jessica higgs, md bradley university acha annual meeting boston, june 1, 2013
TRANSCRIPT
Jessica Higgs, MDBradley UniversityACHA Annual MeetingBoston, June 1, 2013
Identify how to approach difficult unknown case presentations
List differential diagnoses for unknown case presentations
Describe common pitfalls in the approach to difficult cases
Hematology
20 yo AAF presents to the clinic for evaluation of lump in left armpit
States initially noticed lump 6 weeks ago and at that time it was painful
Returned a few days ago but not painful and seems to be getting smaller
No rashes or other lesions noted No other complaints
Exam Vitals – BP 108/60, P 80, Temp 98.9, R 12 NAD Left armpit – palpable firm elongated
nodule, movable, nontender Anterior cervical, posterior cervical, right
axilla, groin exam negative for further enlarged lymph nodes
Patient returns 1 week later States size has been fluctuant over last
week Has become painful again Complains of fatigue, cold symptoms,
loss of appetite, headaches
Exam Vitals – BP 120/70, P 68, T 97.3 CV – RRR, no murmurs Resp – CTA Bilaterally Left axilla – mobile, nonerythematous, no
warmth, slightly larger than previous exam No other lymph nodes palpable
Exam Vitals – BP 120/70, P 68, T 97.3 Left axilla – mobile, nonerythematous, no
warmth, slightly larger than previous exam No other lymph nodes palpable
Labs CBC ESR mono
F/U 1 week later Thinks lymph node may be smaller again
otherwise no change in symptoms CBC
WBC 3.6 Neutrophils – 33, Lymphocytes – 53, Monocytes - 14
ESR - 30 Mono - negative
Exam Vitals – P 72, T97, R 14 Left axilla – 5mm x 2mm firm mobile lesion Shotty lymph nodes anterior cervical area
and right groin
Exam Vitals – P 72, T97, R 14 Left axilla – 5mm x 2mm firm mobile lesion Shotty lymph nodes anterior cervical area
and right groin Labs
CRP LDH
F/U 2 days later for labwork CRP – 1.43 LDH – 853
F/U 2 days later for labwork CRP – 1.43 LDH – 853 Patient does not have insurance
coverage outside of home area Sent home for CXR and lymph node biopsy
DIAGNOSIS????
Rare, benign condition of unknown cause Characterized by cervical
lymphadenopathy and fever in previously well individual
Women are more common than men and most patients younger than 40
Most frequently reported in Asia, but found in all racial and ethnic groups
Some similarities to SLE
Richards, M. Kikuchi’s disease. UpToDate 2013
Differential diagnosis Lymphoma Tuberculous adenitis Lymphogranuloma venereum Kawasaki disease
Richards, M. Kikuchi’s disease. UpToDate 2013
Clinical symptoms include: Low grade fever Lymphadenopathy, most commonly cervical and
localized Fatigue Joint pain Rash Arthritis Hepatosplenomegaly Night sweats Nausea/ vomting Weight loss
Labs Leukopenia in 30%, ESR elevation in up to 70%
Richards, M. Kikuchi’s disease. UpToDate 2013
Diagnosis made by lymph node biopsy Paracortical foci often with necrosis and
histiocystic cellular infiltrate No effective treatment known,
symptoms usually resolve within one to four months
Recurrences have been reported and can develop SLE
Richards, M. Kikuchi’s disease. UpToDate 2013
Gastroenterology
22 yo WM presents to the clinic for abdominal pain
Right sided pain for 16 hours No fevers or chills, no nausea,
vomiting, diarrhea or constipation Decreased appetite but drinking fluids
Exam Vitals – BP 120/80, T 98.1, P – 80, R – 12 NAD Abdomen – soft, +tenderness without
distension, Negative Murphy’s, McBurney’s, rebound
Positive right CVA tenderness
Exam Vitals – BP 120/80, T 98.1, P – 80, R – 12 NAD Abdomen – soft, +tenderness without
distension, Negative Murphy’s, McBurney’s, rebound
Positive right CVA tenderness Labs
CBC UA
F/U the following day Right sided abdominal pain getting
worse, now rates 7/10 Constant sharp pain with radiation to
back Anorexia and mild nausea Pain with walking No constipation or diarrhea
Exam Vitals – BP 122/80, T 98.3, P 96, R 12 +tenderness right side, +McBurney,
+rebound, +guarding Negative murphy, psoas, obturator signs
Exam Vitals – BP 122/80, T 98.3, P 96, R 12 +tenderness right side, +McBurney,
+rebound, +guarding -murphy, psoas, obturator
Lab CT scan of abdomen CBC CMP
DIAGNOSIS???????
