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1) A 55-year-old man has had heel pain and an associated limp for 1 month. He works as a police officer…
Plantar fasciitis
- Middle-aged man with an active job presents with heel pain that is most severe when he first stands/walks after rest with increased pain upon palpation of the plantar surface of the heel with an x-ray demonstrating a heel spur, most consistent with plantar fasciitis
- Key idea: Plantar fasciitis commonly associated with heel spurs
- Differential for heel pain:
- Plantar fasciitis: Pain at plantar aspect of heel worse with weight bearing and dorsiflexion of toes; often in obese patients and patients who spend extended periods walking on bare feet
- Achilles tendinopathy: Exercise-induced heel pain at posterior heel with palpable thickening of the tendon that can be reproduced by passive dorsiflexion of ankle
- Calcaneal stress fracture: Significant increase/amount of exercise –> Pain at the heel worse with weight bearing and the heel squeeze test
2) One hour after delivery at term, a 3750-g (8-lb 4-oz) female newborn begins to choke, cough, and regurgitate while…
Insertion of a nasogastric tube
- Newborn with normal APGAR score begins to choke, cough and regurgitate while breast feeding with exam demonstrating drooling, concerning for a possible tracheoesophageal fistula –> Next best step is insertion of nasogastric tube to determine whether it can be passed into the stomach
- Key idea: Difficulty with breastfeeding can be a sign of:
- Tracheoesophageal fistula: Choking/regurgitation, trouble handling secretions
- Choanal atresia: Cannot breathe through nose so will potentially become cyanotic and sweaty when feeding that improves when they stop
- Cardiac abnormalities: Breastfeeding is a newborn’s primary form of exercise/exertion!
3) A previously healthy 27-year-old woman is brought to the emergency department because of a 3-hour history of increasingly…
Laparascopy
- Young woman presents with acute severe lower abdominal pain and is found to be febrile with an enlarged, tender ovarian mass, with next best step being laparoscopy given morbidity/mortality associated with possible diagnoses (including ovarian torsion)
- Lower quadrant abdominal pain in reproductive-aged women:
- Appendicitis: Pain starts in epigastric region then moves to RLQ, associated with inflammatory signs (fever, leukocytosis, etc.)
- Pelvic inflammatory disease: Diffuse lower abdominal pain associated with inflammatory signs (fever, leukocytosis, etc.) in a sexually active woman; pelvic exam demonstrates cervicitis and cervical motion tenderness
- Tubo-ovarian abscess: Complication of pelvic inflammatory disease, where patient has same features as above along with a multiloculated, cystic adnexal mass on abdominal ultrasound
- Ectopic pregnancy: Can’t miss diagnosis in women presenting with lower quadrant abdominal pain (rule out with pregnancy test!); classically presents as patient with positive pregnancy test with an empty uterus, can present with hemodynamic instability if it causes fallopian tube rupture
- Ovarian torsion: Lower quadrant abdominal pain with abnormal flow on Doppler ultrasound, often associated with ovarian mass (particularly teratomas), can be intermittent!!!! (lower quadrant abdominal pain worse with exercise is classic story)
- Mittelschmerz: Mid-cycle lower abdominal pain associated with inflammation from ovulation event
- Primary dysmenorrhea: Lower abdominal pain + other non-specific symptoms (headache, nausea, etc.) seen a few days prior to period starting due to increased prostaglandin production (treat with NSAIDs –> block prostaglandin production)
- Functional ovarian cyst: Subacute/chronic lower abdominal pain that often worsens with menses and can present acutely if it ruptures, pelvic ultrasound demonstrates a simple adnexal cyst
4) A 57-year-old woman is brought to the emergency department after being found comatose. During the past…
Hypercalcemic crisis
- Middle-aged woman with metastatic breast cancer who received radiation therapy for painful bony metastases 2 weeks ago presents with acute altered mental status without localizing neurologic signs, concerning for possible hypercalcemic crisis –> First step in treatment would be IV saline to dilute calcium and ensure adequate hydration in setting of likely polyuria
- Key idea: Hypercalcemia leads to stones (kidney stones), bones (bone pain), thrones (polyuria due to nephrogenic diabetes insipidus), groans (abdominal pain and constipation) and psychiatric overtones (altered mental status)
- Differential for altered mental status –> MIST
- Metabolic: Hyponatremia, hypercalcemia, acidosis, uremia, etc.
- Infectious: Primary CNS infections (encephalitis, meningitis) and non-CNS infections (urosepsis, pneumonia, etc.)
- Structural: Stroke, seizure, mass, etc.
