Word Associations
PANCE/PANRE Word Associations Word Associations This study sheet is used to help you recognize key words and patterns associated with certain diagnosis. It is NOT intended to steer you to remember answers to test, but instead to help you recognize the intent or most likely diagnosis. The information of that specific diagnosis is up to your level of knowledge. It’s to help narrow that differential so you can focus on the specifics of the most likely diagnosis. CARDIO Description Diagnosis Associated DOE, PND, edema. Echo w/ LVH or RVH, hypokinesis S3 High output heart failure CHF CHF, dilagted cardiomyopathy Pregnancy, thyrotoxicosis, anemia, beriberi, paget’s disease Ischemic heart disease, HTN, dilated CM, valve disease, arrhythmia Myocarditis Low output heart failure Heart failure after URI Young athlete with syncope during athletic event or practice. No physical exam abnormalities Alcoholic with DOE, heart failure Alcoholic with palpitations, arrhythmia Irregular irregular Hypertrophic CM or fatal arrhythmia. Get EKG or Echo Primary dilated CM Atrial fibrillation (Holiday heart) Atrial fibrillation; (if > 48 or chronic – anticoagulate) Warfarin (2 – 3 for Afib; 2.5 – 3.5 for valve); Tx Warfarin OD is vitamin K Atrial fibrillation or prosthetic valve Hx angina but no acute sx. EKG no acute changes. Crushing CP, dyspnea, palpitations, radiation to neck or left arm Do Exercise stress test Constant, sharp CP worse lying down, better sitting up and leaning forward Pericarditis Angina (if lasts minutes), AMI if lasts > 30 minutes. Acute Ischemia – ST elevation; Injury – T wave depression; Infarct – Q wave 1 PANCE/PANRE Word Associations pulsus paradoxus Pericardial effusion/tamponade, pericarditis, asthma attack, tension PTX, SVC obstruction Pericardial effusion/tamponade Electrical alternans, narrow pulse pressure, pulsus paradoxus JVD, Hypotension, muffled heart sounds Pericarditis post open heart surgery Pericardial effusion/tamponade (Beck’s triad) Dressler’s syndrome. Tx w/ ASA #1. Indomethacin or other NSAID OK. Sudden onset ripping, tearing chest pain, diminished pulses Flank pain, hypotension, pulsatile abdominal mass Aortic dissection EKG changes, N, V, yellow-green visual disturbances Digoxin toxicity (Hypokalemia will make worse) Hx CHF on diuretic & digoxin Suspect dig toxicity (hypokalemia from diuretic = dig toxicity) Grossly elevated blood pressure esp. w/ signs of EOD HTN Tx w/ meds, cough or angioedema DM & HTN Heart failure, LVH Malignant or Urgent HTN AAA ACEI is cause ACEI is best choice ACEI (improves survival, prevents development of heart failure Sx) Beta-blockers SE is postural Hypotension Think secondary HTN most likely Renal artery stenosis (infrarenal artery). Post MI Tx of HTN w/ alpha-blocker HTN not responsive to basic meds Mechanical valve or prosthesis & Dental, GU, GI, or ortho procedure prophylaxis Bacterial endocarditis (strep. Viridians) prevention 2 PANCE/PANRE Word Associations IVDA w/ new murmur Bacterial endocarditis (strep. Viridians) Aortic stenosis (due to calcifications – age related (or bicuspid valve congenital) Aortic stenosis Elderly w/ systolic murmur Diamond shaped, blowing systolic murmur. May have angina, syncope, CHF Lateral displaced PMI, Canon “a” waves, Quincke’s pulse, Corrigan’s pulse, Austin flint murmur, deMusset’s sign, water Aortic Regurgitation/Insufficiency: Quincke’s pulse (subungual capillar pulsation), Corrigan (rapid rise and fall), Austin filnt (low pitch middiastolic murmur at apex) Mitral stenosis (ARMS are BAD) Diastolic murmur best heart at apex without radiation Systolic ejection murmur heard best at base with radiation to left clavicle Female or Post MI, systolic murmur best @ apex preceded by click without radiation Systolic murmur heard best at apex with radiation to left axilla (apical systolic) New murmur after MI (esp. if apical systolic) Murmur & Hx rheumatic heart disease Pulmonary stenosis Mitral valve prolapse Mitral regurgitation Mitral regurgitation (caused by papillary muscle rupture) Mitral stenosis #1, Tricuspid Stenosis #2 PDA Continuous harsh, machine-like murmur Cyanotic infant with systolic thrill @ LSB, systolic ejection murmur +/- click Tetralogy of falot Holosystolic murmur @ LSB, may have ventricular hypertrophy Infant w/ dyspnea, difficulty feeding. Holosystolic murmur @ LSB, 3rd ICS. LVH & RVH VSD VSD 3 PANCE/PANRE Word Associations Peds w/ leg pain after physical activity, abnormal heart sounds, unequal UE & LE pulses, rib notching Coarctation of aorta Short PR, wide QRS, Delta wave Wolf-parkinson-white; avoid Digoxin, Young female (<30yo), palpitations, long arms & fingers, pectus excavatum, ectopic lentis, flexible joints Marfan’s Syndrome – MVP, Aortic regurgitation, Aortic dissection, Aortic root dilatation, ectopic lentis LE rubor, no hair, brittle nails, pallor on elevation, calf or LE pain