Professional Documents
Culture Documents
Underground Clinical Vignettes - Anatomy
Underground Clinical Vignettes - Anatomy
VISHAP, PALL,MBBS
Govert~rnentMedical Cc~llegc,Chandigarh. India, C h w nf 1996
Serirs Editol; U , of Texar, gal vest or^. Resident i11 Internal Medicine &c
Preven live %ledicine
TAO LE, MD
Universiry
PARAG MATEFUR, MD
Mayo Schotll oT Medicine, Class nf 2001
JOSE M. ITERRO,
La Sallc I;nivrrsitv. hRlcxicn City
Blackwell
Science
CONTRIBUTORS
Fadi Abu Shahin. MD
l~i~ivei-si
tv or Da~r~a*cr~u,
Svl-ia. CF:ws of 19W
Aarchan Joshi, MD
lrCI.AJi~lesS ~ r i T;.vc
i ~ Knsti~~ite
Vipal Soni,
Ir(:L4 School nf \frrlirinc. C:la<snT 1 qI10
Diego R~uix,MD
F'CSF Schrml 01 Mcclirinc, [;law o f 1909
Notice
The :~urho~-s
of 111ih tulumc IIAVP
t ; ~ k 13r.t'
~ ~ i 111artlir inthrm;~ric~n
cunlair~ccl11crci11i q arcumrr and compuiIjlc wilt1 tlie \tnnrlartE~ge-rnrl.al11arrrptt-rl at the ~ i i n c
of p~lhlicnrion.Y~vrrthrlesh~
it i?dim<rdt 10 C I I S U ~ C
that all thr ~nfnrmation~ v e r is
r r r ~ tclv
i ~ accllrate I'or a17 crrrtImsrancc<. The p ~ ~ l , l i ~ h
anrl
c r a~lthnrs,do nut
Fiamntee Lht- rtlntents of thih I>c~r)k
and disciaim arlv liahilite 10%. o r rfanlagc iflcllI'red ac ii mTIVCqUeIlCe,
(lirt*cll\ ar intlircctlv, nf t l l r Il\r and hppliration o f any o f tllc con1cnL.u ol' l h t f vnltln~?.
CONTENTS
Acknowledgments
Preface t o the 3rd Edition
How t o Use This Book
Abbreviations
Cardio 1ogy
Gastroenterology
General Surgery
Arteriovenous Fistula
Atrial Septal Defect
Carhac Tamponade
Coarctation of the Aorta
Femoral Hematema
Patent Ductus Arteriosus
Tetralogy of Fallot
Ventricular Septal Defect
Hypoparathyroidism-Iatro genic
Choanal Atresia
Choking
Sialolithiasis
Thyroglossal Duct Cyst
Tonsillitis
Boerhaave's Syndrome
Congenital Biliary Atresia
Dmping Syndrome
Hiatal Hernia
Hirschsprung's Disease
Pancreatic Pseudocyst
Peptic Ulcer-Perforated
Portal Hypertension
Tracheoesophageal Fistula
Abdominal Aortic AneurysmRuptured
Femoral H e r n i a 4 txangulated
Hemorrhoids-Thrombosed External
Inguinal Hernia-Direct
Inguinal Hernia-Indirect
Meckel's Diverticulum
Mesenteric Ischemia
Petit's Triangle Hernia
Popliteal Fossa Trauma
Richter's Hernia
Sigrnoid Volvulus
Splenic Rupture
Straddle Injury
Gynecology
Ureteral Injuy-Iatrogenic
Varicose Veins
Gartner's Duct Cyst
Uterine Prolapse with Cystocele
Heme/Onc
Immunology
Neonatology
N~phroiogy/Urology
Neurology
Nerve Palsy
Obstetn'cs
Orthopedics
Erb's Palsy
Facial Nerve Injury
Femoral Nerpe Palsy
Hypoglossal Nerve Palsy
Humpke's Palsy
Long Thoracic Nerve Injuy
Mass in Jugular Foramen
Medial Medullary Syndrome
Obstructive Hydrocephalus
O b s t r u ~ v eSleep Apnea
ParEnson's Disease
Recurrent Laryngeal Nerve Lesion
Spina Bifida
Trigeminal Neuralgia
Wallenberg's Syndrome
Ectopic Pregnancy-Ruptured
Pudendal Nerve Block
Ankle Sprain
Arm-Radial Nenre Palsy
Clavicle Fracture
Elbow-Lateral Epicondylitis
Forearm-Monteggia's Fracture
Hand-Boxer's Fracture
Hip-Legg-Calve-Perthes Disease
Hip-Trendelenburg Gait
Hip Dislocation-Congenital
Hip Dislocation-Traumatic
Hip Fracture
Knee-Combined Knee Injury
Knee-Osgood-Schlatter's
Disease
F?7
r+<
1
1:. \
F "3
>r
c-
>
:+?
C- i
1-
,$
r A +t
-- 1
~eg-compartment Syndrome
Pelvic Fracture
Shoulder Dislocation
F"
Shoulder Separation
Spine-Prolapsed Intervestebral Disk
r.--
* A
"
- 8
r+''f
Wrist-Scaphoid Fracture
Wrist-Slash Injury
Lung Cancer-Lymphatic Metastasis
Lung Cancer-Pancoast's Syndrome
I
F
,"
i
r
.1
-1
<o
-z,q
ACKNOWLEDGMENTS
T l i r ~ ~ ~ the
g h production
o~~
of this book, we have had the s u p
port of marly friends and colleagz~es.Special thanks to our support team including rZnu Gupta, Andrea Fellows, Anastasia
Anderson, Srishti Giipta, Mona Pal1,Jonathan Kirsch and Chirag
Amin. For prior con tril>t~tiotis
we thank Giarlrli LC N,pyen,
Tan111Mathur, Alex Grimm, Sonia S ~ I I ~ Cand
I S Elizabeth
Sand~rs.
Ilrc Irave elljoyed working with a world-class interna~ionalp u b
l i s h i n ~RI-OUP at BEackwell Science, irncluding Lnt~raDeYnrnlg,
Arny ?lutthrock, Lisa Flarlagan. Shawn Girsberger, Earna Hind
and G o r d m ~T i b h i t ~For
. help with securing images for the
entire series we also thank Lee Martin. Kristopher Jones, Tina
Panizzi and Peter Anderson at the University of Nabanla, the
.bed Forces Institute nf Pathology, and many of otir fellow
Rlackwell Scicnce authors.
For sublnitting cornmentr, corrections, editing, proofreading,
and a<sistat~ceacross all of the vignette titles in all eclitions, we
collectiveIy thank:
Tara hdamo\rich, Catnlyl A m x c k r , rCris rllden, Ht-nry E.
h y a n , Lynman Bacolor, Natalie Eartenem, Dcar~Earthnlom~w,
I)rhast-lish Bchera, Sumit Lhatia, Sanjay Binclra. Dave Erin tot],
Juliailne Brown, Alexander Brownie, Ta~naraCallahan. David
Canes. Bryan C:a?ey,h r o n Caughev, Hehert Chcn,Jonathan
Chet~g,
Arnold Cllcung, Arnold Chin, Simion Chirlsea, Yoon QIO,
Samuel Chung, Gretchen Conant, Vladimir Coric, Christopher
Cosgrove. Ronald Cowan, Karelzin R. Cunningham, A. Sean
Dalley, Rama Dandam licli, Sunit Das, Ryan Armando Dave, John
Dnvid, Emmantiel rlr la Cruz, Robcrt DeMello, Nnvneet Dhillnn,
Sharmila nissanaike, David Donson, Adolf Etchegat-ay. N e a
Etwebio, Priscilla A. Frase, Ilavid Frenz, Kristin Gaurner,
Yohannes Gukreegziabhrr, Anil Gcbi, Toriy George, L.M.
Gotanco. Panrl GoyaI, Alex Griinnl, Rxjrev Gupta, Ahmarl
Halirn, Sue Hall. David Hasselhacher, Tamm Heimert, Mich tile
Higley, Dan H u i ~Eric
,
Jackson, Tim Jacksor-l, Sundar Jayarxtnan,
Pei-Ki Jot~e,
L ~ r c h a n J o s h i Rajn
,
i K. Jutla, E a i p Kapadi, Seth
Karp, Aaron S. I<essellieirn,Sana Khan, Atldrew Pin-wei KO,
Francis Kong, Pal11 Konitzky, Warren S.Ktac kov. Benjamin H.S.
Lau. ,Inn LaCxsce. Connie Lee, Srott Lee, Guillenno Lehmann,
k c i n h u n g , Pat~lLevett, Warren Levirlson, Eric Ley, Ken Lin,
Figures2.14,2.I.5.2.lti,2.27,2.28,2.31,2.55,2.3f.2.38,2.41(,
2.65~.