- Toxins: Intoxication (opiates, benzo’s) and withdrawal (delirium tremens)
5) A 49-year-old man with type 1 diabetes mellitus remains hospitalized 2 days after admission for management of…
Femorotibial bypass grafting
- Middle-aged man with long-standing, poorly-controlled type 1 diabetes presents with gangrene of the second toe of the left foot with duplex ultrasound demonstrating occlusion of all 3 tibial arteries in the proximal calf, meaning that femorotibial bypass grafting
- Indications for revascularization in setting of peripheral artery disease:
- Rest pain
- Ischemic ulceration
- Gangrene
- Key idea: No Ankle-brachial index (ABI) cutoff to determine need for revascularization
- Key idea: Just like with cardiac ischemia, if multiple vessels are involved then bypass grafting is preferred over angioplasty
6) A 72-year-old man with esophageal adenocarcinoma comes to the physician for evaluation 2 weeks prior to a scheduled…
Low-molecular-weight heparin therapy
- Elderly man has a subtotal esophagectomy planned in 2 weeks for esophageal adenocarcinoma, and in addition to early ambulation should receive heparin therapy to decrease risk of DVT
- Key idea: Antiplatelet agents (aspirin, clopidogrel) not commonly used for DVT prophylaxis
- Key idea: IVC filter appropriate for patients with DVT complicated by pulmonary embolus who cannot receive anticoagulants
7) A 72-year-old man is admitted to the hospital because of hematochezia for 12 hours. He has mild chronic obstructive…
Ischemic colitis
- Elderly woman with cardiac risk factors presents with acute, self-resolving hematochezia with colonoscopy demonstrating edema, ulceration and friability of the sigmoid colon, concerning for possible ischemic colitis
- Key idea: Ischemic colitis commonly occurs due to atherosclerosis and often leads to episodes of abdominal pain and/or hematochezia
- Key idea: Ischemic colitis most commonly affects watershed areas of the colon (distal portion of arterial supply), which are the splenic flexure and rectosigmoid junction
- Ulcerative colitis –> Subacute/chronic abdominal pain with bloody bowel movements with colonoscopy demonstrating continuous lesion beginning at the rectum
- Diverticulitis –> Acute LLQ abdominal pain + fever + leukocytosis
8) A 67-year-old man comes to the physician because of a 5-day history of chest pain, fatigue, shortness of breath…
Echocardiography
- Middle-aged man who underwent CABG procedure 3 weeks ago presents with 5-day history of pleuritic, positional chest pain, dyspnea and cough and is found to have a fever and friction rub with a normal ECG, with next best step being an Echocardiography to evaluate for possible pericarditis
- Typical ECG findings in pericarditis: Diffuse ST elevations and PR depressions
- Pleuritic chest pain differential
- Pericarditis
- Pleuritis
- Pulmonary embolism
- Pneumothorax
- Common causes of pericarditis
- Post-viral
- Uremia
- Immediate post-CABG or MI (inflammation)
- ~6 weeks post-CABG or MI (Dressler’s syndrome)
- Lupus
9) A 63-year-old man has a 3-month history of painless hematuria. Cystoscopy shows a superficial small tumor of the…
Endoscopic resection
- Surgical approach to bladder cancer treatment:
- Bladder cancer that is superficial and has NOT invaded muscle –> Endoscopic resection
- Bladder cancer that has invaded muscle –> Partial cystectomy
- Large bladder cancer or cancer that involves multiple areas in bladder –> Total cystectomy
10) A 57-year-old woman who had tuberculosis many years ago comes to the emergency department because of hemoptysis…
Aspergilloma
- Middle-aged woman with previous history of tuberculosis who presents with progressive hemoptysis with x-rays demonstrating a round mass located within an upper lobe cavitation, concerning for an aspergilloma
- Aspergillosis can lead to several distinct pulmonary pathologies:
- Allergic bronchopulmonary aspergillosis: Patient with asthma or cystic fibrosis who presents with recurrent fleeting infiltrates associated with eosinophilia due to hypersensitivity response to Aspergillus; treat with months of itraconazole and oral steroids
- Angioinvasive aspergillosis: Immunocompromised patient who presents with fever, chest pain and hemoptysis with imaging demonstrating a halo sign (ground glass opacity surrounding nodule); treat with voriconazole and caspofungin
- Chronic pulmonary aspergillosis: Patient with history of cavitary lung disease (tuberculosis, aspiration, Klebsiella) who presents with chronic weight loss, cough and hemoptysis and is found to have a cavitary lung lesion with a fungal ball (aspergilloma); treat with surgical resection +/- azole medication
11) A 35-year-old woman has newly diagnosed pancreatitis. Physical examination shows fibrocystic changes of the…
Parathyroid adenoma
- Young woman presents with pancreatitis and is found to have hypercalcemia and hypophosphatemia, most concerning for hyperparathyroidism
- Key idea: The parathyroid gland’s job is to increase serum calcium levels so it both increases calcium levels and decreases levels of phosphate (given phosphate can bind to free calcium), whereas Vitamin D’s job is to mineralize bone so it increases both calcium and phosphate levels (given calcium-phosphate complexes are what mineralize bone)
- Key idea: Top 2 causes of pancreatitis are gallstones and alcohol, but if those are not present (patient denies EtOH use and RUQ U/S negative), then next two most common causes are hypertriglyceridemia (>500-1000) and hypercalcemia
12) A 4-year-old boy is brought to the physician because of pain and burning of his right eye after playing in a sandbox…
Conjunctival instillation of fluorescein
- Young boy playing in a sandbox presents with unilateral blurry vision with pain, blurring, tearing and redness of the eye and therefore should undergo fluorescein staining to look for a possible corneal abrasion
- Measurement of intraocular pressure –> Glaucoma (loss of peripheral vision)
13) A 42-year-old woman comes to the physician after finding a mass in her left breast on breast self-examination…
Fibrocystic disease
- Young woman presents with a unilateral, well-circumscribed breast mass with aspiration demonstrating clear brown fluid, most concerning for fibrocystic disease
- Key idea: Fibrocystic disease commonly leads to bilateral “lumpy-bumpy” breasts, but the main feature of the disease is cysts that can be filled with non-bloody fluid (brown, yellow, clear, etc.)
