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Young adult, no meds, presents with non-pitting lip edema that: Began in adolescence Triggered by strong emotions, crying Preceded by tingling lips and swelling over 24 hrs Resolves in 1-2 days 2-4 attacks/ year Unresponsive to antihistamines low C4 during episodes correct answers Hereditary angioedema Young female with 6 month H/O Fever, wt loss, arthralgias Recurrent sinus infections Intermittent hematuria Papulosquamous rash on cheeks, extends to nose, spares nasolabial folds Violaceous mottled rash on forearms, thighs Bilateral active synovitis of MCPs Low WBC, Hgb, plts, + Coombs, hematuria, proteinuria, + anti-dsDNA and anti-Sm H/O childhood pneumonia with one episode of pneumococcal bacteremia correct answers SLE presenting with early complement deficiency See complement deficiency, esp C1q Young adult, H/O N. meningitidis bacteremia at age 15, presents with: Fever HA Stable BP Diffuse erythematous maculopapular rash on extremities and thorax. Petechiae on oral mucosa and conjunctiva Absent Kernig, Brudzinski BCx- Gram neg cocci correct answers N. men meningitis with terminal complement deficiency Usually have a less fulminant disease course Healthy patient with acute onset of: Generalized hives Dyspnea, wheezing after using latex gloves for the first time Tachycardia hypoxia Decreased air movement in lungs with audible wheezing correct answers Anaphylaxis Do NOT require HoTN Common triggers: drugs (B-lactams), insect stings, foods (shellfish, peanuts), food additives Healthy pt with: Itchy hives on thighs, chest after exercise and hot showers
No wheezing, dyspnea correct answers Cholinergic urticaria Healthy pt with: Chronic rhinorrhea and nasal congestion in the spring and fall Bilateral conjunctival injection, dark circles around the eyes, Dennie-Morgan lines (accentuated lines under the eyes) Pale blue nasal mucose with edema of the turbinates correct answers Allergic rhinitis Pt presents with: Chronic nasal congestion, worse in spring and fall Swollen and "beefy red" or "boggy, erythematous" nasal mucosa correct answers Rhinitis medicamentosa Note nasal exam is different from AR Young patient with: Diarrhea Foul smelling stools PMH: frequent ear, sinus infections as a child, allergies to several foods
- Giardia stool antigen correct answers Selective IgA deficiency 85% have no symptoms Can see false positive pregnancy test, anaphylaxis with blood transfusion Previously healthy person presents with 1 week of: Exertional dyspnea and fatigue Chest discomfort and fullness Leg edema with clear lungs Low BP, SBP drops >10 with ispiration JVD with rapid x descent (nl/ absent y descent) EKG: sinus tach, low voltage, diffuse ST elevation with some T wave inversions CXR- enlarged cardiac silhouette correct answers Acute pericarditis with tamponade Subacute onset, usually idiopathic Pulsus paradoxus (also in asthma, COPD, PE) Could see PA cath with equalization of diastolic pressures DDx - constrictive pericarditis (both x+y descent), MI (different EKG), Ao dissection (no JVD, edema) Pt with HO HTN, presents with acute CP and: HoTN JVD, increased a+v waves EKG: sinus brady, ST elevation in II, III, aVF, and V4R-V6R PA cath: low CO, PCWP, increased RAP correct answers IWMI with RV infarct Pt with confusion and hypotension: low CO High PCWP
low pO High D-dimer High troponin correct answers Pulmonary embolism Young patient with history of primary Raynaud syndrome presents with: Acute chest discomfort HTN Positive UDS for cocaine EKG: ST elevation >1mm in II, III, aVF, returns to nl as soon as chest discomfort subsides Cath- nl coronaries correct answers Variant angina (Prinzmetal;s) Vasospasm is usually inferion MI- EKG doesn't return to nl that quick See it more often in pts with H/O raynauds Pt with hyperlipidemia, HTN now with MI, 3 days ago: Acute dyspnea Hypotension Bilateral rales +/- JVD Hyperdynamic precordium with new systolic murmur at the apex with wide radiation correct answers Papillary muscle rupture See acute onset new MR murmur Patient post-MI 3 days with: Hypotension JVD, bilateral rales, edema Hyperdynamic precordium with a thrill, new loud, harsh, holosystolic murmur at the LLSB with wide radiation correct answers Ventricular septal rupture See biventricular failure, murmur in different location Pt with MI, now 3-5 days out, presents with: Acute recurrent CP Nausea Restlessness Hypotension PR prolongation and ST elevation consistent with pericarditis correct answers Ventricular free wall rupture Leads to tamponade, then death This was an incomplete rupture that clotted over 40-50 y/o smoker presents with: Claudication in feet and calves +/- hands, which progresses to rest pain Ulceration on the toes and fingers Negative ANA, RF, anti-centromere, anti-Scl-70, APLA Nl complement TEE: no intracardiac thrombus, valve lesions correct answers Thromboangiitis obliterans
