Pearls

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Pearls

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Pearls & Pitfalls 63 y/o man with long standing HTN, hyperlipidemia arrives in office Friday afternoon with chest pain 80 pack-year smoker 1 year ago: cardiac cath ... – PowerPoint PPT presentation

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Title: Pearls

1
Pearls Pitfalls
2

63 y/o man with long standing HTN, hyperlipidemia
arrives in office Friday afternoon with chest
pain
80 pack-year smoker
1 year ago cardiac cath 3v CAD, not amenable to
CABG/PCI medical management (beta blocker, ASA,
statin)
Severe pain centrally, to left arm and back

BP 180/110, pulse 90, resp 14, afebrile
No CHF, new AI murmur
Otherwise unremarkable exam

4
EKG
5

You start ASA, give a dose of metoprolol
Call Cardiology

6
What is your next step (diagnostic/therapeutic?)
7
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8
Aortic dissection

h/o HTN, tearing pain, radiation to back
Can dissect into renal / mesenteric / carotid /
coronary arteries (presents as acute MI, as in
this case)
New AI murmur from aortic dilatation
PITFALL
no thrombolytics/anticoagulation if
dissection suspected
Diagnosis confirmed with ECHO, CT, MRI
Call CT surgery

9
Objective recognize the clinical presentation
of aortic dissection
10

27 year old man is admitted with chest pain after
a rear-end motor vehicle accident 6 days ago
belted, 10 mph
History of HIV
Occasional thrush, no other opportunistic
infections

11
How do you manage this patient?
12

Tube thoracostomy
2. Bactrim for presumed PCP

Objective recognize PCP as a cause of
spontaneous pneumothorax in patients with HIV
13

50 year old man is admitted with chest pain
Becomes confused, clammy
Bp 90/58, pulse 106, rr 22
Which ABG below would most likely fit the
clinical picture?
a) 7.40/40/100 c) 7.32/52/82
b) 7.52/26/90 d) 7.30/28/88

Objective identify the blood gas findings in a
patient with acute MI / cardiogenic shock
14

You evaluate a 47 year old woman with chronic
kidney disease for hypertension. She has no
history of diabetes, no cardiac problems, and
other medical problems. She has followed a low
sodium diet. She does not smoke or drink
alcohol.
She is 5 8 tall and weighs 230 lbs. BMI is 35.
Blood pressure is 158/92, pulse 70. The exam is
unremarkable. She appears well hydrated.
Creatinine is 3.2, glucose 90, and the remainder
of the metabolic panel is normal.
Urinalysis shows 2 proteinuria.

Which of the following interventions is most
likely to reduce this patients risk of requiring
dialysis in the future?
a) implementing a low protein diet
b) starting hydrochlorothiazide
c) starting an ACE inhibitor
d) starting amlodipine
e) weight reduction until BMI is 30

Which of the following interventions is most
likely to reduce this patients risk of requiring
dialysis in the future?
a) implementing a low protein diet
b) starting hydrochlorothiazide
c) starting an ACE inhibitor
d) starting amlodipine
e) weight reduction until BMI is 30

17
ACE inhibitors and kidney disease

Clearly reduce progression to ESRD in diabetic
patients (especially with proteinuria micro or
macro)
Nondiabetic patients have similar benefit
MDRD trial
Benazapril trial
REIN trial
REIN 2 trial
AASK trial
Even patients with creatinines up to 5.0 mg/dL
had reductions in progression to ESRD
Be sure the patient is well hydrated, evaluate
diuretic use.
AARBs similar antiproteinuric effect, but
outcome trials lacking

Objective Rx to limit progression renal disease
in a 47 y/o woman w/chronic renal insufficiency
18

64 year old woman with DM II for 20 years, gout,
HTN seen in the office
No S3, no displacement of PMI, no increased JVD,
no rales
History of blood clot, very high cholesterol
(TC 320)
Findings below on BOTH legs
Most likely cause of the exam finding?