2.65h, 2.6.5c, 2.103h, 2.105h,3.20h, 3.21, 5.27. 8.2717,
8.731, S.77c, 10.81h, I0.96a. 12.28a, 14.6, 14.16, 14.50.
Bannister R, Begg N,Gillespic S. I nf~rte'oz~s
D k s ~ 2""
, Edition.
Osney Mrad: RIackwell Scierice t t d , 2000. Figures 2.8, 3.4,
5.28, 18.10, M'5.32, M75.(i.
And most important of all, the 111ird edition sets now include
two brand new COLOR A T W suppIcmena, one for each
Clinical Vignette scries.
The UCV-Bnsir ScGnrr C:lrl~rAttm (St+ I ) includes over 250
color plates, divided into gross pathology, microscopic patl~olow (hi~tology).hematolom, and microbinlogy (sinears).
Each atlas image is descriptivelv captioned and linked to its corresponding S ~ e p1 case, Step 2 caw. and/or Step 2 MiniCase.
FR = Fmergeilcv hlerllc~nc
IM 1 = Inremail \ft.rI~clr~e.
t'ol. 1
1M:! = lntri nal CIrdirir~e.\bl. 11
SlCU
Nrrimln~?;
nn = OH/(:W
PEn = Pedistnrs
SLIR = surge^ v
SW = Pavchint~1
\lC = MinrGa~t.
\/ A
Case hlumber
T1--u
M-P3-032A
4 i~na~;es.
( i . ~ . Srep
,
1 Casc with h e Rasic S c i ~ n Step
c ~ f Atlas link).
TI' ~11elink is not bold-Eaced lhiri itidicates that the link is
indirt-ct (Step 1 case with Clinical Sciencr Step 2 Atlas link or
vice versal.
* Each current ancl Cuture crlition of our popular Ant Aid for
IJlr
The CoIor Atlas i s also speciallv designed for qui~zingcaptions are descriptive anrf rlo not give away t1lc caw name
directlv.
We hope the updated UCV series will remain a u n i q ~ and
l ~ rve!linzegnted study tool that providc~cclrnpacL clinical con-eIations
to hasic scici~ceinfurmation. They are designed to bc casy and
fun (comparatively) to read, ancl helpful for both licensing
exams and the wards.
We invite yolxr corrections ancl suggestions For the fourth ediEion of these hooks. For r he first submission of each factltal cop
rcctior~or new vignette that is seIccted for inclusion in the
rourth edition, yo11will rec~ivea personal acknowleclgment in
the revised hook. If vou submit ovc-1- 20 higliqual iiy corrections,
additions or new vignettes we will also consider inviting you to
become a "Contributor" on the book of your choice. Tf )roll are
interested in becorning a poten rial "Conrnihutor"ol-"12nthnr"
on a fi~tureUCV hook, or working with our teaor in devrloping
additional books, please also e-mail us ynur W/rcsllme.
Tan 12
October 2001
,4RH
AFI'
5aminosalicvlic acid
arterial hlood gases
adriamyc:cin/bleornycin/~incristi~c/daca~b~ine
angiotensin-converting enzyme
adrenocr>rticntmpic hormonr
antidiuretic hormone
aIpha feral protein
A1
aortic insufficietlcy
ATnS
acquired i~nrni~nodeficiency
syndmmnp
.ALL
5-ASA
ARGs
ABVD
,4CE
ACTH
,4LT
AWL
ANA
mns
ASD
AS0
-4ST
AV
BE
BP
RUN
CAD
CALLA
CBC
CHE
CK
CIALA
CML
cwr
CNS
ccwn
CPK
CSF
CT
C17A
CXR
DIC
DIP
DTW
DM
DTRs
DVT
;~rtcrio~renous
barium enema
hloocl pressllre
blood urea nitrogen
coronary artcry disease
common acute lymphohlastic leukcmia antigen
curnplete blood count
congestive hcart fajlure
creatirle kinast.
chronic Iympt~ocyticleukemia
chronic myeIogenous leltkemia
cpornegalovirus
cen trai nervous system
chronic ohstl-uctive p u l n ~ o n a ~disease
y
creatinp pho~phokii~ase
cere hrospinal fluid
computed tomographv
cet-el~r;nvwc
izlar acciden 1
chest x-ray
disseminated intravascular coagulation
disral inrerphalangeal
diabetic ketoacidosis
diabetes rnellitus
deep tendon reflexes
Ep=+tein-Rarr vi.inls
clcctmc:rl-cliography
echocardiography
Eclirs
qjerti(111lLrac-tion
EF
t-sop~~a~op~~rod~1nc1~noscopy
FGD
clec~rnii~v~~g~~phy
EMG
cndascopi~rrcrogr-;ldr c h o l a n ~ o p a n c r r a t u ~ ~ i ~ ~ h v
ERCP
ESK
erythrocyte s~clime~~tatic,n
r-atr
rcrrcrti expirxtn1-v rwlunle
FE\:
fine irceclIe aspil.ation
FNA
FTtZ-,%I3 S [luorrsct-nt trrponcn~alant ihndy ahsorption
Inrcrrl v i ~ dc i ~ p a r i ~
F5-(:
glomcn~larfilrration r;~tc
c;1:1-t
grow111 l ~ o r m o n c
1
~ a s t r o i trstinal
n
GI
I;M-CSF granulocyte macroph;\gc coton\ qtirnt~lating
li~ctor
gvlii~ o ~ ~ r i i ~ a r y
GP'
hcpatiti? h L~I-11s
1 Li\'
hw11;~ncl-turirtnic gc~n;z<lntropt~il~
I1cC
HEEKT head. evr.;, rai-9. nnsr, and thr-oar
hl~rnnnimtnunocleficici~cvvirus
Hn'
hnman lu~rkr>c),te
a~~rigen
I TL4
history of prrserlt illnesc
I IPl
hcan rate
HR
lniman t-allies in~lnuneglr~hufin
HKJC;
hcrcclitarv spher.r>cy~usis
f.lS
identification anrl c hieC colnplain t
ID/C:C:
ii~.;itIin~lrlr~r~cletii
rliahelc-3 rnellitus
rDnv
itnm
i
~
n
o
g
l
n
h
~
~
l
in
IK
irls~tlin-likejirowth Cactor
rC:T;
i13 traml~scul;t~*
I hl
j~igularT-enouspreqsurr
.PT
E131'
FCC;
RUE
Iti~lneys/i~r~ter/t~IacLrler
1,DM
Iariale deh~rlrr~genasr
lower tsophagewl splliilcler
li\.er- li~tlctiontests
lumhar p~lnrizll-e
left vetr tr-icular
Icft 'tvenfric(tl;tr hyperi rt)phy
electl-nlytey
mean cr>rplisct~f;lr
hpnjt~glol>in
rnncrntration
meail CCEI-~IISCZI~:II~ml~~rnt'
rnilltiple endocrinc ncolslxia
LES
LIT5
LP
I ,I'
LW-l
1,l't
PS
R.IC:IIc
MCW
MEN
MHC
Nl1
h,lOPP
pracarbazine Jprc-dnisone
hlK
t\TfIl,
NIDDM
NPO
NSATD
PA
PIP
PBS
PE
PFTF
PMI
PMN
PT
PTCA
l'TH
TTT
PUD
KHC:
Rl'R
RR
RS
R17
RXW
S BFT
SIiZDH
SLE
STT)
TITS
P.4
TSEI
TIIIC:
TIPS
TPO
*rsH
-rrP
LTA
LTCl
LTS
pr-othrombin time
percliiaileotis transIuminal angioplasy
pat-athyt-<)idliorn~o~lu
partial t h rorn boplalirl ~ i m c
peptic ulcer disexre
r r d blood cell
r-espiralnry rare
Rced-Sternbet~ (cell)
right vcntricrilar
right v e n t ] - i r 11ar
~ hypertropll!~
s ~ r ~ abowrl
ll
follow-through
sy~ldrorneof inappropriate secret ion 01' ,AnH
systemic 111p1isei~tYlemat~sus
srx~raI1yt~~i-lsrnitted
disease
tliyroirl lrlnctien tesw
tissrie pln5minc~genactir*;lzor
thyroirl-stim ~rlacingyhormone
rota1 ir-on-binding capacity
transjugular intrah epa tic pr>rtos).stumicshunt
~hyroiclpcroxiclase
1hyrr3icl-stimulating hormone
t h r o ~ hatic
n
thrornhr>cytopei~ic
purpr~ra
urinalysix
upper G1
VDRL
VS
TJT
WXC:
MT'M'
SR
ID/CC
HPI
P
XI
Labs
Imaging
G ~ S Pathology
S
MR/.4n*o:
Treatment
Discussion
ARTERIOVENOUS FISTULA
r
0
G7
<
ID/CC
HPI
PE
Labs
Imaging
Gross Pathology
Treatment
Ileeti
Discussion
Oxygerlaterl hlt~urlli-rrin l l ~ el ~ f a1
i rit~rn~ ~ S S Pinto
T
the right
atrium. irlcrcasing r i g h ~ventricular ontput ancl pulrnonasy flow.