- Key idea: Fibrocystic disease common among women 35-50 years old whereas fibroadenoma more common among women under 35 years old
- Carcinoma –> Fixed, irregular mass
- Fibroadenoma –> Mobile well-circumscribed mass that fluctuates in size according to the menstrual cycle
- Paget disease –> Eczematous-like dermatitis involving the areola/nipple in setting of underlying carcinoma
14) A 52-year-old man comes to the physician 3 weeks after an episode of dysphagia while eating meat. He has had…
Omeprazole
- Middle-aged man with chronic history of heartburn presents following an episode of dysphagia and is fond to have mild iron deficiency anemia with follow-up upper endoscopy demonstrating a hiatal hernia with linear erosions and erythema of the lower esophagus, concerning for GERD complicated by reflux esophagitis
- Key idea: Two best treatments in setting of GERD are proton pump inhibitors (like omeprazole) and H2 blockers (like ranitidine)
- Indications for upper endoscopy in setting of patient with GERD (“alarm symptoms”)
- Dysphagia
- Iron deficiency anemia
- Weight loss
- Chest pain
- Melena/hematemesis
15) An 82-year-old man comes to the emergency department because of a 2-day history of extreme difficulty voiding…
Diphenhydramine
- Elderly patient presents with urinary retention complicated by likely overflow incontinence with BPH and increased post-void residual volume (suggestive of obstructive pathology), which is worsened by anticholinergic medications such as diphenhydramine
- Key idea: Anticholinergic medications block parasympathetic functions (mydriasis, tachycardia, urinary retention, constipation, etc.) with decreased sweating (given sweat glands are stimulated by acetylcholine)
- Key idea: Overflow incontinence can be seen in patients with reduced bladder outflow in setting of atonic bladder (diabetes, MS) or obstructive pathology (BPH, pelvic organ prolapse)
- Terazosin –> Orthostatic hypotension in patients also receiving nitrates or sildenafil
16) A 32-year-old male firefighter is brought to the emergency department after being rescued from a burning building…
Transoral endotracheal intubation
- Young man is rescued from a house fire with signs of inhaled smoke (hoarse voice, coughing up carbonaceous sputum, facial burns) and he should therefore be intubated given concern for impending respiratory collapse/obstruction due to mucosal edema
- Key idea: For all emergent presentations, the first step is to ensure ABC –> Airway, Breathing and Circulation
- Indications for endotracheal intubation:
- Expanding hematoma, emphysema or edema in oral cavity or neck
- Glasgow-Coma scale of 8 or less (8 –> intub-8) [inability to protect airway]
- Severe inhalation injury (house fire, ash on face/mouth)
- Breathing is noisy (stridor) or patient is gurgling
- Indications for cricothyroidotomy:
- Same indications as endotracheal intubation except normal intubation not possible due to:
- Inability to intubate or ventilate
- Massive facial/nasal trauma
- Same indications as endotracheal intubation except normal intubation not possible due to:
- Indications for tracheostomy:
- Patient who will need to be intubated for >1 week to decrease risk of laryngomalacia
17) A 62-year-old man comes to the emergency department because of swelling and discomfort of the left foot that began…
Loss of afferent sensory nerve function
- Middle-aged patient with type 2 diabetes who presents with pain and swelling of the foot after exertion found to have fragmentation/destruction of foot joints on x-ray concerning for Charcot joint due to loss of sensation (afferent function)
- Key idea: Charcot joint/foot is a condition primarily seen in diabetic patients with neuropathy in which there is a vicious cycle in which patients injure their foot –> don’t feel injury so continue to use it normally –> increased foot injuries/inflammation –> Still don’t feel –> Continued injury/inflammation in foot –> etc.
- Key idea: Medical treatment of Charcot foot/joint aimed at offloading the foot and preventing further fractures, which can be done in this case with splinting
- Key idea: In a patient with poorly controlled diabetes, would likely try conservative therapy >> Surgery of the foot because they are at high-risk for poor wound healing and post-op infections that could result in foot amputation
- Immunologically driven synovial proliferation –> Rheumatoid arthritis –> 40-60 year old woman with inflammatory polyarthritis
- Intra-articular precipitation of calcium pyrophosphate crystals –> CPPD –> Monoarticular arthritis after surgery/stressor with weakly positively birefringent rhomboid crystals
- Intra-articular precipitation of monosodium urate crystals –> Gout –> Monoarticular arthritis of knee or big toe with negatively birefringent needle-shaped crystals
- Osteomyelitis –> Fever + tenderness over bone (often in IVDU)
18) A 62-year-old man comes to the physician because of a 1-year history of pain in his calves and thighs after he walks…
Aortoiliac occlusive disease (Leriche syndrome)
- External iliac occlusion –> Thigh claudication alone
- Aortoiliac occlusion –> Thigh claudication + Gluteal claudication + Impotence (Leriche syndrome)
- Differences between claudication and pseudoclaudication (spinal stenosis)
- Claudication
- Calves > Thighs
- No changes with position
- Signs of distal artery ischemia (decreased hair over legs with shiny skin, decreased pulses, etc.)
- Atherosclerotic risk factors (smoking, diabetes, hypertension, etc.)