Described over 100 years ago Etiology unknown 90% present with right-sided abdominal
pain Males more frequently affected Occurs mainly in 4-5th decade although a
significant proportion of cases described in pediatric population as well
Epstein, L, Lempke, R. Annals of Surgery, 1968
Differential Diagnosis Appendicitis Cholecystitis diverticulitis
Soobrah, R, et al. Case Reports on Medicine, 2010
Incidence estimated to be around 0.1% of all laparotomies performed for acute abdomen
Predisposing factors may include Obesity Trauma Recent abdominal surgery Postprandial vascular congestion Sudden increase in intra-abdominal pressure Hypercoagulability
Soobrah, R, et al. Case Reports on Medicine, 2010
Clinical findings include acute or subacute abdominal pain temperature normal to slightly raised localized tenderness with varying degree of
guarding on right side of abdomen Nausea, vomiting, anorexia and diarrhea are
rare WBC and CRP may be elevated
CT or ultrasound can make diagnosis Management either conservative or surgical
Soobrah, R, et al. Case Reports on Medicine, 2010
Oncology
20 yo WF presents to clinic for lump on side of trunk
Unsure how long it has been there, feels hard to touch, slightly painful, not red
No other complaints
Exam Vitals BP 104/76, P 68, T 97.2, wt. 130 lbs Right chest – 1cm smooth somewhat firm
mobile mass overlying right lateral lowest rib
nontender
Exam Vitals BP 104/76, P 68, T 97.2, wt. 130 lbs Right chest – 1cm smooth somewhat firm
mobile mass overlying right lateral lowest rib
nontender Labs
CXR with right rib views
F/U 1 week later CXR with rib views – negative States lump is still there but not painful
anymore
Exam 10th rib – soft tissue mass, firm, mobile
over top of rib Plan?
3 months later Returns to clinic for recheck of cyst on
right side States has doubled in size in last 4 days Now very painful, even without
palpation, kept awake last night Denies fevers, weight changes, cold
symptoms, N/V/D
Exam Vitals BP102/70, P 68, T 97.6, wt. 131 Right rib cage – 2inch x 2inch round, firm
fixed, raised lesion extending from rib along midaxillary line, no erythema, nontender
Remainder of exam - WNL
Exam Vitals BP102/70, P 68, T 97.6, wt. 131 Right rib cage – 2inch x 2inch round, firm fixed, raised
lesion extending from rib along midaxillary line, no erythema, nontender
Remainder of exam - WNL Labs
MRI CBC LDH ESR Uric Acid
DIAGNOSIS???
Highly malignant tumor occurring in adolescents and young adults ages 10-25
Can develop in almost any bone or soft tissue but most common in pelvis, axial skeleton, and femur
Overt metastatic disease present in less than 25% at time of diagnosis but assumed present due to 80-90% relapse rate if treated locally
Typically present with pain or swelling of a few weeks or months of duration
Aggravated by exercise and worse at night Fever, fatigue, weight loss, or anemia are
present in 10-20% of casesClark, et all. NEJM, 2005
Labwork CBC CMP LDH
Imaging Radiographs CT scan
DeLaney, et al. UpToDate, 2013.
