Pattern Recognition (Wiki)

2yo M with recurrent infections and eczema. Workup reveals thrombocytopenia.
Wiscott Aldrich. X-linked.

70yo white M with easy bruising, visual disturbance, and elevated IgM
Waldenstrom’s macroglobulinemia

12yo M with bleeding, elevated PTT, and reduced quantitative factor VIII level. Platelets do no aggregate with ristocetin test.
von Willebrand’s disease

23yo HIV positive F recently started SMX-TMP with rash, confusion, fever, anemia, thrombocytopenia, tachycardia.

6yo F with itching, joint pain, skin rash who received penicillin six days previously for strep infection.
Serum sickness (Type III hypersens.)

62yo Jewish M with pruritus, melena, epistaxis, and history of DVTs.
Polycythemia vera (itching, epistaxis) Treat with phlebotomy, hydroxyurea for myelosuppression, aspirin for DVT prophy. Risk = develop CML, AML, myelofibrosis.

12yo M with bony-hard swelling above knee.

53yo M with painless lumps in neck, fever, weight loss.
Non-Hodgkin’s lymphoma

54yo M with fatigue, splenomegaly, anemia, and ‘dry tap’ on bone marrow biopsy
Myelofibrosis with myeloid dysplasia

64yo black M with bone pain, fatigue, and recurrent URIs
Multiple myeloma

24yo M with painless lump in neck and CXR with hilar masses.

8yo M with palpable rash, hematuria, and joint pain. CBC reveals normal platelet count.
Henoch-Schonlein Purpura. Small vessel vasculits. IgA deposits. Hemmorhagic urticaria with fever, arthralgias, GI and renal involvement. Associated with URIs.

21yo F with sudden onset bruisability, edema, and rash following diarrheal illness. Low platelet count.

61yo M with mycobacterium avium infection, splenomegaly, and leukocytes with cytoplasmic projections seen on CBC.
Hairy cell leukemia (B cell)

45yo M with fever, rash, diarrhea, and jaundice. Elevated IgE level and history of leukemia.

45yo M with frank rigors 1hr following blood transfusion.
Febrile nonhemolytic transfusion rxn

25yo F with continued bleeding following delivery.

55yo M with no complaints, found on physical exam to have splenomegaly and leukocytosis.

65yo M with lymphadenopathy, hepatosplenomegaly, and leukocytosis with smudge cells.

66yo M with CLL has urine that gets darker during the day.
autoimmune hemolytic anemia

18yo M with pallor, petechiae, and recurrent URIs
aplastic anemia

25yo F with recent infection, gingival hyperplasia, and leukocytosis with bone marrow expansion.

43yo M with epigastric pain and diarrhea refractory to medical management.
ZE syndrome

40yo F with intellectual impairment, jaundice, and choreiform movements.

37yo M with acute pain in anorectal area and BRBPR for 4 months.
thrombosed ext. hemorrhoid

45yo F with pruritus, fatigue, and jaundice.

33yo M with four months epigastric pain radiating to back relieved by eating and leaning forward.
posterior duodenal ulcer

36yo F with difficulty swallowing and craving for ice. Physical exam reveals angular stomatitis and glossitis.
Plummer-Vinson syndrome.

24yo F with crampy abdominal pain and dark spots on lips.
Peutz-Jehghers. Multiple polyposis of small intestine, pigmented melanin macules on oral mucosa. Associated with gynecological cancers, but actually a low to moderate colon CA risk.

51yo M with 4 months pruritus, jaundice, and abdominal pain. Recent 15 pound wt loss.
pancreatic CA (CEA, CA19-9)

65yo M with abdominal pain, nausea, vomiting, and diarrhea. Has been suffering abd. Pain 30 min after eating.
ischemic bowel

50yo M with EtOH cirrhosis develops oliguria and abdominal distenstion.

65yo M alcoholic with RUQ pain, jaundice, anorexia, and distention worsening over two months.
hepatocellular carcinoma

40yo M with increased pigmentation. PE reveals cardiomegaly. UA reveals glycosuria.
hemochromatosis (cirrhosis, bronze diabetes, heart failure)

24yo F found on dental checkup to have supernumerary teeth. Has father with history of colon polyps and
Gardener’s syndrome.

44yo M with hematemesis and melena. Has had recurrent painless hematemesis for several years.
gastric leiomyoma (#1 benign tumor of stomach)

83yo M with epigastric pain, anorexia, and frequent vomiting. Guaic positive stools. Palpable mass over L shoulder.
gastric CA (atrophic gastritis, pernicious anemia, ulcers, type A blood = risk; Krukenberg tumor = retro peritoneal spread to ovaries.

68yo F smoker with dysphagia.
esophageal CA (squamous > adeno in distal third)

54yo F with colicky LLQ pain and bloody stools that have returned intermittently over several months.

45yo M with recurrent epigastric pain that radiates to back and foul-smelling stools.
chronic pancreatitis (alcoholism, cystic fibrosis)

25yo F with diarrhea, foul smelling stools, pruritus, dry skin, and bruising.
celiac disease (anti-gliadin Ab, nutrient malabsorption)

67yo F with several months fatigue, weight loss, intermittent diarrhea with palpable RLQ mass.
cecal CA (anemia and + guaic test + virchow’s node)

52yo M with diarrhea and facial flush.
carcinoid = primary GI tumors arise from neuroendocrine cells “Kulchitsky cells” and secrete 5-HT, histamine, gastrin, and prostaglandins. Malignant or benign.

45yo M with AIDS now with painful swallowing.
candida esophagitis (candida, rx with oral fluconazole)

34yo M with mediepigastric pain, periumbilical/flank bruising, and hypotension.
acute pancreatitis (Cullen’s / Grey Turner’s sign, assoc. with gallstones and alcohol)

33yo F with substernal pain and difficulty swallowing. Sometimes regurgitates food.
achalasia (loss of ganglion cells in Auerbach’s plexus). Esophageal CA risk. Can arise from Chagas disease (also with cardiomyopathy).

50yo F with cold nodule in the neck. Normal TSH, T3 and T4.
thyroid CA (risk = ionizing rad – papillary CA c best prognosis, also follicular, mixed, and medullary assoc c MENIIa and IIb) psammoma bodies on FNA.

30yo F with weight loss, 2yrs amenorrhea following delivery of healthy baby.
Sheehan’s (postpartum pituitary infarction) decreased levels of all trophic hormones, can occur in males and nonpregnant females following trauma, SS anemia, DIC, and stroke)

33yo F with menstrual irregularity and milky nipple discharge.
prolactinoma (most common pituitary adenoma; GnRH suppressed by excessive prolactin, reduces LH and estradiol. In males = HA, impotence, visual disturbance.

56yo F with flank pain, confusion, constipation, thirst and polyuria.
hyperparathyroidism (symptoms of hypercalcemia, bank keratopathy, cystic bone lesions = osteitis fibrosa cystica, adenoma = 1 gland, hyperplasia = 4 gland, renal stones, elevated serum Ca and AP with lowPO4.

42yo F with hypertension, weakness, and decreased urinary volume.
Conn’s (hypokalemia, hypernatremia, hypertension, increased urinary aldosterone, low plasma renin). Usually adrenal cortex adenoma, sometimes adrenal cortical hyperplasia.

53yo F with fatigue, insomnia, depresison. Thinning of skin, hirsutism, vaginal atrophy.
menopause (hot flashes, vaginal atrophy, osteoporosis). Post-menopausal bleeding gets biopsy to r/o endometrial cancer.

48yo F with weakness, lethargy, cold intolerance.
hypothyroidism (weight gain, constipation, coarsening of facial features, hair loss, hoarseness, depression, loss of outer third of eyebrows, delayed recovery phase of achilles. Most common = Hashimoto’s

46yo M with impotence, fatigue and decreased peripheral vision. Is also hypotensive.
hypopituitarism: Low FSH, LH, TSH, ACTH. Most common cause adenoma compressing anterior pituitary.

29yo F with seizure. Has history of thyroid surgery two years ago.
hypoparathyroidism (circumoral and foot numbness, fasciculations, chvostek’s sign, trousseau’s sign, brittle nails, low serum calcium, elevated PO4, low Mg, low PTH. Most commonly d/t thyroidectomy, symptoms d/t hypocalcemia.

24yo F with weight loss despite good appetite, anxiety, menstrual irregularity, and tremors.
hyperthyroidism = diarrhea, heat intolerance, palpitations, tremors, increased T4, decr. TSH. Hot nodule with decreased uptake in surrounding tissue and other lobe d/t atrophy of remainder of gland. Rx with propranolol, PTU, methimazole.

45yo F with anterior neck fatigue, history of RA, and cold intolerance.
Hashimoto’s (anti-thyroglobulin and antimicrosomal Abs, often assoc with other autoimmune dx including SLE, pernicious anemia, Sjogren’s, hepatitis, HLA-DR5/3. May see thyrotoxicosis early during disease course.

55yo M with obesity, thirst, and excessive appetite.
DM2. Can develop nonketotic hyperosmoler coma but not DKA.

44yo F with irritability, easy bruising, weight gain, and glucosuria.
Cushing’s (truncal obesity, moon facies, buffalo hump, hirsutism. Elevated plasma cortisol with high ACTH, hypokalemia, leukopenia, osteoporosis, adrenocortical hyperplasia and pituitary adenoma.

60yo M with rash composed of red plaques with scaling and nodules. Has not responded to steroid rx.
Mycosis fungoides. Malignant cutaneous helper T-cell lymphoma; disseminated disease with exfoliative dermatitis and lymphadenopathy = Sezary syndrome. “Red man’s disease”. CBC shows lymphocytosis.

68yo outdoor construction worker, raised bleeding lesion over upper lip.
basal cell carcinoma. Most common skin cancer. Light-skinned people. Sun-exposed areas, slow growing, metastatic disease rare. Increased incidence in xeroderma pigmentosum.

60yo farmer with skin lesions on forehead, upper lip, dorsum of hands. Scaly rough plaques.
actinic keratosis. Most common precancerous dermatosis –> squamous cell CA. Signs that preceed malignancy include elevation, ulceration, inflammation, and enlargement >1 cm.

35yo M with cramping in calves with walking, smokes 3 ppd. PE reveals pallor and cyanosis of distal extremities.
thromboangiitis obliterans = occluded small and medium arteries, no atherosclerosis, inflammation of all layers of arterial wall. Smoking cessation critical. Amputation may become necessary of fingers/toes.

79yo F with unilateral HA, jaw pain, visual disturbance in ipsilateral eye.
temporal arteritis. Most common vasculitis in US. Often coexists with polymyalgia rheumatica. Ophthalmic artery occlusion –> blindness. Biopsy positive 60%, so treat on clinical picture with steroids before biopsy.

50yo M with palpitations and CP. Has had multiple sexual partners. Has diastolic murmur.
Syphilitic aortitis. Signs include collapsing pulse, wide pulse pressure, LVH with strain, mid-diastolic murmur at apex = Austin-Flint, VDRL / FTA-ABS positive. “Tree bark” calcification of arch and ascending aorta on CXR, tertiary stage syphillis.

30yo F with HTN and elevated plasma renin.
Renovascular hypertension. “String-of-pearls” pattern seen on renal angio. +/- renal artery bruit. Mostly fibromuscular dysplasia (young female), atherosclerosis (older male), <5% of all HTN. Rx with ACE-I but contraindicated in bilateral RAS.

34yo F in 27th week of pregnancy with dyspnea and orthopnea. History of recurrent strep pharyngitis as child.
Mitral stenosis. Opening snap and mid-diastolic murmur at apex. +/- LVH and a-fib.

37yo M with fatigue and dyspnea with exertion. Pansystolic murmur at the apex with radiation to the axilla.
Mitral insufficiency. Common causes: mitral valve prolapase, ischemic papillary muscle, endocarditis, rheumatic. S3 may be present.

42yo M with CP, headache and confusion. Has history of HTN.
malignant HTN. Severe diastolic hypertension, papilledema, hematuria, proteinuria, small scarred kidneys. Rx with sodium nitroprusside or IV beta-blockers to prevent end-organ damage due.