CHF
Nephrotic syndrome
DVT
Gout
e) An overly aggressive GT3 exam

Objective identify cause of edema in patients
with diabetic nephropathy
19

35 year old woman with malaise, abdominal pain,
diarrhea, nausea/vomiting
Recently
visited here
What are you likely to find on stool gram stain?
a) normal flora
b) large parasites with few eggs, many RBC
c) gram positive rods which are germ tube
positive
d) gram positive cocci in grape-like clusters
e) the lost colony of Atlantis

Objective understand the most common cause of
travelers diarrhea and how to identify it
20

You see a 32 year old man in the emergency
department for fever, stiff neck and malaise. He
has a petechial rash on his ankle. Gram stain of
his CSF shows the following

What therapy is warranted for the household
family members of this patient?
a) no therapy, watchful waiting is appropriate
b) Penicillin V-K, 500 mg orally three times
daily x 7 days
c) Ciprofloxacin, 500 mg x1 (adults), oral
rifampin x 2 days (children)
d) meningococcal vaccine, post-exposure dose
e) respiratory isolation, culture anterior
nares, no therapy

What therapy is warranted for the household
family members of this patient?
a) no therapy, watchful waiting is appropriate
b) Penicillin V-K, 500 mg orally three times
daily x 7 days
c) Ciprofloxacin, 500 mg x1 (adults), oral
rifampin x 2 days (children)
d) meningococcal vaccine, post-exposure dose
e) respiratory isolation, culture anterior
nares, no therapy

Objective recognize drug treatment for the
family of a patient with meningococcal meningitis.
23
Meningococcal prophylaixs

Indicated for high risk exposure
household contacts
gt4 hours spent with patient for 5 of 7 days prior
dorms, barrack roommates, day care
mouth-to-mouth
Prophylaxis regimens
rifampin (600mg q 12h x 4) there is resistance
to rifampin in some areas
cipro 500-750 mg x 1
ceftriaxone 250 mg IM x 1

35 year old man with this finding on tuberculin
skin testing
He begins treatment. Which of the following will
help prevent symptomatic side effects of therapy?
a) Vitamin B12, 1000mcg monthly
b) Vitamin B3, 1 mg daily
c) Vitamin B6, 50 mg daily
d) folic acid, 1 mg daily
e) Jack Daniels, nightly

Objective recall the management of side effects
of anti-TB medications
25

You are consulted to see a 72 year old man whose
urine output has diminished 48 hours after
aortofemoral bypass grafting. He has Type II
diabetes and hypertension, and has had
claudication for 1 year, which was
angiographically confirmed the morning of
surgery.
He appears well hydrated. Blood pressure is
148/84 otherwise vital signs are normal. There
is an S4 on exam, but no other abnormalities.
Distal pulses are 1 and symmetric.
Serum creatinine is 2.5 (baseline 1.2).

What is the most likely cause of the renal
failure?
a) contrast-induced nephropathy
b) surgical error
c) renal artery thrombosis
d) atheroembolism to the renal artery
e) post-op MI with congestive heart failure

What is the most likely cause of the renal
failure?
a) contrast-induced nephropathy
b) surgical error
c) renal artery thrombosis
d) atheroembolism to the renal artery
e) post-op MI with congestive heart failure

Objective recognize contrast nephropathy.
28

You are called to admit a 50 year old man from
the emergency department for obtundation. The
family states he has been complaining of fatigue
for nine months, and two weeks of vomiting. He
has also lost approximately 20 lbs. over the
previous two months.
He has no other past medical history, and takes
no medications.
Vital signs
BP 96/60 P 88 R 20 T 38.4 C
On exam, the patient is obtunded but responds to
painful and loud verbal stimuli. He grimaces
when you palpate his abdomen. You notice dark
coloration of his palmar creases.

What is the best initial management for this
patient?
a) Broad spectrum antibiotics
b) Vasopressors
c) Glucocorticoids
d) L-thyroxine
e) Thiamine

What is the best initial management for this
patient?
a) Broad spectrum antibiotics
b) Vasopressors
c) Glucocorticoids
d) L-thyroxine
e) Thiamine

Objective Understand initial treatment for a 50
y/o man w/fatigability/vomiting/wt
loss/obtunded/brown palmar creases.
31

You see a 65 year old woman with Type II Diabetes
who complains of exertional pain in the chest for
the past three weeks. The episodes last a few
minutes, are not associated with nausea or
dyspnea, and resolve either with rest or
spontaneously. She has no history of cardiac or
pulmonary disease. She now presents with a
similar episode of chest pain which has lasted
about 35 minutes.
Her exam is normal.
EKG is completely normal.

