Interested in improving physical exam skills 4th Year Elective MASTER PHYSICAL DIAGNOSIS 28-518 Block IV b J

1. Interested inimprovingphysical exam skills?4th Year ElectiveMASTER PHYSICAL DIAGNOSIS 28-518 � Block IV b (Jan 29-Feb 25 2007) Goals Master / improve physical exam skills Be proficient in interpreting phys diagn literature Use the physical exam as a diagnostic test If interested, contact Carlos Estrada, MD, MS cestrada@uab.edu

2. Clinical Problem Solving December 19, 2006 Discussant: Mark Stafford M.D. Presenter: Stanford Massie M.D.

3. Case #1 53 y.o. WM c/o right eye pain Reports puff of dust into eyes 1 week ago, feels irritated since then, but no foreign body sensation Notes redness of eye with swelling Started with itching, then swelling, then clear white discharge Also notes some numbness around eye Eye is now partially swollen shut Denies visual loss, double vision, F/C, matting of the eye or sick contacts Denies prior visual or eye problems Brought in by daughter. Patient lives next to RR track, was standing nearby when train passed. Says he felt cloud of dust go up and into eye. Brought in by daughter. Patient lives next to RR track, was standing nearby when train passed. Says he felt cloud of dust go up and into eye.

4. Case #1 PMH: Chronic Allergic Rhinitis Alcohol abuse (12 beers/day) SC CA of Right flank s/p excision 2002 Epistaxis Meds: none SH: construction worker, no IVDU or tobacco. +h/o unprotected sex FH: Colon CA (F), no glaucoma

5. Case #1 ROS: Notes purulent sinus drainage for several weeks. Has chronic sinus congestion and runny nose due to his allergic rhinitis. Those sx�s haven�t changed much.

6. Case #1 VS: 160/117 P103 AF Pain 5/10 Gen: A&O, smelled of alcohol HEENT: PERRLA, EOMI without photophobia Right eye with periorbital edema, nearly swollen shut Erythema, medial canthus draining pus Sclera injected but no abrasions or FB Left eye normal Nares patent with clear drainage Rest of exam unremarkable

7. Case #1 Data: WBC 8.4 with normal diff, Hgb/PLT normal Chem 7, coags normal Patient admitted to hospital for IV abx CT orbit: Right sided sinusitis with erosion through ethmoid sinus into preseptal area Complete opacification of frontal sinus

8. Key distinction is preseptal cellulitis vs. orbital cellulitis. Former involved infection/inflammation anterior to the orbital septum. Orbital cellulitis involves infection posterior to the orbital septum, particularly fat and muscle contained within the bony orbit. Key distinction is preseptal cellulitis vs. orbital cellulitis. Former involved infection/inflammation anterior to the orbital septum. Orbital cellulitis involves infection posterior to the orbital septum, particularly fat and muscle contained within the bony orbit.

10. Preseptal vs. Orbital Cellulitis Both can present with fever, redness and swelling of eye and surrounding structures Both are most common in children 1-3% of cases of sinusitis will lead to orbital cellulitis Preseptal cellulitis associated with infection of local structures, trauma, insect/animal bites or foreign bodies

11. Preseptal vs. Orbital Cellulitis Preseptal Cellulitis Less commonly associated with sinus infections Rarely leads to serious complications Treatment as outpatient in most cases Orbital Cellulitis Serious morbidity and mortality possible 1-2% mortality 3-11% vision loss Much less common 73-94% of cases caused by coexisting sinus infection

12. Key features to distinguish:Preseptal vs. Orbital Cellulitis Pain with eye movement: more common in orbital cellulitis, can also occur in preseptal cellulitis. Chemosis (conjunctival swelling): far more common in orbital cellulitis but has been observed in severe preseptal cellulitis. Orbital cellulitis, (not preseptal cellulitis) causes: Proptosis Globe displacement Limitation of eye movements Double vision Vision loss (indicates orbital apex involvement)