Smoking activates it Think about with smoker and PVD symptoms Exclude autoimmune vasculitis, endocarditis 60 y/o male presents with Acute, severe, sharp CP, radiating to back and abdomen Hypotension, >20 SBP between the upper extremities Nl JVP Diastolic, decrescendo murmur loudest at R 2nd ICS EKG: non-specific ST, T wave changes CXR- widened mediastinuim correct answers Aortic dissection With dissection near the AoV, can see it affect coronaries, give MI like EKG changes, but the pain here is like dissection Tearing, ripping, sharp pain Male pt with know bicuspid AoV presents with: Hypertension in the arms Diminished femoral pulses Low BP in the legs correct answers Coarctation of the aorta Look for HTN with unequal pulses, pulse delay in the femoral artery Know assc of Coarc and bifid AoV Adolescent with HO sore throat and fever 2 weeks ago, now with: Migratory swelling and pain in large joints Erythematous, serpiginous rash on thorax Fever Systolic murmur at the apex Nl JVP, clear lungs EKG: prolonged PR interval correct answers Rheumatic fever Most common valve lesion is MS, can see MR/AR Jones criteria: Major- arthritis, carditis, chorea, erythema marginatum, SQ nodules Minor- arthralgias, fever, increased ESR, prolonged PR Pt. older than 60, gradual onset of: Decreased exercise tolerance from fatigue Exertional dyspnea Weak carotid pulse, slow rate of rise Harsh systolic murmur, loudest at R 2nd ICS, radiates to neck No audible S2 split correct answers Aortic stenosis S2 split usually excludes AS Loudness and timing of murmur correlate with severity: louder and later is more severe Can see pulsus parvus at tardus - slow to rise pulse Pt with bicuspid aortic valve presents with:
Holosystolic murmur at the mid-sternum correct answers Tricuspid regurgitation from endocarditis If staph, tend to embolize vegetations into lungs Could include cough, dyspnea, pneumatoceles on CXR Stable pt. with COPD on chronic oxygen, inhaled steroids, long acting bronchodilators, short acting beta agonists, and theophylline presents with: Palpitations HR> EKG: 3 distinct P wave morphologies correct answers Multifocal atrial tacycardia Theophylline use could trigger the ectopic focus Male patient with family history of sudden cardiac death has the following: Fatigue Exertional dyspnea Left ventricular lift Harsh, systolic, crescendo-decrescendo murmur at the left 2nd IC space and apex, decreases with squatting and increases with valsalva and standing from a squat correct answers Hypertrophic cardiomyopathy Key is the murmur description and family history of SCD Usually autosomal dominant Pt. with recent history of ischemic HD and CABG presents with days to weeks H/O: Fatigue Recurrent chest discomfort Fever Leukocytosis +/_ pericardial friction rub CXR- increased cardiac silhouette correct answers Post-pericardiotomy syndrome Without the H/O CABG, it would have been acute pericarditis- the surgery is the key! Similar to post-MI infarction syndrome (Dressler's) Pt. with a recent history of MI, presents with days to weeks h/o: fatigue Recurrent chest disconfort Fever Leukocytosis +/- pericardial friction rub CXR- increased cardiac silhouette correct answers Post-MI syndrome (Dressler) Pt presents with acute onset of: Fever Chronic, pleuritic chest pain, improved by leaning forward Audible scratch, loudest at the L sternal border EKG: nl voltage, depressed PR interval V5-V6, diffuse ST-segment elevation
