Diuretic Drugs --Charts

Common Head And Neck Masses

Common Head And Neck Masses

Thyroglossal duct cyst:

Location: Midline, near thyroid.
Embryology: Epithelial remnant of thyroglossal tract.
Treatment: Follow, or surgical removal if symptomatic.

                                                     Thyroglossal duct cyst


Branchial cyst:

An adolescent girl presents with a rash that is made up of very small, bright red, non blanching macules.

An adolescent girl presents with a rash that is made up of very small, bright red, non blanching macules. The child had nonspecific viral symptoms last week. She appears to be in excellent health except for the rash. She is not on any medications. What is the most common cause of this condition?

A. Penicillin
B. Hemolysis
C. Human immunodeficiency virus (HIV)

D. Lupus
E. Idiopathic thrombocytopenic purpura.

Answer:

A 26 year Old Woman Presents With A Rash That Began As Salmon Colored Patch.

A 26-year-old woman presents with the above rash. She states the rash is minimally pruritic and developed over the last week. She has had some virus-like symptoms and reports the rash began as a large salmon-colored patch on her chest area which later spread all over her trunk and abdomen. The most likely diagnosis is
A) Tinea versicolor
B) Pityriasis rosea
C) Varicella
D) Psoriasis
E) Coccidioidomycosis

The correct answer is

Intravenous Solutions -- Charts

A 42 Year old Woman With a Suspected Melanoma.

A 42-year-old woman presents with the lesion (shown above) on the back of her calf. She has no significant medical problems and otherwise feels well. The lesion has not bled, but seems to have grown over the last few months. Appropriate initial management of this skin lesion should be
A) Observation and removal if bleeding or further change occurs
B) Complete excision with normal margins
C) Complete excision with wide margins
D) Shave biopsy
E) Electrodesiccation and curettage

Answer And Discussion:

A Brief Discussion On Heart Murmurs

Heart murmurs are the sounds other than the normal heart sounds produced that is loud enough to be heard with a stethoscope and is caused by turbulence of blood flow across the ehart valves. 

A normal heartbeat makes two sounds like "lub-DUP", which are the normal sounds of the heart valves closing.

The objective of this article is to help the reader understand:

• Taking history and examining a patient with a heart murmur.
• Differential diagnosis for the cause of heart murmur
• Appropriate investigations for a patient presenting with a heart murmur. 

Heart murmurs can be present at birth (congenital) or develop later in life. A heart murmur isn't a disease by itself but the presence of  murmurs may indicate an underlying heart problem. Some murmurs may be benign and are due to conditions outside the heart. These are known as innocent, functional or physiologic murmurs and does not need any treatment. 

Clinical Features: A patient with a heart murmur may present with the symptoms of the underlying heart condition that is causing the murmur. The doctor my detect the presence of the murmur while doing the physical examination. 

Causes: While taking the clinical history it is important to keep in mind the different etiologies that can cause a heart murmur. These may include: 

- Physiologic causes: 

• Anemia
• High blood pressure
• Overactive thyroid
• Fever
• Pregnancy

- Abnormal Heart Murmurs: 

• Septal defects
• Cardiac shunts
• Heart valve abnormalities. 
• Endocarditis 
• Rheumatic fever

A Brief Discussion On Clotting Disorders

Disorders of clotting may be congenital or acquired.
Clotting disorder is a condition in which the blood's ability to coagulate (form clots) is impaired. This can cause a tendency toward prolonged or excessive bleeding which may occur spontaneously or following an injury or medical and dental procedures. 

hemarthroses in a patient with hemophillia

Causes: 

Congenital: 

• Hemophillia
• von Willebrand's disease. 

Acquired: 

• Vitamin K deficiency.

                - Hemorrhagic disease of the newborn

                - Obstructive jaundice

                - Fat malabsorption

• Liver disease
• Disseminated intravascular coagulation
• Autoimmune disease e.g SLE
• Massive transfusion
• Drugs

               - Heparin

               - Warfarin

               - Thrombolytic therapy. 

Clinical History: 

1. Onset and Duration: The duration of symptoms and age of presentation is very useful in determining the underlying etiology.