- Pseudoclaudication:
- Thighs > Calves
- Improves with spinal flexion (grocery cart sign, walking up hills, riding bicycle)
- No signs of distal artery ischemia
- Claudication
- Coarctation of the aorta –> Continuous murmur heard best between shoulder blades + Upper extremity hypertension + Decreased pulses/pressure in lower extremities
19) Ten minutes after transfusion of packed red blood cells is begun, a 62-year-old woman has chest pain…
Direct antiglobulin (Coombs) test
- Middle-aged woman receiving a transfusion develops chest pain, dyspnea and fever and should have a Direct Coombs test performed to determine whether reaction is hemolytic
- Key idea: Direct Coombs test is best test to differentiate between hemolytic and non-hemolytic transfusion reactions (which are managed differently)
- Key idea: Both hemolytic and non-hemolytic febrile transfusion reaction lead to fever, diaphoresis, tachycardia and dyspnea, with features more characteristic of a hemolytic transfusion reaction including:
- Flank pain + Dark urine
- Positive urine dipstick for blood without RBCs on microscopy (indicative of hemoglobinuria or myoglobinuria)
- Positive direct Coombs test
20) A hospitalized 37-year-old woman with type 1 diabetes mellitus and chronic renal failure has the sudden onset…
Needle aspiration of the right chest
- Young woman undergoes difficult right subclavian catheterization for hemodialysis and develops acute shortness of breath with hypotension and asymmetric breath sounds concerning for tension pneumothorax –> Immediate needle thoracostomy
- Note: Tension pneumothorax classically leads to jugular venous distention due to increased pressure pressing on the vena cava, but may not be distended in acute tension pneumothorax because enough air has not accumulated
- Two basic types of pneumothorax:
- Spontaneous pneumothorax (Collapsed lung (chest pain, dyspnea) WITHOUT hemodynamic instability)
- Commonly seen in thin, young individuals (classically men) or secondary to rupture of a bullae in the setting of underlying pulmonary disease (COPD)
- Tx: Observation (<2 cm) versus Needle thoracostomy (>2 cm, not self-resolving)
- Tension pneumothorax (Collapsed lung WITH hemodynamic instability)
- Commonly due to penetrating trauma (motor vehicle accident) or iatrogenic (central line placement, mechanical ventilation)
- Tx: Immediate needle thoracostomy to prevent hemodynamic collapse
- Spontaneous pneumothorax (Collapsed lung (chest pain, dyspnea) WITHOUT hemodynamic instability)
- Lung exam findings:
- Hyperresonant –> Less dense than normal lung –> Air –> Pneumothorax
- Hyporesonant –> More dense than normal lung –> Water, Blood or pus –> Pulmonary edema, pleural effusion, hemothorax, pneumonia, etc.
21) A 57-year-old woman has a decreased urine output (15 mL/h) 2 hours after undergoing a radical hysterectomy for endometrial…
Decreased renal blood flow
- Middle-aged woman who underwent hysterectomy with episode of hypotension during surgery who presents post-op with decreased urine output concerning for a pre-renal AKI
- Key idea: Hypotension/Hypovolemia can lead to pre-renal AKI or Acute tubular necrosis, with main differences being:
- Pre-renal AKI
- BUN:Cr > 20
- Highly concentrated urine (Urine Na < 20, FeNa < 1%, urine concentration > 550)
- No casts or waxy casts
- Acute tubular necrosis
- BUN:Cr < 15
- Poorly concentrated urine (Urine Na > 40, FeNa > 2%, urine concentration < 450)
- Granular (“muddy brown”) casts
- Pre-renal AKI
- Key idea: Hysterectomy classically complicated by ureter injury, but would require bilateral ureter injury to lead to oliguria
22) A 67-year-old woman with essential hypertension comes to the physician because of a 6-month aching of her left…
Blood pressure measurement of the right upper extremity
- Elderly woman with atherosclerotic risk factors (hypertension, smoking) presents with pain in her left arm and pre-syncope with exertion concerning for peripheral artery disease complicated by subclavian steal syndrome, and therefore should undergo blood pressure measurement of the right arm to look for asymmetric blood pressures
- Key idea: Although the left arm blood pressure falls within the range of normal, patient is known to have essential hypertension so that may actually be a relatively diminished pressure in her case
- Key idea: Basic pathophysiology is that stenosis of the left subclavian artery means that when the left arm is exerted, there will be vasodilation of the capillary beds (in the setting of hypoxia) and this will cause blood destined for the posterior circulation of the brain to flow in a retrograde fashion towards the left arm, leading to cerebral hypoperfusion with resulting syncope
- Unequal blood pressure in arms –> Aortic pathology (Takayasu’s arteritis, aortic dissection, etc.) or Subclavian steal syndrome (recurrent syncope when exerting one arm)
- Neck auscultation –> Carotid artery atherosclerosis –> Patient presenting with stroke or amaurosis fugax (ipsilateral, unilateral episodes of monocular blindness)
23) An 82-year-old man comes to the physician because of a growth on his face for 6 months. It bleeds easily..
