Put on your big girl PANCE

Drug eruption

***

Kaposi sarcoma

***

Left bundle branch block

***

Orthostatic hypotension

***

Paronychia

***

Pulmonary regurgitation

***

Right bundle branch block

***

Aortic insufficiency (regurg)

- DeMusset sign (head bobbing) - Muller sign (rhyhmic pulsation of uvula) - Quincke pulse (arterial pulsation in nail bed) Suspected diagnosis

- Mitral stenosis - Age, weakness and hemoptysis, opening "snap" of diastole - If grew up in Haiti - likely rheum fever, if not, could be pregnancy - A fib - Heart rate - so ventricle can fill - Pulmonary edema, decline in exercise

28 yo Haitian woman admitted for transient weakness, palpitations and then hemoptysis. PE shows normal vitals, irregularly irregular heart rate, 2/6 systolic murmur, 1/6 diastolic murmur, loud sound in diastole. What do you think she has? Why? What likely caused it? What other diagnosis is associated with her rate/rhythm? What is important to control? What is important to control? What symptoms indicate valve replacement?

- Genital herpes simplex virus - Direct viral culture or PCR - Tzanck smear - The -cyclovirs to decrease symptom but can also resolve on it's own - Use condoms - can spread without symptoms

32 year old female patient with "a bunch of painful vesicles along my bikini line that have a red base." What does she have? How do you test for it? How do you treat it? Any instructions?

- SVT - cardiogenic shock - dysrhythmia (SVT or VT), cardiomyopathy (infarction), mechanical (valvular) - No - STEMI is - *left* causes pulmonary edema, *right* causes peripheral edema and JVD - cardiac enzymes - mechanical (diuretics, surgical correction), cardiomyopathy (CABG or fibrinolytic), dysrhythmia (tachy with cardiovert, brady with external pacing or atropine)

32yo M (PA student) BIB roommate CC: awoke w/ SOB/palps x3h, light headedness, nausea, CP. Denies: V/D/F/C/HA/neck pn/ill contacts. Studying for finals all day. PMHx: None Meds: None Habits: denies tob/drugs; "2 beers" earlier VS: HR=180 regular BP=88/60 RR=28 O2 sat=95% Afebrile. PEx: Anxious Lungs: CTA Extr: no edema. EKG: (attached) What does the ECG show? What is he at risk of developing? What are the three types? Is this the most common cause? What are the symptoms of left vs right sided? What are important labs to add to your typical workup? How do you treat the three kinds?

- HTN urgency (elevated BP *without* end organ dysfunction) vs HTN crisis (elevated BP *with* end organ dysfunction - Urgency treated with monitoring and oral meds, crisis treated with IV blood pressure medications - IV nitroprusside or IV labetalol

58 yo M coming to the ED with a blood pressure reading of 190/100 at CVS. What are the two types of HTN issues you need to differentiate here? How do their treatments vary? What is the drug of choice for crisis?

- Atrial septal defect - EKG - RBBB and right axis deviation - Echo - Surgery or catherization if symptomatic - if 1-3 yo, closure can still be spontaneous

A 14 year-old boy whose chief complaint is that he tires easily, is sent by his pediatrician to a cardiac referral for evaluation. The cardiologist found the patient's general appearance to be unremarkable. Listening to the boy's heart, he heard a wide split second heart sound and a pulmonary flow murmur. What do you think is going on? What is your next diagnostic test? What will this show? What do you do after that? How do you treat?

- Coarctation of the aorta - Narrowing of proximal descending aortic arch - EKG (usually reveals left ventricular hypertrophy), CXR, and echo - First stabilize with prostaglandin, then surgical repair

A 15 year old male patient presents to the clinic with chest pain when he is playing soccer. The vitals taken by the MA reveal a blood pressure of 150/90 on RUE. Because you are an awesome and savvy PA, you check his blood pressure on his left leg, which is 120/70. You listen to his heart and hear a murmur in the left axilla. CXR demonstrates the *"3 sign"* What do you suspect is going on? What is that? What is a normal UE vs LE BP change? What diagnostic work up will you do? How do you treat?

- Deep vein thrombosis - Pulmonary embolism - OCP - Acute - LMWH/heparin bridge to warfarin for 3 mos. Each treatment individualized to patient.