21yo M with DOE and an episode of syncope while playing tennis.
HCM. Signs = S4, SEM incr by valsalva, decr by squatting. EKG shows LVH. Echo: asymmetrical septal hypertrophy, ant. motion of mitral valve. Rx with beta-blockers, avoid sports, amiodarone may prevent fatal arrythymia, surgical myomectomy.

29yo F recently delivered baby, now with dyspnea and pedal edema.
dilated cardiomyopathy. Systolic dysfunction, decr ejection fraction Peripartum period (3 mo.), alcoholism, hypothyroidism, Freidreich’s ataxia, previous myocarditis coxsackie B, adriamycin, tricyclic antidepressants, lithium, cyclophosphamide.

60yo M with COPD with severe dyspnea at rest, bulging neck veins, and peripheral edema.
cor pulmonale. Right heart failure d/t pulmonary cause, usually COPD. Other causes include pulmonary fibrosis, pneumoconioses, recurrent PE, PPHTN, obesity with sleep apnea, kyposcoliosis.

24yo M with angina, DOE, occasional fainting, and systolic ejection murmur to right of sternum.
aortic stenosis. Crescendo-decrescendo SEM, paradoxical splitting. Causes include congenital bicuspid valve, degenerative calcification, rheumatic.

31yo M with ankylosing spondylitis develops severe SOB.
aortic insufficiency. Signs include bounding pulse, wide pulse pressure, diastolic decrescendo murmur at left sternal border. Causes include rheumatic, ankylosing spondylitis, marfan’s, reiter’s, tertiary syphillis.

35yo M with nonproductive cough and chest pain worse with inspiration, relieved by sitting up.
pericarditis. +/- friction rub, incr JVP (c inspir = Kussmaul’s sx), elevated ESR, CPK-MB nl, diffuse ST elev., pericardial effusion. Coxsackie A/B, TB, staph/strep, amebiasis, actinomycoses, CRF, SLE, scleroderma, RA, CA, MI, trauma.

25yo F with myalgias and low-grade fevers starting one week after a dental extraction.
subacute bact. endocarditis. Ass. c rheumatic dx, mvp, etc. AB prophy prevents. Janeway = periph hemmorhage, Osler’s = painful, Splinter hem. = subungal linear, Roth’s spots = oval retinal. Strep viridans = most common subacute.

25yo M with SOB and ankle edema following severe URI.
viral myocarditis. Cocksackie B > Borrelia burdorferi (Lyme), trypanosome cruzi (Chagas), hypersensitivity rxn in SLE or drug rxn, radiation, sarcoidosis. Echo: dilatation c low EF. ASO titers not elevated. ESR elevated.

35yo M develops pruritus and blistering rash over shins following camping trip.
Contact dermatitis = type IV hypersensitivity rxn. Papulovesicular rash c oozing and crusting. Rx c topical and systemic corticosteroids. Also occurs with various irritants, diaper rash.

5yo M with yellow crusty lesions behind the ear and around the mouth.
impetigo. “honey-colored” lesions. Group A strep. Rx with cephalosporin, pcn, or erythromycin. ASO titer negative. Highly communicable. Staph. aureus superinfection may cause bullous impetigo. Group B strep impetigo in newborns.

30yo homosexual M with skin eruption on upper limbs, trunk, anogenital areas.
molluscum contagiousum. Poxvirus. Opportunistic AIDS infection. Painless, pearly-white, dome-shaped, waxy, umbilicated nodules, 2-5mm, palms and soles not affected.

16yo M with headache, fever, and rash on the palms and soles. Recent camping in North Carolina. UA demonstrates proteinuria and hematuria.
RMSF. Rash periph. to central, palms/soles, petechial, thrombocytopenia, + Hess’ test = Rumpel-Leede phenomena, + Proteus OX19 / OX2 Weil-Felix rxn. Rickettsia rickettsii. Rx tetracycline. Dermacentor wood tick. East coast of US.

24yo F with extensive denuding of skin and recent skin infection.
Scalded skin syndrome. Vesicle fluid is sterile. S. aureus on blood culture. Rx IV methicillin or oxacillin. Phage group 2 staph exotoxin.

30yo M with bilateral circular red eruption in the groin.
tinea corporis = ringworm. Circular papulosquamous eruption. Hyphae on KOH skin scrapings. Rx clotrimazole, miconazole, ketoconazole cream. Also systemic griseofulvin, keto/itraconazole prn. Tinea capitis = children.

28yo M treated for UTI develops raised, red, pruritic rash over trunk and limbs.
urticaria. wheal and flare rxn, “hives”. Rx: stop causative agent, H1/2 blockers, calamine lotion, corticosteroids.

11yo M with jaundice, dark urine, and recent shellfish ingestion.
Hep A. Hyperbilirubinemia, ALT>AST, +/- AP, incr PT, incr. urine urobilinogen and bili, + IgM Ab to HepA. No infectivity in 3wks. Fecal/oral, bad water. Not chronic. HAV = naked, ssRNA, picorna. Prevent with killed vaccine and immune globulins.

25yo M with jaundice following needle stick two months ago.
HBV. Hyperbili, ALT>AST, +/- AP, HBsAg +, IgM anti-HBc + (window period). Liver biopsy = Councilman bodies. 5% progress to chronic c risk cirrhosis and HCC. Long incubation = 3 months. Enveloped DNA hepadna. HBsAg = chronicity.

30yo M intermittent jaundice for two years following a motorcycle accident.
HCV. Percutaneous transmission = 90% of cases. >50% progress to chronic, leading to cirrhosis in 20%. PCR test.

50yo alcoholic with fever, abdominal pain, and progressive distention of abdomen.
SBP. Ascites fluid leukocyte count >500/cc; PMNs >250 = diagnostic, low protein and glucose, ascites culture may be negative. Rx empirically, then organism-specific if possible. E. coli = most common.

56yo M with diarrhea for 2 months, arthritis, and weight loss.
Whipple’s disease. Increased fecal fat. Macrocytic, hypochromic anemia. Small bowel biopsy c PAS + macrophages. Gram + actinomycete bacilli in macs. Rx with bactrim or ceftriaxone for 1 year. Tropheryma whippellii. Vitamin malabsorption.

19yo F with recurrent episodes of periorbital swelling and dyspnea lasting up to 24hrs.
C1 esterase inhibitor deficiency. Autosomal dominant. Decreased C4= best screening test. Decreased C1 inhibitor (confirmatory test). Decr. C2, but normalC3, normal IgE. Also called hereditary angioedema.

3yo M with albinism and recurrent infections with recurrent staph and strep infections.
Chediak-Higashi. Also nystagmus, photophobia. Decreased neutrophil count. Normal platelet count. Large cytoplasmic granules (Giant Lysosomes) in WBCs. Autosomal recessive, defect in microtubule polymerization in leukocytes. Defective chemotaxis.

2yo M with recurrent fungal and staph furunculosis and neutrophilic leukocytosis.
Chronic granulomatous disease. X-linked disorder of neutrophils, deficient NADPH oxidase . Normal chemotaxis, degranulation, and phagocytosis. Deficient killing d/t myeloperoxidase system. Recurrent staph infections. Rx SMP-TMP prophy.

25yo F with recurrent sinusitis, multiple allergies, watery diarrhea, and hypopigmented skin lesions.
IgA deficiency. No blood or plasma transfusions! #1 congenital immunodeficiency. Diarrhea usually G. lamblia, sinopulmonary infection with S. pneumo, H. flu, or S. aureus. Assoc with allergies/autoimmune dx. May be d/t isotype switching defect.

7 month M recurrent URIs, skin infections, and asymetric arthritis of the kness. No tonsillar tissue on exam.
X-linked hypogammaglobulinemia. Selective B-cell defect. Recurrent bacterial infections. a.k.a. Bruton’s disease. Tyrosine kinase receptor defect, impaired maturation of antibodies. Labs = panhypoglobulinemia: very low IgG; IgA and IgM not detectable.

15yo M with thick yellow discharge that prevents eye-opening in the morning.
Conjunctivitis. Rx topical AB drops. Usually viral = adenovirus. Self-limiting. Secondary staph/strep may result.

8yo F with rash, diffuse joint pain, fever, and sore throat two weeks ago.
Acute rheumatic fever. Erythema marginatum = blanching ring-shaped over trunk and extremities. Elevated ASO titer, incr ESR, incr C-reactive protein. Blood culture negative. Endo/myo/pericarditis. Rx aspirin/corticosteroids, pcn/erythromycin.

35yo F with pain in upper teeth and face, nasal congestion and discharge.
sinusitis. boggy nasal mucosa. Common pathogens = S. pneumo, other streptococci, H. flu, Moraxella. Rx amoxicillin or TMP-SMX, decongestants.

48yo missionary returns from West Africa with lethargy, nuchal rigidity, HA, drowsiness.
African trypanosomiasis. Tsetse fly. Painless lymphadenopathy in posterior neck & supraclavicular = Winterbottom’s sign. Does not respond to antibiotic rx. Chancre with induration at bite site. AKA African sleeping sickness. Rx suramin / pentamidine.

45yo M Peace Corps in Mexico with spiking fever, RUQ pain, and bloody diarrhea with mucus. Tender hepatomegaly on exam.
Amebic liver disease. Entamoeba histolytica. Cavitating liver lesion with chocolate-colored pus that is sterile, ameba obtained from periphery of lesion. Rx includes metronidazole and abscess drainage.

30yo sheep farmer with dyspnea, nonproductive cough, and black skin lesions.
Anthrax. CXR c mediastinal widening = hemorrhagic mediastinits. Vesicular papules covered by “black eschar”. Bacillus anthracis. Rx IV penicillin G. Isolation precautions. Cell-free anthrax vaccine for high risk groups.

38yo M on chemotherapy with pleuritic chest pain, fever, and productive cough.
Aspergillosis. Multiple nodular infiltrates. Branched hyphae c silver stain, vascular invasion –> thrombi. Rx Amphotericin B c flucytosine. Lobectomy for fungus ball. Invasive dx: AIDS, neutropenia, chronic granulomatous dx, steroid rx, transplant pts.

25yo M c sudden onset double vision, dry mouth, weakness, dysarthria, and dysphagia. Ate some home-canned peaches the night before.
Botulism. Flaccid paralysis. Rx antitoxin, resp. support. Botox cleaves synaptic docking/fusion machinery. Disease d/t ingestion of toxin produced by C. botulinum. Often seen in infants after honey.

28yo M with hip pain, undulating fever for two months, and pain in testicle. Drinks unpasteurized milk.
Brucellosis. Blood culture demonstrates B. abortus, transmitted from milk or direct contact with animal tissues. Rx combination of doxycycline/SMX-TMP plus rifampin/streptomycin.

49yo obese, diabetic F with pruritus underneath her breasts.
candidiasis. Denuded, beefy red areas with whitish curd-like material. Budding cells with short hyphae on KOH prep. Rx clotrimazole, keep area dry.

24yo F with fever and swelling over eye after trip to Brazil.
Chagas dx. Eye swollen shut = Romana’s sign. Encapsulated, nodular area at bite site = Chagoma. Ipsilateral retroauricular & cervical nodes. Trypanosoma cruzi, reduviid bug injects feces. Complications = dilated cardiomyopathy, megaesophagus/colon.

30yo M with profuse watery diarrhea, vomiting, and abdominal pain following trip to India.
Cholera. Vibrio cholerae. Severe dehydration, rice-water stools gram – rods c darting motility, O1 antigen, decreased serum chloride with increased serum sodium. Heat-labile exotoxin, stimulates Gs via ADP ribosylation incr cAMP –> secretory diarrhea.

19yo Arizona migrant worker with cough, pleuritic CP, fever and tender nodules over the both shins.
Coccidioidomycosis. Erythematous skin rash, erythema nodosum, positive skin test with coccidioidin, dimorhphic fungi, eosinophilia, caseating granulomas. Rx amphotericin B. Endemic in southwestern US. Inhalation of spores.