Acyanotic (Iefi-ro-I-i~hr
s h u n t ) ; ~ t l emnqt cotntnotl congenital
11c;lrr rliscasc in aclults. Scquclae r ~untreated
f
acrial scptal
clcfrc t~ inrIudc paradoxic emboli, infective endocarditis, ; ~ n d
congestive heart failure.
Atlas Link
LTT-=
PEA-002
A T R I A L SEPTAL DEFECT
ID/CC
HPI
PE
VS: hypotension (BP 'JOJ40) that does not respond to rehydration; ir~spira~ory
Io~veringoTq5rolic RP hv > 10 mmHg (~rrr.sris
r;la~ncrxrls).PE: increase in venous pressure wi Ih itlspiratory
lilling nf rlerk veins during inspiri~tion(Eirrss~.e.ku~'s
SIGN);
cI(n-ingdrawing of venous hlootl, svl-inge filler1 qpon tat-ieo~~sly
(clue to increased venous pt-ess~we
f : apical impulse diminished;
heart sounds seem distant; paticnc a150 cyanotic.
Labs
Imaging
Gross Pathology
BIood rrom sitrs of injury fills pericardial sac, causing conlpression of all l ~ e a rrhamlwrs
t
anct pl-ruenting vennns i-etril-11,heart
filling, and artcrial Q I I ~ ~ O ~ V .
Treatment
Immediate pericardiocentesis ancl subseqllelzt operative thorncotomv and pci-icar-dialcFecornprrssion with rrpair of laceration.
Discussion
C A R D I A C TAMPONADE
;o
s
R<
IO/CC
HPI
n-
B
PE
Labs
Imaging
Gross Pathology
fl
^
Treatment
Discussion
FEMORAL HEMATOMA
g6
I 3
<
ID/CC
HPI
PE
Labs
Imaging
Gross Pathology
Brachiocephallc artery
Left subclavian
artev
Ductus
arterlosus
Left
pulmonary
artery
Septum II
Foramen ovale
Pulmonary
trunk
Septum l
Aorta
Clmbilrcal arteries
Figure A-006A
Fetd circ~~larinn.
Treatment
Discussion
Atlas Link
E E I T " 3 PG-A-006
ID/CC
rS.
:i
HPI
PE
Labs
CBC: polycytl~rmin.M G s : 11 ypnx~rnia (Pat 72Yh). ECC:: I-ighti1xi.c clevis tion : evidrtl r e of right ventricular hypertmphy and
right at~ialclilntarion.
TETRALOGY O F FALLOT
Imaging
Grass Pathology
hypertrophy.
corruc ti7.c opun hcarr surgery.
Treatment
Palliative shnnt
Discussion
AtZas Link
01-
PG-A-007
ID/CC
rZ 2-montIl+Id I'emnle presents with dyspnea, feecliilg difficulties. poor p w t h , and profuse perspiration.
HPI
Thc cllild had pneumonia when she was 7 days old. at which
~ i m c11er parLen&
we]-e informed of a c*otlgenital heart tnurtnur-.
PE
Labs
Imaging
Gross Pathology
Treatment
Stu-qical clr>sii~-e
of' large \tSIls s h n ~ ~ lI>e
r l pel-formed heforc
nppcarancc of irrcvr.rsil>lr puln~onaryvasculai. hvperrensinn.
Discussion
Acyanotic. Ventricular scptal dcfect is a common cardiac malformation that accounts for 25% of all cases of congrnital lirart
C I ~ S Small
P : ~~lelkc-ts
~.
niav r l o ~ e~ p n n ~ a n ~ o ~Tihsel develop
y
rnrnlt of p~ilmonarv
vnsuular hypcrtrnsion m a v Icad rt) reversal
(11' the shun 1 (illto I-iglit-(+left\ and cyanosis (F;ISF:NMF,N(;FK'S
SITIIR~I
F,} .
Atlas Link
"
Labs
Imaging
Gross Pathology
Treatment
Calcium supple11ient.s.
Discussion
HYPOPARATHYROIDISM-IATROGENIC
ID/CC
HPI
PE
Labs
Imaging
Treatment
Snrgical correction.
Discussion
CHOANAL ATRESIA
IDJCC
MPI
He had hecn drinking heavily most of the dtcrnoon while celehratin~his school's football victory (and thus was less able to
chew his food properly, had decruased sensation in his mouth,
exel-cised less caution, and had impairment of tile cough
reflex). He W ~ also
C
laughing hcartilv while eating.
PE
Imaging
XR: latcral V ~ M of
: neck may show foreign hndy causing alrwav
ol~ststiction(obtained in stable patients with partial ohsauction).
Treatment
Discussion
CHOKING
ID/CC
HPZ
PE
Imaging
Gross Pathology
Treatment
S ~ o n c scomposed of a m ~ ~ c i n o core
u s surmunded hv calcium
and pfiosphat~s a l ~depmition.
Have patien r suck on lemon to atrempt stone expzilsion through
incl-easedsalivation. I<emt>val cri' stones (1 I-~HC)T~\')
hy duct
dilatatinn n r s~~rgical
gland removal.
Iliscussion
All the salivarv gland4 and tl~ictsnrav present wiih stnrtp rnrmatinn (SIAIX)~.I I 1 tl,e<~s):the condition is Creqnentlv associated wit11
r t>ronicinrection of the glands. Apprnximately 80% of salivary
gIand stones are rorincl in the submandibular gland (Mrhal-ton's
duct).
ID/CC
HPI
The swelliag has been getting larger over the past several weeks
but has not been p a i n f ~ ~ l .
PE
Labs
Imaging
Treatment
XR, lateral neck: may see mass compo~edof soft tissue with n o
calcification. Nuc: ratlioactive iodine may localize in cyst if cyst
corltains Cunrtionin~;thyroid tissue.
Surgical removal of ~hyroglossald ~ ~ ccyst,
t , and midportiotl of
Ilyoid aftcr confirnzing presence of adequate-furlctioning
tllj~oidtissue rlsrwhere.
m
Z
4
o
-0
Discussion
--I
$
3
0
r
o
I 3
<
8'
Imaging
Treatment
Qiscussion
Atlas Link
IDJCC
HPE
PE
Labs
Imaging
Gross Pathology
m+
%
-+
Treatment
Discussjon
BOERHAAVE'S SYNDROME
0
z
rn
7
A
0
r
0
G
I
-<
HPI
PE
Labs
Imaging
Gross Pathology
" <?.
Treatment
Discussion
CONGENITAL B I L I A R Y ATRESIA
ID/CC
HPI
PE
Labs
Imaging
spaces.
Treatment
Discussion
DUMPING SYNDROME
0-
Cn
-4
m
0
z
m
rn
--I
0
r
0
C;r
ID/CC
HPI
Micro Pathology
Treatment
Discussion
Most hiatal hernias are sliding (the srnii-racli herniate5 intn the
thorax ~ogetl~elw i ~ hthe g a s t t ~ e s ~ p l l a g ejunction,
a!
producing
Figure A-018
supraphrtnir dilatation.
r-
HIATAL H E R N I A
H I A T A L MEFNIP,
lD/CC
HPI
PE
Imaging
XR, ahclomen: massively dilated colon with gas and feces; rectal
air nurmally tisible in presacral area is ahsent on lateral erect
view, BE: a h r ~ ~ cI~ar~ges
pt
~ I Ecaliber between gxnglienic and
a911glinnic segments: fail t~l-eto evacuate barium.
Micro Pathology
fi
Treatment
Discussion
HIRSCHSPRUNG'S D I S E A S E
TD/CC
HPI
PE
Labs
Imaging
GKISS Pathology
I -
Treatment
Discussion
PANCREATIC PSEUDOCYST
ID/CC
HPI
I-le is a heavy smoker. For the past 3 years he Ilas suffcscd frorn
chronic. episodic, burning epigastric pain that was diagnosed
as a p s i r i c dcer and treated with antacids and H2 receptor
blockers.
PE
Labs
Imaging
Treatment
Discussion
Atlas Links
PEPTIC ULCER-PERFORATED
ID/CC
HPI
PE
Labs
Imaging
Gross Pathology
Esophagoscopy: active bleeding of markedly dilatcd and tortiious suhmucosal veins (BLEEDING V ~ R I G E S ) .
illcoholic hepali~isgives rise to fibrosis (CIRRHOSIS) of the livcr,
rr.hich inmaws portal vein resistance.With the dcwlopmen t of
portal hypertension f > 10 ~ n m H g )there
,
nre portal-ysternic
anastomoses fornled such as the left gastric-qgou.4 (esophageal
varices ), the superior-middle and inferior rectal veins
(hemorrhoids), the paraumbilical-inferior gastric (navel
caput medusae), and the retroperitoneal-red vein svstem.