A 28 year old woman presents to urgent care with posterior right knee pain. She doesn't recall any injuries and she went for a run yesterday but that is her typical exercise. She is worried she tore her ACL. Upon physical exam her knee joint is completely unremarkable, but she has swelling and warmth in the popliteal fossa. The patient does not have any pertinent medical history and her only medication is birth control. What do you think could be going on? What is the biggest complication of this? What likely caused it? How do you treat?

- Aortic insufficiency (regurg) - Lowered diastolic pressure, SOB, systolic and diastolic murmurs - Syphilis (rash on hands/feet) - Symptoms: aortic valve replacement - No symptoms: Rx that decreases after load (ACE, CCB)

A 32 year old man with active IV drug use presents with dyspnea, cough, hemoptysis, fever and a "new rash" on his hands and feet. PE shows BP 145/50, R20, 92%o2 on room air, 2/6 sys murmur, 2/6 diastolic murmur heard over right 2nd rib space and apex. What do you think he has? What made you think that? What caused it? How do you treat if symptomatic? No symptoms?

- Pericarditis - Myocarditis (inflammation/infection of heart muscle) and pericarditis (inflammation of the pericardium) are similar, but pericarditis chest pain is relieved based on position and has ST changes consistently - the two may coexist in 20-30% of patients - Diffuse ST elevation with PR depression - Echo - Limit exercise until symptoms resolve, NSAIDs/ASA, colchicine to prevent recurrences. If severe, pericardial stripping.

A 36 year old woman comes to urgent care 2 weeks after an upper respiratory infection. She is concerned because she has had chest pain and difficulty breathing. When she lies down, the pain gets worse. Cardiac PE reveals a friction rub. EKG She recently had a cold. What are you concerned she has? What is the difference between this and myocarditis? EKG findings? What is the recommended imaging?

- Mitral insufficiency (regurg) - Likely congenital in this case - can also be caused by chordae tendineae rupture, degeneration, infection or inflammation - Valve replacement if symptomatic or LVEF is less than 60%

A 40 year old man is seen by his primary care physician for recent shortness of breath and easy fatiguability. Upon PE, you hear a pansystolic blowing murmur heard at the abpex which increases with expiration and radiates to the axilla. What do you suspect is going on? What caused it? How do you treat?

- Cardiac tamponade - increased fluid and pressure in pericardium - Most common: trauma (knife wound) or metastatic cancer - Echo - Give oxygen, give bolus of saline to maintain volume expansion - call cardio for consult for thoracotomy and pericardiocentesis - Diuretics or nitrates which can cause hypotension

A 47-year-old woman presents to her oncologist with decreased exercise tolerance. She was diagnosed with breast cancer 3 years ago and has undergone radical mastectomy, radiation, and aggressive chemotherapy. Despite these measures she was diagnosed recently with metastatic disease. She seems anxious and tachypnoeic, has an elevated JVP, and her heart sounds are muffled. Her blood pressure is 90/50 mmHg, heart rate is 110 beats per minute, and pulsus paradoxus is 15 mmHg. What do you think is going on? What is that? What can cause it? How do you diagnose? How do you treat? What is contraindicated?

- Restrictive cardiomyopathy - Amyloid structural proteins are infiltrating the muscles of the heart making it less elastic so it cannot fill, but it can pump - Very uncommon form of cardiomyopathy - Echo is necessary - REFER to cardiologist, treatment depends on amyloid protein and disease extent (can also effect kidneys, liver or other organs) - may involve chemo, bone marrow transplant, or heart transplant

A 50 year old man comes to your clinic with recent syncope, fatigue and weakness, shortness of breath, and numbness. PE reveals a periorbital purpura, thickened tongue and hepatomegaly. Echo reveals ventricular flow is not effected with respiration. What do you think he has? What is going on? Is this common? What is the key diagnostic test? How do you treat?

- Torsades de pointes - Congenital long QT - With him (stable) IV mag sulfate. If pulseless, defibrillation, if unstable but pulseless, cardioversion

A 54-year-old man with a history of schizophrenia presents to the ED after a syncopal episode. During your evaluation, he becomes diaphoretic and complains of dizziness. You are able to feel a radial pulse, and he is alert and talking with you. His rhythm strip is seen above. What is going on? What is this most commonly caused by? How do you treat?

