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- Diarrhea: food toxins
- puffer-fish, ciguatoxin, scombroid
- 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.
- 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.
- 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.
- 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.
- 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.
- Common causes of lower GI bleeding?
- hemorrhoids, anal fissure, inflammatory bowel, diverticulitis, carcinoma, intussusception.
- Ectopic ACTH tumors?
- Bronchial carcinoma, carcinoid.
- 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
- Common causes of upper GI bleeding?
- Duodenal ulcer > stomach erosions / gastritis > GERD > gastric ulcer > Mallory-Weiss > duodenal erosions > esophageal/gastric varices > stomach CA
- 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.
- 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.
- 11yo M with with color blindness, midline facial deformity, and anosmia.
- Isolated gonadotropin deficiency = Kallman's syndrome. Prepubertal onset, hypogonadal hypogonadism.
- 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.
- 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.
- 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.
- 64yo M with testicular swelling.
- Lymphoma of testis. #1 testicular neoplasm in elderly.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- Upper GI bleeding?
- GUMBLEEDING = Gastritis, Ulcer, Mallory-Weiss, B, L, Esophagitis, Esophageal varices, angioDysplasia, Infection, N, GERD.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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).
- 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".
- 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.
- 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.
- 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.
- 22yo F with abnormal Pap smear and no history of irregular menstrual, postcoital bleeding, or vaginal discharge.
- Cervical carcinoma in situ.
- Causes of cold antibody autoimmune hemolytic anemia.
- Infectious mononucleosis, mycoplasma pneumonia, malaria, idiopathic (IgM paraprotein).
- 25yo with eosinophilia, chronic cough, and distal small bowel obstruction.
- Ascaris lumbricoides. Larvae migrate to lung, small bowel obstruction are complications.
- 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.
- 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.
- Hormone:
- Stimulation test and markers:
- 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.
- 25yo M with progressive dysphagia and no past medical history.
- Esophageal ring. Occur at or near GE junction. Cause unknown.
- Diarrhea: chronic GI disorders
- Ischemic colitis, malabsorption, irritable bowel, inflammatory bowel disease
- GI utility of US and CT?
- Liver, pancreas, and biliary tract.
- 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.
- ADH
- Fluid deprivation:
- 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.
- 38yo F presents with melena and epigastric pain. Barium study revealed rugal hypertrophy.
- Menetrier's disease (giant hypertrophic gastritis). Assoc. with protein-losing enteropathy.
- 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.
- 64yo with CAD deficiency develops diarrhea, vomiting, and vague abdominal pain that rapidly progresses to hematochezia and severe abdominal pain.
- Acute mesenteric ischemia.
- 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.
- 64yo peanut farmer with jaundice, weight loss, and right upper quadrant pain.
- Hepatocellular CA. Test for alpha-fetoprotein. Ultrasound / CT to evaluate.
- 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.
- 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).
- 31yo F with morbilliform rash and jaundice. Recently seen by a neurolgist for epilepsy.
- Drug-induced hepatitis. Phenytoin (anti-epilepsy).
- Common causes of amenorrhea?
- Hyperprolactinemia, weight loss, anorexia nervosa, autoimmune associated ovarian failure (Addison's or other).
- 49yo alcoholic with confusion, stupor, and nystagmus following 5% dextrose infusion.
- Wernicke's encephalopathy. Due to thiamine deficiency.
- LH, FSH
- Gonadotropin releasing hormone: FSH, LH, spermatogenesis, ovulation
- 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.
- 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.
- 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.
- 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 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.
- 29yo HIV + F with eosinophilia, liver, heart, and renal failure.
- Strongyloidiasis. Can result in systemic invasion in IC'd pts.
- Newborn with ambiguous genitalia, clitoral hypertrophy, and partial fusion of labioscrotal folds.
- Congenital adrenal hyperplasia. 21-hydroxylase defiency. Excess androgenic cortisol precursors.
- 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.
- Diarrhea: bacterial invasive
- E. coli (enteroinvasive), Shigella, Salmonella, Yersinia enterocolitica, Vibrio parahemolyticus, Campylobacter jejuni.
- Diarrhea: drugs
- laxatives, antacids with magnesium
- 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.
- Diarrhea with systemic illness
- Salmonella typi (enteric fever with diarrhea as late symptom)
- 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.
- 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.
- 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.
- Diarrhea: bacterial toxin
- E. coli (enterotoxigenic), Vibrio cholerae, Staph aureus, Clostridium perfringens, Clostridium difficile, Clostridium botulinum, Bacillus cereus.
- GI utility of plain film?
- Demonstrate dilatation (toxic megacolon), obstruction.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 31yo M with HIV and odynophagia.
- Esophagitis due to candidia, herpes, or CMV.
- 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.
- 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.
- ACTH
- CRH: ACTH, cortisol
- 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.