Basal cell carcinoma
- Elderly white man with significant occupational sun exposure presents with ulcerated nodule on a sun-exposed surface, with the lesion having prominent telangiectasias concerning for basal cell carcinoma
- Squamous cell carcinoma –> Non-healing, scaly ulcer on sun-exposed skin; can also develop at site of prior burn
- Melanoma –> Pigmented lesion that is asymmetric with unclear borders, multiple colors, a diameter > 6 mm, and is evolving (ABCDE)
24) A previously healthy 42-year-old woman has the abrupt onset of severe headache, followed several hours later by lethargy…
Fresh subarachnoid hemorrhage at the base of the brain
- Young woman with severe headache presents with lethargy and nuchal rigidity and dies within 24 hours, concerning for a subarachnoid hemorrhage
- Key idea: Subarachnoid hemorrhage classically presents as “worse headache in my life” and can occur due to trauma but also due to non-traumatic rupture of a berry aneurysm (often a bleed on the bottom of the brain [basal cisterns])
- Key idea: Meningismus (nuchal rigidity, etc.) can be seen in either meningitis (due to infection of meninges) OR subarachnoid hemorrhage (due to blood irritating the meninges) (HIGH-YIELD!!!)
25) A 20-year-old man is brought to the emergency department 30 minutes after being involves in a motor vehicle collision…
Hip dislocation
- Young man involved in a motor vehicle accident has a shortened, adducted and internally rotated left lower extremity concerning for posterior hip dislocation
- Key idea: Hip dislocation can lead to sciatic nerve injury –> Sensory problems of lower leg and impaired foot movement (dorsiflexion, plantarflexion, external rotation, etc.)
- Femoral neck fracture –> Shortened and externally rotated lower extremity
26) A 92-year-old woman is brought to the emergency department 6 hours after the sudden onset of abdominal pain…
Adhesions
- Elderly woman with past abdominal surgery presents with abdominal pain + distention + vomiting + obstipation (no flatus) + increased bowel sounds with imaging demonstrating air-fluid levels with dilated small bowel concerning for a small bowel obstruction due to adhesions
- Key idea: Small bowel has lines going ALL THE WAY through the bowel (plica circularis) whereas the large bowel has lines only halfway through the bowel (haustra)
- Top causes of small bowel obstruction:
- #1: Adhesions (history of abdominal surgery)
- Tumor
- Hernia
27) A 36-year-old man comes to the physician because of a 4-day history of bloody diarrhea. He has a 16-year history…
Segmental colectomy
- Constricting, apple-core sigmoid mass –> Colorectal carcinoma!
- Key idea: Proctocolectomy often used in colorectal carcinoma in setting of ulcerative colitis and familial adenomatous polyposis (FAP) syndrome
- Key idea: Patients with IBD have a greatly increased risk of colorectal cancer and should therefore begin colonoscopy screening 8-10 years post-diagnosis with screenings every 1-3 years
28) A 60-year-old woman has had left shoulder and arm pain for 2 weeks. She has smoked two packs of cigarettes…
Bronchogenic carcinoma
- Middle-aged woman with significant smoking history presents with left shoulder and arm pain with exam significant for dilated and fixed left pupil with left eye ptosis and chest x-ray demonstrating radiopaque left upper lobe mass concerning for Pancoast tumor (lung cancer of lung apex)
- Key idea: Tumor at lung apex can press upon brachial plexus (leading to upper extremity pain/weakness), superior vena cava (leading to plethora and swelling of face), subclavian vein (leading to plethora and swelling of upper extremity) and sympathetic chain (leading to Horner’s syndrome [ptosis, miosis and anhidrosis])
- Upper eyelid innervated by CN3 and sympathetic chain, with damage to CN3 leading to ptosis with dilated pupil (since CN3 carries parasympathetic innervation to eye) and damage to sympathetic chain classically leading to ptosis with constricted pupil (given loss of sympathetic stimulation)
29) Thirty-six hours after hospitalization for treatment of multiple fractures sustained in a motor vehicle collision…
Fat embolism
- Key idea: Fat embolism classically presents 24-72 hours after a long bone fracture with triad of respiratory distress, neurologic dysfunction (confusion) and petechial rash
- Delirium tremens –> Confusion + Sympathetic hyperactivity (tachycardia, hypertension) 2-4 days after last drink
- Note: Within 24-48 hours of last drink patients can develop hallucinations and seizures, along with non-specific withdrawal symptoms (tremors, diaphoresis, etc.)
- Aspiration pneumonitis –> Dyspnea and CXR infiltrates hours after aspiration event that should self-resolve
- Pulmonary embolism –> Respiratory distress, chest pain and tachycardia in patient with risk factors for deep vein thrombosis (stasis, hypercoagulability, endothelial damage)
30) A 65-year-old man is brought to the emergency department 1 hour after an episode of syncope. He has a 1-day history…
Bedside transabdominal ultrasonography
- Middle-aged man with significant atherosclerotic risk factors (hypertension, smoking, hypercholesterolemia) and one day of back pain presents following a syncopal episode and is found to be tachycardic with a pulsatile abdominal mass, concerning for a rupture abdominal aortic aneurysm –> Best diagnostic test is abdominal ultrasound
- Key idea: One-time screening with abdominal ultrasound indicated for men 65-75 years old with ANY smoking history (don’t need to meet pack-year threshold like low-dose CT imaging screening criteria)
- Key idea: Tachycardia is often the first sign of shock and should be taken very seriously!