- Essential HTN - Yes, it accounts for 95% of HTN pts - Lifestyle modifications - If after 3 mos no change in BP, discuss different BP lowering meds and choose most appropriate for this patient (usually thiazide diuretic + ACE, or ARB, or BB, or CCB)

A 60 year old male patient is in your office with the chief complaint of headache for the last month. Your MA's recorded blood pressure is 152/92 and when you repeat it, it is 160/94. Looking at his history, his blood pressure has been slowly increasing over the last two years and was been over 150/90 at his last visit. He does not have a history of elevated kidney function labs, diabetes, or abnormal serum electrolytes. What is his likely diagnosis? Is this a common HTN diagnosis? What *classification* of blood pressure is 160/94? What will be your first treatment discussion? When do you start drugs?

- Tricuspid stenosis - Initially, *diuretics*. If severe, surgical replacement/repair

A 60 year old patient comes in with fatigue and shortness of breath. She has elevated JVP, and you hear a diastolic rumble along the lower left sternal border that increases with inspiration. What do you think is going on? How do you treat?

- Acute arterial occlusion (arterial embolism) - YES - medical emergency - Doppler imaging - Immediate revascularization *within 3 hours* and heparin IV - Statins, aspirin, plavix - treating underlying cause

A 62 year old male patient with a history of claudication comes to your clinic with sudden pain and numbness in his foot. He is afraid he did something to his back. The savvy PA you are, you first check his lower extremity pulses and see he has pallor, coolness, and absent pulses in his foot. What do you think he has? Is this serious? What is the gold standard diagnostic tool? How do you treat? What do you do after treating?

- Premature ventricular contractions (PVCs) - 48 hour Holter monitor - Anyone can get it, but incidence is higher in certain heart disease populations - If no structural disease, PVCs are usually benign - Generally, no treatment - B-blockers and Ca ch blockers if symptomatic

A 72 year old patient presents with palpitations. He reports that he has noticed a strong beat or "flip flop" in his chest off and on since his heart attack 9 mos ago. He reports that the sensation has made him anxious and he is afraid he will have another heart attack. He hasn't had any symptoms today. PE is unremarkable. What do you think he has? How would you test it in this patient? Who gets this? Is it serious? Do you need to treat?

- Pulmonary stenosis - Baby, systolic ejection murmur - Echo - Depends, mild PS only requires cardiac follow up (no therapy), baloon pulmonary valvuloplasty is indicated in severe cases - Tet. of Fallot

A full-term 7.3 lb newborn nondysmorphic girl is found to have a systolic ejection murmur shortly after birth. She is clinically asymptomatic and fully saturated while breathing room air. What could be going on? Why? How do you confirm? Will she need surgery? What other congenital heart disorder involves this diagnosis?

- Sudden cardiac death - Ventricular fibrillation (VFib) - ICD

A patient was clinically well but died within 1 hour without trauma. When paramedics first arrived, EKG showed: What likely happened? What was the cause? How would you have treated this if he were to have survived?

- Atrial flutter - A flutter is not as common, has a regular rhythm and is more difficult to treat. It also has different pathophys - it does not originate at pulmonary veins like a fib does. - But has many similarities (risk factors, increases stroke risk, increases HF risk, etc.). - Generally the same as a fib, but may require cardioversion to terminate rhythm (control rate/ rhythm and prevent clotting)

A pleasant 67 year old woman with unremarkable PMH comes to urgent care complaining of palpitations and chest tightness. She reports these symptoms abruptly started as a racing heart and palpitations 3 hours ago. Her BP is 168/102, and her HR is 142. What do you think she has? What is the difference between this and the other similar diagnosis? Similarities? Management?

- brown recluse - no antivenom, no surgery until stabilized. Provide serial wound evals and most are self-limiting, healing on their own - give tetanus prophylaxis - hospitalize if systemic symptoms

After PA school you want to move somewhere new. You pack your bags and head to Dallas, Texas. Working at an urgent care clinic, you see a 16 year old brought in by his mom. He has been working in the back yard moving a pile of old decking for the last few days. He doesn't remember being bitten by anything, but has this big pimple, his lymph nodes feel swollen and he feels pretty crummy. What do you think is going on? How do you treat? When is it a big deal?

- Herpes zoster - Usually just clinical - or PCR - Antiviral if still open lesions, if not, treatment will not help (symptom treatment) - it should resolve after 2-6 weeks

After my third week of FOCA I noticed this painful rash going across my chest but it's only on one side. Some might say the pimples look like new drops on a rose petal. It is also really itchy. What do I have? How do you test it? How do you treat it?