CXR- nl correct answers Acute pericarditis Different from MI with prolonged pain, diffuse ST elevation Adolescent with asthma presents with: long standing intermittent, pruritic, papulosquamous eruption over antecubital fossa, behind knees; worse after hot showers correct answers Atopic dermatitis (eczema) Adult pt with: "dandruff" and scaly rash around the nose with underlying redness when the scales are removed correct answers Seborrheic dermatitis Can also present on eyebrows, lashes, facial hair HIV can have a much worse presentation Pt develops: Itchy, papulosquamous rash on abdomen- scaly, well circumscribed lesion at the area of the belt buckle correct answers Contact dermatitis Common triggers: plants (poison ivy, oak), nickle, perfumes, rubber, synthetic shoe materials Adolescent develops: Erythematous, nodular, painful papules and pustules on the face, thorax, back Multiple open and closed comedones and inflamed, deep nodular lesions on the forehead, cheeks, thorax, and back correct answers Acne vulgaris Severe acne with nodules can form sinus tracts - called acne conglobata- on chest and back Middle-aged female develops: "Acne" on the cheeks Repeated eruptions of facial flushing and erythematous papular lesions, made worse with alcohol intake Multiple small papules on the cheeks without comedones Scattered telangiectasias correct answers Rosacea Keys: lack of comedones, worse with alcohol, telangiectasias Female presents with: Pain under both axilla x 2 mo- began as small bumps but getting larger Significant pain and erythema around the bumps x 24 hrs Deep, nodular lesions in both axilla without any cental area of necrosis Few comedones in the axilla correct answers Hidradentis suppurativa DDx- boils (furuncles, not symmetric, get central necrosis), acne conglobata (not in axilla) Pt with: Wt. loss x 3 mo Intermittent fevers Bilateral white plaques on the lateral aspect of the tongue that cannot be removed with a tongue depressor
- HIV ELISA, Western Blot correct answers Hairy Leukoplakia
Confused with condyloma lata of syphilis (flat, wet, not verrucous) Pt with: Multiple, painless clustered papules with central umbilication on the arm (or anywhere else) correct answers Molluscum contagiosum Key- central umbilication Have depressed center to the lesions Can be large, numerous with HIV African American male, complains of hair loss after getting his hair cut by an electric razor Annular scaly patch of hair loss Small black dots over the hair follicles Palpable small posterior cervical lymph nodes correct answers Tinea capitis Keys: elderly, African American, barber, black dots. Usually an unclean razor Pt with: annular scaly rash on arm, present since week after getting a new cat Clear towards center of rash with raised advancing erythematous margin and scale correct answers Tinea corporis Clues: cat. Could be wrestler. Often confused with herald patch of pityriasis, but that doesn't itch. Granuloma annulare doesn't scale. Nummular eczema looks different on micro Pt wears heavy shoes and goes to then gym with: Itchy rash between toes Multiple intensely pruritic pinpoint vesicles between the toes correct answers Tinea pedis Can also see vesicles, nail thickening Dark skinned individual prEsents with: Scaly rash on chest Numerous hypo and hyper pigmented areas No large isolated patch No itching KOH stain- spaghetti and meatball fungal hyphae correct answers Tinea versicolor Patches tend to be worse in the summer Disseminated skin rashes can be syphilis, micro gives diagnosis From malassezia furfur Adolescent from a group home with: Scalp itching Erythema at the base of the scalp Mild bilateral posterior auricular lymphadenopathy Woods lamp- small area of pale blue fluorescence at the base of multiple hair shafts correct answers Pediculosis capitus= head lice Might see nits, louse picture
Young sexually active adult with: Itching in pubic region Multiple small bluish macules along the upper abdomen and inner thighs Palpable small inguinal lymph node correct answers Pediculosis pubis = pubic lice Blue macules not always present Can be visible Ddx scabies- see itching in other parts of the body as well Nursing home pt with: Itching, worse at night, x1 month Multiple excoriations in both axilla and groin, on the wrists, between fingers correct answers Scabies May describe mite burrow Intense itching, ESP axillary and interdigital webs Middle aged Caucasian woman with: Skin lesion on forehead HO extensive sun exposure as child with repeated sunburns Flesh colored papular lesion with pearly sheen, multiple telangiectasias correct answers Basal cell CA Key: pearly papules. May ulcerate Middle aged Caucasian woman with: Skin lesion on forehead HO extensive sun exposure as child with ,multiple sunburns Multiple rough scaly patches on forehead, dorsum of hands One patch on the forehead has a firm hyperkeratotic macule correct answers Multiple actinic keratosis with squamous cell CA in situ AKs turn into SCC Middle aged Caucasian woman with Skin lesion on her thigh HO extensive sun exposure as a child with repeated sunburns Flat, asymmetric, pigmented lesion, lacks uniform color, is 8mm in size Enlargement over the last few months correct answers Melanoma Remember the ABCDEs Pt with Hep C, cirrhosis with: Blistering lesions on dorsum of hands, began as erythematous macules with adherent scale Intermittent sun exposure in past month Elevated urine uroporphyrin levels correct answers Porphyria cutanea tarda Always think of with Hep C, isolated rash on hands Urine uroporprin levels just confirm it Can be scaly, blistering, vesicles