30yo M with AIDS presents with profuse, nonbloody diarrhea.
Cryptosporidium parvum. Dehydration. Acid-fast stain –> oocyts in fresh stool. Rx is supportive only. Self-limiting in immunocompetent pts.

13yo F s/p BMT on immunosuppresion now with fever, dyspnea, dry cough.
CMV pneumonitis. Insterstitial pneumonitis, intranuclear inclusions with surrounding halo (owl’s eye). Rx ganciclovi ). #1 pneumonia and death in BMT patients. Common in AIDS. Enveloped dsDNA herpesvirus.

5yo M with fever, cervical lymphadenopathy, and grey membrane on tonsils.
Diptheria. Cornybacterium diphtheriae growth on Loffler’s blood agar. Heat-labile exotoxin –> myocarditis and neuritis (blocks EF-2 via ADP ribosylation –> decr ribosomal fnctn & protein synth. Rx: PCN or erythromycin, antitoxin.

56yo veterinarian with sudden high fever, jaundice, and RUQ pain.
Echinococcosis. Hepatomegaly, + immunoblot test : echinococcal antigens, large septated liver cysts. +/- lungs/kidneys/bone/brain. Scoleces c inner germinal & outer laminated layer, fibrotic rxn. Rx: surgical cyst removal, albendazole.

36yo woman with AIDS and pneumonia develops spiking fever, chills, and delirium.
Endotoxic shock/gram neg. sepsis. E. coli on urine & blood culture. CXR with fluffy infiltrates (ARDS). Sequelae: ATN, DIC, multiorgan failure. Rx: fluid, IV ABs, manage ARDS c O2 and PEEP. Usually d/t gram negative endotoxins &gram positive exotoxins.

28yo Guatamalan refugee with severe headache, fever, and rash on trunk and extremities; palms and soles spared. Spent time in refugee camp.
Epidemic typhus. Rickettsia prowazekii. Cerebral edema/myocarditis/pneumonia, peripheral spreading rash. + Weil-Felix rxn. Path: Zencker’s degeneration of striated musc. Rx: tetracycline, chloramphenicol. Intracellular. Lice vector. war/famine/crowding.

21 yo F with low-grade fever, pain and swelling over left knee, and dysuria.
gonnococcal arthritis. Intracellular diplococci bean-shaped. Migratory polyarthralgias. Incr WBCs c urethral smear & synovial fluid. Rx: IV ceftriaxone. Rapidly destroys cartilage. Associated with skin rash over affected joint, complement deficiencies.

19yo M with burning urination and greenish-yellow purulent discharge.
gonorrhea. Intracellular gram negative diplococci, confirmed c Thayer-Martin medium culture. Rx: Ceftriaxone + doxycycline/erythromycin for Chlamydia coverage. Gonorrhea can involve throat, anus, rectum, epididymis, cervix, fallopian, prostate, joints.

25yo M with painful skin rash in the perianal area.
Herpes simplex 2. Vesicular in clusters with clear fluid over erythematous base. Giant cells on Pap-stained scraping. Rx: acyclovir. dsDNA virus. Transmitted to fetus through birth canal.

27yo F with two months fever, mouth ulcers, fatigue, and weight loss. Started new job on farm in Ohio.
histoplasmosis. Histoplasma capsulatum.Rx: itraconazole or amphotericin B. Intracellular budding fungus in reticuloendothelial cells. Hilar adenopathy. Associated with bird or bat feces. Transmitted by inhalation of mold spores.

37yo M black male from the Caribbean with swollen glands in armpits and groin, feeling of heavyness in abdomen.
Human T-cell leukemia virus type 1 (HTLV-1). Lymphadenopathy & splenomegaly. Skin biopsy –> leukemic CD4+. Type C is assoc. c adult T-cell leukemia/lymphoma –> high incidence blacks in Carribean/SE US, Subsaharan Africa/Japan.

20yo M with sore throat, lymphadenopathy, and malaise.
IM (EBV). Lymphocytosis c atypical lymphs. Incr ALT/AST/bili. Positive heterophil Ab test (Monospot / Paul-Bunnell test). IgM antibodies to viral capsid = monospot positive.

40yo M smoker with high fever, nonproductive cough, pleuritic CP, and coworkers with similar symptoms.
Legionella pneumonia. Gram stain shows no organisms. Direct immunofluorescence confirms indirect fluorescent antibody titer. CXR: ill-defined nodules. Rx: erythromycin. Outbreaks d/t drinking water, humidifiers.

30yo Pakistani immigrant with history of red papule on arm following insect bite; now with chronic fever, skin darkening, and massive splenomegaly.
Leishmaniasis / “kala azar”. Leshmania donovani zoonosis. Transmitted by Phlebotomussandfly. Labs = anemia, leukopenia, thrombocytopenia. Amastigotesin buffy layer. Rx: pentavalent antimony = Na stibogluconate; amph. B, or pentamidine.

26yo M from India with hypopigmented anesthetic skin patch on face and swelling in elbow in area of ulner nerve.
Leprosy: Mycobacterium leprae. Acid-fast bacillus. Thermolabile, divides slowly –> long course. Tuberculoid = skin with limited nerve /involvement (ulner/peroneal). Lepromatous = diffuse skin involvement/eyes/nerves/disfigurement (leonine facies).

12yo M with fatigue, joint pain, and rash.
Lyme. Borrelia burgdorferii, spirochete. IgM ELISA, confirm c WB. Rx: doxy or amox. 3 stages; 1= erythema chronicum migrans + constitutional si/sx. 2= cardiac & neuro. 3= persistent migratory arthritis/synovitis/acrodermatitis chronicum atrophicans.

25yo with tender masses and painful groin ulcers after unprotected sex.
Lymphogranuloma venerum. Inguinal adenitis, buboes. + complement fixation and IF tests. Ulcerated nodule –> secondary = inguinal bubo (enlarged node +/- fistula/balanitis/phimosis/rectal involvement. Rx: doxycycline. An STD d/t C. trachomatis (L1/2/3).

30yo missionary with high fever, chills, and severe HA after returning from Africa 1 wk ago.
Malaria. peripheral smear = plasmodia in erythrocytes. Rx: chloroquine, quinine for cerebral malaria, tetracycline for resistant areas. Anophelesmosquito. Plasmodium falciparum may be lethal –> cerebral malaria.

12yo F with fever, severe HA, and stiff neck who fainted at school.
Meningococcemia. +/- petechial rash. Kernig’s / Brudzinski’s. CSF = incr prot, low gluc. Hypoglycemia, hypo-Na, hyper-K = Waterhouse-Friedrichsen’s = adrenal necrosis –> death. Rx: steroids, IV fluid, DA, PCN-G. Prophylactic rifampin for contacts.

24yo F in hospital for DKA develops periorbital swelling and purulent postnasal discharge that fails to respond to ABs. PE reveals black ulceration of nasal mucosa.
Mucormycosis. Irregular nonseptate hyphae branching at wide angles. Mucor and Rhizopus molds. Conjunctival swelling = chemosis, black ulceration of nasal mucosa, CNIII palsy, necrotic destruction. !Suspect if AB-resistant sinusitis in DM/lymph/leukemia!

20yo M college student with productive cough, malaise, and fever. Cough started out nonproductive.
Mycoplasma pneumonia. CBC: normal leukocyte count. Elevated cold agglutinin titer >1:128. CXR: patchy infiltrates appear worse than clinical picture. Rx: erythromycin. #1 atypical pneumonia. Rapid spread in close quarters.

45yo M undergoing chemotherapy for Hodgkin’s now with SOB/cyanosis; has had greenish sputum for 3 months.
Nocardiosis. Gram + filamentous, partially acid-fast bacteria. Nocardia asteroides. Chronic infection: DM/leukemia/lymphoma/IC’d pts. Usually lungs, +/- brain/SC tissue. Rx: SMX-TMP 6mo.

56yo F with visual acuity change, generalized itching after showering, and recent travel to tropics.
River blindness. Hypopigmentation, nodules, keratitis, chorioretinal lesions.Diethylcarbamazapine –> pruritus, rash, fever, conjuctivitis = Massotti reaction. Rx: ivermectin. Blackfly –> Onchocerca volvulus. Larvae in SC tx and lymphatics.

28yo diabetic with immobility of knee, swelling, tenderness, and elevated ESR.
Osteomyelitis. Periosteal thickening. New bone = involucrum traps necrotic bone = sequestrum. Rx IV ABs, surg. #1 =Staph > strep > enterobacteria. SC = E. coli > Salmonella. DM/puncture = Pseudomonas. IC’d = Sporothrix.Human bite = anaerobes.

18 month F with irritability and ear discharge. Recurrent URIs.
Otitis media. E. coli,staph, Klebsiella (neonates); S. pneumo, H. flu, Morexella, group A strep (kids). Rx amoxicillin-clavulanate. Complications = ingrowth of epithelium of middle ear = cholesteatoma. Hearing loss, mastoiditis, CNS abscess.

25yo M bitten by a cat with shiny, edematous tender hand draining purulent fluid.
Pasturella multicoda. Gram neg rod with bipolar staining. Catalase and oxidase positive. Rx: Incision and drainage + amoxicillin/clavulanate, tetracycline, or penicillin. Can progress to osteomyelitis.

14yo M bitten by younger sister with shiny, edematous, tender hand draining fluid.
Eikenella corrodens. Rx: PCN + I&D.

44yo archaeologist returns from dig site in Arizona with high fever, severe myalgia, and painful inguinal swelling.
Plague. Yersinia pestis. Enlarged inguinal nodes = buboes. No genital lesions. Gram negative bacilli c safety pin appearance in aspirates from buboes. Rx: streptomycin / tetracycline. Rodents and fleas in Southwestern US. Death rapid if untreated.

11yo M with blood-tinged, mucoid sputum and pleuritic chest pain.
Pneumococcal pneumonia. Incr fremitus & dullness over afffected lobe. Gram positive diplococci in sputum, alpha-hemolytic colonies. CXR = homogenous opacification of affected lobe +/- pleural effusion. Rx: IV PCN. #1 community acquired pneumonia.

32yo HIV + M with progressive dyspnea over 3 wks.
PCP. dry cough, fatigue, hypoxemia out of proportion to clinical findings. Rx: SMX-TMP. Interstitial pneumonia in IC’d pts. Bactrim prophylaxis for HIV pts if CD4 <200. Labs: serum LDH elevated.

14yo M Russian immigrant with weight loss, fever, night sweats and bloody sputum.
TB. Primary = lower lobes / subpleural. Secondary = cavity lesions in upper lobes. Rx: RIPE therapy = rifampin, isoniazid, pyrazinamide, ethambucil.

28yo M with numbness of R arm following bat bite. Refuses to drink water.
Rabies. Hydrophobia, neuropathy. Long incubation period 3-8wks, prevent occurrence with vaccine. Negri bodies = cytoplasmic inclusions in Ammon’s horn. Positive rabies antigen on corneal scraping.

27yo Peace Corps volunteer in Africa with fever, sweats, abdominal pain. Had an itchy rash after swimming several weeks ago.
Schistosomiasis. CBC: eosinophilia. Rx: praziquantel. Snail-infested ponds/lakes. Hepatosplenomegaly d/t portal hypertension d/t granulomas = periportal fibrosis.

36yo M executive with sudden nausea, vomiting, and diarrhea with blood and mucus after business trip to South America.
Shigellosis. + fecal leukocytes. Shigella on stool culture. Not motile. Outbreaks c overcrowding, fecal-oral. Can be complicated by Reiter’s syndrome = arthritis, conjunctivitis, urethritis (HLA-B27 individuals). Rx: ampicillin or SMX-TMP.

37yo with ulcerated nodule on hand after trauma while doing yardwork.
Sporotrichosis. Sporothrix schenckii. Nonpainful, soft, ulcerated nodule at inoculation site = sporotrichotic chancre. Rx: itraconazole. (Sporothrix is a dimorphic fungus = cigar shaped budding cells). May cause bone/joint infection.