- Endocarditis - Cat scratch + increased risk from prosthetic valve - Blood culture is the most important tool - 3 sets of cultures 1 hr apart - Major: Two + cultures, new murmur, positive echo - Minor: predisposing condition, fever, elevated immunologic signs, one + culture, positive echo (outside of major criteria) - Mitral valve - Antibiotics - empiric vancomycin then treat with culture results

An 80 year old man comes to the ER with fever after falling in his assisted living facility. He has a history of prosthetic valve replacement. He reports that two days ago he was scratched by his cat and has since been feeling "off." What do you think is going on? What caused it? What is the most important diagnostic tool? What are the major criteria for diagnosis? Minor criteria? What valve is most likely involved? Treatment?

- Varicose veins - Family history and pregnancy - Compression stockings to reduce pressure and prevent progression. Sclerotherapy to fibrose and obliterate target veins. Other options: chemical irritants, hypertonic saline, or ablation.

An otherwise healthy 45 year old woman presents to clinic with "these ugly veins" on the back of her leg. She started to notice them after giving birth to her second child a year ago. She came to see you because they have started to ache when she stands for prolonged periods. What do you call these? What possibly caused them? How do you treat?

- Patent ductus arteriosis - Echo or Ultrasound - Surgery - Hoarseness - RECURRENT LARYNGEAL

During a routine sports physical, the physician noted that a twelve-year-old boy, had a long continuous heart murmur at the second intercostal space near the left sternal border. A systolic thrill was also noted in the same region. When questioned, the patient's mother recalled that the child had periods of cyanosis and breathlessness as an infant, but that his previous pediatrician said that the murmur and the symptoms were nothing to be concerned about. The child mentioned that he tires easily during physical activity. CXR shows slight left ventricular hypertrophy. What do you think is going on? What is your next imaging step? How do you treat? What can be a complication? From what??

- Bullous pemphigoid - Autoimmune disorder effecting sub-dermal tissue - Mild: ultrapotent topical steroids. - Widespread disease: immunosuppressants. If not treated, sepsis.

I am a 65 year old male patient. I started having this itchy hive like bumps, but now they are tender, tense blisters. What do I have? What is going on? How do you treat it? What if it gets worse?

- Giant cell (temporal) arteritis - maybe - Biopsy is definitive - 60 mg prednisone for 1 month then taper

I am a 68 year old woman. I have a headache, and every time I pull my hair back my scalp hurts. I came in because my vision has changed a bit. What is going on? Do we need to test it? How do we treat it?

- Lichen planus - Biopsy to confirm - Idiopathic - Calcineurin inhibitors, steroids, or retinoids

I am a 31 year old patient with this shiny pink itchy rash on my neck (some might call them *planar, purple, polygonal, pruritic, papules, plaques*...). I also have these weird white streaks on the inside of my mouth. What is it? How do you tell? What causes it? How do you treat it?

- Seborrheic dermatitis - Unknown - Selenium shampoos, ketoconazole shampoo - Prone to remission - hypo pigmentation

I am a 45 year old male patient and I have this dry itchy rash on my hairline that almost looks greasy. What is this? What causes it? How do you treat it? Any complications?

- Scabies - Microscopic eval (KOH) - see organism, ova or feces - Permetrhin 5%

I got back from a mission trip in Haiti a week ago. I have severe itching between my fingers and on my wrists. What do I have? How do you test it? How do you treat it?

- Molluscum contagiosum - Poxvirus - Liquid nitrogen (but this can cause scarring) - will also heal with time.

I have AIDS and found these little dome shaped waxy looking papules on my abdomen. What do I have? What causes it? How do you treat it?

- Acne vulgaris - Comedomes (whiteheads) are required for diagnosis of any type of acne - no labs required - Mostly genetics - MILD: topical abx + benzoyl peroxide gels + topical retinoids. MODERATE: add temporary oral abx (minocycline) SEVERE: isotretinoin (acutane) - Scarring

I'm 15 and I have acne... ugh. What do you call it? How do you diagnose it? How did I get it? How do you treat it? What if it gets worse/doesn't get better? Any complications?