Chronic headaches Secondary amenorrhea Galactorrhea Possible bitemporal hemianopsia Low FSH, LH correct answers Pituitary prolactinoma Increased PRL causes low LH, FSH, causing amenorrhea Galactorhhea= prolactinoma or hypothyroidism Postmenopausal female on no Meds with: HA, weight gain, constipation Alopecia Delayed reflexes Low Na, FSH, LH, glycoprotein alpha- subunits correct answers Pituitary gonadotroph tumor causing mass effect, hypogonadism, secondary hypothyroidism GP alpha subunits are seen in some pituitary tumors Premenopausal female with: Chronic malaise Constipation Alopecia Cold intolerance Galactorrhea MRI- increased pituitary size Prolactin level high, but <200 correct answers Primary Hypothyroidism causing hyperprolactinemia Usually severe hypothyroidism Prolactinoma itself shouldn't cause hypothyroid symptoms Postmenopausal female with: Gradual development of HA and mental fogginess Constipation Alopecia Episodes of diaphoresis, pallor, tremors that improve with eating Low Hgb, Hct with nl MCV, MCHC Low Na, nl K High cholesterol, low FSH, LH correct answers Hpopituitarism Has secondary hypothyroidism, adrenal insufficiency, hypogonadatropic hypogonadism. Hypogonadism, hypoglycemia from secondary adrenal insuff. Primary adrenal insuff would have hypokalemia; secondary doesn't Pt with HO: Primary hypothyroidism, adherent to thyroid replacement Takes multiple vitamins Chronic elevated TSH at FU correct answers Malabsorption of Levothyroxine from Ca intake
Male with OSA and : increased ring and shoe size Frontal bossing Deepening of voice Paresthesias in ring and pinky fingers Tan colored fleshy rash in armpits Multiple dental caries High fasting plasma glucose correct answers Acromegaly Screen for with IGF-1 level Pt with DM, possibly on Warfarin, develops: Acute onset HA Bilateral hemianopsia Possible neck stiffness Possible confusion or loss of consciousness MRI- high density mass in sell correct answers Pituitay apoplexy Key is bitemporal hemianopsia= dz at optic chiasm Hemorrhage has no antecedent sxs, vascular supply compromise from adenoma usually does have antecedent sxs Pt on lithium for bipolar develops: Polyuria Polydipsia Confusion Hypernatremia and low urine specific gravity correct answers Nephrogenic diabetes insipidus from Lithium distinguish from psychogenic polydipsia- look for increased water drinking; may need to do water restriction test Pt with gradual onset of: Wt gain, cold intolerance, constipation, alopecia, galactorrhea, amenorrhea, coarse hair, periorbital edema, non-pitting ankle edema Bradycardic, delayed reflexes Low Hgb, Hct, nl MCV, MCHC Hyponatremia High cholesterol, prolactin (<200) high TSH, low FT4 correct answers Primary hypothyroidism These are all classic s/sx Pt with: Hospitalization for acute, non-thyroidal illness Low TSH, FT4, FT3 correct answers Euthyroid sick syndrome Why you don't test these in the hospital! Healthy female, gradual onset of:
decreased RAIU correct answers Subacute hyperthyroidism Due to a virus Healthy pt with: Recent onset anxiety, tremulousness that improves within days to weeks Decreased TSH, increased FT Decreased RAIU correct answers Painless hyperthyroidism self resolving, has the decreased RAIU Reasonable amount go on to chronic autoimmune hypothyroidism Postpartum patient develops: Anxiety and tremulousness Nontender goiter
- anti-TPO correct answers Postpartum thyroiditis same as painless, but positive anti-TPO and pregnant Healthy patient with: Midline palpable thyroid nodule Nl TSH US- solid mass without suspicious characteristics Thyroid scan= single cold nodule correct answers Single cold thyroid nodule Needs bx Healthy pt develops: Gradual onset anxiety, tremulousness Palpable thyroid nodule Undetectable TSH Thyroid scan= single hot nodule correct answers Toxic thyroid adenoma does not need bx Healthy pt with: Gradual onset anxiety, tremulousness, increasing neck mass Multiple palpable thyroid nodules of varying sizes Undetectable TSH Thyroid scan=multiple hot nodules with prominent cold nodule correct answers Toxic nodular goiter with suspicious nodule The cold nodule needs biopsy Premenopausal female with: Gradual onset truncal weight gain, acne, amennorhea HTN, excess hair on chin and cheeks, fat in cervicaodorsal distribution, moon facies, plethora, bright purple abdominal striae High fasting glucose Nl anion gap Hypokalemia, alkalosis