9yo M with odynophagia and erythematous tonsils with white exudate.
Strep pharyngitis. Rx: oral penicillin V. Streptococcus pyogenes. Complications include glomerulonephritis and rheumatic fever.

38yo diplomat in Nigeria with diarrhea, fever, dry cough, and dyspnea. Frequently walks barefoot through his neighborhood.
Strongyloidiasis. Eosinophilia with motile rhabditiform larvae. Rx: thiabendazole or ivermectin. Results from poor hygeine in tropics. CXR: bilateral transient migratory infiltrates.

54yo F with spiking fever, loss of appetite, and RUQ pain who underwent emergency cholecystectomy 10d ago.
Subdiaphragmatic abscess. Rx: percutaneous drainage. Findings include pain on percussion, left-shift, fluid collection below diaphragm. Occurs typically >1wk after abdominal surgery.

18yo M with painless ulcer on penis.
Syphillis. Dark-field exam of exudate = treponemes. VDRL and FTA-ABS positive. Rx: Benzathine PCN IM, 2.4U single dose. STD d/t Treponema pallidum.

23yo F with nonpruritic skin rash, hair loss, and copper-colored maculopapular rash on palms and soles.
Secondary syphilis = generalized tender lymphadenopathy, rash on palms/soles, coalescent papules/plaques in groin = condyloma lata, hair loss = alopecia. Rx: IV benzathine PCN.

12yo M with dysphagia. Stepped on a nail about a week ago.
Tetanus. Clostridium tetani. Trismus = jaw m rigid, Risus sardonicus = facial m spasm; dysphagia, neck rigidity, painful facial spasms, opisthotonos. Rx: debride wound, tetanus immune globulin IM or intrathecally, diazepam; tetanus toxoid; IV PCN.

40yo HIV + M with severe HA. Has 2 cats at home.
Toxoplasmosis. Toxoplasma gondii. Host = cats. Rx: pyrimethamine or sulfadiazine. PE reveals generalized lymphadenopathy, papilledema. CT/MRI-head reveals mass lesions with ring or nodular enhancement. Compl include seizure, brain abscess.

50yo M with generalized myalgia and low-grade fever. Had severe abdominal pain and diarrhea several weeks ago after eating at a pigroast.
Trichinosis. Labs: elevated CPK, LDH, and AST. Normal ESR. Eosinophilia. Raw/undercooked pork. Trichinella spiralis. Affects facial, neck, lower back, and diaphragm. Biopsy of SCM reveals organism.

20yo M with ulcer on wrist, lymphadenopthy in ispilateral axilla with suppuration. Recently trapped and disposed of rabbit on his property.
Tularemia. Francisella tularensis. Rabbits, squirrels, rodents, ticks. E levated ESR. Lymph nodes with suppuration + necrosis. Direct fluorescentantibody staining. May be tonsillar, oculoglandular, pneumonitic, typhoidal. Rx: streptomycin + tetracycline.

27yo M with increasing fever, constipation, and faint erythematous macules over the trunk. Visited Southeast Asia three weeks ago.
Typhoid fever. Salmonella typhi. Rx: ciprofloxacin. Infection of Peyer’s patches c subsequent mucosal necrosis. Fever c stepladder pattern. Macules = “Rose spots” Infection from contaminated food or water. Typhoid vaccine available.

5yo M with pruritic rash on scalp, face and trunk.
Varicella zoster. Lesions appear in crops q3-5d. Macules, papules, vesicles, pustules, and scabs all present at same time. Leukopenia. Tzank smear = inclusion bodies (Lipschutz bodies) + MNG cells. DNA herpesvirus.

45yo HIV+ M with painful, burning skin rash on left side of chest.
Zoster (shingles). Vesicular rash on erythematous base. Dermatomal distribution. Exquisitely tender. Acantholytic cells on Tzanck smear from base of vesicles. Cowdry A = intranuclear eosinophilic inclusions surrounded by clear halo. Rx: acyclovir.

24yo South American male develops high fever. He develops yellow eyes, and coffee-ground emesis four days later.
Yellow fever. Flavivirus transmitted by Aedes mosquito. Affects liver and kidneys: liver midzonal lobular necrosis, severe renal tubular damage. Rx: symptomatic only. Preventable by vaccine. 5-10% mortality, most cases mild.

50yo M with sudden fever, chills, neck stiffness.
Bacterial meningitis. S. pneumoniae = most common adult. Photophobia, obtundation. Tap = high pressure, cloudy, high protein, very low glucose, high cells mostly WBCs.

33yo HIV+ M with persistent HA.
Cryptococcal meningitis. Encapsulated spherical fungi on India ink prep. CT/MRI-brain multiple ring-enhancing lesions. Rx: amphotericin B + 5-flucytosine. Acquired from pigeon droppings, usually seenin IC’d pts.

30yo HIV+ M with rapidly progressive visual loss.
CMV retinitis. Cotton-wool exudates, necrotizing retinitis, perivascular hemorrhages. Rx: ganciclovir; foscarnet. Occurs in 20% of AIDS pts. Blindness in HIV = toxoplasmosis, PML, and CMV.

45yo hog farmer with visual loss, severe HA, and projectile vomiting.
Neurocysticercosis. Taenia solium. Papilledema, free-floating cysts in vitreous body of right eye. Ingestion of ova is fecal-oral. CT/MRI-brain: intracranial cysts or calcifications. Eosinophilia.

54yo man with ataxia, MS changes, deformed ankles, and shooting pain in extremities.
Tertiary syphillis. Gummas = subcutaneous nodules. Dorsal column –> reduced position/vibration sense. Charcot’s neuropathic arthropathy. Broad-based gait. Romberg’s sign. Light reflex lost with retained accomadation = Argyll Robertson. “Tree-bark” aorta.

25yo F with dysuria, frequency, and hematuria after her honeymoon.
Acute cystitis. E. coli > Proteus, Klebsiella, Staph. saprophyticus, and Enterococcus. Hemorrhagic cystitis may also result from adenovirusinfection.

28yo F in 27th week of pregnancy with R flank pain, fever, and dysuria.
Acute pyelonephritis. UA: proteinuria, WBC casts, >100,000 cfu E. coli. Rx by sensitivity, ampicillin empirically. E. coli, Klebsiella, Proteus, and Enterobacter.

19yo M with painful urination and yellow-green urethral discharge. No bacteria seen on Gram stain.
Nongonnococcal urethritis. Rx: doxycycline. Most common = C. trachomatis, also Ureaplasma urealyticum. Frequentl coinfection c gonnococcal urethritis. Direct immunofluorescence using monoclonal Ab to Chlamydia. No growth on culture.

15yo M with painful bilateral parotid swelling and left-sided scrotal pain.
Orchitis. Mumps, E.coli, enterobacteria, chlamydia, gonnorhea, mycobacterium tuberculosis. May cause sterility if bilateral. Rx: scrotal support, ice packs, steroids. CBC: lymphocytosis, hyperamylasemia.

25yo F with burning on urination.
UTI. E. coli, staph saprophyticus = #1 and 2 causes. Others include proteus, klebsiella, enterobacter, serratia, psuedomonas, enterococcus, chlamydia, neisseria. Risk = females, sex, pregnancy, obstruction, bladder dysfunction, reflux, catheters.

34yo M with multiple myeloma develops reticular skin infarction, necrosis, and ulceration.
Cryoglobulinaemia. Associated with paraproteinemias, RA, SLE, mononucleosis, lymphoma, PBC, and HCV. Small vessel vasculitis that may involve kidneys = renal failure. Rx: plasmapheresis.

54yo F with RA develops Bence Jones proteinuria.
Monoclonal gammopathy of uncertain significance (MGUS). Monoclonal paraprotein without B-cell tumor. Assoc c hepatitis, leptospirosis, autoimmune dx. Follow closely 10-20% develop myeloma. Rx: None necessary. Close f/u.

78yo M with fever, anemia, fatigue, petechiae and recent lacunar stroke.
Waldenstrom’s macroglobulinemia. Old men 2:1. Normochromic normocytic anemia. Rouleaux RBCs. ESR elevated. Serum M protein, cryoglobulin, and cold-reacting Abs. Hyperviscosity –> stroke, MI, Raynaud’s, pyoderma gangrenosum.

55yo M with anemia, leukopenia, thrombocytopenia and bone pain.
Multiple myeloma. Infections (70%), renal failure (50%), bone pain (100% with progression), bleeding (10%). Very high ESR, rouleaux RBCs. Diagnosis = 2 of following: Bence Jones, bone marrow plasma cells, punched-out bone lesions.

19yo M with recurrent DVTs for one year.
Antithrombin III deficiency. Diagnosis = antithrombin level. Rx: coumadin. AT-III activity enhanced by binding heparin (don’t use heparin to treat AT-III deficiency). Inherited disorder, screen family. Onset in late teens typical.

24yo M with recurrent DVTs. Family history of DVTs affecting mother and sister.
Factor V Leiden. #1 thrombophilia. 20-40% of pts c DVTs esp. young ages. Auto dom: homoz’s with 80x risk, hetero 7x risk. Incr risk in pregnancy & contraceptive use. Mutation eliminates protein C cut site. Rx: coumadin for homos, prophy for hetero’s.

23yo M bitten by snake now with purpuric skin lesions.
DIC. Causes include meningococcal, snakebite, staph septicemia, obstetric, malignancy (bronchus, pancreas, ovary, prostate, leukemias), shock, massive transfusion, vasculitis (HUS/TTP), bypass, cavernous hemangiomas.

16yo M with massive hematomas and no history of trauma.
Differential includes: Christmas dx, von Willebrand’s, hemophilia, or uncontrolled anticoagulation.

15yo M with acute hot, red, swollen knee and easy bruising.
Hemophilia. Prolonged aPTT, normal PT. Rx: factor VIII replacement. X-linked recessive.

13yo M with recurrent bleeding episodes and normal factor VIII levels and activity assay.
Christmas disease. Factor IX deficiency. Complications of both include: chronic degenerative joint dx, compression neuropathy, renal pelvic / ureteral obstruction, intestinal obstruction.

53yo homeless man with bleeding gums, purpura, and perifollicular bleeding.
Scurvy = vitamin C deficiency.

6yo F with generalized skin rash following mild URI. Rash became purpuric after one day.
HSP. Drugs, food, insect bites, infections. Purpura +/- glomerulonephritis. Immune complex deposition. Children > adults. Glomerulonephritis in 33%.

14yo with recurrent epistaxis and multiple small red lesions on lips, mouth, tongue. Mother and uncle have similar condition.
Hereditary hemorrhagic telangiectasias = Osler-Weber-Rendu. Autosomal dominant. Mucosal bleeding. Association with pulmonary AV fistula.

9yo F with recurrent URIs, diarrhea, and failure to thrive.`
CF. High Cl sweat test.CXR: brochiectasis. Pseudomonasand staph infections of the lung. Mucous plugging, small bowel obstruction = meconium ileus. Rx: pulmozyme (DNAse breaks up airway). Azithromycin. Inhaled tobramycin (Tobi). Male sterility.

23yo M with chronic productive cough and wife with difficulty becoming pregnant. Apical impulse not present on L side.
Kartagener’s syndrome. Sperm immotility, bronchiectasis. Dynein defect leads to immotile cilia. Autosomal recessive. Dextrocardia.

23yo M goes to family doctor for evaluation of sterility. Found to have height greater than arm span, crown-pubis length greater than pubis-floor.
Klinefelter’s. 47XXY. Male hypogonadism. High incidence of breast CA, COPD, DM, mild mental retardation. PE: small testes, gynecomastia, “eunuchoid” body proportions. Increased gonadotropin with reduced testosterone.

26yo M with flat nose, and single palmar crease. Had silver spots on iris at birth.
Down’s. Epicanthal folds, Brushfield spots, Simian crease. Double bubble on KUB: dilated stomach proximal duodenum d/t duodenal atresia. Hypoplastic phalanges in 5th digits (acromicria). Usually nondisjunction; Robertsonian translocation or mosaicism.