- pericardial tamponade - obstruct. - anaphylaxis - distr. - valvular dysfunction - cardio - AAA rupture - hypovol - tension pneumo - obstruct. - SVT - cardio - neurogenic - distrib - trauma - hypovol - sepsis - distr. - infarction - cardio - adrenal insufficiency - distrib. - massive PE - obstruct

Identify the following as hypovolemic, distributive, obstructive or cardiogenic shock. - pericardial tamponade - anaphylaxis - valvular dysfunction - AAA rupture - tension pneumo - SVT - neurogenic - trauma - sepsis - infarction - adrenal insufficiency - massive PE

- Seborrheic keratosis - Cryotherapy

My wife wanted me to get these weird "barnicles" on my back checked out. They sometimes get caught on things and are pretty annoying. Otherwise they aren't painful or itchy. What are they? How can we get them off?

- Rosacea - Unknown what causes it - acneform diagnosis with capillary involvement - Avoid triggers (hot liquids, alcohol, spicy food and sun exposure) - Topical metronidazol - Rhinophyma (elarged nose) or ocular involvement - systemic doxycycline

My cheeks get like this every time I drink hot tea. I haven't been out in the sun too much recently, and there aren't any pimples. What do I have? What is going on? How do you treat it? I can't do that... any medications? What happens if it gets worse?

- Alopecia areata - Unknown, suspected immunologic origin - Injected corticosteroids

My hair is falling out in well circumscribed, circular areas. The skin isn't scarring, but my beard and eyebrows are also involved. What is this called? What causes it? How do you treat it?

- Head lice - pediculosis capitis - Look at nape of neck and behind ears for LIVE louse (not nits = eggs or shells) - Permetrhin cream 1% (for 10 minutes then rinse) or go to a lice salon :)

My kid came home from school and has been itching his head... it it what I think it is?? What do I have (specific)? How do you test it? How do you treat it?

- Cellulitis - Blood- + cultures or neutrophilia - Gram + cocci - Oral abx if outpatient - IV abx may be required depending on bug

My left leg had a small tender patch that has grown and covered my entire foot over the last day! My right leg looks fine. My lymph nodes are also swollen. What do I have? How do you test it? What causes it? How do you treat it?

Endocarditis

Osler nodes and Janeway lesions - suspected diagnosis?

True When it leads to increased pericardial pressure limiting cardiac output = cardiac tamponade

T/F: Most people with effusions had no recognizable cardiac disease. When does a pericardial effusion become a problem? ***pericardial effusion

- Malignant melanoma - Superficial spreading (70% of melanomas) - Depends on stage/depth - excision, possible lymph node dissection - Most malignant tumor of the skin - metastasize

Upon doing a routine DRE, you notice a strange mole on your patient's upper posterior thigh. He says he has never noticed it before. As the savvy PA you are, you perform a biopsy. What does the patient have? What kind? How do you treat it? What is the risk of not removing it?

1. Lavine sign - hand to chest 2. Cigarette - smoking increases risk 3. Restaurant - recent foo intake can trigger 4. Brief case - increased stress/work load can trigger 5. Cold temperature - can trigger 6. Stairs - exercise can trigger

What are the 6 things in this picture that point you toward angina pectoris?

- Angina pectoris: relieved by rest, ECG normal at rest, nitroglycerine improves - Unstable angina: chest pain *not* relieved by rest - Admit unstable angina to r/o heart attack, treat stable with nitro, ASA, statin, TLC unless risk factors. - Both have ST depression and similar prevention

What are the differences between stable and unstable angina pectoris? How do their treatments vary? Similarities?

- Ventricular tachycardia (VTach) - Usually caused by acute MI - Not good prognosis if not from acute MI - ICD, amiodarone, or ablation therapy

What is it called if there are 3 or more beats on an EKG with wide QRS complex at a rate of >100 BPM? What likely caused this? If that wasn't the cause, is prognosis good? How do you treat?

A. ASD is not part of it Overriding aorta is missing

Which of the following is not a component of tetralogy of fallot? A. ASD B. VSD C. Pulmonary stenosis D. Right ventricular hypertrophy BONUS: Which on is missing?

- Abdominal aortic aneurysm - 80% are asymptomatic - 90% are below the renal arteries - typically is at the aortic bifurcation - Abdominal ultrasound - If diameter exceeds 5 cm - ultrasound eval every 6 mos, elective repair if diameter >5.5 cm or rapidly expanding aneurysm. - Prognosis is poor for rupture - most don't make it to the hospital in time, and surgical survival is 50%

You are seeing a 57 year old male patient with mild low back pain. He attributes it to working in construction his whole life. Upon physical exam, his back exam is unremarkable, but he has marked tenderness in one point of his abdomen. Vitals are within normal limits. What do you think he has? Are these typically symptomatic? What is the most commonly affected vessel? What diagnostics will you do? How do you treat? What if it ruptures?