Treatment
Discussion
Atlas l i n k
PORTAL HYPERTENSION
RE
Figure A-023A
prmcli anrI
F-
PI-ouirnxlcnrl of ~ h t rsoljtlagr~s
.
enrlinq in a I d i r ~ c l
sexmen1 con~nl~rr~ic;~tii~q
wi t l ~the r r a r h ~ a .
TRACHEOESOPHAGEAL FISTULA
Imaging
Gmss Pathology
~rachea.
Treatment
Discussion
ID/CC
HPI
Imaging
Gmss Pathology
At~ii~psv
showed a lO-cm4iameter aneurysmal dilatation of
abdominal aorta (normal diarnutcr is 2 cm) with abundant
atherosclerosis of the wall and rupture.
Micro Pathology
Treatment
Immedialr surgical resection and grarting, Patients with asympinmatic ahilorninal aorric aneurysms > -5 r m us~tallyundergo
elective ~urgicalresection.
Discussion
A B D O M I N A L AORTIC ANEURYSM-RUPTURED
ID/CC
HPI
PE
Labs
Imaging
CRT;/LVI~S:
normal.
Treatment
Mscussion
FEMORAL HERNIA-STRANGULATED
I DJCC
HPI
PE
Labs
"
He i s a S Y T I O ~ivit11
C ~ a chronic cough anrl is overweight. He i t 1 ~ 0
st~fft-rs fro111proststtic hyperplasia Illat forcrs him ttr strain in
n i . r l ~ rn
i i n i ~ i a t 1nict~1ri1i0.11.
r
Patient r17alksvery slowly with both ?ear apart anrl sits down in
r'liair .;irlewavr; extert~alr ~ c l aex;lm
l
r.pvp;~lsprewnce d ' a
rounded.3c-111, purple mass in thr anal verge i l ~tais tense and
extremely painfill to the touch: ititeri~aldigital rectal exam
impcr~cibleC ~ I I tcl
P acllte pain: maw Ir)caIi7~rIto nuter anal
region.
Gross Pathology
Dilil~<>~I.
~ngorgcctvein wit 11 clot.
Micro Pathology
Treatment
Acute tlii~ornl~c~sis
\vill suhride ~ p o n ~ a i i e o ~ iin
s l ymnqt cases with
sitz baths, atrti-it~fla~nn~atorie~~
local sternirls, xncl laxatives. If
rccul-l-rn't,snrgic;~lrcscction is warrantccl. IF ;ic~~iely
painf~tlor if
rniict-l-vativr rreatmpiit Ii~ils.exciriora wiih local aneqthesia mav
IIC clone.
Discussion
Attas Link
1
' 1 1 '1
SUR-028
HEMORRHOIDS-THROMBOSED
EXTERNAL
ID/CC
HPI
PE
Treatment
Sirrgical repair:
Discussion
IT eatmerlt
r_I1A:1_-
SUR-029
I N G U I N A L HERNIA-DIRECT
ID/CC
HPL
PE
Labs
Imaging
Treatment
Discussion
I N G U I N A L HERNIA-INDIRECT
lD/CC
HPI
PE
Labs
Imaging
2-yearald boy is ! , m ~ i ~t lo
h the en-lergencyroom I>? his parents l~ecausrof a n increase in the size o f his beIIy and persi5tent
vomiting.
\t
Two weeks ago the hnv had bright red blood in his stools For
4 davs.
Gross Pathology
Micro Pathology
tiswe.
Treatment
S~rl-gicalexcisio~l.
Discussion
ap~endiciris),nr hleerling.
19
z
m
m
$
VI
c
;E)
m
CI
;D
Atlas Link
LT_mlPG-A-032
MECKEL'S DIVERTICULUM
<
IDJCC
HPI
PE
Labs
Imaging
Cross Pathology
fl
Smgiral ~ p ~ c i n reveals
~ c n cotnpletelp black ancl i ~ e c r o ~ileum
ic
ai~d~jcjunuin;
multiple clots in superior mesenteric artery (SMA)
branc hu?.
Treatment
Discussion
MESENTERIC I S C H E M I A
IQ/CC
HPI
PE
Labs
Treatment
Sm-gical.
Petit's tri:~nglei s for-merl h v the iliac crest iihferiorlv, thr. posterior border or the external ohliqlzc anteriorly, :;ntl the an ierior
bnrrler or I h e latissimus ctnrsi rnuqclc pc>stcriorly.Petit's triangle
hernias arc srcr~irl all age groltps ancI are more common in
males, arising morp frequwtIy on the left side.
PETIT'S TRIANGLE H E R N I A
lD/CC
HPI
PE
Imaging
Treatment
Discussion
EDJCC
HPI
PE
Labs
Imaging
Treatment
Discussion
RICHTER'S HERNIA
ID/CC
HPI
140/95) :
Imaging
Gross Pathology
CBC: neutrophil ic leukocpsis. Increaserl RUN; nrlrnlal crea tinine: amylaso mildly clc\~atcd.GTX: increascd specific gravity.
Treatment
Discussion
SIGMOID VOLVULVS
ID/CC
A 2Syear-old tnale is hrougl~tto the ernergen7 room i11 a confused state after being iilvolvccl in a high-speed rlorvnhill skiing
accident.
HPI
PE
Labs
Imaging
Treatment
Discussion
SPLENIC RUPTURE
to the ernergcncy rorm ljr? his parents a r c r a n accident at school: hc was walking along n $[eel
~ ~ ' n i -rail
d whcn he slipped and fell, straddling the rail.
HPI
PE
Labs
Imaging
Ure~hmgl.aphv:extrxva5ation
t~rirleinro scrota1 ri~stieand
perincum (rupture of urethra).
Treatment
Discussion
STRADDLE INJURY
ID/CC
HRI
PE
Labs
CBC:: le~~kocytosis
with neutrophilia. BLT and crearinine
i~icreased.T.yte5: normal. UA: proleinuria and rnicm~mpic
llernaturia.
Imaging
Treatment
Discussion
URETERAL INJURY-IATROGENIC
PE
Ohese: rliffiri~lryI>reart~ir~g
after clinlhing a flight nT stairs; facial
pletliorn; examination of lo~vcrextremities rrvrals swelling with
dilatation of veins in territory n l greater saphenous vein.
Treatment
Discussion
Atlas Link
TT'T? MC-364
VARICOSE VEINS
I DJCC
HPI
PE
Labs
Imaging
Micro Pathology
Simple. cyst wilh serous fluid, lincd with a single layer of col~tmnar epitl~eliun~.
Treatment
Discussion
ID/CC
HPT
of cervix
Imaging
with
Treatment
L%laddrsrew~spensionsllrgery.
Discussion
A GG-\:ear-oldrliah~tichigll-~cllonlhirlloq teacher goel; to a Fllrgeon for an cvaluatinn or n smalI nodule on his lower lip.
The n o r l ~ ~ il lea ~heen tl~crcfur o w r vcal; and h c wclnders if it
might he re1;lted to his llahil of chewing tobacco while watching
bas~hallFanre5 aftrr w-hc)ol.
rn
Ind~~ralcrt,
ill-defi~lcd,vir,laceous, rlc)~imo~ile
mars fell in IOM~PT
lip: uiilargernent nf submental lymph nodes (wli irh drain the
rnedial ~>or-lion
of t h e lower. lip) arlrl suhrnandibular lymph
nodes (wl-tichdi;lii~ the Iaiel-a! pnl-tinn o f
lower lip): enlargeInenl o I deep cervical lymph nodes neat. omohvoid m ~ ~ s c l e .
r t i r a
Labs
Ernaging
Grass Pathology
Micro Pathology
Treatment
Discussion
Atlas Links
m
3
=.
0
Z
rn
--
IOJCt
HPI
PE
A I P-ruuckuld male in Fat11 is brought to the hospi~alTor e ~ d u a tion of recurrent oral thrush and t R L 5 .
T h e cllild had seizures (due LC, Ilypocalccmia) s h o x ~ l yaftcr
birth. I4is mother is an Il' drug uscr.
Labs
Ernaging
Treatment
Discussion
DiGeorge's syndl-ome is duc to a11 e m bryologir dcfec t ctiaracterizcd hv lack nf rlev~lopnientof the third and fourth pharyngeal
pouches. It is associated ~ i t l lack
l
of thymus and thur 110
cell-incdiatrcl irnrril~niq(henre recurrcnl viral and fungal inkctions) as well as wit la congenital hcart defec tq. The associated
lack of parathyroid gtands rcsults in livpocalce~nia.leading to
ID/CC
;2 newborn female
colic-et-n~.
MPI
PE Ncwlmrn
Treatment
Observation.