esp. with walking short distances relieved with rest or at PM Claudication with rest pain, (ABI < 0.4) Arterial insufficiency/PAD, Intermittent claudication (ABI best choice, ateriogram gold standard) LE pain after long periods of standing. Dilated, tortuous, veins Trendelenberg test of extremities Varicose veins. Tx w/ compression stockings Tests for veinous insufficiency. Blue extremities worse w/ cold exposure, improves w/ warming Acrocyanosis Tx is arterial bypass PULMONARY Description Diagnosis Associated Rapid, deep labored breathing Kussmaul breathing – DKA, Metabolic acidosis Deep breathing alternating w/ apnea Cheyne-Stokes breathing – heart failure, brain damage Cavitations on CXR Infections – lung abscess, TB (Gohn focus) 4 PANCE/PANRE Word Associations Apical infiltrates, F, C, dry cough Pleural thickening on CXR Hilar mass on CXR Eggshell pattern on CXR TB Mesothelioma Lung Ca Silicosis (Sandblasters) Ground glass appearance on CXR Asbestosis (shipbuilders, building demolition) Coal Miner’s lung Farmers lung Sarcoidosis Reticular to nodular pattern on CXR Patchy fibrosis on CXR Granulomas and inflammation of alveoli, small bronchi and small blood vessels Dyspnea after surgery, travel (airplane), LE Fx. May have c/o calf pain also. Lung scan with perfusion defects DVT/PE Venous stasis, vessel wall injury, hypercoagulability DVT/PE (Virchow’s triad) Pediatric with barking cough, stridor viral croup (laryngotracheobronchitis); Tx w/ racemic epi and glucocorticosteroids if stridor at rest. lower respiratory FB, asthma Epiglottitis PE Pediatric wheezing Drooling, sniffing position, tripod, toxic Thumbprint sign Steeple sign Epiglottitis FB, viral croup (laryngotracheobronchitis) FB, viral croup (laryngotracheobronchitis) Inspiratory stridor Premature infant with respiratory distress Preemie CXR w/ hypoexpansion (ATX), air bronchograms Hyaline Mb Disease Hyaline Mb Disease 5 PANCE/PANRE Word Associations Smoker, chronic productive cough. NO hemoptysis, wt. loss. Smoker, DOE, cough Hyperinflation on CXR, tear drop heart Wheezing, prolonged expiration Airway edema with eosinophils, neutrophils, lymphocytes Brochitis (COPD) Fever, cough, sputum. Crackles, decreased breath sounds, dullness to percussion, +egophony, pectoriloquy. CXR – infiltrates or consolidation >35yo with PNA. Rusty colored or yellow-green sputum. Acute onset F/C <35 yo, college students. Fever, cough, +/- sputum, chills, muscle aches Bullous myringitis PNA w/ Smokers, COPD PNA w/ DM, immunocompromised, EtOH. Currant color sputum. PNA w/ Water, late summer, construction site. Diarrhea. Toxic looking PNA from Nursing homes, chronic care facility. Purulent sputum PNA & HIV+, AIDS, Immunocompromised. Sx out of proportion to exam. Diffuse interstitial & alveolar infiltrates PNA & decreased mental status, poor dental hygiene, dentures, foul smelling sputum, bronchiectasis. Patchy infiltrates in dependant lung zones Pneumonia Pediatric with Hx recurrent lung infections, pancreatitis, reproductive problems, FTT Cystic fibrosis (Staph & Pseudomonal infections usually cause of death) COPD Emphysema Asthma Asthma Strep. Pneumonia Mycoplasma pneumonia Mycoplasma pneumonia H. influenza Klebsiella Legionella Staphylococcus aureus Pneumocystis jerovecii; TMP-SMX = Drug of choice Aspiration PNA 6 PANCE/PANRE Word Associations Sweat chloride test Cystic fibrosis w/ PNA Cystic fibrosis Pseudomonas aueroginosa causative agent < 2 days post-op with fever Atelectasis Stab wound, hyperresonance to percussion, decreased breath sounds, tympany Stqb wound, dullness to percussion, decreased breath sounds. Tall, skinny, male, band student, acute onset one-sided chest pain, dyspnea Pneumothorax Stab wound to chest. Hypotension, tracheal shift Tension PTX Hemothorax Spontaneous PTX Poor sleeping, obese, daytime fatigue & Obstructive sleep apnea drowsy, snoring, HTN, PM wakening s/p thoracic trauma. Multiple rib fractures. Chest wall moves in with inspiration, out with expiration. Flail chest (pain control, incentive spirometry, pulmonary toilet, intubation) GI/NUTRITION Description Diagnosis Associated Fat, forty, female, fertile w/ RUQ pain Cholelithiasis or Cholecystitis Fever, RUQ pain, radiation to back Cholecystitis Elevated Alkaline phosphatase, urinary Cholecystitis bilirubin F, RUQ pain, Jaundice, gallstones & dilated common duct on US Ascending cholangitis (Charcot’s triad) 7 PANCE/PANRE Word Associations Hx IBD, progressive RUQ pain, wt loss, F, jaundice & pruritis. Elevated bilrubin & alkaline phosphate. ERCP with bile duct stenosis, dilatation Primary sclerosing cholangitis (diffuse intra- and extrahepatic duct sclerosing and dilatation) Elevated AST, ALT, indirect bilirubin Isolated elevated indirect bilirubin Elevated indirect bilirubin w/ defective glucuronyl transferase Hepatitis Gilbert’s syndrome Crigler-Najjar Dz Photosensitivity, abd pain w/ neurologic