Scoliosis- Case Study.

A 12 year old boy is seeing you for a physical examination required for junior high school sports. You plan to evaluate him for scoliosis.

Q 1. Which screening method is the most sensitive for detecting scoliosis?

Answer: The "Forward Bending Test" which is accomplished by having the patient bend at the waist with feet together and hands hanging free. Observe the patient (with shirt off) from behind and note any elevation of the ribs or paravertebral muscle mass on one side. The elevation should be measured in degrees (inclinometers are available), and an inclination of 5 degrees or more should be evaluated further.

Q 2. Define Scoliosis?

Answer: Scoliosis is a lateral curvature of the spine, usually accompanied by rotation and generally occurring in the thoracic or lumbar areas. It can occur with excessive kyphosis (posteriorly convex curvature) or lordosis (anteriorly convex curvature).

Q 3. On forward bending test, you find slight elevation of the left paravertebral muscles mass, which you estimate to be 7 degrees. The remainder of the examination is normal. You decide to obtain radiographs that show 12 degrees of angulation (Cobb angle).
This patient’s scoliosis is most likely:
A) Congenital.
B) Idiopathic.
C) Related to a tumor.
D) Secondary to infection.

Answer and Discussion

Disorders Of The Nails

Examining the nails is an important part of physical examination and certain features may point to the underlying medical disorder. In some cases the nails may have local disease causing a disorder or abnormal findings.
Here we try to give a brief description of some of the nail disorders along with pictures for a better understanding.

1. Absent part: also known as Anonychia . It may be congenital or secondary to severe infection or allergic reaction. It is also seen in self inflicted trauma or in people who have a habit of nail biting.

Partial Anonychia 







                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 Congenital Anonychia 










2. Nail Pitting: characterized by depressions on the surface of the nail is seen in conditions like psoriasis and connective tissue disorders like alopecia aerata and sarcoidosis. Nail pitting in one or two finger nails may be due to local trauma.

First Aid Management Of Heat Stroke -- Charts

A Case Of Syphilis

A 39-year-old woman presents with a non healing ulcer over her upper lip (picture shown below) for 1 week and a new-onset rash on her trunk .
The ulcer on her upper lip was misdiagnosed as herpes simplex by the previous physician. Sexual history revealed that the patient had oral sex with a boyfriend who had a lesion on his penis and she suspected that he had been having sex with other women.

The examining physician recognized the nonpainful ulcer and rash as a combination of primary and secondary (P&S) syphilis. An RPR (rapid plasma reagin) was drawn and the patient was treated immediately with IM benzathine penicillin. The RPR came back as 1:128 and the ulcer was healed within 1 week.

Case Discussion:

Syphillis: 
Syphilis, caused by Treponema pallidum, is a systemic disease characterized by multiple overlapping stages:

• primary syphilis (ulcer), 
• secondary syphilis (skin rash, mucocutaneous lesions or lymphadenopathy),
• tertiary syphilis (cardiac or gummatous lesions), and 
• early or late latent syphilis (positive serology without clinical manifestations).
• Neurosyphilis can occur at any stage. 

A 21 year Old man Presents With A Rash On His Feet

An 21-year-old surfer presents to your office with a rash that he noted on his foot. The vesicular rash has been present over the last week and has been enlarging.
The rash is shown in picture below:

The most likely diagnosis is
A) Sea lice
B) Cutaneous larva migrans
C) Swimming pool granuloma
D) Jellyfish sting
E) Bathing suit dermatitis

Answer And Discussion:

Based on the given ECG, the most likely diagnosis is....

Based on the above ECG, the most likely diagnosis is
A) Supraventricular tachycardia with 3:1 block
B) Early myocardial infarction
C) Incomplete right bundle branch block
D) Pericarditis
E) Wolff–Parkinson–White syndrome

Answer : is E :  Wolff–Parkinson–White syndrome

Discussion: The two major features of Wolff–Parkinson–White (WPW) syndrome include

Causes Of Ascites

Ascites is the accumulation of excess fluid in the peritoneal cavity.
A list of causes is given below:

1.  Hepatic Causes:

• Cirrhosis
• Hepatic tumors.