Discussion
Ci~p~ir
s~tccedaneumrefers tn a benign edema or the soft tissues
of the head during ddelivcry: it charxctel-iqticallvcrosses the
midline and cranial suh~lasand is riot assr~cialerltvith an
onrlerlyir~gfi-act11re. The diiTerer1iiaI dizgnosis includes
crphal hrmatoms. rvltich does not prcscn t wit11 C C C ~ I ) T ~ ~ O is
S~S,
som~tinicsassociated with a fracture. docs not cross suturr line5
(a~l~pcrictstral
hlcccling is limiter1 to o n e hnne), anrl may take
F P I I P ~ ~ I 1 1 o 1 1 r ~to heco n ~ eviclent
e
(caprlt i q imtnecliateIv srcn) .
CAPUT SUCCEDANEUM
ID/CC
MPI
PE
Imaging
Gross Pathology
Treatment
R e s ~ ~ state
c i and stal~ilireneemale, intubatiotl, aqsisted ventilation
follo~verlkv ~urgicalrepair.
DTscussion
S p ~ n a cord
l
Vertebra
Rib
Aorta
pleuroperttoneal
lnferror vena..
Mesentery of
oesophagus
Cef t
pleuroperitoneal
membrane
Contr~bution
from body wall
traosversum
Oesophagus
Figure A-044 Muscular structure composed of the sepninl transverrum, dorsal rsophageal meqrntrry, hncly~vall,ancl plcuroperitoneal
rnernlxar~e.
CONGENITAL DIAPHRAGMATIC H E R N I A
BOCHU,ULIC),
leading to protrr~sionof [he abdomina! viscera
into the chest; it is usually located on the left side. Parasternal
or- retrosternal (FORLIEN OF MOR~;AC;NI)
hernias are also congenital bur usrlally do not produce symptoms so early and are
located antcriorlv (11s. Roclida~ek'spostcrolateral location).
Pulmonary hypoplasia is the tnort common cause o f death in
infants w i ~ hdiaphragmaric hernia.
ID/CC
HPI
PE
Imaging
(i7.s.
Treatment
Sl~rgicalrepair.
Discussion
DUODENAL ATRESIA
ID/CC
HPI
H e hiis ZIPPH
rpffrlrgit-aringh o d and has l ~ a doccasional hoirts
oi-vt~mitingfm- 1 week. The chilcl is thc first-barn son of n
28-~~ar-old
white feimalc and i s the p r o d ~ ~ of
c ~ ;+
t 1101-ma!r1eliver.y.
His mother had hypermphic pyloric stenosi5 w1lt.n she was bar-n.
PE
Labs
Lytcs: hvpokalrmia: hyonatrcnria. ARCS: hyporbloremir alhdusiq (rllre ro loss ofg-astl-ic hudrochlnric acid in votnitus).
z
m
0
Z
o
3
C)
<
Imaging
Gross Pathology
Treatment
Discussion
ID/CC
HPX
PE
Labs
Imaging
Treatment
Discussion
Renal ir-act stones may produce one or the most severe forms of
pain known duc to obstruction arid s ~ n o o t hmtiscle contraction.
Ihlculi inav he bornirrl of calcium oxalate, inagnesium
arnmoraium phnspl~ate,cvstitle, or uric acid. Approximately 85%
of renal calculi ai-e radiopaque calcium oxdate stones. Uric acid
stoncs arc radioluccnt.
Atlas Link
U-1111-J PG-A-047
NEPH R O L I T H I A S I S
ID/CC
HPI
PE
Imaging
Treatment
A 4.5-year-old man. ~tlefarher of swen children, comes to a ramily planning clinic fnr acl~-iceregarding birth control.
recanalization).
Discussion
IDJCC
HPE
PE
Labs
Imaging
GTOSS Pathology
Treatment
S l ~ r ~ i crmn~ov;tl.
i~l
Discussion
Atlas Link
DJ-LA PG-A-049
ACOUSTIC SCHWANNOMA
ID/CC
HPI
PE
Tlir patient is obese and sedenlarv and never exercises. His paill
startccl after h e wenk outside and shovelet-I rhe firqt m o w withor~t
ws~rmingup (sudden, ~ i g o r o l ~plysiral
s
rserrise).
I-Iead tilted t o one side: par ieut callnut straighten hear1 without
rnnsiderahlc pain: accornpn ied by considerable muscle s p m
in left drle or neck.
Imaging
Treatment
Muurle ~ . e l a x a r ~ tKSMDs,
s.
local h a t , masxilge.
Discussion
ACUTE TORTICOLLIS
ID/CC
HPX
PE
Labs
Imaging
Treatment
Discussion
Figure A-051
, ",,,
,
,
,
G
':
1:
,
;
(A-Rahinski'ssign)
,il
,
,
I
8
.,
blCq
c
<
,$
,;
and altcrna-
,,
j::$
Demonstration
of ir~voluritarytlorsiflexio~iof
thr lees in rcspolnsr to stroking
on the sole of the fool
-\
k.:;>,,--,,,<
,+
;,
APHASIA-WERNICKE'S
,,
,,, ,
,
,
,
,,
:,
,
,,
,
,
,
,
,,
,
,
, , "
,,
,"
, "
,
,
,
, ,
, , , , , , , ,<
,
,
, ,
, , ,, , ,,,
, ,
",
,
A
::,,;!
A,
; "
., ..
(bOppenhrinl3,rsign), and
l;lier:~ltn:xlleolt~s(GC:hadrlock's
sign} o r to tir~nlvahdk~ctirig(lie
fifih cligii Tor 2 s ~ c o i ~ d s .
(n-Srru~isky'ssign).
lD/CC
HPE
A 7-year-olrl girl is hl-oiqht hy her parents to the pcdiatric umergencv drpartrnen t hecarl~eor a severe headache t11:t~does not
respo~ldto treatment wit11 analgesics.
Her fa~lieris cot-rcerned aho-iit "weird movements" of thr girl's
ryes
PE
(NIS I-AC;~TLIS).
Imaging
Gross Pathology
Treatment
'Discussion
Attas Link
U
PG-A-052
z
m
c
A
o
Gi
<
ID/CC
A 43-ycar-old diabetic male comcs to the emergency room fearing that he has had a strolic; he conlplains oCinabiIity to move
the right side of his face and cannot blink his right eye or s e d
his lips (lesion (31' CN %TI-Facial iiCrre).
HFI
PE
Cabs
Gross Pathology
Treatment
Discussion
diwase. rumors. ancl sarcoirlosip but i~most c o ~ n m o n l yirliopathic. InvoI~ernent or tile en tire half of the i'ac~rle~nonqtrates
lowc-r motor neuron (CN\FI)patholop; ir~voIver~lrrl
t or nrilv 111e
lower halt'd'the f a c ~
S I I ~ R P S ~llpper
S
1noro1-nrlsrnll pathology
(11ppe1-mator neurons have ct-nqq-innet-i~tionto the Cnrehead).
It is sclf-limited in mast cases (~picaI1yrrsolves in F, to 12 ~nonths).
with only a small pclrentage oTcases i-es~~ltinfi:
i l l permanent
disfiglrr.munt. It is lIiougl~tto rrprrsunt a viral cranial polyneu-
BELL'S PALSY
..
m .
m
y
-
&
'I
Figure A-053B
?'
-.
"3.
:-
$<i
Detnnnstra~inn
of n v ~ ~ r o l o f deficit
ic
secondarv
rn a cranial nerve Frsion-low
of tipturn of right angle of
mouth on heitig asked to smile
clue to orl~iczilarisoris muscle
palsy.
>..,
1':
>
,
,,
, ",
,
,
, ,,
,+ ,
,,,,,
,
,
<
<,
,
A,:,
A
,,<,A
" ^
+ A ,
,,
' g
",
<;">
<*<<
,,,
- , ,,,,
'
', , '
A,
,, ,
.,
,,
i'
toacr~~~ialner~~elcsion-loss
OF liarisverse f r o n d wrinkling
on l~pwal-rlRue due to right
ri.011 talis rn uscle palsy.
ID/CC
HPI
H e was stabbed in the back 2 houl-s ago while defending his wife
frotn a nlligger.
PE
Imaging
Gross Pathology
Treatment
Discussion
Sensory deficit
Figure A 4 5 4 A
Lnqq
BROWN-SEQUARD SYNDROME
qide as h e spl~lallesion.
and trmpcrature sense helow the Iwel of thr lesion (spi11otha1i1mic tract). It is risually clue to a pench-ating injr~syto the spine,
resuli ing in functional hemisection of the spinal cord.
Sensory deficit
Figure A-054B
ID/CC
HPI
PE
Labs
Imaging
Gross hthotogy
The patienr has a long hiqtory o f diabetes mellitus that has been
11-ea~ed
with irtsulin. H e also complairls of in tertnittent vomiting,
nau5ea, and episorlec o l deliri iim. His hearlaclie i 5 particularlv
severe on the right sidy.
fever. PE: neck muscles stiff; right cheek swollen and red
~ i t area
h
of plirulcnt discharge: right side of nose hard and
swollen:rixh t rye very painful ancl pro tr~tdes(EXOPETI~ 4 1 , ~ o . :S )
right rvelicl srvo1lc.n wit t i hlack discoloralinn; loss of'f ~ ~ n c t i oon
r
right extraocular eye muscles; 'tingling and burning
(P~XRFSTI-EESIA)
of right upper quadrant of facc.