dysfunction, erythema or skin fragility Porphyria H.pylori gastritis Chronic cough, bitter taste in mouth or throat, dyspepsia Multiple or constant GI ulcer pain despite medications 2antibiotics & PPI GERD N/V, epigastric abdominal pain, worse supine, caused by alcohol ingestion, or following fatty meals Acute pancreatitis Peri-umbilical or flank ecchymosis Acute pancreatitis (Cullen & Grey Turner’s Sign) Zollinger-Ellison Syndrome Abdominal distension, bloating, SBO intermittent, colicky pain, high-pitched rushes & tinkles Air fluid levels on upright abd plain SBO film Air under diaphragm, rigid board-like Perforated viscus, perforated ulcer abdomen >60yo F, LLQ pain Diverticulitis. IV Abx, fluids, NPO. 8 PANCE/PANRE Word Associations Elderly, Hx atherosclerosis. Dull crampy periumbilical pain post-prandial Mesenteric ischemia Neonate w/ projectile vomiting. Olive sized mass. Choking, cyanosis, respiratory distress, increased secretions in 1st hours of life Painless rectal bleeding in pediatrics Alcoholic with massive hemoptysis Pyloric stenosis Female with recurrent abdominal pain, alternating diarrhea, constipation. Pain relieved with defecation. IBS. TCA’s (nortriptyline) good if diarrhea predominant symptom Bloody Diarrhea Ulcerative colitis Supraclavicular LAD (L > R) Virchow’s node – metastatic abdominal cancer Sister mary Joseph nodule = indicates metastatic gastric and pancreatic cancers Gastric Ca Tracheoesophageal fistula Meckel’s diverticulum Esophageal varicies (Tx w/ octreotide) Hard periumbilical nodule PUD, Pernicious anemia (Type A Gastritis), H. pylori Apple core lesion Elderly with positive hemmocult. Colon Cancer Colon Cancer – get colonoscopy CEA Colon Carcinoma Family history of young age colon cancer, multiple polyps found on colonoscopy AFP Familial adenomatous polyposis (Gardner’s syndrome) Hepatocellular carcinoma, testicular seminoma (germ cell tumor) Pancreatic Ca Ovarian Carcinoma Treat with Ondansetron (Zofran) (5HT3 blockers) CA 19-9 CA-125 Chemotherapy induced N&V 9 PANCE/PANRE Word Associations Traveler’s Diarrhea Greasy, foul smelling, floating stools. Pear-shaped flagellated protozoan w/ 2 “eyes”. Water, travel, camping history Afebrile, watery or loose stool. No blood or mucus Abdominal pain, diarrhea after picnic/party. Eaten ham, cream, custards, mayonnaise Acute bacterial diarrhea w/ prodrome of HA, F, then crampy abd pain & diarrhea E. coli is cause. Hydration & Cipro to treat Giardia Viral Gastroenteritis Staphylococcus aureus infectious diarrhea Campylobacter jejuni – most common cause of acute bacterial diarrhea Painless rectal bleeding. Bulging perianal mass w/ straining Internal hemorrhoids Pediatric with perianal pruritis esp. at PM. Positive cellophane tape test Pruritis ani – Pinworms (enterobiasis). Tx is Mebendazole Weight loss, recurrent greasy stools (steatorrhea) mixed with diarrhea after certain foods Anti-endomysial antibodies Celiac Sprue Beriberi Pellagra Thiamine; Alcoholics, Neuro Sx Niacin (4D’s dermatitis, diarrhea, dementia, death), bright red tongue Vit C (easy bleeding, bruising, hair & tooth loss, joint pain & swelling) Vit D (Osteomalacia) Vit A deficiency Riboflavin deficiency (B2) Scurvy Rickets Night blindness Magenta tongue s/p gastric bypass surgery or gastric surgery. N, abd cramping, dizziness after eating. No masses, bleeding Celiac Sprue Dumping syndrome 10 PANCE/PANRE Word Associations ENDOCRINE Description Diabetic w/ anorexia, anemia, wt loss, pallor Gastroparesis, impotence, recurrent infections, stocking-glove paresthesia Diagnosis Associated CRF Diabetic neuropathy (Treat w/ TCA (amitriptyline) Hypoglycemia despite glucose administration. Increased C-peptide Insulinoma Hypoglycemia in alcoholic Give Thiamine before glucose to prevent Wernicke’s encephalopathy Decreased radioactive iodine uptake, decreased free T4, increased TSH Female, weight loss, palpitations, atrial fibrillation Exopthalmos, palpitations, wt. loss. Elevated radioactive idodine uptake Hashimoto’s thyroiditis Post thyroidectomy – most likely injury Recurrent laryngeal nerve = hoarseness Post thyroidectomy – electrolyte watch Hypocalcemia Infant w/ round face, large protruding tongue, dry skin, umbilical hernia, constipation, enlarged abdomen, poor feeding, delayed developmental milestones Congenital Hypothyroidism Recurrent HA, HTN not responding to meds, sweating Attacks of severe HA, HTN, glucosuria Urinary catecholamines, urinary Pheochromocytoma – Tx pre-op w/ alpha blocker Hyperthyroid (work it up with TSH, T4) Hyperthyroid, Graves Dx – Tx w/ Radioactive iodine 11 PANCE/PANRE Word Associations metanephrines HTN not responsive to meds HTN w/ hypernatremia, hypokalemia Renal artery stenosis (Infrarenal artery) Primary Aldosteronism Wt. gain, edema, coarse dry skin, hair, menorrhagia, cold intolerance, hx transphenoidal surgery & radiation Hypothyroidism