7yo boy with diminished visual acuity and long arms, legs, and fingers.
Marfan’s syndrome. Arm span > height, arachnodactyly, ectopia lentis, severe myopia, high-arched palate, flat feet = pes planus, aortic insufficiency, pectus excavatum. Rx: beta-blockers, endocarditis prophy. Auto-dom. fibrillin = elastin scaffold.

17yo F with amenorrhea, lack of breast development, and harsh systolic murmur.
Turner’s. Short stature, webbed neck, shield-like chest with wide-spaced nipples. High serum FSH/LH; no Barr bodies on buccal smear. Get US pelvis –> streak ovaries. Karyotype 45, XO; sometimes mosaicism –> skeletal, CV, horshoe kidney.

5yo Asian F with sudden eye pain and loss of vision after watching a film. Reports seeing halos around lights at night.
Acute glaucoma (angle closure). Hazy cornea, elevated intraocular pressure. Rock-hard eye. Rx: analgesics, IV acetazolamide, topical beta-blocker, steroids, pilocarpine, laser iridotomy. Precip’d by mydriatics and switch from dark to well lit areas.

49yo M with progressive weakness, difficulty speaking, and fasciculations.
ALS. Bilateral hand wasting, DTRs absent in upper limbs, muscle weakness, + Babinski sign (upgoing great toe) = upper motor neuron sign. Involves both upper and lower motor neurons. CSF normal. CT/MRI-brain normal.

40yo M, now unresponsive, found in bathroom at work projectile vomiting. Said he was “seeing double”.
Cerebral aneurysm. Papilledema, CNIII palsy. Congenital Berry aneurysms associated with polycystic kidney disease, AV malformation. Cause subarachnoid hemmorhage. ACOMM > PCOMM > POST CEREBRAL.

14yo M with short stature, history of polyuria, and peripheral vision loss.
Craniopharyngioma. #1 supratentorial tumor in kids. Derived from Rathke’s pouch remnants. Common cause of growth retardation, diabetes insipidus, bitemporal hemianopia, and headache d/t obstructive hydrocephalus. Bimodal with peak in fifth decade.

62yo M with rapidly progressing decline in cognitive function, somnolence, and clonus on exam.
Creutzfeld-Jakob. Subacute spongiform encephalopathy. Risk = dura mater, corneal transplants, cadaveric growth hormone, neurosurgical contamination. Lithium OD may mimic presentation.

19yo F horseback rider was thrown off horse. Lost consciousness then recovered. Now with HA, confusion, and weakness of left side with projectile vomiting.
Epidural hematoma. “Lucid interval” is classic. Signs = bradycardia, papilledema, mydriasis and CNIII palsy on ipsilateral,extensor plantar response and weakness on contralateral. CT –> lens-shaped, convex extra-axial fluid collection btwn dura & skull.

19yo M with wide-based gait, clubfoot, and lateral curvature of spine.
Friedreich’s ataxia. #1 hereditary ataxia. Auto-dom, chromosome 9. Degeneration of doral root ganglia –> prorioceptive loss, areflexia, ataxia, Babinski’s. Also causes visual loss, hypertrophic cardiomyopathy.

60yo M with HA worse in morning, nausea, and vomiting for six weeks.
Glioblastoma multiforme. CT = irregular enhancing left-sided mass with necrotic center; mass effect and surrounding edema.

38yo M with symmetric muscle weakness started in feet, now involving legs and shoulders. Had diarrhea and fever.
Guillain-Barre. Symmetrical proximalweakness / flaccidity. Increased CSF protein concentration without cellular increase. VDRL negative. Decreased nerve conduction velocity. Preceeded by GI/respiratory/EBV/Campylobacter/CMV +/- respiratory paralysis.

65yo M with sudden severe HA and hemiplegia. Now incontinent.
Hypertensive stroke.

59yo F with retro-orbital HA and diplopia. Diagnosed with lung cancer.
Metastatic dx. Intracranial mets from lung, breast, GI, GU, CA, and melanoma.

25yo with weakness, droopy eyelids, double vision, and dysphonia.
Myastenia gravis. Autoimmune c Abs to acetylcholine receptor subunits. Thymoma is present in 20% of cases.

46yo M with HAs in the morning, seizures, and CT showing nodular calcifications in a frontal lobe mass.
Oligodendroglioma. Usually low grade, but may be anaplastic. More sensitive to chemo than astrocytomas. Calcification in 90% of cases.

30yo M with anesthesia and weakness in both arms, occipital HAs, and stiff gait.
Syringomyelia. MR/CT –> cystic dilatation within central cervical cord. Hydromelia is lined by ependymal tissue, syringomyelia is not.

18yo M with wide-based gait and headaches. Father died of renal cell carcinoma at young age.
von Hippel-Lindau. Auto-dom, renal cell CA + renal, hepatic, pancreatic cysts + cerebellar ataxia.

49yo alcoholic with confusion, stupor, and nystagmus following 5% dextrose infusion.
Wernicke’s encephalopathy. Due to thiamine deficiency.

22yo F with abnormal Pap smear and no history of irregular menstrual, postcoital bleeding, or vaginal discharge.
Cervical carcinoma in situ.

29yo Vietnames F with nausea, vaginal bleeding, dyspnea, and hemoptysis.
Choriocarcinoma. Can develop during normal pregnancy, s/p hydatidiform mole, or previous spontaneous abortion. Elevated hCG.

45yo F with gross difference in size of her breasts with sensation of fullness but no pain. Exam reveals large, firm mass.
Cystosarcoma phyllodes. Less common benign tumor of breast. Mass tends to be mobile and is well circumscribed. Path = cystic spaces on cut section, producing recesses and longitudinal openings with ‘leaflike’ (phyllodes) appearance.

25yo W with amenorrhea for 6 weeks and development of pelvic pain for 1 day.
Ectopic pregnancy. Risk factors = previous tubal surgery, tubal ligation, endometriosis, previous ectopic pregnancy, ovulation induction, pelvic inflammatory disease. Test of choice = hCG and ultrasound (can get transvaginal US if needed).

60yo F with obesity presents with intermittent vaginal bleeding for three months. Has never had children.
Endometrial CA. Estrogen-dependent cancer. Rx: hysterectomy, radiation. Important to include in differential of postmenopausal bleeding.

27yo with inability to conceive, painful intercourse, and painful menses.
Endometriosis = extrauterine endometrial tissue. Can be located in various locations with unique symptoms , most frequently bilateral ovaries = chocolate cysts.

27yo F marathon runner with painful lump breast. Mammography reveals irregular mass with focal areas of calcification.
Fat necrosis. Indurated lesion with retraction of overylying skin. Unilateral localized process associated with trauma, breast biopsy, and radiation. Easy to confuse with CA… pain is the key distinguishing feature.

25yo F with right breast lump that is small, encapsulated, and freely moveable.
Fibroadenoma. #1 benign breast tumor in young women; sometimes enlarges during pregnancy or normal menstrual cycles. Mammogram = “popcorn calcifications”.

20yo F with chronic left lower quadrant pain and left adnexal mass on exam.
Follicular ovarian cyst. #1 cause of ovarian enlargement. Test = US to look for cyst. Rx: Follow-up ultrasound (many disappear spontaneously); laparoscopic removal if persistent.

52yo nulliparous F with painles lump in breast. PE reveals fixed, hard, nontender mass with retraction of overlying skin and palpable ispilateral nodes.
Infiltrating ductal CA = #1 breast cancer. Risk = family hx, estrogen “exposure”, atypical hyperplasia, previous breast cancer. Fibrosis with induration = desmoplastic reaction. Rx = surgery, tamoxifen if E receptor positive.

59yo F with pain and swelling in breast with erythematous overlying skin with peau d’orange appearance.
Inflammatory carcinoma of breast. Highly malignant with early and widespread metastases.

39yo F with heavy and frequent periods, occasionally painful.
Leiomyoma. #1 tumor of uterus, most common tumor in women. Estrogen-dependent. US reveals multiple heterogenous masses, 95% intramural myometrium location, round, firm, well circumscribed.

60yo F with foul-smelling, blood-tinged, purulent vaginal discharge. Tumor projecting from cervical os on speculum exam.
Leiomyosarcoma. CT = large complex mass in uterus. Biopsy = spindle-shaped cells with many mitotic cells. Rx: adriamycin, progestins, combination therapy. Aggressive malignant tumor of the myometrium, can arise from leiomyoma or de novo.

56yo F with history of breast CA with pelvic mass identified on routine physical exam.
Ovarian carcinoma. Serous type most common, often bilateral and advanced at diagnosis. Elevated CA-125, psammoma bodies.

68yo F with itchy, painless scaling and oozing of erythematous nipple.
Paget’s carcinoma. Characteristically a scally skin lesion of areola and nipple arising from ductal adenocarcinoma.

35yo F with bloody nipple discharge originating from one of the duct openings.
Papilloma of the breast. Benign proliferation of ductal epithelial tissue. #1 cause of serous / bloody nipple discharge.

88yo M with purpura over extensor aspect of both hands. CBC reveals not abnormality.
Senile purpura. Benign disease of elderly, characteristically extensor hand surfaces, forearms, and neck. Defect in collagen support of dermal cappillaries. No treatment available. Cosmetic consequence only.

18yo M with small purple skin lesions following URI two weeks ago.
ITP. Abrupt onset. Viral illnesses, drugs = thiazides, gold, carbamazepine, phenothiazines, quinine, rifampicin, valproate, sulphonamides, penicillins. Drug binds pltlt or drug binds plasma protein, forms immune complex, binds pltlt. Rx: steroids.

Causes of purpura.
Senile, Osler-Weber-Rendu (hereditary haemorrhagic telangiectasia), giant cavernous hemangioma (can cause DIC), Ehler’s-Danlos, Marfan’s, HSP, scurvy, Cushing’s, steroid use, uremia, liver dx.

64yo M with testicular swelling.
Lymphoma of testis. #1 testicular neoplasm in elderly.

29yo M with painless lymph node in the axilla, normochromic, normocytic anemia, and elevated ESR. Next test?
Node biopsy. Hodgkin’s –> Reed-Sternberg. Non-Hodgkins’ –> spectrum small lymphocytic (low-grade) to large cell centroblastic (high grade). A2 staging; I=nodes 1 region II=2 regions, same side III=nodes both sides hemidiaphragm, IV=diffuse.

45yo F with anemia, bone tenderness, and abdominal distension. Smear demonstrates blasts at all stages of maturation. Recent DVT.
CML. Philadelphia chromosome 22 bcr-abl translocation 9:22 (95% of cases). Complications = hyperviscosity (rx with leukophoresis).

60yo F with diffuse lymph node enlargement and smear with increased lymphocytes, smudge cells.
CLL. Most common leukemia in US and Europe. Monoclonal transformation of B cells. Diagnosis = persistent lymphocytosis with increased lymphs. Warm antibody hemolytic anemia may result. No rx if asymptomatic.

Causes of asplenia (anatomic or functional).
SLE, sickle cell, celiac, lymphoma, post-surgical. Risk of infection with S. pneumo, H. flu, N. meningitidis, malaria.

34yo M with facial plethora (redness), conjunctival suffusion, and splenomegaly.
Polycythemia. True or d/t excess EPO –> polycystic kidneys, renal CA / cysts, chronic glomerulonephritis, liver disease, hepatocellular CA, overian CA, bronchial CA. Hypoxia, lung disease, congenital heart disease, smoking. Enlarged retinal vessels.

P. vera: Hyperuricemia (rx with allopurinol), thrombotic events (less risk in secondary dx), 20% progress to myelofibrosis. Rx with phlebotomy. High incidence of HTN, itching, hepatomegaly, gout.

Causes of warm antibody autoimmune hemolytic anemia.
Lymphoma, leukemia (CLL), SLE, HIV. Causes spherocytes (also seen in congenital spherocytosis). Rx: prednisolone may induce remission; consider splenectomy.