2. Malignant disease:

• Carcinomatosis
• Abdominal tumor
• Pelvic tumor
• Psudomyxoma peritonei
• Primary mesothelioma

3. Cardiac Causes:

• Cardiac failure
• Constrictive pericarditis.
• Tricuspid incompetence

4. Renal Causes:

Emergency Management Of Heavy Bleeding

Emergency Management Of Seizures -- Charts

Blood Types For Transfusion

A 30 year old man Presents with Acute Painful Swelling of the Right Parotid

A 30 year old man presents with acute painful swelling of the right parotid for 1 day.
Answer the following questions:
1. What 3 questions you would ask in history?
2. What examination would you conduct?
3. What will be your management plan?

( Question from MCPS paper October 19th 2016).

                                                   Acute swelling of the parotid . 


Solution:
1. What 3 questions you would ask in history?

Answer:

Erythema Toxicum Neonatorum

You are rounding in the newborn nursery. A healthy 2-day-old term infant has a new rash characterized by yellow pustules on an erythematous base involving the trunk and extremities but sparing the palms and soles.

What is the diagnosis?
A) Transient neonatal pustular melanosis.
B) Herpes simplex.
C) Miliaria.
D) Erythema toxicum neonatorum.
E) Epidermolysis bullosa.

Answer And Discussion
The correct answer is “D.” Erythema toxicum neonatorum.

Erythema toxicum neonatorum is a common, benign, self-limited rash seen in term infants. Lesions usually appear after 24 hours of age. Lesions may begin as erythematous macules that progress to

Disorders Of The Gum

Disorders of the gum are a common clinical finding and may be due to local disease or a manifestation of a systemic disease.

1. Bleeding From The Gums:
Causes include:

• Dental disease.
• Infection ( may be bacterial, viral or fungal) 
• Bleeding disorders.
• Use of anticoagulant drugs. 
• As a side effect of chemotherapy and radiotherapy. 

Clinical Features: Periodontal disease is probably the most common factor causing bleeding from the gums. Poor hygiene is usually obvious from the condition of the teeth . Infection may cause the patient to complain of red, inflamed gums, which bleeds spontaneously or on brushing the teeth. The patient may give history of malignancy for which they have undergone either chemotherapy with associated blood dyscariasis or local radiotherapy. 

2. Hypertrophy Of The Gums: 

Causes Include:

• Infection associated with dental disease
• Phenytoin
• Nifedipine 
• Cyclosporine

In Gingival hyperplasia the gum hypertrophy predominantly involves the interdental papillae.

NSIADs (Non-Steroidal Anti Inflammatory Drugs) -- Charts

Interpretation Of Hepatits B Serological Results

Cardiovascular Drugs- Charts

Primary Oral Herpes (Herpetic Gingivostomatitis)

This picture is from a 4 year old child who was brought to the pediatrician with temperatures of 103◦F at home for 2–3 days. She has had no upper respiratory symptoms. Her oral intake has decreased, but she is maintaining good urine output. She has had no vomiting or diarrhea.

The examination reveals a febrile child that is slightly irritable. She is nontoxic and not dehydrated. Her oral cavity shows increased tonsil size with ulcers on her tongue and lips but not on the tonsillar pillars. Her anterior cervical lymph nodes are enlarged. The rest of her exam is noncontributory.

What is the most likely diagnosis?

A) Streptococcal pharyngitis.

B) Hand, foot, and mouth disease (coxsackie virus).

C) Herpetic gingivostomatitis.

D) Varicella.

E) Infectious mononucleosis.

Answer And Discussion

The correct answer is “C.”  Herpetic gingivostomatitis.

Giardiasis

Which of the following statements about giardiasis is true?
A) Transmission occurs through fecal–oral contamination.
B) Chlorination of drinking water kills the cyst.
C) Diagnosis can be achieved by peripheral blood smears.
D) The cyst form is responsible for symptoms.
E) Asymptomatic carriers do not require treatment.

