and HTN comes in due to difficulty walking and mild left foot pain for months. Exam shows a deformed left ankle and foot. X-ray with weight bearing shows bone loss, large osteophytes, and extraarticular bone fragments. Diagnosis?
Charcot joint
-significant diabetic neuropathy-> weakening of the bones in the foot-> fractures and deformity (funky use of the joint causes damage)
*bony destruction and loss of joint spaces
(neurogenic arthropathy)