Tetany, hypocalcemia, cataracts Hypoparathyroidism Exogenous corticosteroid use Dexamethasone suppression test Central obesity, abdominal stria, hyperglycemia, moon facies, buffalo hump, easy bruising Cushing syndrome Cushing syndrome Cushing syndrome Acute steroid withdrawal Addison’s disease, crisis Hyperpigmentation, hypoglycemia, orthostatic hypotension, hypotension not responsive to fluids, hypotension following an illness, trauma, or surgery Addison’s disease, crisis (Low aldosterone; get Random or AM cortisol, ACTH stimulation test) Worsening fatigue, wt loss, weakness, recurrent abdominal pain, hair loss, hyperpigmentation. Hyponatremia, hyperkalemia Hyponatremia, hyperkalemia Addison’s disease, crisis (Low aldosterone; get Random or AM cortisol, ACTH stimulation test) Polyuria, polydipsia. Dilute urine, Hypernatremia Concentrated urine. Hyponatremia Diabetes insipidus Acute adrenal insufficiency (Addison’s crisis) SIADH 12 PANCE/PANRE Word Associations 45,X – low hairline, low set ears, webbed neck, short stature; shield chest, wide set nipples, infertility, lack of Secondary sex characteristics Turners (gonadal dysgenesis XXY ♂ - short stature, ↓ intelligence; small firm testes, gynecomastia, abn arm-body length Klinefelters (hypogonadism) GU/ELECTROLTES Description Hyaline Casts Increased BUN/Cr, low FeNa Diagnosis Associated Normal (may be present after febrile illness, strenuous exercise) Prerenal Failure (Azotemia) Irritative voiding symptoms, Fever, chills, CVA tenderness Pyelonephritis Crush injury, alcoholic on ground, elevated CPK, ARF Rhabdomyolysis Painless hematuria, flank pain or mass Renal cell Carcinoma Oliguria, hematuria, proteinuria following streptococcal infection Hematuria, purpuric rash following streptococcal infection Hematuria, RBC casts, proteinuria RBC casts Kidney & lung bleeding (hematuria, hemoptysis) Acute glomeruloneprhitis Fibrous band on lateral penis Can’t retract foreskin Inflammation of glans Peyronie’s disease Phimosis Balanitis Glomerulonephritis, HSP Glomerulonephritis Goodpasteures 13 PANCE/PANRE Word Associations < 40 yo male with Fever, perineal pain, dysuria. >50 yo obstructive voiding sx, nocturia. Firm smooth enlarged prostate. Nl PSA Acute prostatitis caused by Chlamydia & N. gonorrhea. Treat accordingly (Bactrim #2 choice). > 40yo think e. coli is cause (Tx w/ FQ) BPH. (Cancer would have firm, irregular, nodular non-tender prostate, elevated PSA) Incontinence with straining Stress Peaked T-waves U waves QT prolongation Recurrent kidney stones, elevated Calcium, decreased phosphorus HyperKalemia HypoKalemia Hypocalemia Hyperparathyroidism Hearing loss or tinnitus w/ metabolic acidosis Aspirin OD NEURO Description Head trauma, disoriented – lucent – coma Lens shaped hemorrhage Concave Diagnosis Associated Epidural Hematoma LP w/ decreased glucose, increased protein LP w/ decreased protein, very few neutrophils Meningitis and rash Meningitis & <2mo Bacterial meningitis Epidural Hematoma Subdural Hematoma syphilitic meningitis Meningiococcal Grp B Strep, E. coli (Tx < 1yo = Vanco + Rocephin) Meningitis < 4yo H. inlu, Grp B strep, N. meningititis 14 PANCE/PANRE Word Associations Meningitis > 2yo, adults Strep, N. meningititis Viral Meningitis Mumps Unilateral facial weakness w/ inability to close eye Bell’s palsy (self-limiting) Adolescent female w/ HA. +FHx. Severe HA, N/V, photphobia. +/auras Male, recurrent relapsing HA. Worsened w/ EtOH, Lacrimation, salivation, rhinorrhea Sudden onset thunderclap HA, “worse HA of my life” >50 yo female w/ HA. Temporal artery tenderness or blindness Migraine HA Recurrent episodes of vision change, diplopia, weakness & tingling in extremities that resolve myelin fragments, ↑ IgG, oligoclonal bands (Pathognomonic); Lhermitte’s sign = electrical sensation down body w/ neck flexion MS HA worse in AM w/ focal neuro deficits Brain Tumor (MC is glioma) s/p Fall w/ bilateral LE weakness, urinary and rectal incontinence, decreased rectal tone Cauda equine syndrome = neurosurgical consult Cluster HA Subarachnoid hemorrhage Temporal arteritis (Giant cell arteritis). Elevated ESR, get temporal artery biopsy MS Ascending paralysis GBS Paralysis after Campylobacter enteritis GBS 15 PANCE/PANRE Word Associations Weakness and fatigue in upper limbs, blurry vision, diplopia, respiratory distress Myasthenia gravis Young kid with difficulty standing from seated position. Calf muscle wasting Muscular dystrophy (weakness begins at pelvic girdle) Pediatric with fever or Hx URI with encephalopathy, emesis, hyperactive reflexes, hepatomegaly, elevated liver enzymes Reye’s syndrome from URI/post-flu or aspirin use Pediatric with episodes of blank stares Absence (petit-mal) seizures. 