13. A computer-generated image of the reconstructed face of St. Nicholas that was produced by Image Foundry Studios based on the model that was made by Caroline Wilkinson. Courtesy of Image Foundry Studios/Anand Kapoor.  December: The Many Faces of Santa Claus Long before Clement Moore, Thomas Nast, and Haddon Sundblom gave us our modern concept of that �right jolly old elf,� St. Nicholas was the Bishop of Myra, a Christian city in Asia Minor, in the fourth century c.e. A prominent figure in the church during his life, Nicholas became far more prominent�superhuman, in fact�in legend in the centuries that followed his sainthood. Regarded highly in legend for his kind deeds and good acts, if St. Nicholas had a specialty, it was children. He was, in fact, the patron saint of children (among many other classes of people, churches, and geographical locations). Some of his legends have him even more specialized, focusing on rescuing children of the poor who�d been sold or captured into slavery. He accomplished these feats through acts of gift giving and by more �miraculous� means, such as flight. Surely, the face of this man would be rosy-cheeked, smiling, and beatifically kind�something between Moore�s description and the Catholic Church�s favorite portraits of recent popes. But old St. Nick�s face has been carefully reconstructed, using modern forensic techniques, and the face that resulted wasn�t exactly straight out of an animated Christmas special. What are believed to be the bones of St. Nicholas are kept in a sacred crypt in Bari, Italy. They were exhumed in 1953, during some work that was being done on the church, and an anatomist from a local university, Luigi Martino, was given permission to examine and x-ray the remains. A half-century later, an anthropologist named Caroline Wilkinson used those data to produce a clay model of St. Nicholas, employing the same techniques that are used to build an identity onto the skull of the victim of a suspected crime. If the face that Wilkinson produced had been that of an actor looking for work as an extra in Hollywood�s golden era, he would have been plucked right off the street, broken nose and all, and cast as a longshoreman or a mob thug. The features are square and heavy, and he probably had a swarthy cast to his complexion. It�s hard to picture him in the outfit that Clement Moore assigned to him, but then, he was a fourth-century Catholic bishop and probably usually wore something a bit more ceremonial. A computer-generated image of the reconstructed face of St. Nicholas that was produced by Image Foundry Studios based on the model that was made by Caroline Wilkinson. Courtesy of Image Foundry Studios/Anand Kapoor. December: The Many Faces of Santa Claus Long before Clement Moore, Thomas Nast, and Haddon Sundblom gave us our modern concept of that �right jolly old elf,� St. Nicholas was the Bishop of Myra, a Christian city in Asia Minor, in the fourth century c.e. A prominent figure in the church during his life, Nicholas became far more prominent�superhuman, in fact�in legend in the centuries that followed his sainthood. Regarded highly in legend for his kind deeds and good acts, if St. Nicholas had a specialty, it was children. He was, in fact, the patron saint of children (among many other classes of people, churches, and geographical locations). Some of his legends have him even more specialized, focusing on rescuing children of the poor who�d been sold or captured into slavery. He accomplished these feats through acts of gift giving and by more �miraculous� means, such as flight. Surely, the face of this man would be rosy-cheeked, smiling, and beatifically kind�something between Moore�s description and the Catholic Church�s favorite portraits of recent popes. But old St. Nick�s face has been carefully reconstructed, using modern forensic techniques, and the face that resulted wasn�t exactly straight out of an animated Christmas special. What are believed to be the bones of St. Nicholas are kept in a sacred crypt in Bari, Italy. They were exhumed in 1953, during some work that was being done on the church, and an anatomist from a local university, Luigi Martino, was given permission to examine and x-ray the remains. A half-century later, an anthropologist named Caroline Wilkinson used those data to produce a clay model of St. Nicholas, employing the same techniques that are used to build an identity onto the skull of the victim of a suspected crime. If the face that Wilkinson produced had been that of an actor looking for work as an extra in Hollywood�s golden era, he would have been plucked right off the street, broken nose and all, and cast as a longshoreman or a mob thug. The features are square and heavy, and he probably had a swarthy cast to his complexion. It�s hard to picture him in the outfit that Clement Moore assigned to him, but then, he was a fourth-century Catholic bishop and probably usually wore something a bit more ceremonial.

