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- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.