3 mHz spikes on EEG Absence (petit-mal) seizures. “Ash leaf” hypopigmentation of trunk Tuberous sclerosis & Ext, shagreen patch, sebaceous adenomas, seizures, mental retardation; Ass. w/ PCK, renal hemartomas HEENT Description < 70 yo blindness > 70 yo blindness Afferent papillary defect, marcusgunn pupils Bilateral pinpoint pupils Bilateral DILATED pu;ils Diagnosis Associated DM retinopathy (MCC) Macular degeneration Optic nerve lesion. Tertiary syphilis (marcus-gunn) Pontine hemorrhage Anticholinergics, TCA, antiparkinsonian drugs, profound hypoxemia Bilateral hemianopia Optic chiasm lesion 16 PANCE/PANRE Word Associations Loss of central vision Superior contralateral quadrantopia Ipsilateral optic nerve lesion Temporal optic radiation Temporal field loss Eye trauma, diplopia. Exophthalmos, fixed upward gaze, hyphema Ipsilateral optic tract lesion Orbital blow-out fracture; Immediate ophthalmology referral Painless, nontender nodule on upper or lower eyelid Painful swelling of upper or lower eyelid Painless, yellow triangular nodule on conjunctivia Chalazion Curtain or veil over my eyes, new onset floaters Transient monocular vision loss Painless vision loss. History of TIA, palpitations, arrhythmia, carotid disease, embolic source Painless vision loss. History of HTN Retinal detachment Vision loss over hours to days, painful EOM Recurrent episodes of vision change, diplopia that resolve Red eye, watery discharge, preauricular LAD Red eye, copious purulent discharge Red eye, hyperemia, chemosis, nodular conjunctivia Acute Painful red eye, halos (or colored rings around lights), hazy, steamy cornea. Pupil is fixed and (mid) dilated. Onset after being in dark room Hordeolum Pinguecula (more common on nasal side) Amaurosis fugax – TIA, emboli CRAO (pale retina, cherry red macula) CRVO (blood & Thunder, retinal hemorrhages) Optic Neuritis (assoc. w/ MS) MS Viral conjunctivitis Gonococcal conjunctivitis Allergic conjunctivitis Acute angle-closure glaucoma 17 PANCE/PANRE Word Associations Diplopia, dysarthria, dysphagia Vertibrobasilar insufficiency Unilateral foul smelling or purulent nasal discharge in a pediatric patient HA, sinus pressure, yellow – green nasal discharge Sneezing, clear rhinorrhea, post-nasal drip, nasal congestion seasonal occurance Pale, edematous, boggy turbinates Nasal Foreign body Bullous myringitis Otitis media Mycoplasma pneumonia Strep. Pneumonia, H. influenza, strep. Pyogenes, moraxella catarhallis Otitis externa MOE, Pseudomonas, IV abx (FQ), CT head Swimmer with ear pain, discharge Diabetic, ear pain Sinusitis – CT is gold standard Allergic rhinitis. Nedocromil effective Tx. Allergic rhinitis Tinnitus and metabolic acidosis Sudden dizzy, vertigo, hearing loss, tinnitus Salicylate Ingestion Meniere’s disease; Treat w/ diuretics & low-sodium diet Dix-hallpike maneuver Sudden vertigo with changes in head position Sudden dizzy, N, V. NO tinnitus, hearing loss. Recent URI Unilateral nerve deafness in middle age Pt Sensorineural loss > 50yo Vertical Nystagmus, insidious onset vertigo Horizontal Nystagmus, acute onset vertigo BPPV BPPV Smoker, white mouth lesion cannot be rubbed off Leukoplakia, rule out oral cancer Vestibular neuronitis, labrynthitis Acoustic neuroma (order MRI) Presbyacussis (Hi freq sounds 1st to go) Central lesion (tumor) Peripheral lesion 18 PANCE/PANRE Word Associations Gray pharyngeal pseudomembrane, rash, splenomegaly, supraclavicular LAD Diphtheria College student with sore throat. Enlarged tonsils, anterior cervical LAD. Splenomegaly. CBC – elevated atypical lymphoctyes EBV - mononucleosis HEMATOLOGY/ONCOLOGY Description Philadelphia chromosome Auer rods Reed-sternberg cells Painless LAD (us. Neck or axilla), LAD in orderly fashion; “B” signs + pruritis; splenomegaly; LN pain after drinking alcohol Fatigue, PM sweats, weight loss, painless LAD or neck mass Painless LAD us. Scattered. “B” signs Hx HTN, nephrotic syndrome, CRF or Renal insufficiency. Know CBC. PICA, Pregnant & fatigue, Menstruation. Cheilosis Anemia after colectomy, partial gastrectomy. Glossitis, decreased vibratory sensation G6PD + Quinidine, Nitrofurantoin, Sulfa Fatigue, weakness, low fever, purpura, pallor, gingival bleeding. No HSM Diagnosis Associated CML AML Hodgkin’s lymphoma Hodgkin’s lymphoma Lymphoma – do Lymph node biopsy. Bone marrow Bx and CT scan used for staging Non-Hodgkin’s lymphoma Anemia Fe Deficiency Anemia B12 or Pernicious anemia Hemolytic anemia Aplastic anemia 19 PANCE/PANRE Word Associations Elevated Hgb, Hct, splenomegaly, post showering pruritis, plethora, engorged retinal veins Polycythemia vera; Tx = Phlebotomy Splenectomy Pneumococcal vaccine Sickle cell Autosomal Recessive, pain in extremities after exercise, priaprism Spontaneous Hemarthrosis Hemophilia A Mucosal or gingival bleeding, epistaxix, Von Willebrand disease menorrhagia Continuous bleeding post-op or DIC trauma. Given multiple blood transfusions. Low platelets, increased PT, INR, + fibrin split products (increased d-dimer) INFECTIOUS DISEASE Description MRSA Clear vulvar