DXA- Z score <-2.0 correct answers Cushing syndrome All classic symptoms Chronic alcoholic with HTN, obesity presents with: Concentration of fat in truncal region Small cervicodorsal fat pad Slight increase in urine free cortisol 1mg overnight dexamethasone suppression test: suppression of AM cortisol production correct answers Pseudo-Cushing syndrome Can see with depression, obesity, alcohol abuse Suppression with low dose dex-suppression test confirms dx, regular cushings wouldn't suppress Pt with gradual onset of: Truncal wt gain, acne, hirsutism, amenorrhea, cervicodorsal fat pad, moon facies, plethora, bright purple abd striae, HTN High fasting glucose, Nl anion gap HypoK, alkalosis DXA- <-2. High dose dex suppression- no suppression correct answers Adrenal adenoma or carcinoma Classic Cushing syndrome Pit tumors don't suppress with anything, have low ACTH Pit adenoma would have high ACTH CA would also have high DHEA, urine 17-ketosteroids; adrenal adenoma with mild increase in DHEA Pt with gradual onset of: Truncal wt gain, acne, hirsutism, amenorrhea, cervicodorsal fat pad, moon facies, plethora, bright purple abd striae HTN High fasting glucose, nl anion gap HypoK, alkalosis DXA- Z-score <-2. High 24 hr urine free cortisol Low dose dex suppr- no suppression High ACTH High dose dex suppr- suppresses correct answers Pituitary adenoma with ACTH production Classic Cushings Do suppress with high dose dex suppression, not low ACTH increased Could also see same with ectopic ACTH secreting tumor, usually from lung CA or carcinoid Pt with gradual onset of: Weakness, N/V, sporadic abdominal pain Fever Hypotension, tanned skin
Tumor produces aldo, suppresses renin 55 yo, long standing HTN and DM, uncontrolled blood glucose, microscopic proteinuria, develops: Gradual increase K Stage 2-3 CKD on ACE Recent orthostatic HoTN mild low bicarb nl AG correct answers secondary hyperaldosteroninsm caused by long standing DM Kidney complication of DM See the NAGMA= RTA Cosyntropin stim test would exclude hypoaldo (HoTN and HyperK) Healthy 30-40 yo, gradual development of episodic: HA Palpitations Sweating HTN correct answers Pheochromocytoma 20 yo, primary amennorhea with: short stature wide spaced nipples minimal breast development webbed neck minimal axillary and pubic hair correct answers Turner syndrome 45, XO 52 yo female with: Amenorrhea Episodes of diaphoresis and heat intolerance high FSH, LH correct answers Menopause Pheo can do everything but the amenorrhea 38 yo female, HO other autoimmune diseases (ex. chronic autoimmune hypothyroidism) develops: Amenorrhea Episodes of diaphoresis and heat intolerance High FSH, LH Nl TSH Nl PRL correct answers Premature ovarian failure 35 yo runner develops Amenorrhea Neg urine pregnancy Mild decrease in LH, FSH
Nl TSH, PRL correct answers Functional hypothalamic amenorrhea Female develops: Increased BMI Acne Hirsutism Amenorrhea Fasting glu 100- Low FSH, High LH, FSH:LH>2, slight increase in testosterone, DHEA correct answers Polycystic ovarian syndrome Lots of similarities to Cushings, but don't see the FSH, LH changes in Cushings, don't see hypokalemic metabolic alkalosis in PCOS Tall, introspective male with: Long arms and legs Small testes Sparse hair growth and muscle development Gynecomastia +/- learning disabilities High FSH, LH Low testosterone correct answers Klinefelter syndrome XXY Can just see effects of testosterone deficiency, osteoporosis Osteoporosis in male is always something to work up Obese pt with: Weight gain Polyuria Polydipsia Fasting glucose >126 (or 2-hr glu >200 after 75g glu load, or A1C>6.5) on at least 2 separate occasions correct answers New onset DM Obese pt with: Fasting glu 100-125 or 2hr GTT 140-199 on 2 separate occasions correct answers Impaired glucose tolerance Pt with FH of MEN I develops: DM Wt loss chronic diarrhea beefy red tongue painful, pruritic blistering rash correct answers Glucagonoma Known diabetic has: Confusion