31) A previously healthy 47-year-old man comes to the emergency department 2 hours after the sudden onset of constant…
Perforated duodenal ulcer
- Middle-aged man presents with acute severe epigastric pain and is found to be tachycardic with significant rigidity and leukocytosis, concerning for perforated peptic ulcer
- Key idea: Rebound and guarding are signs of peritonitis, meaning there is air within the abdominal cavity due to a perforated hollow viscus –> Indication for immediate surgical exploration/intervention
- Acute cholangitis –> Fever + RUQ pain + jaundice + dilated CBD on RUQ U/S
- Acute cholecystitis –> Fever + RUQ pain + pericholecystic fluid on RUQ U/S
- Acute diverticulitis –> Fever + LLQ pain in patient with chronic constipation
- Acute pancreatitis –> Severe epigastric pain + elevated amylase/lipase
32) A 42-year-old woman, gravida 3, para 3, is brought to the emergency department because of severe abdominal pain that awoke…
Abdominal ultrasonography
- Woman in her 40’s presents with severe RUQ abdominal pain + leukocytosis + mild hyperbilirubinemia concerning for acute cholecystitis –> Next best step is RUQ U/S looking for pericholecystic fluid and gallbladder wall thickening
- Key idea: Unequivocal RUQ U/S in a patient with suspected acute cholecystitis should be followed up with HIDA scan
- Key idea: Acute cholangitis should lead to severe jaundice, whereas cholecystitis shouldn’t theoretically lead to jaundice given disease is limited to the gallbladder and cystic duct
- Key idea: Colic should theoretically last less than 6 hours during each episode
- Endoscopic retrograde cholangiopancreatography –> Only indicated in setting of acute cholangitis and pancreatic mass (pseudocyst); NOT GALLSTONE PANCREATITIS!!!
33) A 42-year-old woman has had fatigue, exertional dyspnea, and palpitations for 4 months. She has a history of frequent…
Atrial septal defect
- Young woman presents with chronic history of fatigue, dyspnea, palpitations and frequent respiratory infections and is found to have a prominent RV impulse with wide fixed splitting of S2 and a systolic ejection murmur concerning for atrial septal defect complicated by pulmonary hypertension
- On the test, fixed splitting should make you think of atrial septal defect!(BUZZWORD!!!)
- During inspiration –> Increased right sided filling –> Delayed pulmonic valve closure –> Splitting between aortic valve and pulmonic valve closure
- During expiration –> Increased left-sided filling –> Increased left-to-right shunting across ASD –> Delayed pulmonic valve closure –> Splitting between aortic valve and pulmonic valve closure
- Key idea: Right ventricular heave + loud S2 + prominent pulmonary arteries concerning for pulmonary hypertension
- Causes of pulmonary hypertension include:
- Genetic mutation (pulmonary arterial hypertension) –> Progressive dyspnea with pulmonary hypertension symptoms in young woman
- Left-sided HF
- Obstructive/Restrictive lung disease (Cor pulmonale)
- Chronic thromboembolic disease
- Other (HIV, sarcoidosis, schistosomiasis, etc.)
34) An asymptomatic 72-year-old woman comes to the physician for a routine health maintenance examination. Her pulse is 76/min…
Cecal malignancy
- Elderly woman presents with microcytic anemia with positive occult blood, which should be assumed to be colon cancer until proven otherwise!
- Key idea: While hemorrhoids can lead to lower GI bleed, it typically does not lead to significant enough bleeding to lead to iron deficiency anemia (microcytic anemia)
- Meckel diverticulum –> Most common cause of GI bleed in children
35) Three days after an exploratory laparotomy for a stub wound to the abdomen, a 14-year-old boy has jaundice. He recently immigrated…
Bile duct obstruction from migrating worms
- Young boy with recent exploratory laparotomy significant for roundworms within the lumen of the bowel who presents on post-op day 3 with cholestatic liver injury concerning for bile duct obstruction due to roundworms
- LFT abnormalities can generally be broken down into:
- Hepatocellular (ALT/AST increase >>> Alk phos and bilirubin increase)
- Toxins (acetaminophen, alcohol, etc.)
- Ischemia (shock liver in setting of sepsis/hypovolemia)
- Viruses (hepatitis A-E, CMV, VZV, etc.)
- Other (autoimmune hepatitis, Wilson disease, etc.)