What is the best initial management for this
patient?
a) Admission, cardiac enzymes, medical therapy
for acute coronary syndrome
b) Reassurance, prescribe GI cocktail
c) Begin aspirin, schedule outpatient stress
test
d) Send for CT of the chest with PE protocol
e) Immediate cardiac catheterization

What is the best initial management for this
patient?
a) Admission, cardiac enzymes, medical therapy
for acute coronary syndrome
b) Reassurance, prescribe GI cocktail
c) Begin aspirin, schedule outpatient stress
test
d) Send for CT of the chest with PE protocol
e) Immediate cardiac catheterization

34
EKG in Acute Coronary Syndrome

Initial ECG is often not diagnostic in patients
with an ACS
In two series,
not diagnostic in 45 percent
normal in 20 percent of patients subsequently
shown to have an acute MI
Patients with history suggestive of ischemia /
ACS should be managed as such despite a normal or
non-diagnostic EKG

Objective Manage a 64 yo woman w/type 2 DM with
3 weeks of exertional chest pressure and a normal
ECG.
35

A 62 year old man with a history of chronic
bronchitis is admitted to the hospital with lobar
pneumonia. He presented to his physician after
one day of cough and shortness of breath. He has
no other chronic medical conditions. Baseline
arterial blood gas is as follows
pH 7.34 pCO2 68 pO2 60
Vital signs on admission
BP 130/80 P 100 R 24 afebrile
Pulse oximetry shows an SAO2 of 84 on room air.
He is begun on cefuroxime and azithromycin,
oxygen therapy (40 by face mask), and IV fluids.
Twelve hours later, he appears somnolent.
Arterial blood gas shows the following
pH 7.18 pCO2 88 pO2 160

What is the most likely reason for the blood gas
findings in this patient?
a) Worsening pneumonia non-responsive to chosen
antibiotics
b) Antibiotic-induced respiratory depression
c) Exacerbation of chronic COPD
d) Reduction in ventilation caused oxygen
therapy
e) Exacerbation of heart failure from excessive
IV fluids

What is the most likely reason for the blood gas
findings in this patient?
a) Worsening pneumonia non-responsive to chosen
antibiotics
b) Antibiotic-induced respiratory depression
c) Exacerbation of chronic COPD
d) Reduction in ventilation caused oxygen
therapy
e) Exacerbation of heart failure from excessive
IV fluids

Objective Understand the cause of blood gas
changes in a 62 y/o man w/lobar pneumonia and
chronic bronchitis.
38

A 48 year old man with no past medical history
complains of six months of pain in his buttocks,
especially when walking. He has had no chest
pain or shortness of breath, and no leg pain.
He is a smoker (1-2 packs per day) since high
school but does not drink alcohol. He takes no
medications.
Review of systems is positive only for erectile
dysfunction he asks you for a prescription for
the blue pill.

Further studies would be most likely to show
which of the following?
a) Central disc herniation in the L4-L5 area
b) A hard, nodular prostate exam with an
elevated PSA
c) Colonic dilatation on CT scan
d) Reduced arterial blood flow in the distal
legs
e) Loss of the sacroiliac joint space on plain
X-rays

Further studies would be most likely to show
which of the following?
a) Central disc herniation in the L4-L5 area
b) A hard, nodular prostate exam with an
elevated PSA
c) Colonic dilatation on CT scan
d) Reduced arterial blood flow in the distal
legs
e) Loss of the sacroiliac joint space on plain
X-rays

Objective Diagnosis in a 48 y/o man with a
6-month history of pain in the buttocks w/walking
and erectile dysfunction.
41

An 80 year old woman complains of fatigue and
weakness for the past two months. She has
otherwise been in good health, and takes no
medications. Her age-appropriate cancer
screening is up to date.
She appears well but pale. Vital signs are
normal. There is loss of vibratory and position
sense of both legs.
Initial labs show a hemoglobin of 9.0 g/dL
peripheral smear is shown below

What is the most likely diagnosis in this patient?
42
Pernicious anemia

Vitamin B12 deficiency
Megaloblastic anemia (hypersegmented PMN)
MCV often very high (gt110)
Other cell lines may be affected in severe
disease
Subacute combined degeneration of the posterior
(and lateral) columns - neurologic disease not
seen with folic acid deficiency
Paresthesias, ataxia, vibratory/position sense

Objective diagnose a patient with fatigue /
anemia, a hemoglobin of 9, and an abnormal
peripheral blood smear
43

You see a patient with knee pain and this joint
aspirate. His liver is slightly enlarged and his
blood glucose is 211. How do you work up the
underlying hereditary disorder?