Answer and Discussion
The answer is A.

Giardia lamblia is the causative agent in parasitic giardiasis. Most cases are asymptomatic. However, these patients pass infective cysts and must be treated.

Terminology For Different Types Of Fractures

Closed fracture. Fracture that does not communicate with the outside.

Open fracture. Fracture that communicates with the external environment.

Comminuted fracture. Consisting of three or more fragments.

Avulsion fracture. Fragment of bone pulled from its normal position by a muscular contraction or resistance of a ligament.

Paronychia

A 35 year old female comes to the clinic complaining of pain and swelling of one of her fingers. The swelling and pain is just proximal to the finger nail and she has also noticed pus coming from this area. Examination reveals redness, swelling and purulence of the nail fold as shown in the picture above. The area is very tender to palpation.

What is your diagnosis?

Paronychia

Case Discussion:
The term Paronychia refers to the inflammation of the nail fold. It can be acute or chronic and can occur secondary to a number of reasons that include:

Iron Deficiency Anemia

The above picture is from a 28 year old woman who presented to her family physician with complains of fatigue and shortness of breath on walking. On further history she mentions having heavy menstrual bleeding that has existed over the past year. On general physical examination she had pale conjunctiva, palms and nail beds.
Her clinical history of prolonged chronic blood loss due to underlying menstrual disorder and examination points to the diagnosis of iron deficiency anemia.

Case Discussion :

Iron Deficiency Anemia: Is most commonly seen in menstruating women or undernourished populations. 

Causes: Include:

• Blood loss e.g menorrhagia or GI bleeding.
• Poor diet
• Malabsorption
• Hookworm infestation.

Scleral And Conjuctival Pigmentation

A 40-year-old white man came to see his physician about a brown spot in his eye . He noticed this spot many years ago, but after recently reading information on the Internet about brown spots in the eye, became concerned about ocular melanoma. He thinks the spot has changed in size. He denies any eye discomfort or visual changes. He was referred for a biopsy, and the pathology showed a benign nevus that did not require further treatment.

Case Discussion:

Scleral And Conjuctival Pigmentation:

Introduction: Scleral and conjunctival pigmentation is common and usually benign. Nevi can be observed and referred if they change in size. The etiology of scleral or conjunctival nevi is not well understood. Racial melanosis is genetically determined.

Clinical Features: depend on the cause of the pigmentation.
1. Physiologic melanosis is typically bilateral and symmetrical.
2. Primary acquired melanosis (PAM), Nevi, and melanoma are typically unilateral.
3. Intrinsic cysts are common in conjunctival nevi.

Diagnosis: Definitive diagnosis of pigmented ocular lesions is by biopsy.

A Brief Description Of Scalp Lesions

Lesions on the scalp are common and the causes are listed below:

Causes:

1. Traumatic:

• Hematoma
• Cephalhaematoma

2. Sabaceous cysts.

3. Neoplastic:

• Bening - Ivory osteoma
• Malignant: basal cell carcinoma, Squamous cell carcinoma, malignant melanoma, myeloma
• Secondary metastases from breast, bronchus, thyroid, prostate.

4. Infective:

• Cock's peculiar tumor
• Tinea capitis

5. Others:

• Psoriasis
• Seborrhoeic dermatitis.

Clinical History And Physical Examination: 

1. Hematoma: A history of truama will be present and a boggy hematoma may overlie a skull fracture. X ray is required to exclude an underlying fracture. 

2. Cephalhematoma: is seen in newborn babies following a traumatic delivery. The hematoma spreads beneath the periosteum of the skull and is therefore limited by skull sutures. 

                                             Cephalhematoma

3. Sebaceous cysts: these may be multiple and noticed when combing the hair. The sebaceous cysts are spherical tender, firm swellings in the scalp. rarely a punctum is visible with a sebaceous cyst on the scalp. 

                                                 Sebaceous cysts

4. Ivory Osteoma; A benign lesion which may present as a rock hard swelling on the scalp. The patient is usually a young adult and asymptomatic. The skin is freely mobile over it. 