- Diarrhea: viral
- Rotavirus, Norwalk, Adenovirus.
- Elevation of prolactin level due to physiolgic cause?
- Sleep, stress, nipple stimulation, coitus, pregnancy, suckling.
- 65yo M with sudden severe HA and hemiplegia. Now incontinent.
- Hypertensive stroke.
- 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.
- 18yo M with small firm testes, gynecomastia, and female distribution of body hair.
- Klinefelter's. Infertile, may be unusually tall, 47XXY.
- 58yo F from central Africa with large goiter.
- Endemic goiter. Can be euthyroid. Due to iodine deficiency.
- Cigar shaped erythrocytes.
- Hereditary elliptocytosis. Usually asymptomatic.
- Drug induced aplastic anemia.
- Chloramphenicol, chlorpropamide, chlorpromazine, carbimazole, carbamazepine, gold salts, methotrexate, phenytoin.
- Diarrhea: secretory
- Vibrio cholera, campylobacter, E. coli, Salmonella.
- 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.
- 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.
- 15yo M with acute hot, red, swollen knee and easy bruising.
- Hemophilia. Prolonged aPTT, normal PT. Rx: factor VIII replacement. X-linked recessive.
- 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.
- Test for bacterial overgrowth?
- glycochocolate breath test, based on deconjugation of radiolabeled bile acid and exhalation of labeled CO2.
- Apthous ulcers?
- poor dental hygeine, gluten enteropathy, inflammatory bowel dx, Behcet's.
- Diarrhea: parasites
- Giardia lamblia, Cryptosporidium parvum, Entamoeba histolytica.
- 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.
- GI disease with finger clubbing?
- malabsorption, small intestinal disease, and cirrhosis.
- 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.
- 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.
- 71yo M smoker with progressive dysphagia.
- Esophageal CA
- 17yo M with tremor, athetoid movements, and elevated LFTs.
- Wilson's disease. Low ceruloplasmin. Kayer-Fleischer ring in cornea. Rx: penicillammine chelation therapy.
- 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.
- ACTH and GH
- Glucacon: GH, blood glucose
- 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.
- 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.
- 59yo F with retro-orbital HA and diplopia. Diagnosed with lung cancer.
- Metastatic dx. Intracranial mets from lung, breast, GI, GU, CA, and melanoma.
- Causes of asplenia (anatomic or functional).
- SLE, sickle cell, celiac, lymphoma, post-surgical. Risk of infection with S. pneumo, H. flu, N. meningitidis, malaria.
- Spherocytes on peripheral smear.
- Perform osmotic fragility test. Spectrin defect = hereditary spherocytosis.
- 58yo F with recurrent episodes of thrombophlebitis in the legs and arms.
- Pancreatic CA. Thrombophlebitis may preceed diagnosis by many months.
- 48yo M with recurrent abdominal pain after eating. Also has hypercholesterolemia.
- Chronic mesenteric ischemia (intestinal angina).
- 16yo M with massive hematomas and no history of trauma.
- Differential includes: Christmas dx, von Willebrand's, hemophilia, or uncontrolled anticoagulation.
- 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%.
- 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.
- 73yo F with hypothermia and altered mental status and history of hypothyroidism.
- Myxedema coma. marked by hypothermia, cardiac failure, altered MS, convulsion. Mortality 50%.
- 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.
- GH
- GHRH: GH
- Most common goitrous hypothyroidism?
- Hashimoto's. Women >> Men. Older women > younger.
- 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.
- TSH
- Thyrotropin releasing hormone: TSH, T3, T4, prolactin, GH
- Most common cause of iron deficiency anemia worldwide.
- Hookworm.
- Enlarged tongue?
- Acromegaly, myxoedema, amyloidosis, motor neuron disease.
- GI utility of angiography?
- GI bleeding of obscure cause or suspected mesenteric ischemia.
- 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).
- 34yo F with short stature, large head, prominent forehead and disproportion of body and limbs.
- Achondroplasia. Autosomal dominant. #1 short stature with abnormal proportions.
- 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 sore tongue?
- Systemic: folate/B12/Fe deficiency, collagen-vascular dx, diabetes. Local: smoking, fractured tooth/dentures/crowns, candidiasis, dry mouth.
- 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.
- 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.
- Diagnosis of celiac disease?
- Biopsy! Flattening of vili. Definative diagnosis requires trial of gluten-free diet.
- 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.
- 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.
- 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.
- 53yo homeless man with bleeding gums, purpura, and perifollicular bleeding.
- Scurvy = vitamin C deficiency.
- 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.
- 29yo F with SLE and history of DVTs develops increased skin pigmentation and profound hypekalemia.
- Primary adrenal insufficiency. Antiphospholipid syndrome can destroy adrenal glands.
- ACTH and GH
- Insulin hypoglycemia test: GH, cortisol, blood glucose
- 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.