Transferrin saturation (UIBC) Fe/TIBC
HFE gene DX CPPD/hemachromatosis
(hyperparathyroidism, hypomagnesemia,
hypophosphatemia)
44

A 59 year old man with a history of alcoholism is
admitted to the hospital for cellulitis. He is
coherent, and MMSE is 28/30.
Upon admission, his blood alcohol level is 10
mg/dL (BAC 0.01). He is begun on antibiotics.
24 hours later, you are called to evaluate him
for altered mental status. He is afebrile no
rash is noted. His MMSE is 27/30, and his
neurologic exam is non-focal. He describes
spiders crawling on the walls and on his arms,
and thinks he saw his dead mother sitting in the
nurses station.
WBC is normal.

What is the most likely cause of this patients
change in mental status?
a) Delirium tremens
b) Vitamin B12 deficiency
c) Acute Wernickes encephalopathy
d) Alcoholic hallucinosis
e) Adverse effect of antibiotics

What is the most likely cause of this patients
change in mental status?
a) Delirium tremens
b) Vitamin B12 deficiency
c) Acute Wernickes encephalopathy
d) Alcoholic hallucinosis
e) Adverse effect of antibiotics

47
Alcohol withdrawal syndromes

Acute Wernickes usually rapid onset after
administration of glucose in patients with
underlying thiamine deficiency
Hallucinosis
usually visual, but may be auditory
No clouding of sensorium
DTs
Later manifestation

Objective explain the change in mental status
24 hours after admission in a patient with
alcoholism
48

You see a 28 year old man with hyperlipidemia.
His father, grandfather, and uncle all had
coronary artery disease at an early age, and
multiple family members have Type II diabetes.
He does aerobic exercise regularly.
On exam, he appears well. Height 67 inches,
weight 180 lbs. (BMI 28)
Vital signs bp 126/78 p 52 r 14 t
35.9
His exam is normal.
Labs TC 270 LDL 190 HDL 36 TG 220
You start a statin. In addition to checking
liver enzymes in a month, and a fasting serum
glucose, what other lab tests would you order?

Objective recognize secondary causes of
hyperlipidemia (hypothyroidism - up to 4 of
patients with hyperlipidemia).
TSH
49

60 year old man, in good health, has a positive
FOBT
Colonoscopy at age 51 was normal
Sent for colonoscopy one polyp is found
(pedunculated, hyperplastic by pathology)
When is his next colonoscopy due, assuming no
abnormal signs/symptoms and negative FOBT in the
interval?
6 months
1 year
3 years
7-10 years
Depends upon polyp size

50
Hyperplastic polyps

No malignant potential
routine screening interval
Need to differentiate from adenomatous polyp (ALL
have malignant potential)
Tubular
Tubulovillous
Villous (highest potential)
Sessile polyps harder to fully remove than
pedunculated (but this is simply descriptive, no
relation to malignant potential)

You are asked to see a 23 year old man, s/p
repair of a torn medial collateral ligament, who
has become yellow.
He is healthy, with no chronic medical problems,
no medications, no exposures or travel outside
the U.S. Up to date with immunizations. No
alcohol or drugs.
ROS recalls similar eye discoloration after the
flu 2 years ago.
Exam normal except for eye changes above,
yellowish skin discoloration
HBsAg - Anti-HBS Anti HBc - HAV
ab
AST 40 ALT 36 AlkPhos 110 Bili (T) 3.2
Bili (D) 0.4 CBC, Chem 7 normal

What do you do next?
Reassurance, no testing
CT abdomen
RUQ ultrasound
d) Liver biopsy

Objective recognize common benign causes of
hyperbilirubinemia (Gilberts)
52

A 22 year old woman is seen for a rash. She was
on a camping trip in the Shenandoah Valley one
month ago. She has no other symptoms.
On exam, vital signs are normal, and the exam is
normal except for the rash pictured below

What treatment should be begun?
a) doxycycline
b) erythromycin
c) dicloxacillin
d) vancomycin plus bactrim
e) no treatment warranted at this time

What treatment should be begun?
a) doxycycline
b) erythromycin
c) dicloxacillin
d) vancomycin plus bactrim
e) no treatment warranted at this time

A 22 year old woman comes to you because she is
worried about Lyme disease. One week ago, she
went on a camping trip to the Shenandoah valley.
On the morning of the second day of the trip, she
found a tick on her arm, and removed it with
tweezers. She stated it was not easy to remove,
but she thinks she removed the entire tick.
On exam, vital signs are normal. There is no
redness and no signs of retained tick parts at
the site of the bite. There is no rash.