\;St
Treatment
Discussion
b
Facia1 vein and superior ophthilmic vtin to one of the paired
cavernous sinuses, onr on each side of the ?ella turcica: lack of
valves in the vein5 of the face facilirared migration of infectious
thrnmhosis throughout the race. Pulmonary septic thronlbi and
meningitis are common complications.
G)
-<
IO/CC
HPI
PE
Imaging
A 34-year-olrl rorlstr~~ctinn
wol-k~ri.s 1,roilghr 1r1 a clinic arirr. a
fl!ing pic-ce or s1lr;tpnel cut his l e g < j ~h~~' il ~o uI 'he lateral surface
of the head of the fibula: the paticn t also cornplnir~qof numbness and tingling along the dorslun of his foot and thc lateral
qiirfacr. of hi.: leg.
Ffe complains of Inss or qrahiliry when walking and inability to
domiff ex h
i
s foot ( F C K ~I ) K ~ I ~ , )[-It=
.
nllzst raise Elig i 11j11t-erIleg
higher than not-rnal during walking to prevent his toes ~YCEIII
hilti rlg thr grc>imd. and his foot slaps against the ground w h e n
walking (steppage gait rl11e to tinoppc>svrIactinn ol'plantar flrxars; n~rlsclesinnrrvaterl I n prror~ealn e i w are pa~xlvzed:extmsor digitorurn longus, tihialis anterir)r, extensor h:llIri~islong11s).
\t'r,unrl in proxi~niryot head of Rbtila { ; ~ l .whcl-P
~a
rhe common
fihular riel-vr i s most ~nperfirialas i t wraps arnunrl rlre head of
the f?hula): diminished cutaneous sensation nicer antt=rolateral
aspcci of leg and cIor.s~rtnor root (cutaneous h r a n r h e ~or thc
uupf=r-fitialfibl~larnerrr .;ul>plyt h i s arr%i):i ~ ~ a l ~ i l10i t )extend
'
toer (pal-alv~iq
or t ihiali~atllerinl; peroneti5 Inngl15 and tit-evi5).
Treatment
Discussion
Figure A-056R
I h.rnnl-isrration nl p o . c ~ ~ i oIIJI.
n ixhwcsincnt nTlowrr
rsir-rrr~ilr;
t l e ~ plerirlor~reflexes-patcll;lr
rct1r.x.
< >pos~lior~
~~
i ( . ~; ~ s v t s s n ~ c r-)I~ >1orvc1t
r~strcmi~
Figure A-056% E ) c i i l o i ~ s ~ i - ; u iut
cIerp lrnrlun I-eflexes-,Achilles reflex.
ID/CC
HPI
PE
Imaging
Treatment
Discussion
DEAFNESS-CONDUCTIVE
I DJCC
HPI
PE
Imaging
Elhow skin shows dermal abrasions and soft tissue edema with
tenclernew on palpation: inability to abduct Ffingers; poor asp
of fourth and fifth digits (due to ulnar nerve damagc; all hut
Live ni' the in tern?seo~isnltlscles are innermtetl t h e ultlar ~lerve).
Treatment
Isolation of clhow after reunion of frdckirecl ends: physical therapy for hai~drnovernen~(crusher1 ncne will regenerate).
Discussion
ID/CC
HPI
PE
Labs
Imaging
Treatment
Discussion
ERB'S PALSY
ID/CC
HPI
PE
Gross Pathology
Treatment
Upon a w a k e n i ~ ~from
g
anesrhe~iaafter removal nC the gland,
she was asked to smile hut could not d n so prnperlv.
Surgical wound ct)vered hy sterile gauze with n o apparent blueding; small drain it1 place; when patient i s asked to wrinkle forehead, patient's left side woz~ldnut rvrinMe (affected side); left
comer of mouth does not rise tip as right one rloex when pat i e n ~is asked to smile: patient cannot raise her left eyebrow or
lnwcr it when asked to frown: mouth does not lift on left side
when patient is asked to slloubteeth.
Sl~rgicalspecimen consigts of a malignant adenocarcinoina of
parntirI gland; a I).5cm-long portion of facial nervc wns found
resected. enmeshed in carcinomatous lobules.
Facial nerve can he sun~redol-grafted with suraF nerve il'lesion
is voluntary or involun~rvhut cannot 11r overlooked: otherwive,
physiotherapy.
Discussion
z F- -
t h posterior
~
hclly of the digastric. The Llcial nerve gives taste
sensation to the anterior two-third? of the t o n g ~ eThe
.
pal-oticl
gland consists of two lobules, rhc anterior and posterior: the
facial nerve ancl its branches (ceriical, buccal, qgomatic,
trmpoml, and mandibular) coursc between thc hvo after exiting
rn
;D
o
I 3
ID/CC
HPI
Eight v:euI;s ago, he fell from his bicycle during a race and suffered a pelvic fracture.He was treated through use of a sling
and bed resc and i s riow trying to hegin rehabilitation 14th
crutches.
PE
Imaging
Treatment
Phwiother-apy, ~ur~gical
exploration and repair in selected cases,
Discussion
ID/CC
PE
Treatment
Discussion
flaccid paralvsis accompanied IJV atrophv of t h e tongue denotes a lniver motor nenrt)n lesion of rhc liypoglo~s~l
riel-VP.
Cauqes includc parotid ancl casr~tidbody tuIrmrs, ~ubetculous
adcnitiq. ancl metastatic neck tumors.
Atkas Link
E m 1 2-A-061
Figure A-061
III
torque
o ~ ~ i w ' i~u+
1 l e v ~ ~>I)
~ ir >ct ~lir
r o n p r ro t h c rigt~rindicaung an ipsilaieral
I:K \'TI ltiwrr motor tirllrnn Ir<ion.
ID/CC
HPI
PE
Labs
A newhorn chilcl is noted on his first complete phvsical examination to have h i s right hand in a "claw" position.
H e is the son nf an lFCyea~--nldrernaIe who was attundcd at
homc. by a midwife; he was hurl1 with shorllder dystocia.
In adclition to claw hand, examination disclose%p~rpiIlat-yconstric tion (vlcnrs) w i ~ hrishr-dr-oopinx welid ( i ~ r o s r . ; ) and lack or
sweating (,tusrr~~osrs).
oormal.
Imaging
Treatment
Discussion
KLUMPKE'S PALSY
ID/CC
HPT
PE
Treatment
D i ~ c u s ~ i o nI n
Atlas Link
C1.~ ~ ~ - 0 6 4
ID/CG:
,475vear+ldman complainsoCdifficultydawing
(n\.irrs.\cr~)
and speaking ( I>WARTHRI.Z)(due to corn pression of
C N IX, X): Lhese s y p t o n have
~ ~ pr~~qessivcly
worsened over
the past several months.
HPI
PE
la
vated
Uvr la not
M A S S I N JUGULAR FORAMEN
Labs
Imaging
CN IX,X, XI at
Gross Pathology
Micro Pathology
Treatment
Discussion
MASS I Y J V G U l A ? F 0 9 A M E N
ID/CC
HPI
PE
Imaging
Micro Pathology
Infiltrating glioma.
Treatment
Discussion
Midlii~e
stslictr~l-es
are invnlved. including CN XI1
( I ~ O T , L . O S S ~ I L . ) , pFmi rlal motor tracts, the medial lemniscus
ID/CC
HPL
The mother- had art appwentlv unuvcntf~rlprt.gnilncv and drliverv. At hirth the c h i l r l ' ~hodv weight atlrl head circumference
were at the fi5th percentile (normnl).
RE
Labs
Imaging
Gross Pathology
C o n g ~ n i t aoh~tructiun
l
of aquedrict of Sylvius duc to asachnoidiris, with marked ventrictllar dilatation anrl atrophy of ccreI~ralt i ~ s u e(most common site of congenital obstrucrion is at the
aqueduct).
Z
Treatment
Surgical inserrion of shunt either from lateral ventricle to inferior vena cam or directly l r n ~ nthird vet~tl-icletn subarachnoid
space.
rn
C
r
0
<
Discussion
OBSTRUCTIVE MYDROCEPHALUS
ID/CC
HPI
PE
Labs
Imaging
Treatment
Discussion
O h s t r ~ ~ c t i vslrep
c
apnea is seen i l l middle-aged males who arc
usually mol-hidlvohcse, smokcrs. ancl I-typertensive.I1 i s due to a
n timber of causes, mainly obesity pharyngeal malformations,
dl-z~g~,
a n d alcohnl. Patirn~qpre~entryrliral perioris or h y ~ o r ~ e n tilation and apnca sometimes lasting minutcs. which cause
anoxia, ar.rh.r?tl~mi;-ls,
and lack of nrwrnal sleep. I t reqults in poor
phvsical well-being dl [ring the day, mood changes, and work and
rarnily pl-rjblern5.