- Cholestatic (Alk phos and direct bilirubin increase >> ALT/AST increase)
- Choledocholithiasis +/- acute cholangitis
- Pancreatic cancer (head) or cholangiocarcinoma
- Primary sclerosing cholangitis
- Primary biliary cirrhosis
- Rare: Roundworm obstruction of biliary tree (immigrant patient with eosinophilia)
- Hepatocellular (ALT/AST increase >>> Alk phos and bilirubin increase)
36) A 15-year-old boy is brought to the emergency department by his parents because of a 3-hour history of severe pain in his…
Surgical exploration of the scrotum
- Adolescent boy presents with 3-hour history of severe atraumatic testicular pain and is found to have an exquisitely tender and elevated right testicle concerning for testicular torsion –> Surgical emergency with immediate OR exploration
- Key idea: Testicular torsion classically leads to loss of the cremasteric reflex (elevation of testicle with stroking of inner thigh) due to twisting of the genitofemoral nerve within the spermatic cord
- Indications for immediate surgical intervention/exploration:
- Peritonitis (rigidity/guarding/air under diaphragm)
- Testicular torsion
- Ovarian torsion
- Necrotizing fasciitis or Fournier gangrene
- Open bone fracture
37) A previously healthy 42-year-old woman is admitted to the hospital for treatment of acute biliary pancreatitis. On hospital day 5…
Refeeding syndrome
- Young woman who hasn’t eaten in nearly a week is started on TPN, with labs demonstrating hypomagnesemia and hypophosphatemia, concerning for refeeding syndrome
- Key idea: Re-initiation of food intake –> Increased insulin release/activity –> Electrolyte shifts into cells –> Depletion of phosphate, magnesium and thiamine
- Key idea: Refeeding syndrome can precipitate Wernicke encephalopathy (confusion, ataxia and ophthalmoplegia) and therefore in patients who are found down it is best to give thiamine prior to giving glucose
- Hyperparathyroidism –> Hypercalcemia + Hypophosphatemia
38) A 57-year-old woman with metastatic cancer of the sigmoid colon is admitted to the hospital because of a 2-day history of…
Discontinuation of heparin
- Middle-aged woman with metastatic cancer presents with a provoked upper extremity DVT and is started on heparin with development of thrombocytopenia, most concerning for heparin-induced thrombocytopenia –> Best next step is to stop heparin and start alternative anticoagulant (dabigatran)
- Key idea: Use of heparin –> Development of antibodies against heparin-platelet factor 4 complex –> Thrombocytopenia (>50% drop in platelets) and hypercoagulable state
- Antithrombin 3 deficiency –> Hypercoagulability
39) A 47-year-old woman with breast cancer has the sudden onset of confusion and lethargy. Fundoscopic examination…
Corticosteroid therapy
- Young woman with breast cancer presents with papilledema and imaging demonstrating a cerebellar metastasis and should therefore receive IV corticosteroids (classically dexamethasone) to limit inflammation
- Key idea: Brain tumor and spinal cord compression classically treated with corticosteroids to reduce inflammation/compression
- Key idea: Papilledema = Increased intracranial pressure
40) A 47-year-old woman is brought to the emergency department 30 minutes after being found unresponsive by her husband on the…
Streptococcus pyogenes (group A)
- Middle-aged woman with relative immunosuppression (diabetes) had a scratch on her labium with progressive redness, firmness and swelling at the site with exam concerning for tachycardia, hypotension and purulent discharge from the labium with debridement demonstrating liquefactive necrosis involving the underlying fascia and muscle, concerning for necrotizing fasciitis –> Most common pathogen causing “wet gangrene” (AKA necrotizing fasciitis with purulence) is Group A Strep
- Key idea: Most common pathogen causing “dry gangrene” (AKA necrotizing fasciitis with crepitus) is Clostridium perfringens
- Key idea: Necrotizing fasciitis should be suspected if patient has:
- Significant pain (“Pain out of proportion”)
- Crepitus
- Bullae
- Violaceous/Dark coloration
- Significant illness (hypotension, tachycardia, fever)
- Key idea: Necrotizing fasciitis is an indication for emergency OR exploration/intervention
41) A 25-year-old woman has a 2-year history of episodic bloody diarrhea, sometimes productive of blood and mucus without stool…
Cancer of the colon
- Young woman with presentation consistent with ulcerative colitis (chronic bloody diarrhea + lead-pipe sign of large intestine (see below) + mucosal microabscesses on biopsy), who is therefore at increased risk for colon cancer
- Key idea: Patients with IBD have a greatly increased risk of colorectal cancer and should therefore begin colonoscopy screening 8-10 years post-diagnosis with screenings every 1-3 years
42) A previously healthy 37-year-old woman comes to the physician because of a persistent headache for 1 week with…
Fibromuscular dysplasia of the renal artery
- Young woman with subacute neurologic symptoms (headache, papilledema) found to have a right carotid bruit and stenosis of the right renal artery with significant hypertension, most concerning for fibromuscular dysplasia
- Key idea: Fibromuscular dysplasia most commonly affects the renal artery (leading to secondary hypertension) and the internal carotid artery (leading to recurrent headache, TIA, stroke, etc.)