What treatment should be begun?
a) doxycycline
b) erythromycin
c) dicloxacillin
d) vancomycin plus bactrim
e) no treatment warranted at this time

What treatment should be begun?
a) doxycycline
b) erythromycin
c) dicloxacillin
d) vancomycin plus bactrim
e) no treatment warranted at this time

58
Lyme disease

Treatment
Early localized (EM) doxycycline, amoxicillin,
cefuroxime
more serious disease (neurologic, cardiac,
arthritis) ceftriaxone
Evaluation treatment after a tick bite
Rare disease unless tick attached for gt48 hours
Patients who meet all guidelines for antibiotic
prophylaxis should be treated
Attached tick identified as an adult or nymphal
I. scapularis tick
Tick is estimated to have been attached for 36
hours
Prophylaxis is begun within 72 hours of tick
removal
Patient was in an endemic area
No contraindication to treatment (single dose
doxycycline)

59
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60

You see a 40 year old woman with fever, weakness,
pallor, confusion
Blood smear is below
Chem-7
PT 11.6, PTT 28
HIV testing is negative
All cultures are negative

138 100 42
104
4.6 20 3.7
Objective recall the clinical / lab findings in
TTP

What is the most likely diagnosis?
AIHA (autoimmune hemolytic anemia)
West Nile meningitis
DIC (disseminated intravascular coagulation)
TTP (Thrombotic thrombocytopenic purpura)
e) Chronic renal failure with sepsis

37 year old woman is seen for eye and abdominal
pain, and nausea. Her eye feels hard to the
touch.
Has this finding

Objective recognize clinical presentation of
acute angle closure galucoma
Acute angle closure glaucoma
62

24 year old woman with acute flank pain,
hematuria.
History of weight loss, intermittent bloody
diarrhea over past 12 months.
What is the underlying illness?

Has this skin rash
And this urinalysis
Objective identify extraintestinal
manifestations of inflammatory bowel disease
(Crohns) Calcium oxalate crystals /
nephrolithiasis, pyoderma gangrenosum
63

78 year old man with BPH admitted with anuria.
Foley inserted, 2100 cc urine in bladder.
Creatinine 4.6
EKG

Initial treatment?
64

23 year old nurse sees you for a painful finger

Herpetic Whitlow
65
Pityriasis rosea
66

Which vitamin should NOT be used alone in this
patient?

Folic acid (folate)
67

To which non-ID specialist should you send this
patient immediately

Ophthalmologist (herpes ophthalmicus nasociliary
branch)
68

What immune system dysfunction might be found in
this 19 year old man with fever, headache, stiff
neck, photophobia, and gram negative diplococci
on gram stain of lumbar fluid

Terminal complement deficiency (neisseria
meningitidis)
69

What is the antibiotic of choice for this 42 year
old man who was bitten by his cat?

Amoxicillin/clavulanate (Augmentin) pasteurella
maltocida
70

A 45 year old CDC scientist presents with fever,
headache, malaise, vomiting, and this rash

What is her mortality?
Variola major 20-30 if unvaccinated (probably
much less if vaccinated widespread smallpox
vaccines stopped around 1972) Variola minor 1
71
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72
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73

Why do you NOT give steroid eye drops to this 21
year old student complaining of a painful, itchy
eye

HSV keratitis (dendritic pattern)
74

Name the immunization which may prevent
overwhelming bacterial sepsis in this patient

Pneumovax (Howell-Jolly bodies)
75

Pel-Ebstein fevers and this biopsy finding are
associated with which malignancy?

