Dewdrop on a rose petal appearance in a CN V1 dermatomal distribution. Rash is painful and weeping. Immunocompromised host (s/p chemo)
Impetigo: honey colored crusting lesion related to group A strep infection
Pyoderma gangrenosum: think green cheese; usually a single large round ulcer. Rapidly progresses from small papule or pustule to large painful ulcer with purulent, violaceous border. Associated with IBD (crohn disease, UC, RA, trauma). Most commonly lower limbs.
Syphilis: Causes a few types of skin lesions: chancre, gummas, etc. Chancre: most common, painless, genital. Doesn't really fit the story here anyway.
SLE: doesn't fit
Again, acute RUQ pain (especially in an obese woman) should set off the gallstone alarms. Fever and other systemic signs, white count, etc lead you down the acute cholecystitis. Simple pain leads you to symptomatic cholelithiasis. Either way the first step is to get a RUQ sono to see those stones! HIDA is used as an adjunctive study in cases of cholelithiasis to assess for cystic duct obstruction (and thus likely acute cholecystitis) in equivocal cases.
Meets the 5 FAT RN criteria:
Also, Indirect hyperbilirubinemia and increased LDH should tip you off to MAHA
When old men stop peeing so well, consider the poorly designed straw-crusher, the prostate. Chronic outlet obstruction isn’t so great, but it also predisposes to acute prostatitis which in turn can further worsen said obstruction when the gland swells. First thing to do is see how much the gentlemen is backed up, which in turn tells us if he has earned catheterization. Old people and UTIs go together like [insert your own clever comparison].
FEV1/FVC will be > 80% in mild or intermittent asthma
Organ donation is a complex organizational dance, and the regional procurement organization manages the nitty-gritty aspects.
Anesthesia to the anterolateral thigh is the distribution of the lateral femoral cutaneous nerve. LFC neuropathy can be caused by compression near the inguinal ligament (say, from a hematoma). Note that it’s the compression of the nerve that causes decreased sensation, not the hematoma itself.
Unstable and hypotensive patients after blunt trauma get laparotomies (don’t put an unstable patient in the CT scanner). In addition to saline and blood products, definitive surgery is how you address the C in ABC.
The STD that forms a painful ulcer aka chancroid = H ducreyi (ducreyi makes you cry, as they say).
This is a keratoacanthoma.
It's a cup shaped squamous cell carcinoma that's filled with keratin debris. It rapidly grows then usually spontaneously regresses. But, it's still an SCC, so we should excise.
The thing you do with things that look like skin cancer is excise them completely.
Post-traumatic AV fistula! Just like dialysis AV fistulae have bruits and thrills, so do non-purposefully created ones. These can take a long time to form but can be associated with steal syndromes due to decreased perfusion to the distal extremity, venous incompetence, varicosities, and eventually stenoses due to unreasonably high flow, and even high-output heart failure.
We can only put the laboratory tests into context if we have an accurate gestational age. Since her LMP is unreliable (totally unknown), we need an ultrasound to date her pregnancy. The most common cause of an abnormal MSAFP is wrong dates.
TTP always seems like too many disparate symptoms but just remember the pentad: thrombocytopenia, microangiopathic hemolytic anemia, neurologic symptoms, renal failure, and fever. If the symptoms list seems super long, keep TTP in mind.
Working up serious hypoglycemia involves measurement of both insulin and C-peptide (the cleaved by-product of endogenous proinsulin) to assess for hyperinsulinemia and distinguish endogenous (e.g. insulinoma) from exogenous (e.g. Munchausen’s) causes. “Nurse” is a common Munchausen tip-off (someone with the know-how and skills to pull it off well).
These questions can be a true pain of biochemistry on the Step 1 or relatively straightforward depending on how well you know it. This patient has classical Galactosemia, caused by a deficiency in galactose-1-P uridyl transferase deficiency, the enzyme that converts galactose and lactose to glucose. Intolerance to dairy, hepatomegaly/liver disease/jaundice with hypoglycemia due to decreased gluconeogenesis, and reducing substances in urine are classic. Listlessness and lethargy ensue with mental retardation and eventually death if untreated. Cataracts are also common. If you didn’t get to galactosemia (or thought it was Von Gierke’s disease, which isn’t all that unreasonable), the answer is still A. By process of elimination, given the serum hypoglycemia but no urine glucose, the issue is the inability to make glucose from stores (not to absorb it).
This is Paget-Schroetter disease
An upper extremity thrombosis triggered by extreme activity.
He's a fit young jackhammerer just trying to do his jackhammer thing
Atopic dermatitis (eczema) is the “itch that rashes.” It’s one leg of the allergic triad: asthma, allergic rhinitis, and atopic dermatitis. Treatment is with topical steroids and rigorous emollient therapy.
This patient has urge incontinence, which is commonly caused by detrusor instability (and can be treated with anticholinergics like oxybutynin). This is opposed to stress incontinence, the other most common type, which is worsened by abdominal pressure/coughing/laughing/etc and can be caused by pelvic floor prolapse secondary to multiple childbirths etc. Neurogenic bladder can cause overflow incontinence.
Hypercalcemia + lytic spinal lesions = multiple myeloma
What about the fever, leukocytosis, and consolidation?
MM predisposes to infection! It's PNA.
Multiple lytic bone lesions equals multiple myeloma. Blastic/sclerotic lesions should make you think of metastatic prostate cancer (in men) and breast cancer (in women).
Eeaaasy there, partner. They said they don't want insulin and you're gonna kick them to the curb?