vesicles, inguinal LAD Giant Multinucleated cells Tzank Smear Acetowhitening Wood’s light fluoroscopy Bite w/ fever, lacrimation, rhinorrhea, bradycardia, HTN, tachyarrhythmias Bite with local edema, erythema, central necrosis Diagnosis Associated “spider bite” appearing lesion that turns into abscess. Tx w/ Vanco +/rifampin, gentamicin, linezolid Herpes virus (Genital) Herpes virus (Genital) Herpes virus (Genital) Condyloa acuminata Dermatophytes infections, Erythrasma (coral red) Black widow (neurotoxin) Brown recluse 20 PANCE/PANRE Word Associations Woods, forest, hikers. Macular rash at wrist, ankles then moves up extremities then trunk. After 5 days rash at palms & soles RMSF (Rickettsia rickettsia) Indirect immunofluorescent Ab, WeilFelix rxn, complement RMSF (Rickettsia rickettsia) Target lesion, arthralgia, Bell’s Palsy Lyme Dz (Borrelia Burgdorfi) Intense pruritis esp. PM. Burrow like lesions at wrists, elbows, hands, webs of fingers Scabies Raccoons, bats, skunks Rabies; give Ig, Rabies vaccine if animal is not caught and tested Gangrene Clostridium infection – an anaerobic bacteria. Tx w/ hyperbaric oxygen, Penicillins, surgical excision Gram negative intracellular diplococcic Sexually active, multiple or new partner, urethral discharge, Gram negative intracellular diplococci Gonorrhea Red cervix w/ mucopurulent discharge in sexually active female FTA-ABS, MTA-TP Chlamydia Malaria prophylaxis Chloroquine Gonorrhea Syphilis diagnosis 21 PANCE/PANRE Word Associations MSK/RHEUMATOLOGY Description Shoulder pain after repetitive activity, point tenderness at anterior humerus or AC joint. + drop arm test or apprehension test Football player with burning pain, numbness, tingling from shoulder to hand which resolves FOOSH, Radial fracture w/ dorsal displacement, dinner-fork deformity Typing, secretary wrist pain and numb/tingling from wrist to hand. New mothers, pregnant may worsen Pain at base of thumb, distal radial styloid. Pain reproduced with ulnar deviation of clenched fist. Hand injury after a punch Diagnosis Associated Rotator cuff injury (SITS muscles) Brachial plexus neurapraxia, “stinger”. Caused by stretching of brachial plexus Colle’s Fx; Tx = volar splint Carpal Tunnel syndrome deQuervain’s tenosynovitis Boxer’s fracture. Ulnar gutter w/ intrinsic plus positioning. ORIF if angulation > 40 degress Female exam, asymmetric posterior chest wall or uneven scapula height with forward bending Scoliosis (> 25 degree Cobb angle = surgery) Tibial pain after running (military recruits), athletic activity (running sports) Knee injury during football game Shin splints, stress fracture. Get bone scan if negative x-ray 8 – 10yo male with limp, knee pain 12 – 15yo overweight male knee pain, limp, hip pain (knee XR normal) Adolescent male with knee pain, tenderness over tibial tuberosity Retropatellar knee pain esp. in females ACL (look for description of lachman or drawer test) Legg-Calve-Perthes Disease SCFE Osgood-schlatter disease Patellorfemoral pain syndrome – increased Q angle, strengthen quadriceps 22 PANCE/PANRE Word Associations Pain on plantar foot @ 2 – 3rd metatarsal. Associated w/ tight shoes, relieved by removing shoes. Palpable painful mass Morton’s neuroma; Tx w/ NSAIDs, wide shoes, then steroid injections Pain after tx of fracture w/ cast Compartment syndrome HLA-B27 Ankylosing spondylitis, Reiter’s syndrome Acute joint pain. Swollen, warm, Septic arthritis (synovial fluid = erythema. leukocytosis, low glucose) Large joint pain. Knees w/ medial joint Osteoarthritis. Acetaminophen #1 space narrowing, osteophytes. No choice erythema or warmth. Enlarged PID, DIP Osteoarthritis (herberden – PIP; bouchard – DIP) Female morning joint pain & stiffness Rheumatoid arthritis. Methotrexate esp. hand/wrists. MCP joint swelling, (DMARDs) #1. ulnar deviation Acute swollen big toe Gout Proximal symmetric muscle pain & Polymyalgia rheumatica stiffness esp. shoulder, neck, pelvic girdle Male w/ low back pain, stiffness. Pain Ankylosing spondylitis; Tx = NSAIDs worse wakening, improve during day. (Indomethacin) Decreased ROM at spine. Plain films show sacroiliac abnormality. HLA-B27 positive Conjunctivitis, iritis, arthritis, Reiter’s syndrome cervicitis, urethritis Erythema nodosum Female with Arthralgias, malar rash, +ANA, + anti-double stranded DNA antibodies, +anti-phospholipid antibodies Systemic autoimmune diseases (RA, IBD), OCP SLE 23 PANCE/PANRE Word Associations dusky red, well localized single or multiple papules or plaques usually of face Female, fatigue, general aching, pain at neck, upper shoulders, sleeping problems, tender points Discoid lupus Cold induced pain at extremities with color change as they warm up Raynaud’s phenomenon Osteomyelitis after stepping on nail wearing sandals or tennis shoes Pseudomonas aeruginosa (foam padding in shoes) Teenage female with long bone pain without trauma or injury. XR