Causes of cold antibody autoimmune hemolytic anemia.
Infectious mononucleosis, mycoplasma pneumonia, malaria, idiopathic (IgM paraprotein).

Cigar shaped erythrocytes.
Hereditary elliptocytosis. Usually asymptomatic.

Spherocytes on peripheral smear.
Perform osmotic fragility test. Spectrin defect = hereditary spherocytosis.

2yo with frontal bossing and “hair-on-end” appearance on skull x-ray. Has painful swelling of the fingers.
Sickle cell. Salmon-patch retinal hemmorhages. Homozygotes affected, heterozygotes asymptomatic until exposed to low O2 tension. Test with Hb electrophoresis and sickling test.

25yo black M develops painful joints and severe stomach pain one day into ski trip in the French Alps.
Sickle cell trait. Crisis at low O2 tensions.

Drug induced aplastic anemia.
Chloramphenicol, chlorpropamide, chlorpromazine, carbimazole, carbamazepine, gold salts, methotrexate, phenytoin.

Most common cause of iron deficiency anemia worldwide.

58yo F with recurrent episodes of thrombophlebitis in the legs and arms.
Pancreatic CA. Thrombophlebitis may preceed diagnosis by many months.

64yo peanut farmer with jaundice, weight loss, and right upper quadrant pain.
Hepatocellular CA. Test for alpha-fetoprotein. Ultrasound / CT to evaluate.

Causes of cirrhosis.
Glycogen storage, Fanconi’s, alpha-1-antitrypsin (neonatal hepatitis with cirrhosis in childhood), cardiac cirrhosis (late complication of R heart failure), methotrexate, hereditary hemorrhagic telangiectasias, ulcerative colitis and Crohn’s.

17yo M with tremor, athetoid movements, and elevated LFTs.
Wilson’s disease. Low ceruloplasmin. Kayer-Fleischer ring in cornea. Rx: penicillammine chelation therapy.

55yo F with pruritus and jaundice that progressed over 3 years.
Primary biliary cirrhosis. Anti-mitochondrial Abs. Assoc. c Sjogren’s, Raynaud’s, thyroid dx, Addison’s, RA, fibrosing alveolitis, dermatomyositis, scleroderma. Women 9:1, age 40-60. ERCP reveals normal intra/extrahepatic bile ducts. Gallstones common.

31yo M with jaundice, pruritus, and RUQ pain. Markedly elevated AP with slight elevation in AST and ALT.
Primary sclerosing cholangitis. ERCP shows patchy dilatation and stricturing of biliary tree. High risk of ulcerative colitis. Progresses to hepatic cirrhosis. Risk = ascending cholangitis. HLA B8, DR2, DR3.

30yo F with hypothyroidism and rheumatoid arthritis develops jaundice.
Autoimmune hepatitis. Type I = history or family history of autoimmune disease. Type 2 = anti-liver and kidney microsomal autoantibodies, occurs in younger children. Type 3/4 = soluble liver antigen, type 4 ill-defined similar clinical as type 1.

31yo F with morbilliform rash and jaundice. Recently seen by a neurolgist for epilepsy.
Drug-induced hepatitis. Phenytoin (anti-epilepsy).

25yo with eosinophilia, chronic cough, and distal small bowel obstruction.
Ascaris lumbricoides. Larvae migrate to lung, small bowel obstruction are complications.

29yo HIV + F with eosinophilia, liver, heart, and renal failure.
Strongyloidiasis. Can result in systemic invasion in IC’d pts.

23yo M former aid worker in Guatemala has resolving bloody diarrhea nd develops stricturing and mucosal damage to colon.
Entamoeba histolytica. Don’t confuse with inflammatory bowel disease.

Diarrhea: viral
Rotavirus, Norwalk, Adenovirus.

Diarrhea: bacterial toxin
E. coli (enterotoxigenic), Vibrio cholerae, Staph aureus, Clostridium perfringens, Clostridium difficile, Clostridium botulinum, Bacillus cereus.

Diarrhea: bacterial invasive
E. coli (enteroinvasive), Shigella, Salmonella, Yersinia enterocolitica, Vibrio parahemolyticus, Campylobacter jejuni.

Diarrhea: parasites
Giardia lamblia, Cryptosporidium parvum, Entamoeba histolytica.

Diarrhea: drugs
laxatives, antacids with magnesium

Diarrhea: food toxins
puffer-fish, ciguatoxin, scombroid

Diarrhea: chronic GI disorders
Ischemic colitis, malabsorption, irritable bowel, inflammatory bowel disease

Diarrhea: secretory
Vibrio cholera, campylobacter, E. coli, Salmonella.

Diarrhea with systemic illness
Salmonella typi (enteric fever with diarrhea as late symptom)

64yo with CAD deficiency develops diarrhea, vomiting, and vague abdominal pain that rapidly progresses to hematochezia and severe abdominal pain.
Acute mesenteric ischemia.

48yo M with recurrent abdominal pain after eating. Also has hypercholesterolemia.
Chronic mesenteric ischemia (intestinal angina).

53yo M with abdominal pain and diarrhea with blood. Plain abdominal film reveals “thumbprinting” pattern in the descending colon and narrowing of the colonic lumen.
Colonic ischemia. More common than mesenteric ischemia, typically affects splenic flexure and other watershed areas.

55yo F previously treated for carcinoma of cervix, now with nausea, vomiting, and rectal bleeding.
Radiation colitis. Intestinal ischemia may develop due to endarteritis obliterans. Sometimes pseudo-obstruction. Barium study = thickening of mucosal folds, narrowing of lumen. Symptoms due to rapid transit time and malabsorption.

38yo F with celiac disease with chronic diarrhea and weight loss. Has been strictly adhering to gluten-free diet.
Intestinal lymphoma. Increased risk in celiac disease.

19yo F with diarrhea and bullous skin eruption.
Dermatitis herpetiformis. Gluten senstive enteropathy (celiac disease) + bullous skin eruption. Both may respond to gluten-free diet.

8yo M with chronic diarrhea, steatorrhea, abdominal distention, and failure to thrive.
Celiac disease (Gluten-sensitive enteropathy). Adult presentation more vague with megaloblastic anemia, diarrhea, vague abdominal symptoms. Abs include endomysial, gliadin, and reticulin. IgA endomysial Ab with high sensitivity and specificity.

Diagnosis of celiac disease?
Biopsy! Flattening of vili. Definative diagnosis requires trial of gluten-free diet.

Causes of malabsorption.
Stomach: post-gastrectomy dumping, ZE, pernicious anemia. Hepatic/biliary: bil. obstr. / cholestasis. Pancreas: CF, pancreatitis, CA. Sm. bowel: celiac, crohn’s, removal of sm. bowel, fistulae/blind loops, infection, radiation, lymphoma, drugs, whipple’s.

Approach to malabsorption?
1. confirm impaired absorption (fecal fat, Schilling test) 2. Identify specific deficiencies (CBC, Fe, iron, folate, B12, PT/PTT, vit D 3. establish cause.

34yo M with severe recurrent peptic ulcer, diarrhea, and weight loss.
Zollinger-Ellison. Gastrin producing tumor associated with MENI (usually pancreatic). Diagnosis = high gastrin level and high basal secretion of acid.

Upper GI bleeding?
GUMBLEEDING = Gastritis, Ulcer, Mallory-Weiss, B, L, Esophagitis, Esophageal varices, angioDysplasia, Infection, N, GERD.

Common causes of lower GI bleeding?
hemorrhoids, anal fissure, inflammatory bowel, diverticulitis, carcinoma, intussusception.

Test for bacterial overgrowth?
glycochocolate breath test, based on deconjugation of radiolabeled bile acid and exhalation of labeled CO2.

GI utility of US and CT?
Liver, pancreas, and biliary tract.

GI utility of plain film?
Demonstrate dilatation (toxic megacolon), obstruction.

GI utility of angiography?
GI bleeding of obscure cause or suspected mesenteric ischemia.

Unusual causes of lower GI bleeding?
AV fistulae, hereditary-hemorrhagic-telangiectasias (Osler-Weber-Rendu), angiodysplasia, vasculitis, amyloidosis. Meckel’s, blood disorders (hemophilia, thrombocytopenia), rupture of AAA into bowel.

Common causes of upper GI bleeding?
Duodenal ulcer > stomach erosions / gastritis > GERD > gastric ulcer > Mallory-Weiss > duodenal erosions > esophageal/gastric varices > stomach CA

Causes of sore tongue?
Systemic: folate/B12/Fe deficiency, collagen-vascular dx, diabetes. Local: smoking, fractured tooth/dentures/crowns, candidiasis, dry mouth.

Teeth and gums
Blue line at tooth/gum margin = lead; gingivae swollen and purplish = scurvy; hyperplastic gingivitis = phenytoin, cyclosporin, and calcium antagonists; yellow staining = tetracycline.

Apthous ulcers?
poor dental hygeine, gluten enteropathy, inflammatory bowel dx, Behcet’s.

Enlarged tongue?
Acromegaly, myxoedema, amyloidosis, motor neuron disease.

71yo M smoker with progressive dysphagia.
Esophageal CA

25yo M with progressive dysphagia and no past medical history.
Esophageal ring. Occur at or near GE junction. Cause unknown.

31yo M with HIV and odynophagia.
Esophagitis due to candidia, herpes, or CMV.

H. pylori infection.
Association with duodenal ulcer (100%) > gastric (80%) > duodenitis/gastritis. Increased risk of gastric cancer and MALT lymphoma. Test: serology or urease breath test.

Gastritis causes?
Infectious = rotavirus, norwalk, E. coli, H. pylori. Drug/chemicals = aspirin and other NSAIDs, alcohol. Asymptomatic chronic = elderly persons often with H. pylori. Atrophic = autoimmune (positive parietal cell Abs) with pernicious anemia.

38yo F presents with melena and epigastric pain. Barium study revealed rugal hypertrophy.
Menetrier’s disease (giant hypertrophic gastritis). Assoc. with protein-losing enteropathy.

GI disease with finger clubbing?
malabsorption, small intestinal disease, and cirrhosis.

Stimulation test and markers:

Insulin hypoglycemia test: GH, cortisol, blood glucose

Glucacon: GH, blood glucose

Thyrotropin releasing hormone: TSH, T3, T4, prolactin, GH

Gonadotropin releasing hormone: FSH, LH, spermatogenesis, ovulation


CRH: ACTH, cortisol

Fluid deprivation:

11yo M with with color blindness, midline facial deformity, and anosmia.
Isolated gonadotropin deficiency = Kallman’s syndrome. Prepubertal onset, hypogonadal hypogonadism.

28yo F with resolving meningitis develops polyuria.
Central diabetes insipidus. Most frequently associated with craniopharyngioma. Rarely with anterior pituitary disease. Test = water deprivation and measure urine osmolality.

43yo M with thick skin, broad nose, and prominent supraorbital and nuchal ridges.
Acromegaly. Uncommon. May occur in MEN1. Large spade-like hands. Enlargement of the tongue. Hoarse voice. Cardiomegaly, heart failure, and malignancy causes death. Tufting of terminal phalanges on x-ray.

Elevation of prolactin level due to physiolgic cause?
Sleep, stress, nipple stimulation, coitus, pregnancy, suckling.

Most common cause of Cushing’s syndrome?
ACTH overproduction by pituitary 60% > ectopic ACTH (15%) > adrenal adenoma (15%) > adrenal carcinoma (10%). Cushing’s disease usually pituitary microadenoma (90%) more frequently in women.

48yo F with develops increasing pigmentation following bilateral adrenalectomy for Cushing’s disease.
Nelson’s syndrome. May follow adrenalectomy if ACTH production continues in excess.

Diagnosis of Cushing’s syndrome.
Low dose 48hr dex suppression. Screening with overnight dex suppresion test or 24hr urinary free cortisol. If plasma ACTH is undetectable, usually adrenal tumor. Pituitary-dependent disease suppresses, whereas adrenal tumors and ectopic ACTH does not.

Ectopic ACTH tumors?
Bronchial carcinoma, carcinoid.

