cases Flashcards
(33 cards)
53 yo white male comes in with anemia, splenomegaly and LUQ pain, early satiety, fever and fatigue
elevated WBC
bone marrow biopsy shows abundant, hyper cellular marrow
genetics +BCR-ABL1
CML
chronic myelogenous leukemia
57 yo female presents w jaundice, 22 lb weight loss, and itchy skin at night. over past few weeks also noticed increased thirst and urination.
dx and most likely clinical exam finding
pancreatic adenocarcinoma (blocking the gall bladder duct)
Courvoisier sign = smooth, nontender, palpable mass in RUQ (the gb)
painless jaundice + courvoisier = carcinoma blocking gb
either pancreatic adenocarcinoma or cholangiocarcinoma
young mountain climber in vail, Colorado comes in with SOB, fatigue, and cyanosis. says she’s been drinking the mountain water streams.
when getting a blood sample you notice her blood appears brown in color.
dx and treatment?
methemoglobinemia
methylene blue
16 yo cross country runner with history of acne presents for painful feet.
PE shows raised and rough lesions surrounded by callous on the pressure points of the feet (sole of one, proximal to toes on other)
dx and trx
diagnosis = plantar warts aka verruca plantaris
- associated w HPV, in areas w max pressure
-inc risk w communal showers, history of wards, AIDs
trx= salicylic acid
- will eventually recede
3 yo comes in w 5 days of high fevers, today 102.5. patient has cracked lips, erythematous tongue and oropharynx, and conjunctivitis. diffuse erythematous rash across trunk. erythema and edema of hands and feet.
dx, trx, watch out for what complication
dx = kawasaki
trx= IVIG and ASA
complication = cardiovascular
- coronary A aneurysm–> ischemia, death
82 yo female w history of dementia and osteoporosis presents with symptoms of weakness, fatigue, and increased urinary frequency.
medication list - memantine, calcium carbonate, vitamin D, amlodipine, pioglitazone, and sitagliptin
labs sign for Cr high, Ca high, bicard high, phosphorous low, PTH <1, vitamin D low
dx and treatment
milk alkali syndrome
= a syndrome that develops in patients with renal dysfunction who have an excess intake of calcium
this happens in people who take calcium carbonate or other meds with calcium in the setting of renal ds
- its a cycle bc hyperCa–> vasoconstriction in glomerulus –> worse renal function…
trx = isotonic saline and stop the offending agent (the calcium carbonate)
22 yo female with no sign PMH presents with petechiae and purpura and bleeding gums when she brushes her teeth. is just getting over “the flu”. labs are all normal except platelets at 10k.
dx and trx
ITP
immune-mediated thrombocytopenic purpura
trx= steroids aka prednisone
oft spontaneously resolve in 2 months
differentiate presentations of
ITP
HUS
TTP
ITP = any age, after a recent viral illness the person suddenly develops petechia/purpura and easy bruising/bleeding. only lab is low platelets. no other symptoms
HUS: most often children caused by the toxin of E Coli O157:H7 (after eating a hamburger). they present as SICK with bloody diarrhea, abdominal pain, vomiting. labs show microangiopathic hemolytic anemia, thrombocytopenia, AKI
TTP: associated with loss or x of ADAMSTS13 gene - often in adults. presents w same labs of HUS with hemolytic anemia, thrombocytopenia, and AKI BUT its diff than HUS bc it has NEUROLOGIC SX
26 yo male comes in for 8 months of progressive fatigue and itching. tried taking allergy meds and was not helpful. patient also notes recent 10 point weight loss, severe neck and chest pain immediately upon drinking alcohol. PE = skin excoriations from scratching, and cervical and supraclavicular LAD, no hepatomegaly or jaundice
dx, what would you see on path
Hodgkin’s lymphoma
= constitutional sx, weight loss, pain w alcohol
pain w alcohol ingestion is specific to Hodgkin’s
also on BM path you would see Reed Steinberg cells
7 mo patient presents with intensely itchy vesiculopapular rash on her palms and soles. patient had similar rash at birth but it had went away, returned in last 24 hours.
dx?
infantile acropustulosis
may present at birth or within first year of life and recur chronically within first two years of life
vs transient neonatal pustular melanosis = NOT itchy, small hypopigmented pustules with a NON-erythematous base that fade eventually
- may occur at birth
4 day old baby presents with new onset rash on face, scalps, and thigh folds. not present at birth. PE reveals small groups of erythematous papule and pustules.
dx?
miliaria rubra
etiology= blockage of sweat glands in face, scalp, intertriginous areas
develops in the first week of life.
associated with warmer climates, incubators, lots of clothes
87 yo male hx of diabetes on metformin presents for painful rash on his cheeks and nose. notes he had a subjective fever for a couple days before onset of rash. no known trigger. on exam rash is tender to palpation, erythematous, well demarcated and raised. CBC= elevated WBC otherwise normal, normal vital signs except slight fever at 100.9
dx? trx?
erysipelas = acute onset of fevers and chills followed by “orange peel” rash within 1-2 days that is tender to palpation
VS CELLULITIS= cellulitis has rapid progression and is BLURRED edges, not well demarcated
- E= superficial skin infection, cellulitis = deeper subQ tissue
seen in immunocompromised, alc use, diabetes, impaired lymphatic drainage
TREATMENT
moderate ds = oral penicillins, cephalexin
- if allergic to penicillin, erythromycin, TMP-SMX
severe (sepsis) IV abx^
54 year old female presents with acute onset RUQ abdominal pain and N/V for 2 days. on exam patient is confused and has scleral icterus.
vitals= 108F,
dx?
ascending cholangitis
Charcot’s Triad = fever, jaundice, RUQ pain
Reynold’s Pentad = Charcot’s triad + AMS+ sepsis
2 day old presents for tachypnea, increased work of breathing, and grunting. mother was unable to afford prenatal care and the baby was born at home, complicated by prolonged rupture of membranes.
on exam, patient is irritable and restless. CXR reveals diffuse alveolar infiltrates and moderate bilateral pulmonary infiltrates.
vitals= 102.9F, BP 64/34, HR=180, RR=80, Osat= 92% on 3L NC
dx and the infection most likely causing?
group B strep pneumonia
other causes of pneumonia presenting at birth-3 days old =
-listeria
- E. Coli
patient comes in with sudden onset CP while mowing the lawn , associated w N, diaphoresis, and CP.