                                                       Ivory Osteoma

5. Squamous cell carcinoma: presents as an ulcer with a hard, everted edge.

Rocky Mountain spotted fever (RMSF).

A 35-year-old who has recently returned from an early summer fishing vacation in rural
North Carolina presents with a febrile illness. He reports a 5-day history of fever, malaise, headache, and vomiting. Today, he has developed a nonpruritic rash that began on his extremities and has spread to his body.
On exam he has a fever of 38.3◦C with a pulse of 120 and otherwise normal vitals. The rash is maculopapular and generalized, involving his palms and soles. Oral mucosa is dry but intact, and the exam is otherwise nonspecific.
Basic investigations were done and CBC shows mild thrombocytopenia but is normal otherwise. BUN and creatinine are at the upper limits of normal, and the electrolytes are normal.

The rash on his hand and feet is shown below:

What is the most likely Diagnosis?

Rocky Mountain spotted fever (RMSF).

Case Discussion:

Rocky Mountain spotted fever RMSF is a tick-borne (dog or wood tick) disease caused by Rickettsia rickettsii. Despite its name, RMSF is endemic in the southeastern United States, the Atlantic states, and the northern Rocky Mountains.

Clinical features: It presents with a prodrome of fever and headache several days before the onset of the characteristic rash—a maculopapular eruption that begins at the wrists and ankles and spreads centrally. Eventually, the rash becomes petechial.

A Case Of Scabies

A 10-year-old boy presents with his mother, complaining of intense itching, worse at night, since the
first week of school. He has numerous excoriations in the interdigital web spaces, wrists, and anterior axillary folds. His infant sister has recently developed intensely pruritic linear lesions on her palms,
soles, face, and scalp. Their mother works in a nursing home and has developed pruritus and reddish-brown nodular lesions in her axillae and perineum that have persisted several months after she treated herself with a lotion that was provided at her place of work. As you exam the patient, your skin begins to itch.

Q 1, The most likely ectoparasite affecting this family is:
A) Head lice (pediculosis).
B) Chiggers (mites).
C) Ticks.
D) Fleas.
E) Scabies.

Answer And Discussion
The correct answer is “E.” Scabies.

Scabies’ mites (Sarcoptes scabiei) burrow into the epidermis, lay eggs, and hatch larvae in cycles of 3–4 days. The most notable clinical symptom is intense pruritus that is worse at night.
The typical lesion is small, erythematous, and papular and may resemble eczema in quality and distribution.

                                                         Example of scabies rash 


About 7% of individuals develop a nodular variant(like the mother in this case). Transmission is typically by direct contact and infestations may appear as epidemics in institutions like nursing homes. The organism may be spread by fomites as well, although to a lesser extent. Young children and infants often have involvement of palms, soles, face, and scalp. A clinical diagnosis may be made in the setting of pruritic rash, typical distribution, and multiple family members affected.

Q 2 What is the next best step in this case (the infant child weighs 10 kg)?

A Child Brought For Evaluation Of Seizure Disorder- A Distinct Birth Mark Seen On Face

This female child was brought to the pediatrician for the evaluation of seizure disorder. On examination , a vascular plaque was found along the ophthalmic and maxillary divisions of the trigeminal nerve. (as shown in picture ) . Mother is not concerned about the lesion mentioning it has been present since birth and since then there has been no change in morphology, neither it has caused any pain to the child, other than the cosmetic defect.

The most likely possibility is:

A. Infantile hemangioma
B. Struge Weber syndrome.
C. Congenital Hemangioma
D. Proteus syndrome.

Answer An d Discussion:

A 5 Year Old Girl Presents With A Mass In Her Neck

A 5 year old girl with a mass in her neck is brought to the clinic for an evaluation.

Her mother says that this mass appeared 6 months ago and is increasing in size. There is no pain or discomfort. On examination , the mass is is the midline, inferior to the hyoid bone. Laboratory test reveal normal thyroid panel. Surgery was recommended after a CT scan is performed.

What is the most likely diagnosis?

A, Dermoid cyst
B. Ectopic thyroid gland
C. Lipoma
D. Thyroglossal duct cyst
E. Branchial cleft cyst.