15. Case #2 25 y.o. AAM presents c/o fever Initially seen by PCP in Tuscaloosa 1 week ago with fever, H/A and myalgias and given Zpak without improvement Since then has developed N/V and H/A and fever have gotten worse Fevers typically at night, usually~102 H/A is frontal, mild aching sensation in neck

16. Case #2 ROS: He denies: cough, dysuria, joint pain or swelling, rash, weight loss,, visual changes. No known tick bites or sick contacts

17. Case #2 PMH: None Soc Hx: Military reserve, recent stint in Afghanistan (returned 9 months ago). Sexually active with girlfriend, works in auto parts store. Part time student at local college. No Tob/drug use, occasional Etoh FH: noncontributory

18. Case #2 VS: 126/72 P 80 T 99.0 Gen: alert and appropriate, NAD, mildly diaphoretic HEENT: unremarkable, no adenopathy, no meningismus or photophobia Cardiac: RRR without M/G/R Lungs: clear Abdomen: soft, no organomegaly or masses Skin: no rashes or petechiae

19. Case #2 WBC 7.0 with a normal Differential Hct 29 (MCV normal), PLT 200 Chem 7 normal LFT�s normal except TBili 2.5, IBili 2.0 LDH 290 INR normal Initial peripheral smear normal One done during fever ? intracellular plasmodium vivax As it turns out, patient only took recommended prophylaxis for a short time. He reports that he and several buddies decided to stop it after they heard it could cause liver problems. As it turns out, patient only took recommended prophylaxis for a short time. He reports that he and several buddies decided to stop it after they heard it could cause liver problems.

20. Fever in the returning traveler �Fever in the returning traveler should always raise suspicion of severe and potentially life-threatening infections. Of these, malaria should be considered first and foremost; with an appropriate exposure history, fever in the returned traveler should be assumed to be due to malaria until proven otherwise.�

21. Malaria Four species cause disease, transmission via bite of female Anopheles mosquito 300-500 million cases, 3 million deaths annually world wide 1324 U.S. cases in 2004 (4 were fatal) Of 775 cases that year, only 20 percent reported that they had followed a chemoprophylactic drug regimen recommended by the CDC for the area to which they had traveled.

22. Malaria : Clinical features Incubation period 12d to years Species type determines clinical features Vivax most common cause of infection Falciparum most serious illness Bite?bacteremia?hepatocyte stage? erythrocyte stage Asymptomatic until erythrocyte stage (1-4 weeks)

23. Malaria : Diagnosis Thick and thin smears of peripheral blood are the mainstay of diagnosis Best if blood obtained during febrile period 95% positive on first smear Despite that, smears should be repeated q6-8hrs. for 48 hrs. to rule it out Thick smear for screening, thin for speciation

24. Actual patient smear: ringed form trophozoite, intracellular parasites, varying RBC morphologyActual patient smear: ringed form trophozoite, intracellular parasites, varying RBC morphology

26. Prior to 1973, cut trees were donated for the Pageant of Peace. In that year, a 42-foot blue spruce from northern Pennsylvania was donated by the National Arborist Association, with the idea that it would serve as a permanent National Christmas Tree. Unfortunately, in 1976 that tree began dying, and the following year, a new replacement tree was blown over during a wind storm. In 1978, a 40-foot-tall living Colorado blue spruce, donated by an anonymous family in Maryland, was transplanted to the Ellipse where it has served as the National Christmas Tree ever since. What once was a single Christmas tree, now includes a main tree with 56 smaller trees -- one for each state, territory, and the District of Columbia -- lining the Pathway of Peace. More than 75,000 lights illuminate this year's display, and to signify the beginning of the new Millennium, the National Christmas Tree will remain decorated with multi-colored lights until midnight of New Years Eve, at which time it will change to an all-white illumination, with accents of red garlands and blue in the star. Prior to 1973, cut trees were donated for the Pageant of Peace. In that year, a 42-foot blue spruce from northern Pennsylvania was donated by the National Arborist Association, with the idea that it would serve as a permanent National Christmas Tree. Unfortunately, in 1976 that tree began dying, and the following year, a new replacement tree was blown over during a wind storm. In 1978, a 40-foot-tall living Colorado blue spruce, donated by an anonymous family in Maryland, was transplanted to the Ellipse where it has served as the National Christmas Tree ever since. What once was a single Christmas tree, now includes a main tree with 56 smaller trees -- one for each state, territory, and the District of Columbia -- lining the Pathway of Peace. More than 75,000 lights illuminate this year's display, and to signify the beginning of the new Millennium, the National Christmas Tree will remain decorated with multi-colored lights until midnight of New Years Eve, at which time it will change to an all-white illumination, with accents of red garlands and blue in the star.