One step at a time, bud.
Offer the insulin, let them refuse (they seem to have capacity), but who ever said anything about discharging them.
Where would they go!?
Haven't they been through enough?
Patients who have the capacity to make medical decisions are allowed to refuse life-saving medical treatment. You should offer it but accept her refusal.
We have event rates of 35% for EST and 15% for EPCS, and the number needed to treat (NNT) is the inverse of the absolute risk reduction or 1/ARR. ARR = Control event rate minus experiment event rate. So, we have ARR = 0.35 – 0.15 = 0.2, and therefore NNT = 1/0.2 = 5. Boom, math.
Rapidly progressive dementia (with or without personality changes, psychiatric disturbances, and sudden/jerk movements) raises the possibility of Creutzfeldt-Jakob disease, for which CSF protein 14-3-3 is an important marker.
Slow submersion warming is key when dealing with frostbite. Air and towels/dressings are poor conductors of temperature.
The banana bag! You might be thinking of Flumazenil to reverse his benzo use, but be wary of using in an otherwise stable chronic user as this can precipitate seizures. He’s also probably drunk, but that we’ll just wait out. In this case, he’s awake and protecting his airway but he’s encephalopathic. When an alcoholic is encephalopathic, think Wernicke’s and give thiamine. Even if they’re just plain ole drunk you’re not going to hurt them.
This is a diffuse pontine glioma, a death sentence. You don’t really need to know that, because the stem tells you of the poor prognosis. Whenever someone is presented with a serious diagnosis, any treatment discussion starts with establishing a baseline understanding of the disease process and then discussing goals of care.
We have a middle-aged black female as the setup. Pulmonary disease with CXR showing bilateral hilar adenopathy. She has cutaneous involvement of the face. Cutaneous involvement is present in 1/3 of systemic cases but can have a variety of appearances.
Source control followed by symptomatic relief. Have you seriously ever heard of anyone doing any of that other crazy stuff?
USPSTF recommends clinicians screen all adults age 18-79 for hepatitis C infection.
USPSTF recommends all men 35 and older (women 45 and older) are screened for lipid disorders, and age 20+ for those with increased risk of CAD.
The goal is to hopefully make sure she is safe (and if she is at-risk for partner abuse to provide her with resources). On a related note, unlike for children and elders, there is no reporting mechanism for partner abuse.
Help her feel better. That’s the point of hospice.
Tracing shows late decels: the bad kind, a response to poor blood flow to the fetus during contractions. One cause, particularly common after AROM, is umbilical cord prolapse, where the fetal head compresses the umbilical cord, limiting blood flow as it’s squeezed inferiorly by the contracting uterus. Vertex station doesn’t actually matter as once previously thought, but a nondilated cervix (less than 6 cm) is a risk factor.
Trauma and critical illness can cause acute insulin resistance.
Don’t be a dick. Don’t be a dick. Don’t be a dick. Don’t be a dick. Don’t be a dick. Don’t be a dick. Don’t be a dick.
Stop. Wrong sided surgery is a big no no. Everyone on the team should feel empowered to stop a surgery or procedure if something in the preprocedural checklist is amiss.
Bernard Soulier Syndrome has thrombocytopenia, otherwise looks similar to vWD
Autonomy matters. If a patient has the capacity to make medical decisions (i.e. understands the risks) and is not an imminent harm to self or others (i.e. suicidal or homicidal), then he cannot be held against his will. We don’t institutionalize people just for noncompliance with medical treatment.
A cohort study (as opposed to a randomized controlled trial) is ripe for selection bias, which occurs when the treatment and control groups are not truly comparable. Matching for some factors (age, gender) doesn’t mean you’ve controlled for all possible confounders. That’s what randomization does!
Repetitive vomiting (be it due to viral gastroenteritis or bulimia) leads to hypokalemic hypochloremic metabolic alkalosis. Alkalosis means elevated bicarbonate, which in this case is created as the byproduct of increased stomach acid production.
Two things make this aortic dissection instead of a heart attack or pulmonary embolism. First, the diastolic murmur is that of aortic insufficiency/regurgitation, which is happening because the dissection is involving the aortic root. Second, the presence of diminished femoral pulses implies that the dissection also involves the descending thoracic aorta distal to the takeoff of the brachiocephalic and left subclavian arteries (which supply the arms). Only an issue in the aorta can cause that constellation of symptoms.
Bipolar disorder is the only reasonable answer, as evidenced by the increased energy, elevated mood, labile affect, and poor judgment and focus. You don’t develop ADHD at 32.
Pseudogout (calcium pyrophosphate deposition disease) is an inflammatory arthritis with a predilection for the knee that causes synovial calcifications.
Weight loss and worsening lung symptoms in a smoker mean lung cancer. Non-small cell is by far the most common variety. The small cell variety on tests will usually have fun paraneoplastic syndromes.
Cough is often the only sign of asthma. Exercise-induced asthma is exercise-induced asthma.
Weight gain, fatigue, and constipation go with hypothyroidism. High LDL cholesterol actually does too, but the question is doable even when ignoring the lab values.
It’s not clear that the glucose is a fasting value or not, but it’s clear that the patient has symptoms of diabetes in the context insulin resistance (obese kid with acanthosis nigricans). Diet and exercise are always necessary in DM2 and can reverse many early cases. With a 10% weight loss, for example, the patient may not require pharmacotherapy.
Follow your ABCs. Tachycardia and hypotension mean severe volume loss necessitating aggressive intravenous fluid resuscitation.