IDJCC
HFl
PE
Labs
normal
(vq. Wilson's
disease).
Gross Pathology
Micro Pathology
Treatment
Discussion
z
-rn
<
.I"
PARKINSON'S DISEASE
c
n
o
6
c-i
ID/CC
Durinx her first postope~ttivevivit, a 2ft.yfi1r-olrl [enlate cornpIain~to hcr surgenn or hoarseness.
PE
Labs
Gross Pathology
Treatment
Spccc FI t'tir~-apy.
Discussion
T h ~ r :we
e two recurrenr 131-yigealnrrves (alw c;lllerl inferior
1:lryngc;ll). hot11 of which are hranct~esof the vagus nerve; they
arc- c6~lFcxrl
rrctrrrrri 1 I~uci~urc
th t%y
Loop around the subclavian
artery on the right and thc aortic arch on the left hefore
;~scrnrlingin the t~~chcorsophagcal
groovr iin closc proximity to
thc th~-roiclgIancl trb end up in the 1nry-m. IT t l ~ cleft rrcurrent
I;~r.vn<r;llnrrvo i h involecd. onc shoulrl cor~sirlermass lesiorir
such as enlarger1 Ir~~nph
norips in rile a o r t i c o p u l m o ~
window.
ID/CC
HPI
PE
Labs
Imaging
G ~ S Pathology
S
Head diameter normal for age; patient forirlrl to have pes cavus
;rnd arched legs; deep tendon reflexcs hyporefl~xic;roundetl.
large mass that transilluminates parlially seen iri l ~ ~ t ~ ~ b m a c r a l
area.
CRC/I,vtes: normal.
~ ,
rn
Treatment
Early sm-gery.
Discussion
Atlas Link
nIU7 MC-263
;D
r
0
CI
<
I~outsof
excruciating stabhing pain on tile lrft side of h w face between
the upper lip
lower eyclid (region covered hy the maxillary
1,i.anch of CN V): the pain is so srvere that the patient ha?
conrrider-ecl suicide.
HPI
She first cxperiencerl this paill 2 months ago, while she was
chewing gum. Shc also reports that cold drafts trigger the
attacks.
PE
Imaging
Treatment
Discussion
T R I G E M I N A L NEURALGIA
ID/CC
HPI
PE
nystap1~3
in all directions o f ~ w , (CN
e VIII); duci-eased
sri~siriviryco ligl~tt o i ~ dand
i
pain o n right sick of f a c r (CN V);
right-sidcrl incorl-ect appreriation of clis~ar~ce
in linger-to-nosc
movements ( n \ s ~ ~ . n rimpaired
~);
pain scnsa~ir>nin left
(conlralarel-al) ~ i d cof hod? {spino~hnla~nic
tract).
Imaging
Treatment
Discussion
'
<
WALLENBERG'S SYNDROME
E
m
o
r
o
tl
;=
IO/CC
HPI
PE
Labs
Imaging
Gross Pathology
Treatment
Discussion
A
I
ECTOPIC PREGNANCY-RUPTURED
m
o
-+
w
rn
4
E
r,
V,
PE
Labs
Treatment
Discussion
The ~>udendal1icrl.e provides both motoi- w l d sensorv it1nerva.ation lo tlle pelineal region: it passcs out of the peIvis through
the gl-ea~er
sciatic Eora~nen,wraps around tllc rxtrrnaI srlrface
of rhc: isdiii~lspitjr, and enters the pelvis spin thro~rglithe
Icsses sciatic foramen (crt~ssingthc sacrospinuus ligamerit) .
The nerve travels within the fascia u f ' t f ~ cinternal ohrur;~tor
lD/CC
HPI
PE
normal.
Imaging
Treatment
Discussion
Ankle sprains are the most cotntnon type of sprain in the body
and are usuaIIy undertrrated (i.e., the length of immobilization
timc is often too short), with frequent recurrences; with each
new sprain,the lignments becomr weaker. The ankle joint is
held in pIacu and is protected Crmn inversion 5rresse~by thc
lateral collateral ligatnent complex, which cotlsistq of the
anterior ralofihdar Iigamenc, the calcaneofibular lipmen t, and
the poqtel-ior talofibulir ligametlt. On thc medial side there is
the wide, broad delroid ligament, which confers protection from
eversion stresses. The anterior talofi'bular ligament is the most
common ligament injured in ankle sprains ancl is secondary to a
hyperinversion injury when the foot is p1antarflexed.
ANKLE S P R A I N
ID/CC
PE
Imaging
CVriv
Treatment
Discussion
Figure A-077A
nernr lnq~n'ntinn
r r l I>;i~i(.motor csarniiiatiorl of
the tntlial ncr~r-ar~irrr rxtrn<ion ;IT WT~FI
ARM-RADIAL
NERVE PALSY
;IIICI finarm.
Figure A-077B
Demons-itin11
e x a ~ ~ ~ i ~ l a ~ ~ o n - r anerve
rlixl
tlirtr.ihution (.4):~~Irlxr
nervr
rlistrihutio~~
(Bj.
ID/CC
HPI
AE
Imaging
Treatment
Fractures are usuallv located where the middle and outer third3
( ~the
r clavicl~meet. The m ~ d i a segment
l
is displaced upward
hy thc sternoclcidornastoic1stirnr~scle.while the distal end is
rlepr~sserl11? the weight OF the shozlId~r.
CLAVICLE FRACTURE
ID/CC
HPI
PE
Imaging
A 44-year-old rxuc~~tive
-eco~nesto see his pl~ysicianfor burning
pain in his right elbow.
H e is an avid tennis player.
G ~ S Pathology
S
Micro Pathology
Treatment
Discontirr~~e
~ e n r ~Ibr
i s 6 ~vcuks:NSAIDs, local heat-cold, topical
steroids, sllrgery in sclcctccl cnqes.
Discussion
d
Figure A-079 Demoncrratinn
of ~ l e of
s elhow palpationtrirdial rpirondvlt. (A): cuhital
imn~tel(B); oleciation and overIvin~
hurra {C); ulnar/huineral
-i+
j
-2
H
1
p.
I
6.b
articulntiol~(D); latrral
epicor~dyle( E ) .
1 7 .
-F~:+
ELBOW-LATERAL
..
EPICONDYLITIS
-
- -
lD/CC
1-2 23-year-old
orthopedic
HPI
PE
Imaging
Treatment
7 P
ELBOW-MEDIAN
Discussion
ID/CC
HPI
PE
Imaging
Treatment
Discussion
ELBOW-RADIAL
HEAD SUBLUXATION
ID/CC
HPI
PE
f maging
Treatment
Discussion
This i.; a. tiacturr of the upper third of the ulna with disIocatiun
o I ' t h e rarlial hear1 1-aiiserl 11y i t F,1l7 011 an o11rs11-etched
Iia~irl,will1
thc forearm Forccd into e x c e ~ s i wpronacion. It mav also result
froxn a direct l ~ l u ~on
v the hack of the upper forua~m.
Neurologic examination is importarit in ~ I I ; radial
I~
iirr vc injzlry
may he asq~ciateclwi 111 Moiileggia'~Fr~cLure.
FOREARM-MONTEGGIA'S
FRACTURE
ID/CC
HPI
PE
Imaging
Treatment
Discussion
HAND-BOXER'S
FRACTURE
ot~
ulnar side
or hand.
IO/CC
HPI
PE
Imaging
F*l
Gross Pathotogy
Micro Pathology
Treatment
Discussion
HIP-LEGG-CALVE-PERTHES
DISEASE
ID/CC
HPI
PE When patient stands an his 1cTt leg, his right Iluttnck sags
(TRFYDKLEWVKC
SIGN): no sensory Ioss nolecl in gluteal area;
swing phase of leli Irg seems must affected; to swing lcft leg,
child leans over to right side and then swings lefr leg in front of
righr (the superior gluteal nerve is paralyzed): right Eeg swings
normally (hip rtbdi~ciors h~nctionnormally to prevent pelvis
from tilting over when leg i s winging).
Labs
Imaging
>A<
Treatment
Discussion
HIP-TRENDELENBURG
GAIT
ID/CC
MPI
PE
Labs
Imaging
Normal uewhor~rscr-ecn
Treatment
Ilace the hip joint in flexion and abduction (with a Pavl ik harness or a Frejka pillow) st, that the femoral head inap initiate
and sustain normal acetabular devclopment. Early diagnosis
yirlrl~best results: for treatment. Sllrgrry niav be inrlicatetl when
rliagnosi~is delaved or for refractnrr cases.