Differential Diagnosis Subacute osteomyelitis Eosinophilic granuloma Giant cell tumor Osteosarcoma Neuroblastoma Acute leukemia Fibrous histiocytoma Primary lymphoma of bone
DeLaney, et al. UpToDate, 2013
Prognostic Factors Disease extent Tumor site and size Response to therapy Age Molecular findings
DeLaney, et al. UpToDate, 2013
Cardiology
21 yo HF presents to clinic for pain and numbness in left hand
Seen by ortho over recent break and diagnosed with ulnar nerve issue and given course of steroids that has completed and Lyrica
Problem initially started about 1 month ago Left wrist and hand intermittently turn
bluish in color and cold. Happens when goes outside but can happen anytime
Very painful, denies burning sensation
Exam Vitals BP 110/80, P 72, T 98.3 Patient is tearful CV
Allen test positive, refill ulnar artery 15 sec, radial artery 10 sec hand is cool to touch with pallor Heart RRR, no murmurs
MSK Decreased grip strength left hand with reduction in wrist ROM due
to pain FROM of neck with no change in pain with neck extended and
turned to left No change in pain with shoulder movement
Neuro Tinels and Phalens positive left hand
Exam Vitals BP 110/80, P 72, T 98.3 Patient is tearful CV
Allen test positive, refill ulnar artery 15 sec, radial artery 10 sec hand is cool to touch with pallor Heart RRR, no murmurs
MSK Decreased grip strength left hand with reduction in wrist ROM due to pain FROM of neck with no change in pain with neck extended and turned to left No change in pain with shoulder movement
Neuro Tinels and Phalens positive left hand
Labs Dopplar studies CXR
Dopplar studies No arterial flow seen in left fingers.
Findings raise concern for vasospasm. Small vessel disease or emboli considered less likely
Upper extremity WNL CXR
Hypoplastic left first rib with thickened anterior left second rib
Dopplar studies No arterial flow seen in left fingers. Findings raise
concern for vasospasm. Small vessel disease or emboli considered less likely
Upper extremity WNL CXR
Hypoplastic left first rib with thickened anterior left second rib
Labwork ANA, ESR, CRP, RA factor, phospholipid antibiodies,
CBC, PT, PTT, lupus Plan
Norvasc for vasospasm and vicodin for pain
F/U 3 days later Norvasc is helpful, pain medicine
somewhat helpful, keeping hand warm Complains of dizziness Labwork negative except for elevated
CRP
Exam Vitals – BP 112/80, P 88 Left hand – Pulse palpable, hand is cool
compared to right but not cold, no pallor
Exam Vitals – BP 112/80, P 88 Left hand – Pulse palpable, hand is cool
compared to right but not cold, no pallor Plan
Increase norvasc Referral to vascular
DIAGNOSIS?????
Refers to a constellation of signs and symptoms that arise from compression of the neurovascular bundle by various structures in the area just above the first rib and behind the clavicle
Neurogenic, Venous, or Arterial Anatomy
Scalene triangle and first rib
Goshima, White. UpToDate, 2013.
Pathogenesis Anomalous ribs Muscular anomalies Injury
Clinical Exam Adson’s test – of little clinical value Wright’s test Allen test Hand wasting Arterial – pain, pallor, paresthesia, and coldness
Pulses, bruits
Goshima, White. UpToDate. 2013
Differential Diagnosis Neurogenic Vascular Raynouds phenomenon Shoulder injury
Goshima, White. UpToDate, 2013.
Imaging Radiographs Duplex ultrasound CT/MRI
Surgery
Goshima, White. UpToDate, 2013.
Gynecology
27 yo WF presents to clinic complaining of weight gain over past 6 months
Complains of abdominal distension and occasional side pains
Irregular periods Denies sexual activity PMH significant for PCOS, taking metformin FMH significant for ovarian CA and fibroid
tumors
Exam Vitals – BP 176/88, P 76, T 97.6, wt. 257lbs Anxious appearing Abdomen – firm, BS present, non tender Gyne – unable to discernably palpate
uterus or ovaries due to large mass
Exam Vitals – BP 176/88, P 76, T 97.6, wt. 257lbs Anxious appearing Abdomen – firm, BS present, non tender Gyne – unable to discernably palpate uterus
or ovaries due to large mass Labwork
Pregnancy test – negative CBC, CMP, ESR, CRP sonogram
Labwork CRP – 1.97 CBC, ESR, CMP - WNL
Imaging Sonogram – large cystic mass occupying the
abdominal and pelvic cavity extending from the epigastric to the pubic symphysis. Recommend CT
CT scan – 24 x 34 x 36 cm ovarian cyst
DIANGOSIS???
Adnexal mass may be found in females of all ages
Prevalence in women age 25-40 is around7.8%
Risk of malignancy is higher in prepubescent or postmenopausal females
Hoffmann. UpToDate, 2013.
Differential Diagnosis Physiologic/functional cysts Polycystic ovary syndrome Pregnancy related etiology Inflammatory Benign ovarian neoplasm Malignant ovarian neoplasm
Hoffmann, UpToDate, 2013.