Hodgkins (Reed-Sternberg cell)
76
Acanthosis nigricans
77
Basophilic stippling
78

18 year old patient developed this rash after
treatment for an upper respiratory infection. He
is febrile, very fatigued, and has tender lymph
nodes in the back and front of the neck. There
is a pharyngeal exudate, a few small red spots on
the palate, and a slightly palpable spleen tip.
What do you advise him to avoid?

Alcohol
Contact sports
Sulfa-based antibiotics
Contact with children under age 5
Sex, drugs, Rock Roll

Morbilliform rash common with mono after
amox/ampicillin, palatal petechiae exudates
virtually diagnostic of EBV.
79
What treatment might be helpful for this patient
with malaise, fatigue, anemia, thrombocytopenia,
elevated PT/PTT and a positive d-dimer?
All Trans Retinoic Acid (ATRA) PML (M3),
associated with DIC. Auer rods seen, t1517
mutation common.
80

19 year old man with weight loss, diarrhea
Recurrent bronchitis
This exam finding
What is the diagnostic test of choice?

Objective identify the diagnostic test of
choice for cystic fibrosis
Sweat chloride elevation supports diagnosis of
cystic fibrosis
81

48 year old man with cough (bloody), alcohol
abuse
X-ray
What is the diagnostic test of choice?

Objective recognize TB as a causes of upper
lobe pneumonia
Sputum for AFB (TB)
82

46 year old woman with HTN and this X ray

Gram stain shows this organism
During treatment, she becomes confused. What do
you do next?

Objective recall common causes of meningitis in
adults
Lumbar puncture (pneumococcal meningitis)
84

67 year old woman with ESRD has these lesions on
exam
What is the most likely finding on lab testing?
a) normal PT/PTT, platelet count 25K
b) prolonged PT and PTT, normal platelets
c) PT normal, PTT elevated, platelets 400K
d) PT/PTT normal, platelets 130K

Objective identify lab findings in patients
with chronic kidney disease
85

You see a 27 year old woman for an annual visit.
Her blood pressure is 176/88. She is otherwise
healthy, no significant family history, no drugs,
tobacco or alcohol. Her only exam abnormality is
shown on the next slide.

86
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87

You begin working her up for secondary causes of
hypertension. What would you be most likely to
find?
Creatinine 4.1, creatinine clearance of 18 cc/hr
Na 152, K 2.8, adrenal mass on CT
c) Diffuse atherosclerosis of right renal
artery on duplex ultrasound
d) Vanillomandelic acid levels of 2,200,
metanephrines 1,750 in a 24-hour urine collection
e) A string of beads appearance in the distal
two thirds of the left renal artery on renal
angiography

Objective recognize the most common cause of
secondary HTN in young women (fibromuscular
dysplasia)
88

You admit a 55 year old, alcoholic man s/p
tonicclonic seizure. He is hemodynamically
stable, and post-ictal. Chest X-ray findings are
below

Objective understand the antibiotic management
of aspiration pneumonia

What antibiotics do you begin?
Clindamycin
Metronidazole
c) Amoxicillin

d) Cefuroxime azithromycin
No antibiotics, watchful waiting
f) GORILLAcillin, 8 grams hourly until rash
spreads to entire hospital floor

An 80 year old woman complains of fatigue and
weakness for the past two months. She has a
history of frequent skin infections, which have
responded slowly to treatment. Currently, she
takes no medications. Her age-appropriate cancer
screening is up to date.
She appears well but pale. A few petechiae are
noted on the posterior pharynx.
Initial labs show a hemoglobin of 9.0 g/dL
peripheral smear is shown below

What is the most likely diagnosis in this patient?
90
Myelodysplastic syndrome

Malignant hematologic disorder with abnormal /
inefficient cell production
Infection common (abnormal WBCs)
Anemia, fatigue
Petechiae (thrombocytopenia)
Classification
RA
RARS
RAEB
CMML
RAEB-t
Pseudo-Pelger-Huet anomaly shown

A 19 year old man complains of knee pain for 2-3
months. He recalls a motorcycle accident 3
months ago, where he layed down his Harley, and
had multiple contusions and abrasions, but did
not seek medical care. He has no chronic medical
problems, does not use drugs or alcohol, and
takes no medications. Review of systems is
positive only for occasional sweating episodes.
On exam, vital signs are as follows
110/70 80 14 38.9 C
There is pain with active and passive range of
motion of the right knee, but no overlying
erythema.
X rays show periosteal elevation near the tibial
plateau.