w/ lytic mass, multi-laminated periosteal reaction Painless bony mass. Plain films = stalky or broad-based projection from bone surface Lytic lesions in the back or skull Ewing sarcoma – periosteal “onion skin” reaction Fibromyalgia (exercise program good management) Osteochondroma Multiple myeloma PSYCHE Description Deterioration of cognitive function, memory Rapid onset of cognitive symptoms, mental status fluctuations, anxiety, irritability Paplitations, tremors, hyperventilation or respiratory alkalosis, numb or tingling mouth or extremities Diagnosis Associated Dementia Delerium Anxiety 24 PANCE/PANRE Word Associations Feelings of worthlessness, hopelessness, apathy, weight loss, insomnia, daytime sleepiness. Thoughts of suicide Raw red hands, chafed. Depression (SSRI = drug of choice) Binge eating, laxative use, starvation Bulimia nervosa (Tx w/ SSRI – Fluoxetine) Hypokalemia, metabolic alkalosis Bulimia with electrolyte disorders Obsessive compulsive disorder Antipsychotic meds (phenotiazines), facial tics, lip smacking, tongue disorders, blinking, ataxia Pt on antipsychotic meds develops altered consciousness, lead-pipe rigidity, diaphoresis, catatonia. Hyperthermia, tachypnea, blood pressure changes. Extrapyradimidal signs, BP changes, altered consciousness, hyperpyrexia, muscle rigidity, dysarthria, CV instability, fever, pulmonary congestion, diaphoresis. Pt on antipsychotic meds Tardive dyskinesia Infrequent blinking, tremor, rigidity, bradykinesia, shuffling gait, masked facies Parkinson’s Short lived, intense relationships. Difficulty controlling anger esp. when feeling abandoned. Hx sexual promiscuity and substance abuse. Borderline personality disorder Periods of excessive drinking, buying, spending Manic phase of bipolar disorder Neuroleptic malignant syndrome. Tx supportive care & antipyretics Neuroleptic malignant syndrome. Tx supportive care & antipyretics 25 PANCE/PANRE Word Associations Male w/ gynecomastia, diminished or delayed secondary sex characteristics, small firm testicles, long arms & legs (eunechoid body habitus) Klinefelter Syndrome XXY. Low serum testosterone & infertility. Hyponatremia w/ bizarre behavior. Antidepressant use w/ anticholinergic side effects, dry mouth, dysrhythmias, sedation, orthostatic hypotension Lithium toxicity TCA overdose REPRO Description Frothy, clear – white or yellow-green to gray adherent vaginal discharge, dysuria, vaginal pruritis. Vulvar and cervical erythema. Flagellated protozoa Fishy odor, Thin grayish vaginal discharge, Clue cells Thick white vaginal discharge, hyphae & buds on KOH prep Postmenopausal, dyspareunia, thin vaginal discharge, atrophic vulvar changes, vaginal petechiae Diagnosis Associated Trichomonas Secondary amenorrhea Female with acute abdominal pain. No characteristic acute abdomen pattern Pregnancy Ectopic pregnancy 20yo female w/ rubbery, firm, wellcircumscribed, non-tender breast lesion, doesn’t change w/ cycle 30 – 50yo female, painful, multiple, bilateral breast masses that increase in pain and size before menses Fibroadenoma Bacterial vaginitis; Gardnerella vaginalis Candida Atrophic vaginitis; Tx = topical estrogen Fibrocystic breast disease 26 PANCE/PANRE Word Associations Spontaneous bloody, serous, or cloudy nipple discharge Intraductal papilloma Breast mass, nipple retraction, bloody nipple discharge Breast cancer (mass is most common presenting clinical manifestation) Overweight, irregular menstrual cycles (poss. Amenorrhea), elevated blood sugar, hirsutism Adolescent female with midcycle pain alternating from left to right side. Relieved w/ NSAIDs Dysmenorrhea, dyspareunia, dyschezia. Uterus is fixed, retroflexed. Cyclic pelvic pain. May have palpable pelvic mass Firm irregular shaped, NONTENDER enlarged uterus Softened, tender, diffusely globular uterine enlargement PCOS (stein-leventhal syndrome) 6cm unilateral, mobile, tender adnexal mass Tubo-ovarian abscess Pregnant Pregnant + rash, post-auricular or occipital LAD Pregnant, HA, visual disturbance Pregnant, seizures Nagel’s rule: LMP + 7 – 3 mo Rubella. Give vaccine AFTER delivery Pregnant < 20 wks gestation w/ vaginal bleeding, abd & pelvic pain. Blood from closed cervical os. Pregnant < 20 wks gestation w/ vaginal bleeding, abd & pelvic pain. Tissue at or said to be passed from open cervical os. Threatened abortion Mittelschmerz Endometriosis. Palpable pelvic mass – “chocolate cyst” Leiomyoma Adenomyosis Pre-eclampsia Eclampsia Incomplete abortion (complete abortion will have empty uterus, complete passage of fetal tissue, pain resolves after passage of tissue) 27 PANCE/PANRE Word Associations Pregnant who drinks during pregnancy and inadequate peri-natal care Fetal alcohol syndrome – low birth weight Postpartum hemorrhage Uterine Atony. Tx = uterine massage Postmenopausal vaginal bleeding Endometrial Ca – do endometrial biopsy Ovarian Ca Postmenopausal