BP= 86/55, HR= 95, RR= 25, Osat= 88% on 2L NC
auscultation reveals systolic murmur best heard at left lower sternal border and lungs CTAB, ECG notes ST elevations in II, III, and AvF. patient is given ASA and nitroglycerin. a few minutes after treatment patient becomes substantially worse.
dx and what happened?
patient has inferior wall STEMI
evidence of right-sided heart failure = murmur of tricuspid regurge, clear lungs
dx = right ventricular infarction and failure
= preload dependent so giving nitroglycerin can cause profound hypotension by further decreased preload
53 yo female w history of OA, DM, obesity, and HTN presents for acute onset L knee pain for 1 week. patient has left knee OA but states this is different. notes pain is worse with climbing stairs or standing up from seated
Lachman, McMurray, and patellar grind tests are negative. patient notes tenderness at the joint line and tenderness without swelling at the medial tibia.
dx?
pes anserine bursitis
inc risk = Female, obesity, DM, and OA
-presents with medial knee pain, tenderness over the upper medial tibia, and NO swelling or induration
often present with pain standing from seated, stairs, or lying in bed with one knee pressed under the other.
27 year old female presents with knee pain. states she is having more pain with standing from sitting or climbing stairs. notes pain at front of knee, patellar grind test is positive
dx?
patellofemoral syndrome
= patellar pain caused by mechanical imbalance.
patellar grind test = leg straight with quadriceps tightened, push down on patella = pain
36 yo woman w no sign medical history and hx of IV drug use presents for intermittent fever chills and cough worsening over 3 weeks. progressive fatigue, started coughing blood 2 days ago.
PE: fever 102F, RR=25
- holosystolic murmur heard at left-lower sternal border w some radiation to the right sternal border
CT lungs = multiple areas of lung consolidation with scattered cavitary lesions
dx?
right sided endocarditis = MC cause staph aureus
systolic murmur that is concerning for tricuspid regurgitation
cavitary lesions are likely septic emboli
general sx= headache, myalgia, night sweats, malaise
32 yo man w sore throat and hoarseness.
EKG= 3rd degree AV block
PE= oropharyngeal erythema with thick tonsillar exudate that extends into the pharynx
marked cervical lymphadenopathy
most likely etiology
corynebacterium diphtheria
76 yo female w hx of a fib presents with new onset vertigo, intention tremor and dysdiadochokinesis
what part of the brain is the stroke in, and what are some other tests/signs that localize to this part
cerebellum (balance and motor coordination)
- vertigo
- intention tremor
- dysdiadochokinesis
- dysarthria (motor ataxia of the tongue)
- abnormal gait
- scanning speech
- nystagmus
- dysmetria (inability to judge distance) = failed FTN and heel to shin test
32 yo G1P0 at 37 weeks gestation comes in with new onset hand and face swelling and severe abd pain.
BP= 160/95…170/100
Cr= 0.8–>1.6 now
dx and trx
severe pre-eclampsia
pre-eclampsia= HTN with proteinuria or other end-organ damage (AKI) at 20+ weeks gestation [w/o hx of HTN or renal ds before]
– treat with magnesium sulfate and hydralazine/labetelol
- latter for BP control, former to prevent progression to eclampsia
– once stable, DELIVER if at term= 37+ wks
- earlier if develop to eclampsia or if the fetal heart tones are bad
76 yo male presents with fatigue, night sweats, fever, fatigue, lymphadenopathy and hepatosplenomegaly. genetic markers are + for CD5 and CD23.
immunohisto shows small monotonous lymphocytes with abundant smudge cells
CLL
chronic lymphocytic leukemia
19 yo obese female presents for progressively worsening RUQ pain for 2 days. states pain is worse with inspiration and radiates to the right shoulder, worse w movement, breathing, coughing, and sneezing.
patient is sexually active, smokes 1/2 ppd, drinks socially.
T=100 and TTP on RUQ
pelvic exam = mild purulent discharge
WBC=12k, AST 123 ALT 63
doppler US shwows mild fatty liver but no other abnormalities, no biliary duct dilation, a few gallstones are visualized in the gallbladder fossa
most likely dx?
peri-hepatitis in the setting of pelvic inflammatory disease
- Fitz Hugh Curtis syndrome
32 yo pt presents after a long international flight with a DVT from the posterior tibial vein to the proximal popliteal fossa and distal common femoral vein. patient is hemodynamically stable and CBC+CMP are wnl.
admit or dc?
treatment?
this is a far enough away DVT that you can discharge on a direct oral anticoagulant such as apixaban
DOC are preferred bc safer as long as the patient can afford - if they cannot can start heparin, thrombin inhibitors, warfarin…
reasons that he can get dc are:
- hemodynamically stable
- BMP is unremarkable
- not high risk for clotting per history
- patient is able to take the medication on his own (not IV)
- no symptomatic PE or other comorbid complications that would make it worse
- NO ILIOFEMORAL OR IVC INVOLVEMENT
- no Phlegmasia cerulea dolens = leg is swollen and white due to a clot in the upper leg