29yo F with SLE and history of DVTs develops increased skin pigmentation and profound hypekalemia.
Primary adrenal insufficiency. Antiphospholipid syndrome can destroy adrenal glands.

31yo M with fatigue, weight loss, GI disturbances, and dark spots on the inside of his cheeks.
Addison’s disease. Autoimmmune or rarely TB, granulomatous disease, metastases. Other causes of adrenal insufficiency include withdrawal of steroid therapy, Waterhouse-Friderichsen, anticoagulant therapy. Hyponatremia, hyperkalemia, vitiligo.

Poor growth syndromes?
Rare congenital syndromes, nutritional/emotionald deprivation, GH deficiency (fat with immature facies and genitals), hypothyroidism, Cushing’s. “Fat and short” likely endocrine. Turner’s 45XO, and Noonan’s (45XO/XY mosaic).

34yo F with short stature, large head, prominent forehead and disproportion of body and limbs.
Achondroplasia. Autosomal dominant. #1 short stature with abnormal proportions.

15yo F found on pelvic exam to have bilateral masses in the labia. LH levels is high.
Testicular feminization syndrome. XY male with X-linked deficiency of androgen receptors.

Newborn with ambiguous genitalia, clitoral hypertrophy, and partial fusion of labioscrotal folds.
Congenital adrenal hyperplasia. 21-hydroxylase defiency. Excess androgenic cortisol precursors.

18yo M with small firm testes, gynecomastia, and female distribution of body hair.
Klinefelter’s. Infertile, may be unusually tall, 47XXY.

Common causes of amenorrhea?
Hyperprolactinemia, weight loss, anorexia nervosa, autoimmune associated ovarian failure (Addison’s or other).

24yo obese F with menstrual irregularity, hirsutism, and acne.
Polycystic ovarian syndrome. Stein-Leventhal syndrome = obesity, amenorrhea, and hirsutism. DM2 develops in 40% by age 40. Labs = incr LH, +/- incr T, normal FSH, prolactin and TSH. Pelvic

61yo M with new onset atrial fibrillation, heart failure, and 20lb weight loss over 12 months.
“Masked” hyperthyroidism. Commonly due to toxic multinodular goiter. Lacks typical Grave’s features.

44yo F with diffuse goiter, pretibial myxoedema, and tachycardia.
Grave’s. IgG antibodies against TSH receptor = thyroid stimulating Abs (TSAb). Exopthalmos, lid lag, periorbital puffiness, increased lacrimation, conjunctival edema, ophthalmoplegia, loss of visual acuity.

53yo F with hyperlipidemia, puffy face, and coarse hair, and hair loss.
Hypothyroidism: Spontaneous atrophic, postsurgical, radioactive I, Hashimoto’s (thyroid peroxidase and thyroglobulin Abs in 90%). Dry skin, coarse hair, facial edema, effusion, ascites, cardiac dilatation. Assoc c pernicious anemia and carpal tunnel.

Most common goitrous hypothyroidism?
Hashimoto’s. Women >> Men. Older women > younger.

58yo F from central Africa with large goiter.
Endemic goiter. Can be euthyroid. Due to iodine deficiency.

73yo F with hypothermia and altered mental status and history of hypothyroidism.
Myxedema coma. marked by hypothermia, cardiac failure, altered MS, convulsion. Mortality 50%.

46yo M with painful itchy ear following family vacation to lake. Experiences pain when tragus is pressed during exam.
Otitis externa. Symptoms inlcude pain, pruritus, hearing loss, and fullness. Tragus = semicircular cartilage in front of ear canal. Staph and pseudomonas.

51yo diabetic M with painful itchy ear. Physical exam reveals inflammation and swelling of the pinna.
Cellulitis. Differentiate from otitis externa.

47yo HIV positive M with “boring” ear pain and long-standing ear infection that has not responded well to treatment.
Necrotizing external otitis. Occurs in ICd pts. Refer to otolaryngology.

28yo F with diffusely swollen and tender pinna.
Perichondirits. IV antibiotics, serious condition.

31yo M with circumscribed swellings in the external canal with tenderness on exam.
Furunculosis. Rx with topical ABs.

82yo M with pruritus of the external canal. Whitish exudate with black spots on exam.
External mycotica (otomycosis). Aspergillus niger causes black spots over white.

44yo construction worker with dizziness, tinitus, and conductive hearing loss in the right ear.
Cerumen impaction.

Complications of sinusitis?
Osteomyelitis, periorbital infections (pain with eye motion, ptosis, proptosis), cavernous sinus thrombophlebitis (CN III, IV, VI palsies), brain abscess, meningitis.

Persistent sinusitis?
Consider Wegener’s granulomatosis, cystic fibrosis, Kartagener’s, and TMJ syndrome. Need CT scan to rule out obstruction.

25yo F develops high fever, myalgias, rhinorrhea, and sore throat.
Common cold, due to: influenza virus, rhinovirus, coronavirus, adenovirus, parainfluenza. Rule out bacterial sinusitis, pharyngitis, and allergic rhinitis (history of itchy eyes, nose, and throat).

25yo F develops high fever, myalgias, and palpable tender neck nodes.
Bacterial pharyngitis. No cough or rhinorrhea. Tonsillar exudate may be present. Viral pharyngitis much more common (90%). Group A strep >> other strep, mycoplasma, chlamydia, and neisseria gonorrhea. Diptheria with grey-white pseudomembrane.

25yo F with itchy eyes, nose, and throat. Pale edematous nasal mucosa.
Allergic rhinitis. Seasonal or allergic pattern. Tearing. Mucosa is not erythematous.

25yo F with purulent nasal discharge, tender face, and toothache.
Bacterial sinusitis. Treat with amoxicillin.

Findings suggestive of Group A strep pharyngitis.
Recent exposure, history of infection in past yr, absence of cough, hoarseness, or rhinorrhea, temp > 101, tonsillar exudate, anterior cervical lymphadenopathy.

Causes of secondary hypertension (5% of all HTN, primary/essential HTN 95%)
Aortic coarctation, intrinsic renal dx, renal artery stenosis (young = fibromuscular, old = athero), primary hyperaldosteronism (suspect if hypokalemic and not on diuretic), Cushing’s, Pheo,

1 anatomic, two renal, three adrenal, and four CENTs cause HTN.
CENTs = hyperCalcemia, Ethanol or Estrogen (oral contraceptives) most common causes, Neurologic disease = increased ICP, Thyrotoxicosis.

21yo F develops dramatic increase in creatinine after starting ACE inhibitor therapy for hypertension.
Consider renal artery stenosis!

31yo M with mental status changes and blood pressure of 225/124
Hypertensive emergency. Hypertensive urgency = systolic BP > 220. Hypertensive emergency = Urgency + End-organ damage: encephalopathy (ms changes), intracranial hemorrhage, aortic dissection, MI, unstable angina, hypertensive nephropathy.

HTN treatment: uncomplicated, DM1, CHF systolic, CHF diastolic, isolated systolic HTN, CAD or MI, BPH, pregnancy.
beta blocker or diuretic; ACE or diuretic; beta blocker, diuretic, or CCB; diuretic; beta blocker; prazosin; methyyldopa.

18yo M with painful swollen knee and ipsilateral leg lower leg edema.
Ruptured popliteal cyst.

54yo F with inguinal lymphadenopathy, pelvic symptoms, weight loss and bilateral lower extremity edema. Dry and scaly skin on feet.

43yo F with painless edema worse at the end of the day. Varicose veins present. Improves with elevation.
Chronic venous insufficiency.

54yo F with painful thighs and bilateral lower extremity edema following knee replacement surgery.
Bilateral DVTs.

45yo F with tachycardia, bilateral lower extremity edema, and tremor.
Pretibial myxedema (Grave’s disease)

12yo M with leg length discrepancy since childhood and ipsilateral lower extremity edema.
Congenital venous malformation.

24yo F with SLE presents with bilateral lower extremity edema.
Nephrotic syndrome.

28yo M with taut, shiny skin and extreme sensitivity to touch of right leg. Edema in the right leg on exam.
Reflex sympathetic dystrophy.

43yo M with lots of tatoos develops peripheral edema and necrotic skin lesions.
HCV is associated with cryoglobulins and membranoproliferative glomerulonephropathy.

45yo F with recurrent infections, nonhealing leg ulcers, history of RA, and splenomegaly on examination.
Felty’s syndrome.

Calcinosis, Raynaud’s, Esophageal dysmotility, Sclerodactyly, Telangiectasias.

45yo F with history of PBC with skin thickening of the fingers and difficulty swallowing.
CREST. Associated with PBC and primary pulmonary hypertension.

Causes of chronic cough
Postnasal drip > GERD > asthma. Also cigarette use +/- COPD. Less common causes include bronchiectasis, CHF, ACE-I, post-pertussis cough, malignancy, chronic infection usually c systemic symptoms, and psychogenic cough.

Headache and jaw claudication.
Giant cell arteritis. Diagnosis with biopsy, start steroid rx immediately. Large vessel vasculitis.

26yo Asian F with finger ischemia and arm claudication.
Takayasu’s arteritis. “Pulseless disease”. Diagnosis with aortic arch angiogram.

32yo M with skin ulceration, hematuria, abdominal pain after eating, joint pain, and right hand weakness.
Polyarteritis nodosa (PAN). Necrotizing vasculitis of small and medium muscular arteries. 1/3 associated with HBV, also with HCV. No pulmonary findings!

35yo M with shortness of breath, fever, maculopapular rash, palpable purpura, and cutaneous nodules. CBC reveals eosinophilia.
Churg-Strauss. Granulomatous reaction in medium sized vessels.

28yo M with recurrent sinusitis, hematuria, and hemoptysis. Has had recurrent fevers, weight loss and arthralgias.
Waegener’s granulomatosis. C-ANCA positive vasculitis of small arteries. Upper and lower respiratory infections.

Drug causing palpable purpura.
Hypersensitivity vasculitis.

45yo M with abdominal pain, swollen joints, purpuric rash, and hematuria following URI four days ago.
Henoch Schonlein Purpura. Definition = IgA nephropathy plus abdominal pain, join pain, and purpura.

24yo F with history microscopic hematuria and microalbuminuria, now with gross hematuria following URI.
IgA nephropathy

34yo M with hemoptysis and hematuria.
Goodpasture’s syndrome. Anti-glomerular basement membrane antibody. (Anti-GBM).

50yo M with CLL presents with blurry vision, finger ischemia, headache, and lethargy.
Monoclonal cryoglobulinemia. Rx with plasmapheresis.

60yo M with history of IVDA now with arthralgia, purpura, glomerulonephritis, and neuropathy.
Mixed cryoglobulinemia. Result of immune complex deposition. Associated with HCV, lupus, and RA.

35yo M with one year progressive dyspnea. Oxygen saturation drops with ambulation.
Idiopathic pulmonary fibrosis or PCP pneumonia. Hallmark of interstitial lung disease.

Dermatomyositis patients have increased risk of what?
Malignancy: colon, lung, breast, and prostate.

Causes of wheezing
CARES: Cardiac asthma (CHF), Churg-Strauss, Allergic bronchopulmonary aspergillosis, Reflux esophagitis (GERD), Exposures (irritants, meds), Embolism, Sinusitis, Strongyloides.

Causes of obstructive lung disease?
Asthma, COPD, bronchiectasis, cystic fibrosis.

Causes of restrictive lung disease?
Pleural fibrosis, Interstitial (idiopathic, fungal infection: histoplasmosis, sarcoid), neuromuscular (myasthenia gravis, myopathy, Guillain-Barre), alveolar edema or inflammation, BOOP, pleural effusion, kyphoscoliosis, pregnancy, obesity.

What causes most cases of acute bronchitis?
Viral > atypical bacteria (Mycopl, Chlamydia, Legionella) > typical bacteria rarely (s. pneumo, h. flu, morexella) > allergic. Acute onset of cough and sputum production s hx of chronic pulm dx and no evidence of pneumonia or sinusitis. No Abs needed.