Answer And Discussion:

Brief Discussion On Myeloproliferative Syndromes.

Myeloproliferative Syndromes is the name for a group of conditions that causes blood cells: RBCs, WBCs and platelets to grow abnormally in the bone marrow.

The three major myeloproliferative syndromes are:

1. Polycythemia Vera: It is the most common myleoproliferative disorder and is characterized by an increase in red blood cells (RBC) mass. massive splenomegaly and clinical manifestations related to increased blood viscosity. It also includes neurological manifestations like Vertigo, tinnitus, headache and visual disturbances. Increased RBC mass can also lead to thromboses that can causes complications like myocardial infarction, stroke and peripheral vascular disease.
Polycythemia vera must be distinguished from other causes of increased RBC mass, and this can be done by assaying serum erythropoietin levels. In polycythemia vera serum erythropoietin is low while in other causes  erythropoietin levels are high.

Bone marrow biopsy showing hypercellularity with trilineage growth (panmyelosis) with prominent erythroid, granulocytic, and megakaryocytic proliferation

Management: Patients are effectively managed with phlebotomy. Some patients may require splenectomy, and those with pruritits may benefit from psoralens and UV light.

2. Idiopathic Myelofibrosis: This rare entity is characterized by marrow fibrosis, myeloid metaplasia with extramedullary hematopoiesis and splenomegaly. Evaluation of blood smear reveals tear drop shaped RBC, nucleated RBC and some early granulocytic forms, including promyelocytes.

Lung Abscess - Case Based Study

A 50-year-old male who is a heavy drinker with a history of squamous cell carcinoma of the neck presents to your office complaining of abdominal pain. He has been coughing and expectorating bloody sputum and notes a low-grade fever, chills, and mild dyspnea starting about 1 week ago. He denies nausea, emesis, and chest pain. His squamous cell carcinoma was treated with external beam radiation several years ago.
Examination reveals an afebrile male in mild distress. His vital signs are normal, and his lungs sound clear. The abdominal exam reveals only mild epigastric tenderness
The chest x-ray is shown below:

Findings (  cavitary lesion right upper lobe)

Q 1. Considering this 50-year-old with a cough what will be your next step: 
A) This gentleman will need the ICU.”
B)  This gentleman will need a respiratory isolation room.”
C)  Send this gentleman home with metronidazole.”
D) Work up this gentleman as an outpatient.”

Answer And Discussion

Pyoderma Gangrenosum

Pyoderma gangrenosum is a rapidly evolving and severely debilitating skin disease that is characterized by a painful hemorrhagic pustule that breaks down to form a chronic ulcer. The ulcer is associated with pus production, and there is usually a dusky red or purple halo around the ulcer.

The cause of the lesions is unknown, but they tend to form at the sites of trauma (most commonly the legs).

Clinical Features: The borders of the lesions are usually irregular, and the lesions are boggy and usually quite painful.

Association With Other Medical Conditions: Although as many as 50% of cases have no associated underlying abnormality, other diseases associated with pyoderma gangrenosum include

• Crohn’s disease, 
• ulcerative colitis, 
• leukemia, 
• paraproteinemia, 
• multiple myeloma, 
• rheumatoid arthritis, 
• hepatitis, and
• Behcet’s disease. 

Premature Ventricular Complexes (PVCs)

Which of the following statements about premature ventricular complexes (PVCs) is correct?

A) They are narrow electrocardiographic wave (QRS) complexes that are preceded by P waves.
B) In most cases, they disappear with exercise.
C) They are treated with type IC antiarrhythmics.
D) They may represent a risk for sudden death in healthy patients.
E) Caffeine use is not associated with PVCs

Answer: B ( In most cases, they disappear with exercise.)

Discussion: Premature ventricular complexes (PVCs) are abnormal ventricular beats that are characterized by wide QRS complexes, which are usually not preceded by P waves.

In patients with normal hearts, PVCs usually disappear with exercise. If the patient remains asymptomatic and there is no organic heart disease, no further treatment is necessary.