Discussion
Attas Links
m - 5 1 PED-O51A.PED-051B
H I P DISLOCATION-CONGENITAL
ID/CC
HPI
PE
Labs
Imaging
Treatment
Discussion
ID/CC
HPI
PE
Frail. elderly woman with poor mriscle tone and low body
weight; left leg externally rotated at resl (lateral rotators: piriformis. ohturator internus and externus, superior and inferior
~emcIlus.quadratus fernoris. glnteurj maxitnus) ; left leg slightly
shorter than riglit with tetrderness in remoral triangle; limb in
adduction: cannot raise heel off bed.
Imaging
Treatment
A
Figure A-088 Demonstradon or classic limb po~ri11.c
in an
i l l tel-~rochan
t e r i Frrnoral Fracture-lrlt Icg shnrtened and cxternallv
ro~atcd.
"
H I P FRACTURE
Discussion
ID/CC
HPI
PE
Leg sligh try flexed; rnarkecl tenderness otl medial aspect of knee
(clamagc to medial cnlla~eralliprnen t) and a11[prior knee joint
spacc (damngc to m e d i ~ meniscus):
l
positive anterior h w e r
sign ( r u p h ~ r e dantrrior cruciate lipment); marked b e e effusion.
Labs
Imaging
Treatment
FigureA-089 l ~ t ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ i ~ ~ ~ ~ t ~ ~ ~ l ~ l ~ ~ ~ ~ .
valqr~qstrrss on thr knrc to assrss hinrtinn of thr mrdical collateral
liga~nent.
KNEE-COMBINED
KNEE INJURY
'Discussion
lD/CC
HPI
PE
Imaging
XR. knee: sli~1:lltawlsio~iof ti bial tube-rclc with nsseotlq reqorplion ni~dnew bone formarion. res~iltingin a fragmented appeal-atlce oT the secondary ossification center:
Treatment
Discussion
Gross Pathology
Micro Pathology
Treatment
Discussion
LEG-COMPARTMENT
SYNDROME
ID/CC
HPI
PE
Labs
Imaging
Treatment
XR, pelvis: fractlire of pelvis hilateralh. Retrograde ~lrcthrogmphy: membranous urethral rupture with extravasation of con11-a~tmrdia outside the peritoneal c a ~ l t y CT:
.
large henlaloma
smrot~nding reginn nf pelvic frac~t~rm.
Treat shock. Drain urinr collection. Suprapubic cystustonly;
Discussion
PELVIC FRACTURE
ID/CC
HPI
PE
Labs
Imaging
ill
hlond: n o dl-ligs in
Treatment
Discussion
P SHOULDER DISLOCATION
b ?W,
I DJCC
HPI
PE
Imaging
XR. d~oulcfer(stress view): 1O-pnunclweight suspended from prltient's tvris~cauqes mal-kerl ~ep;lrationat acromiocla~icularjoint
wit 11 acrotnial depresqion.
Treatment
Discussion
SHOULDER SEPARATION
ID/CC
A .l%-\re;t~--uld
mall con~plainsof lower back pain that began after
IIP lifted heavy objects while l~elpinghis son move out or the
famiIv home.
HPI
PE
Imaging
MR. lambar spinc: Focal hcrniarcd disk cuntrally at L+L5 touchi n s 25 I-oot.
Treatment
Phy4ntherapy I~erlrmt: ac~lpllrlrimrr;rhil-opractir thcrap. if sy-mptom5 are nlilrl. Consicler surgical lami~lectnmv
o r Iminotomy if
pain I - ~ c o m prop-essive
e~
o r neurologic dcficits arc present.
Discussion
I.,
.-
SPINE-PROLAPSED
INTERVERTEBRAL DISK
ID/CC
HPI
PE
Imaging
- 1
Treatment
Discussion
.smmdttu(ssaanpo~da~
snxqd p ~ t ? ZjaI
~ qr a m aorssna~ad
:i(.la~.reIr-c!At:pqnr ~ 3 3 ~1 2 2 z0 m q :(.I.s~~~.I
s&~\iost
q r ) I y8!e.t1s
B r t ! ~ uarlM
j
11?1rr~ou
01 srrln1a.r frron~~~dsrr!
rr! ylea.iq ~slrl3urplotl
prrr! %rml!s ; ) I ~ M1.~31at11 OJ pearl S ~ F . I I I1I11,7!1rd r r a l n r SI? I p n l ST?
(X.1a1~euepiqsqns s n t p plrr: apsnnr .io!Jalrrr! s n u n l m s sassnrdrrro:,
q!.~1 ~ 3 ! . 4 ~ . 1IIIJI?
)
JO rlng3npqe uo aqnd pIpe.1 3jal paqspqnna
3d
23/11]
ID/CC
HPI
PE
Labs
Imaging
Nerve cur~cluctionstuclies of median nerve show rlecrea~edconrlucr ion velnciiy atlil increawrl lalei7cy as tlerve en tel-s I~and.
Treatment
Discussion
Carpal h ~ n n e s!rndro~n~'
l
is a tvpc of stcnusing tcnvs~moritis131al
is sccn in p ~ o p l cw h o use their hands in a rcpetitire fjshiorl
(r.~.,
[hose rvl~oure cntnputers) . Thc median nerve lies I~etween
the flexor carpi radialis and flexor digitorurn sublimis tendons,
arid it is coverrd bv the flexor retinaculurn. In all. here are nine
tendons in the tunnel ihat compress ihe nerve agninrt the
retinac~rlurn.
WRIST-CARPAL
TUNNEL SYNDROME
ID/SC
HPI
Imaging
Treatment
ImmobiIizaliorl in a Ir>ng-areathunlb rpica cast, which inln~nkili7es he first thumb phalanx urltil there is radiologic evidence
of fracture healing (may takr tnore than 10 weeks).
Discussion
T?lu scaphoirl and Iunate honeq articulate wit11 the radiw. The
scaphoid is a boat-shaped carpal hone that has a tuhercle;
Cracturcs mas involve Lhe tuhercle, the proximal pole, er llie
middle I hird. 'I'lie fracture oftcn guc5 LITII-ecognizetl,
and thcre
is a chance oCavasm11arnecrosis, rnainiv in disl>lacerlproximal
poIr fracnrrrs, since tlie scaphoirl bone. like the talus and
femoral hrad, has a very tenuous bloocl srlpplv.
WRIST-SCAPHOID
FRACTURE
ID/CC
HPl
PE
Mnclerate hleccling (superficial branch of radial artcry}; inahiliry LO flex wrist (severed tenclon oFpalmaris Iortgnr);failure to
oppose rhumb and anesthesia owr thumb and fil-st/second
digits (paralvsis d t h e n a r muscles and loss of scnsatiorl due to
severed median neme): thumb abd~ictionstill possible by
a b d ~ ~ c tpchlicis
ar
l o n ~ ~innervated
s,
by radial nerve.
Treatment
Discussion
WRIST-SLASH
INJURY
ID/CC
HPI
PE
S~tprarlavicttlart~odushard and enlarged (cancrr has inr tastasizcd to these sentillel node$);ltmg fields filled wit11 disseniin a z ~ ccrackIcs
l
and 1- ale^: chesl barrcl-shapccl (ul~clrrlvit~g
er~~pl~vrenia)
: c111hbing of t?nger.rior1 hot11 hands: patches of
velvety hyperpipentation (AC:,IN I Hr)srs NIL:RI~A~.;S) of both lower
Icp: purpunr s l ~ > t .seen
s
on chest a i d arms.
Labs
Imaging
Micro Pathology
Treatment
CXR: k m mass at lcft lung h i I m ruith thickenii~gof paratrachcal stripes a n d hilar fi~llr~css.
S p u ~ u c)tology
r~~
and lymph tlnde Ijiopsy sllow small-cell
carcinoma.
juvnnt anrl i m r n ~ w ~
c ~l ~ c ~Overall,
~pv.
rate.
Discussion
1 *
LUNG C A N C E R L Y M P H A T I C METASTASIS
ID/CC
HPI
'I'he ~ ~ r e l l i nI1a~
g gotten prngrcwivcIy worse over the paqt sevel-al
months. In arldition. hcr voice. has ht-conie home nrTer-the samr
period of timc (the rctlrr-rc11tlar-?r~~eal
nerve is 11aral77edd u e
to cotnpre5sir~nhv tllc tunlr~r).
S
Z
>
;El
PE
Labs
Imaging
Gross Pathology
Micro Pathology
Treatment
~'s
i s ~ll.odaced
1311anv tumor in close
Di5c~ssion P;i t ~ c n i ~ swndr.c~rti~
proximity to the thoracic idet x ~ i dbv the coiiqeq~~en
I
cr~mprrssionor thc I>rzlclibl plcs~isanrl hnr h I lir vrnous retzlrn
and ar-tck~lflow.
41
LUNG CANCER-PANCOAST'S
SYNDROME
<