Ovarian neoplasm arise from surface epithelium, germ cells, and sex-cord-stromal tissue
Persist unless excised Most common benign ovarian masses
Serous or mucinous cystadenoma Endometrioma Mature cystic teratoma
Hoffmann. UpToDate, 2013.
Genetics
19 yo WF Div. I softball player presents to training room with repeated cramping
Cramping occurs irregardless of heat or hydration status
Occurs predominantly in right arm, but does occur in left arm occasionally and bilateral thighs and calves as well
Diagnosed with rhabdomyolysis last year at community college
Exam Vitals Well appearing female CV – RRR, no murmurs MSK - WNL
Exam Vitals Well appearing female CV – RRR, no murmurs MSK - WNL
Labs CMP, CK, UA, TSH
CK – 4254 CBC – WNL UA – unremarkable CMP – WNL
DIFFERENTIAL???
CK ranges from 101-9131 Muscle biopsy
Histology showed myophosphorylase stain with large number of markedly pale fibers with no staining and peripheral fibers normally staining
Deficiency of phosphofructokinase activity
DIAGNOSIS?????
Differential Diagnosis Rhabdomyolysis Polymyositis Electrolyte abnormalities Trauma Infection Drug Use
A number of inborn errors of glycogen metabolism
Major manifestations of disorders of glycogen metabolism affecting muscle are muscle cramps, exercise intolerance and easy fatigability, and progressive weakness
Focus on Type V – McArdle’s syndrome
Darras, Craigen. UpToDate, 2013
Autosomal recessive Presents in adolescence or early
adulthood with exercise intolerance, fatigue, myalgia, cramps, myoglobinuria, poor endurance, muscle swelling, and fixed weakness
Forearm muscle exercise testing Muscle biopsy with biochemical or
histochemical analysisDarras, Craigen. UpToDate, 2013
Sports Medicine
20 yo AAM soccer player presents after game with right knee pain
Slide tackling another player felt like left knee twisted
Tenderness over lateral aspect of knee with slight increase in opening with varus stress compared to left
Diagnosed with grade 1 LCL sprain and told to ice
Presents to training room following day States knee is feeling much better but
now having trouble lifting his right foot Put ice on after the game and then
went to sign autographs after kids clinic. Left ice on leg for at least 45 minutes
Denies pain in leg
Exam General – NAD, patient of slight build Right leg – no swelling, erythema, warmth, or
tenderness to palpation. Patient has difficulty differentiating sharp and dull sensation over lateral aspect of leg
Right knee – No tenderness to LCL, still slight opening with varus stress
Right foot – unable to dorsiflex foot, weakness in eversion, remainder of movement intact
DIAGNOSIS?????
Most frequent site of injury is just below knee as nerve wraps around lateral aspect of the fibula
Typical presentation is acute foot drop, parathesias over dorsum of foot and lateral shin
Exam shows weakness in dorsiflexion and eversion, sensory deficit at dorsum of foot and lateral shin
Rutkove, UpToDate, 2013
No effective treatment Those presenting with complete
lesions, while mildly preserved strength recover fully
Rutkove, UpToDate, 2013
Psychiatry
Faculty member calls counseling center Concern for student who just finished a
test Reports no previous issues with this
student States “I can’t describe it. I will bring
you the test.”
Bladt, O, et al. Mucinous Cystadenoma of the Ovary. JBR-BTR, 2004. Clark, et al. Soft-Tissue Sarcomas in Adults. NEJM, 2005 Darras, Craigen. Muscle phosphorylase deficiency (glycogen storage
disease V, McArdle disease) UpToDate, 2013 DeLaney, et al. Clinical presentation, staging, and prognostic factors
of the Ewing sarcoma family of tumors. UpToDate, 2013 Epstein, L, Lempke, R. Primary Idiopathic Segmental Infraction of the
Greater Omentum. Annals of Surgery, 1968 Hoffmann. Differential Diagnosis of adnexal mass. UpToDate, 2013. Goshima, White. Overview of thoracic outlet syndrome. UpToDate,
2013 Richards, M. Kikuchi’s disease. UpToDate 2013 Rutkove, Overview of lower extremity peripheral nerve syndromes.
UpToDate, 2013 Soobrah, R, et al. Conservative Management of Segmental Infarction
of the Greater Omentum: a Case Report and Review of the Literature.Case Reports on Medicine, 2010