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Sthanu

@Sthanu5

Oct 11

Diagnosis?

Differential cyanosis in a patient with patent ductus arteriosus, severe PH, and right to left shunt (Eisenmenger syndrome).

Note the severe clubbing and cyanosis of the toes as compared to the lesser degree of clubbing and cyanosis of the fingers

Differential cyanosis

●A difference of at least 5% in oxygen saturation (O2 sat) or 20 mm Hg in partial pressure of oxygen (Pao2) between the arms and legs

●Can be a sign of a patent ductus arteriosus (PDA), persistent pulmonary hypertension of the newborn (PPHN), or left-heart abnormalities

■A rare variation of differential cyanosis is called reverse differential cyanosis, where the upper extremity oxygen value is less than the lower extremity oxygen value.

*This is most often associated with dextrotransposition of the great arteries (dTGA) with coarctation of the aorta/interrupted aortic arch or with PPHN

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Sthanu

@Sthanu5

Sep 29

This 25-yr-old male patient presented to the ED with 3 days of abdominal distension and vomiting.

There is a remote history of laparotomy after getting stabbed.

Thoughts?

Final diagnosis

Incarcerated diaphragmatic hernia with large bowel obstruction

*Radiograph

There is a left diaphragmatic hernia that contains a gas-filled viscus with an air-fluid level.

Right and transverse colon, and small bowel are abnormally dilated.

No gas in the rectum or left colon.

CT abdomen

The transverse and right colon, and ileum are grossly distended.

Cecum measures more than 10 cm in diameter on sagittal images

Left colon and rectum are collapsed

There is a transition point at a left diaphragmatic hernia (ostium 2 cm).

The hernia contains a short segment of the splenic flexure that is distended with gas and fluid.

The colon is thin-walled and there is no evidence or ischemia/strangulation.

There is some free intraperitoneal fluid, but no free intraperitoneal gas

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Sthanu

@Sthanu5

Aug 24

40-yr-old female with altered mental status and hypercalcemia.

Likely diagnosis?

Primary hyperparathyroidism

Skull x-ray (

* "salt and pepper" appearance, characterized by a granular texture that suggests a high turnover bone state,

*a classic sign of hyperparathyroidism

Shoulder x-ray:

Subchondral resorption at the clavicle, leading to widening of the articular space and an irregular, feathery articular surface.

These findings are less common and highlight the severity of bone resorption.

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Sthanu

@Sthanu5

Jul 18

Which of the following is the most likely diagnosis?

A. Erythema multiforme

B. Annular urticaria

C. Secondary syphilis

D. Fixed drug eruption

E. Polymorphous light eruption

A. Erythema multiforme.

Presents with target lesions favoring the extensor extremities.

Without a hx, one must discover distinguishing features in the clinical photo to arrive at the correct diagnosis.

On the dorsal hand, there are variable edematous urticarial papules, some of which feature three zones:

*a dusky center surrounded by two concentric rings of different colors

Although not all of the lesions are fully developed, based on the presence of typical targets, EM is the best answer

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Sthanu

@Sthanu5

Apr 20

A 20-wks pregnant patient is admitted to ICU with septic shock.

Culture reveals listeria.

The patient is known to have had severe anaphylactic reactions to penicillin

What is the drug of choice for this patient?

A) TMP-SMX

B) Clindamycin

C) Vancomycin

D) Ciprofloxacin

Answer:

A) TMP-SMX

In immunocompromised patients, including pregnant women, listeriosis can present as life-threatening sepsis and/or central nervous system (CNS) infection (invasive infection).

In this clinical setting, the mean incubation period is 11 days.

The manifestations of CNS infection include

meningoencephalitis,

cerebritis,

rhombencephalitis (infection and inflammation of the brain stem),

brain abscess, and

spinal cord abscess

●The first line of drugs in severe Listeriosis is ampicillin (or penicillin).

●Some experts add gentamicin, it is not advisable due to its potential toxicity.

●Trimethoprim/sulfamethoxazole (TMP-SMX), is the drug of choice if a pati
nt is PCN allergic.

●Unfortunately, this should be avoided in the first trimester and the last month of pregnancy.

●In the first trimester, this affects folic acid metabolism, and in the last month, it may cause kernicterus in the fetus.

●In those periods, meropenem can be used.

●This patient is way out of those risk periods for the drug, so the answer is A.

●Vancomycin has been proposed, but the failure rate is very high.

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Sthanu

@Sthanu5

Apr 20

65 year old female on day 7 post colectomy with primary anastomosis.

Dysponea ?infective changes.

Decreased breath sounds at both bases.

Findings?

Cause?

Answer

Subdiaphragmatic free gas secondary to anastomotic leak

🔴

Radiograph

Large volume of free subdiaphragmatic gas with air-fluid levels under both hemidiaphragms.

Bil pleural effusions and bibasal collapse/consolidation.

Cardiomediastinal contour is within normal limits.

Surgical clips project over the LUQ.

CT Abdomen/Pelvis performed approximately 4 hours after the x-ray

●Marked amounts of free fluid and gas within the abdomen.

●Surgical sutures in keeping with a recent subtotal colectomy are noted

●The rectal contrast falls short of the site of anastomosis.

●Free gas locules are predominantly centered within the left upper quadrant corresponding to the region of anastomosis suggesting this is likely the site of perforation.

●The segment of bowel opacified by the rectal contrast demonstrates no extraluminal extravasation.

●The small and large bowel loops are dilated without evidence of mechanical obstruction in keeping with an ileus.

●Bil pleural effusions are associated with almost complete bibasal collapse.

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