27. Case #3 47 y.o. WF c/o abdominal pain for 6 weeks Started suddenly; now a persistent, dull ache Located in LUQ and epigastric areas Does worsen with eating at times, associated with bloating too The pain does not radiate elsewhere No relief with OTC antacids No N/V, diarrhea, constipation or change in bowel habits

28. Case #3 No prior abdominal surgery No F/C, weight loss, trauma No travel or sick contacts No urinary complaints

29. Case #3 PMH: Tonsillectomy Knee arthroscopy Hyperlipidemia Meds: Aspirin daily, Advil 2-3 times/wk Soc Hx: No Etoh/drugs, tobacco 10 pk yrs FH: Colon CA (PGF 60�s), CAD (F-70�s)

30. Case #3 VS: 140/80 P-78 R-16 Afebrile Gen: Alert and oriented, mild distress HEENT: No adenopathy Abd: soft, NT, +BS in all 4 quadrants. Liver span 14 cm, spleen palpable Rectal: Heme negative Skin: No rashes or petechiae

31. Case #3 WBC 4.5 with normal differential Hct 34, PLT 120 Chem 7 normal LFT�s normal including GGT (TBili 1.4). Amylase/Lipase normal Hepatitis panel negative

32. Case #3 CT Abdomen: Splenomegaly with extensive collateral circulation. Poor portal vein flow. Liver normal, no evidence of cirrhosis. US Abdomen: Spleen 20 cm EGD: grade 2 varices

33. Portal Vein Thrombosis Obstruction to flow in the portal vein leads to portal hypertension Portal hypertension is classified based on the site: Prehepatic, intrahepatic, posthepatic Intrahepatic is further divided into pre-sinusoidal, sinusoidal, post-sinusoidal

34. Portal Vein Thrombosis Primary cause of Portal HTN in 8% of pts in one series (adults and children) Another study of hospitalized pts. with cirrhosis who had routine U/S found: 11% with PV thrombosis Of those, 43% were asymptomatic, 57% had sx�s referable to the PV thrombosis 25% of adults with PV thrombosis have underlying cirrhosis

35. Causes of Portal Vein Thrombosis Abdominal sepsis Cirrhosis Collagen vascular diseases (eg, lupus) Compression or invasion of PV by tumor (eg, pancreatic CA) Endoscopic sclerotherapy Factor V Leiden Hepatocellular carcinoma Inflammatory bowel disease Myeloproliferative syndromes Omphalitis Oral contraceptives Pancreatitis Paroxysmal nocturnal hemoglobinuria Pregnancy Protein C deficiency Prothrombin gene mutation Retroperitoneal fibrosis Transjugular intrahepatic portosystemic shunt Trauma

36. Causes of Portal Vein Thrombosis Abdominal sepsis Cirrhosis Collagen vascular diseases (eg, lupus) Compression or invasion of PV by tumor (eg, pancreatic CA) Endoscopic sclerotherapy Factor V Leiden Hepatocellular carcinoma Inflammatory bowel disease Myeloproliferative syndromes Omphalitis Oral contraceptives Pancreatitis Paroxysmal nocturnal hemoglobinuria Pregnancy Protein C deficiency Prothrombin gene mutation Retroperitoneal fibrosis Transjugular intrahepatic portosystemic shunt Trauma

37. PV Thrombosis: Clinical Features Variceal bleeding common Splenomegaly can be massive Ascites is rare without cirrhosis LFT�s may be normal

38. PV Thrombosis: When to consider Sudden deterioration in Chronic Liver Disease Known coagulopathy Varices without cirrhosis Splenomegaly Known Cirrhosis

40. Contrast-enhanced CT scan of the liver in a 27-year-old woman with a systemic coagulation disorder demonstrates a large thrombus in the portal vein (large arrow) which is preventing contrast from entering the main portal vein. The liver is being perfused via hepatic arteries (small arrow). Courtesy of Jonathan Krukal, MD. Contrast-enhanced CT scan of the liver in a 27-year-old woman with a systemic coagulation disorder demonstrates a large thrombus in the portal vein (large arrow) which is preventing contrast from entering the main portal vein. The liver is being perfused via hepatic arteries (small arrow). Courtesy of Jonathan Krukal, MD.

41. In 1836, Alabama is the first state in the USA to declare Christmas a legal holiday. In 1836, Alabama is the first state in the USA to declare Christmas a legal holiday.