- Key idea: Two most common causes of renal artery stenosis are (1) Atherosclerosis (older patient with ASCVD risk factors [smoking, hypertension, etc.]) and (2) Fibromuscular dysplasia (young woman with neurologic symptoms + hypertension)
- Key idea: Severe/refractory hypertension + Hypokalemia is indicative of persistent mineralocorticoid receptor activation, with the 3 main causes being:
- Primary hyperaldosteronism (familial, isolated hypertension)
- Cushing’s syndrome (cortisol –> activation of mineralocorticoid receptors)
- Renal artery stenosis (kidney perceives low effective circulating volume –> persistently elevated RAAS)
43) A 50-year-old man with chronic constipation has had anal pain after each bowel movement for 2 weeks…
Anal fissure
- Middle-aged man with chronic constipation presents with significant pain with bowel movement relieved by sitz baths, concerning for anal fissure
- Key idea: Anal fissures occur below the dentate line, meaning they are innervated and lead to severe pain
- Key idea: Chronic constipation can predispose to:
- Anal fissures: Severe pain with defecation
- Diverticulosis: Lower GI bleed in older patient
- External hemorrhoids: Sensation of fullness with mild lower GI bleed
44) A 27-year-old man undergoes Roux-en-Y gastric bypass for morbid obesity. He has type 2 diabetes mellitus, hypertension…
Application of continuous positive airway pressure
- Young patient with obesity and history of sleep apnea develops post-operative hypoxia with bilaterally decreased air movement and ABG demonstrating respiratory acidosis (indicative of poor ventilation), concerning for possible atelectasis in setting of poor ventilation –> Next best step is positive airway pressure to resolve atelectasis
- Key idea: When a patient is on a ventilator (which is not the case here), oxygenation (O2 balance) can be improved by increasing fraction of inspired oxygen (FiO2) and positive end-expiratory pressure (PEEP), whereas ventilation (CO2 balance) can be improved by increasing tidal volume or respiratory rate (both of which increase amount of air moved)
- Naloxone therapy –> Patient with respiratory depression, altered mental status, miosis and absent bowel sounds
45) A 37-year-old woman comes to the physician for evaluation of a mole on her left cheek because her uncle was recently…
Observation only
- Young woman presents with a chronically unchanged pigmented lesion on her face that is brown, 5 mm, well-circumscribed, and symmetric, most consistent with a benign nevus that could be managed through observation
- Key idea: Concerning features of a pigmented lesion can be remembered by ABCDE:
- Asymmetric
- Borders poorly delineated
- multiple Colors
- Diameter > 6 mm
- Evolving/changing
- Key idea: For concerning lesions, the best treatment is excisional biopsy, with shave biopsies NOT being a good option given they preclude you from assessing the depth of invasion (which guides clinical/surgical management [Breslow thickness])
46) A hospitalized 62-year-old woman has a rash over her lower extremities that developed 2 days after she underwent…
Aortic atheroembolism
- Elderly patient with recent cardiac catheterization i/s/o anterior wall ST-elevation myocardial infarction presents with petechiae of the feet concerning for cholesterol crystal embolism
- Key idea: Classically presents with symptoms involving the:
- Skin (livedo reticularis, petechia, gangrene [“blue toe syndrome”])
- Kidneys (AKI)
- CNS (stroke, amaurosis fugax, Hollenhorst plaques in eyes [see below])
47) A 38-year-old man who had been receiving corticosteroids for asthma has an emergency appendectomy for a ruptured appendix…
Administration of hydrocortisone, 100 mg intravenously
- Young man who recently received corticosteroids has an emergency appendectomy performed and in the recovery room develops confusion and hypotensive refractory to fluids, concerning for acute adrenal insufficiency –> Next best step is to administer corticosteroids
- Key idea: Patients with adrenal insufficiency are unable to mount a response to life stressors (illness, surgery, anesthesia, etc.) and therefore will develop hypotension that is refractory to fluids (given it is due to vasodilation from loss of permissive effect of cortisol on effects of epinephrine/norepinephrine)
- Key idea: Chronic steroid use classically leads to secondary adrenal insufficiency, which can be distinguished from primary adrenal insufficiency due to normal K+ balance (due to normal aldosterone levels) and lack of hyperpigmentation (due to low ACTH levels)
48) A 52-year-old man with type 1 diabetes mellitus comes to the physician for a follow-up examination. Three years ago, he underwent…
Chronic rejection
- Middle-aged man who underwent renal transplant 3 years ago and is adherent with immunosuppressive regimen presents with worsening lower extremity edema and increased creatinine concentration, concerning for chronic rejection
- Types of transplant rejection:
- Hyperacute
- Minutes-hours due to preformed antibodies to HLA subtype
- Type 2 hypersensitivity reaction
- Acute
- Months (<6 months) due to cell-mediated (B cell) response to donor HLA
- Chronic
- Months to years due to chronic low-grade T cell response to donor HLA
- Key idea: Immunosuppressive therapy does NOT prevent chronic rejection
- Graft-vs-Host disease
- Dermatitis, enteritis and hepatitis due to donated T cells attacking tissues in recipient
- Hyperacute
- Cyclosporine toxicity –> Neurotoxicity, gingival hyperplasia, hypertension, kidney disease
- HUS –> Brain FART –> Neuro symptoms (brain), Fever, Anemia (hemolytic, schistocytes), Renal disease, Thrombocytopenia
49) Eight months after undergoing an abdominoperineal resection of the rectum for adenocarcinoma, a 62-year-old man has a pelvic…
Maintain the dose of morphine and initiate a daily regimen of oral cathartics and stool softeners
- Elderly man with end-stage cancer receiving morphine for cancer-related pain develops fecal impaction, and therefore would benefit from a bowel regimen
- Key idea: In patients with end-stage cancer, prioritization should be given to patient comfort and pain medications should NOT be held just for the sake of reducing risk of opioid dependence
- Key idea: Expected that cancer-related pain will increase over time, so when these patients ask for additional pain medication it is likely related to true increase in pain rather than “drug-seeking behavior”
50) A 55-year-old man is admitted to the hospital because of progressively severe anginal pain secondary to coronary…
Cancel the operation
- Middle-aged man who originally consented to a procedure develops an adverse reaction to the premedication and no longer wants to go through with the operation, so the best course would be to cancel the operation to respect patient autonomy
- Four medical ethical principles:
- Beneficence: Act in best interest of patients
- Non-maleficence: Do no harm
- Justice: Provide equitable care
- Autonomy: Respect patient’s wishes
- Key idea: Competency is a global assessment determined by a judge, whereas capacity is assessed with each medical decision and can be determined by the physician
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