Most common immunodeficiency?
Selective IgA deficiency. Caused by anti-IgA IgG. Recurrent sinopulmonary infections.

Low IgA, IgG, and IgM. Normal numbers of B cells. Pts 15-30yrs old.
Common variable immunodeficiency. Associated with autoimmune disease and lymphoid malignancies.

Recurrent pyogenic infections of skin and lower respiratory tract. Pruritus, coarse facies, keratotic nails.
Job’s syndrome. Hyper-IgE. Autosomal recessive. Abscess, empyema, staph. aureus.

Thrombocytopenia, eczema, and recurrent infections.
Wiscott-Aldrich. Depressed cell-mediated immunity, high IgA.

Low set ears, opportunistic and viral infections, severly sick after live viral vaccine, hypokalemia and hypocalcemia.
DiGeorge syndrome. Congenital immunodeficiency with no thyroid or parathyroid. 3rd and 4th pharyngeal pouch.

5yo M without tonsils, recurrent URIs and skin infections, and asymmetric arthritis.
Bruton’s congenital agammaglobulinemia.

Recurrent staph and strep infections in albino child.

34yo M with slow onset of cough and pleuritic chest pain several days following resolution of URI.
Pneumococcal pneumonia. Usually abrupt presentation occurs insidiously following viral respiratory tract infection.

57yo M with COPD develops pleuritic CP and worsening cough.
H. flu pneumonia.

88yo F develops cough, fever, and pleuritic CP.
S. aureus pneumonia. Seen in ICd and nursing home pts.

54yo alcoholic presents with productive cough, fever, and lobar consolidation on CXR.
Aerobic GNR pneumonia.

19yo F with mild pneumonia and hemolytic anemia.
Mycoplasma. Prominent extrapulmonary symptoms including: erythema multiforme, myocarditis, erythema nodosum, bullous myringitis, neurological abnormalities.

23yo M with mild pneumonia and hoarseness with severe pharyngitis.
C. pneumoniae. Distinguishing feature = hoarseness with severe pharyngitis.

Atypical pneumonias?
Legionella, Moraxella, Chlamydia, Mycoplasma.

Pneumonia requiring hospital admission?
Two or more lobes, increased A-a gradient or tachypnea, mental status changes, vulnerable patient, homeless patient, very high/low white count.

45yo M with pedal edema, nocturia, and morning headache.
Sleep apnea. Symptoms include snoring, daytime hypersomnolence, morning headache, impotence, nocturia or enuresis, pedal edema, exercise fatigue. Exclude hypothyroidism and acromegaly.

Abdominal Pain due to metabolic / systemic disorders: Puking My Very BAD LUNCH
Porphyria, Mediterranean fever, Vasculitis, Black widow, Addison’s / Angioedema, DKA, Lead, Uremia, Neurogenic (diabetes, syphillis, spinal nerve impingement), hyperCalcemia, Herpes zoster.

Abdominal pain: RUQ
liver, gallblader

Abdominal pain: Epigastric
stomach, pancreas, duodenum, abdominal aorta

Abdominal pain: LUQ

Abdominal pain: lower quadrants
appendix, intestine, ovary, fallopian tubes, testes, kidney, ureters

Abdominal pain: periumbilical
small intestine, appendix, abdominal aorta

Abdominal pain: suprapubic
bladder, uterus, ovaries, fallopian tubes

Causes of secretory diarrhea that persists despite fasting?
Thyrotoxicosis, carcinoid syndrome, colon cancer, colonic polyps, durgs.

Drugs causing diarrhea?
Colchicine, Mg-containing antacids, antibiotics, theophylline, lactulose, laxatives.

Causes of osmotic diarrhea?
Drugs, pancreatic insufficiency, celiac disease, lactose/fructose intolerance, laxatives.

Causes of exudative diarrhea?
(Protein, blood, mucus) Stools with leukocytes and blood. Causes include: Lymphoma, Whipple’s disease, collagenous colitis, IBD, ischemic colitis.

Intestinal motility disorders associated with?
IBS, DM, narcotic use, systemic sclerosis, fecal impaction, surgery (post-gastrectomy dumping, post-vagotomy syndrome).

Causes of malabsorption?
Radiation enteritis, bacterial overgrowth, enteric fistula, ileal resection, short bowel syndrome.

Diarrheas associated with immunodeficiency?
Isospora belli, Microsporidia, Cryptosporidium parvum, Giardia lamblia, Strongyloides stercoralis, Entameba histolytica, Mycobacterium-avium-intracellulare complex, Clostridium difficile, CMV.

What accounts for 50% of cases of diarrhea referred to gastroenterologists?
Functional diarrhea. No organic cause.

34yo M presents with low back pain worse with rest and bloody diarrhea.
Crohn’s disease.

67yo M with CAD and familial hypercholesterolemia presents with bloody diarrhea.
Ischemic bowel.

31yo F with diarrhea, weight loss, and skin rash.
Celiac disease with dermatitis herpetiformis.

Causes of constipation?
Neoplasia, strictures, adhesion/rectoceles, drugs (tricyclics, opiates, neuroleptics, antihistamines, CCBs, iron supplements, antacids without Mg), DM, hypothyroid, hypokalemia, hypomagnesemia, uremia, neurologic disorders, IBS, amyloid, scleroderma.

Type 1 RTA (distal)
H secretion. Low K. pH > 5.3. Rx: HCO2 + K. Hereditary, amphotericin, collagen vascular disease, cirrhosis, nephrocalcinosis.

Type 2 RTA (proximal)
Bicarb reabsorption. Low K. pH < 5.3. Rx: HCO3 + K + thiazide. Hereditary, sulfonamides, carbonic anhydrase inhibitors, Fanconi syndromes.

Type 4 RTA (distal)
Aldosterone defiency. High K. pH < 5.3. Rx: Fludrocortisone, K restriction, HCO3. Hyporeninemic with diabetes, HTN, or chronic interstitial nephritis; aldosterone resistance.

Anion gap metabolic acidosis?
MUDPILES: Methanol, Uremia, Diabetic ketoacidosis, Paraldehyde, Iron/INH, Lactic acidosis, Ethylene glycol, Salicylates.

Hyperchloremic metabolic acidosis (no anion gap)?
Diarrhea, RTA, spironolactone/acetazolamide, TPN

Respiratory acidosis?
Foreign body, pneumothorax, flail chest, hypoventilation d/t sedatives/narcs, obstructive/restrictive pulmonary disease, pleural effusion.

Metabolic alkalosis?
NaCl responsive = vomiting, villous adenoma, contraction alkalosis, diuretics. Rx IVF + K. Not NaCl responsive = Conn’s & Cushing’s, adrenal hyperplasia, licorice, Bartter’s syndrome. Rx: KCl and spironolactone or acetazolimide (enhance HCO3 excretion)

Respiratory alkalosis?
Hyperventilation (anxiety/pain), CVA, head trauma, asthma, PE, CHF, pneumonia, pregnancy, hepatic insufficiency, ASA toxicity, thyrotoxicosis, mechanical ventilation. Rx = treat underlying cause.

High osmolality = hyperglycemia or hypertonic infusion. Normal osmolality = Pseudohyponatremia, hyperlipidema, hyperproteinemia. Low osmolality = hypotonic hyponatremia.

Hypotonic hyponatremia?
Check FeNa: > or < 1%.

Hypotonic hyponatremia with FeNa >1%.
Hypervolemic = renal failure; Euvolemic = SIADH, hypothyroidism, renal failure, drugs; Hypovolemic = diuretics, RTA, adrenal insufficiency, ACE inhibitors.

Hypotonic hyponatremia with FeNa <1%.
Hypervolemia = nephrosis, CHF, cirrhosis; Euvolemic = polydipsia; Hypovolemic = vomiting, diarrhea, third spacing, dehydration.

Treatment fo hypotonic hyponatremia?
Hypervolemic = salt & water restrict; Euvolemic = salt & water restrict; Hypovolemic = normal saline.

Hyperkalemia signs and symptoms?
Intestinal colic, areflexia, weakness, peaked T wave, prolonged QRS and PR, low P.

Causes of hyperkalemia?
Cellular shifts: (tissue injury, acidosis, insulin deficiency, drugs including succinylcholine, digitalis, beta-agonists, arginine);

Decreased excretion: renal insufficiency, drugs (spirlonolactone, triamterene, ACE-I, trimethoprim, NSAIDs), mineralocorticoid deficiency.

Iatrogenic and spurious: hemolysis, fist clenching, leukocytosis, thrombocytosis.

Treatment of hyperkalemia?
C BIG K = Calcium gluconate (cardiac membrane stabilization); Bicarb, Insulin, Glucose; Kayexalate and loop diuretics (furosemide).

Hypokalemia symptoms?
muscle weakness, cramps, ileus, hyporeflexia, parasthesias, flaccid paralysis.

Causes of hypokalemia?

Linear calcification on x-ray of the knee?
Pseudogout. Positive birefringent crystals. Associated with hemachromatosis.

58yo F with long history of RA develops splenomegaly and leukopenia.
Felty’s syndrome.


septic shock, pustules, organisms on gram stain

prositutes, urethritis, joint pain with effusion

typhoid fever
poor sanitation, prolonged fever, constipation, bradycardia, rose spots

staph sepsis
vesicles and bullae, IVDA

vibrio vulnificus
raw seafood, lesions on legs > arms, cirrhotics most susceptible

hot tubs: pseudomonas; swimmer’s itch: schistosomes

streptococcal infection
scarlet fever: sandpaper texture of rash, cellulitis, palms peeling

Toxic shock = palmar desquamation

rocky mountain spotted fever
ascending purpuritic rash on palms and soles

maculopapular rash, viral syndrome

Diagnosis of amyloidosis?
Biopsy of abdominal fat pat or rectal biopsy.

ATPW hypocalcemia?
Serum Ca and Mg. Serum PTH, 25 and 1,25-D, phosphate, Cl, creatinine, amylase & lipase. Obtain EKG to look for prolonged QT.

Causes of hypocalcemia?
HIPOCAL: Hypo-PTH, Infection, Pancreatitis, Overload (rapid IV volume expansion), Chronic renal failure, Absorption abnormality, Loop diuretics.

Causes of hypercalcemia?
MISHAP-F: Meds/malignancy, Intox (vit D or A) or Immobilization, Sarcoidosis, Hyper-PTH or Hyperthyroid, Addison’s or milk-Alkali, Paget’s or Pheochromctoma. Familial hypocalciuric hypercalcemia (benign autosomal dominant condition)

Symptoms of hypercalcemia?
abdominal moan, psychiatric groan, kidney stone, and urination zone.

Most common cause of hypercalcemia?
malignancy or hyperparathyroidism.

Sideffect of lithium?
Hyperparathyroidism: alters setpoint for PTH secretion.

Thiazide diuretic sideffect?
hypercalcemia d/t increased renal reabsorption.

PTH-related peptide secreting tumors?
breast, lung, renal cell

Why does sarcoid and other granulomatous disease cause hypercalcemia?
increased conversion of 25-hydroxyvitamin D to 1,25 in macrophages. Occurs in TB, berylliosis, and lymphoma.

Most common hyperparathyroidism?
Solitary adenoma > 80% of cases. Four-gland hyperplasia 10%, multiple adenomas 5%, MENI or II.

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E. All of the following statements are false Which of the following statements is false? A. President Hoover hurt America during the Great Depression more than he helped it. B. President FDR was very close with the American public. C. …

Description Shingles is the painful inflammation of the nerve ganglia. The eruption of the skin forms a girdle around the middle of the body. The disease is also the same virus that causes the chicken pox. Statistics and Facts 1. …

Dermatomes area of skin in which sensory nerves derive from a single spinal nerve root Shingles Painful blistering skin rash, caused by same virus as chicken pox, dormant and lives in Nervous System, affects where virus is residing, not contagious …

Infectious diseases are characterized often by a disease code and an organism code. When this occurs, it is appropriate to use two codes. True Code B20 is NEVER used once a patient develops AIDS False WE WILL WRITE A CUSTOM …

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