adnexal mass DERM Description Procainamide, hydralazine & rash Photosensitive rash Diagnosis Associated Lupus-type eruptions TCN, Sulfa drugs Wood’s light KOH Coral red = Erythrasma Fungus, Candida; Hyphae & buds, spaghetti & meatballs Bacterial infections Gram stain Beefy red, sharp bordered rash in groin (infants), under breast folds with satellite lesions Warm, erythematous, tender skin with possible induration or fluctuance Red, less distinct borders. Coral red fluorescence under Wood’s lamp Distinct, sharp raised demarcated border with fever, chills. Group A Strep Grouped vesicles on erythematous base Infant or pediatric w/ grouped vesicles on thumb or “tapioca” vesicles on thumb Candida: Tx: Nystatin/Lotrimin cream QID x14d; if fails Ketoconazole Cellulitis Erythrasma Erysipelas Herpes virus Herpetic whitlow 28 PANCE/PANRE Word Associations Pain preceding vesicular rash in dermatomal pattern Hx URI the palpable purpuric rash to buttocks, posterior thighs Honey colored crusts on erythematous base around nose & mouth Small white papules on diffusely red base on buccal mucosa Cough, coryza, conjunctivitis Herpes Zoster (if involved eye = herpes keratitis. NO steroids. Get immediate ophthalmology referral) HSP (Hx post Strep A infection) Impetigo. Tx = Mupirocin Koplick spots – Rubeola (Measles). Spots occur before rash Rubeola (Measles) Pastia’s lines, positive ASO titer Strawberry tongue Pruritic raised erythematous plaques Dewdrops on rose petal, pustules & vesicles at different stages of healing Scarlet fever (Grp A Strep) Scarlet fever (Grp A Strep) Urticaria Varicella (Chicken Pox) Flesh-colored, pink or yellow-brown lesion with rough, sandpaper feel, at sun-exposed areas Non-pruritic, raised, warty brownblack plaques, stuck onto skin feel greasy Flat brown spots with sharp borders on dorsum of hand Erythematous, dome-shaped nodule with central plug Actinic Keratosis Raised pearly-borders, telangiectasia, central ulcer Pearly papule with umbilicated center Basal cell Ca Sexually active person w/ rash on palms & soles, general LAD Secondary syphilis (Money spots); VDRL will confirm Seborrheic keratosis Lentigines Keratoacanthoma Molluscum contagiosum 29 PANCE/PANRE Word Associations Scabies & Pediatrics NO LINDANE (KWELL). Permethrin (Elimite) is drug of choice Christmas tree pattern, erythematous papules w/ oval plaues w/ scaly itchy border. Rash preceded by lagre oval plaque w/ central clearing & scaly border Hypopigmented lesions, white, scaly. Gets worse w/ tanning or sun exposure Erythematic ring with scaly border & central clearing Pityriasis rosea; Herald patch spaghetti & meatballs Thick, yellow, brittle nails Tinea (fungal infection Onychomycosis. Tx = PO Terbinafine Infant w/ erythematous, scaly crusty lesions at vertex of scalp Cradle cap – seborrheic dermatitis (Tx in infants w/ baby shampoo, warm olive oil compress, mild Hydrocortisone cream; Adults – selenium sulfide shampoo) Children < 10yo w/ vesicles on pharynx, mouth, hands, feet w/ NO ulceration Healthy looking < 5yo with lace-like rash on both cheeks – red papules Pediatric with high fever then after fever macular rash over trunk and neck. (rash after defervesence) Truncal Rash in pediatric after fever Hand-Foot-Mouth disease. Coxksackie Virus Erythema infectiosum “Slapped cheek”, “5th Dz”. Roseola infantum (Herpesvirus); Motrin, symptomatic treatment Fever, pharyngitis, “sandpaper” rash over face, neck, trunk, extremities High fever (up to 105oF) x 5 days then rash. May have conjunctivitis, cracking, lip fissures Pityriasis Alba Tinea (fungal infection); KOH prep = hyphae Roseola infantum (Herpesvirus); Motrin, symptomatic treatment Scarlet Fever Kawasaki’s Disease; look for cardiac complications (myocarditis, pericarditis, arteritis, aneurysms) 30 PANCE/PANRE Word Associations Erythema marginatum Rheumatic Fever Silvery scaling plaques on extensor sensors. Ausptiz sign, Koebner’s phenomena Rat bite erosions on XR Psoriasis Dark skinned person with “whitening or lightening” of skin. Hx pernicious anemia or other autoimmune disease Vitilligo. Skin biopsy to diagnose Psoriatic arthritis PEDIATRICS Description Introduce solid foods (cereal, fruits) 1st tooth (central incisor) Walks alone 3 words, fees self w/ spoon, builds tower Diagnosis Associated 4 – 6 mo; after 6 mo add meat, eggs, starchy foods 6 – 8 mo 15 mo 24 mo < 2mo fever < 5yo fever, seizures Septic w/u - blood Cx, LP Febrile seizure Premature birth, fetal maturity Meconium-stained amniotic fluids Give corticosteroids Fetal distress Positive osmotic fragility test Mousy urine G6PD deficiency (hemolytic anemia w/ oxidative drugs – sulfa, nitrofurantoin, quinidine) PKU Vit D – Rickets Hemophilia A, Duchennes MD Neurofibromatosis Sickle cell, CF, PKU X-linked dominant X-linked Recessive Autosomal dominant Autosomal Recessive 31
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