- Combination of four cardiac abnormalities (pulm stenosis, large VSD, overriding aorta, RVH) due to anterior deviation of the infundibulum septum - Listen to that murmur! - Palpate for thrill, check for cyanosis - Surgery by 2 yo

You are dong your rotation in family medicine. Looking at the schedule, you see a 6 day old newborn is on the schedule (!!). Using Care Everywhere, you review his chart from Legacy, where he was born. You see the diagnosis of Tetralogy of Fallot and think, hm, we learned about this in ped.... What was that again? What PE are you going to do first? What other things will you look for? When discussing treatment, when should he have surgery by?

- Androgenic alopecia - Yes - stages I: hair loss in front, stage II: hairloss in front and back, stage III-V - Oral finasteride (androgen receptor blocker on hair follicle) Prince William of course!

You might recognize me... I came to America to have my thinning hair fixed because I'm pretty high profile at home. What exactly do I have? Are there different stages (what are they)? How can you treat it? Do you know who I am?

- Ventricular septal defect - CXR can show cardiomegaly/pulmonary artery dilation - EKG can show LVH - Because he is symptomatic, surgical closure

You see a 12 year old boy for "blue lips." His mom brought him in when she thought he had just had a blue Slurpee, but he denied any ingestion of blue delicious drinks. Physical exam reveals cyanosis of the lips, you hear a split S2 with a harsh pansystolic murmur. What do you think is going on? How do you diagnose? Is it large or small? How do you treat?

- erythema multiforme - it's on the same spectrum as SJS/TEN but lacks any mucous membrane involvement - associated with HSV or M. pneumonia - *reassurance,* treatment is only supportive and sx improve after 1-3 weeks

You see a 62 year old patient with a strange "target looking" rash. His mother is afraid it is Lyme Disease after hearing about target shaped rashes it on tv. The lesions are painful, on the extensor acral surfaces and face - there are multiple of them. She denies he has any other PMH. What do you think is going on? Why is this an emergency? What bugs are associated with this? How do you treat?

- Tricuspid regurgitation - Diuretics - if severe, IV diuretics. Eliminate cause of right ventricle dysfunction.

You see a patient with peripheral edema and pulsating JVD. Upon cardiac PE, you hear a blowing, corse systolic murmur over the 3rd-5th left ICS sternal border that increases with inspiration. What do you think is going on? How do you treat?

- Left sided heart failure - Low cardiac output and lung congestion - CBC, UA, fasting lipids, CMP, TSH, EKG, BNP/NP-proBNP, CXR - Diuretic + ACE + Beta blocker + statin - Reduce salt intake, modify exercise

Your patient presents with cough, wheezes, restlessness, confusion, tachycardia, fatigue and cyanosis. You listen to his lungs and hear crackles. What do you suspect he has? What is going on? What initial tests will you run? How do you treat? Lifestyle changes?

- Paroxysmal Supraventricular Tachycardia (SVT) - Can occur at any age, typically begins in young adults - ECG, Holter monitor, echo - Vaso-vagal maneuvers at time of episode, meds (adenosine) or SVT ablation

A 19 year old girl comes to clinic complaining of episodic palpitations and dizziness. Symptoms started recently and she has had 2 episodes in the past month. The first episode lasted 5 minutes, the second for 12 minutes and both resolved when she squatted down. Her mom, an RN, checked checked her pulse during her second episode and it was 210 BPM. What do you think she has? Who gets this? What is the work up? What is the treatment?

- Verruca vulgaris - Usually HPV 2 - Liquid nitrogen or salicylic acid

I have these warts on my hands.... They are rough and flesh-colored, the under surface is pink when I pick at them. What do I have? What causes them? How do you treat it?

- Impetigo - S. aureus - Mupirocin ointment or cream

My son has this honey-colored crusted plaque that has been getting bigger. What do I have? What causes it? How do you treat it?

- Candidiasis - Fluconazole

My son has this terrible rash where his diaper sits. He is itching it but it also seems like it is tender. What does he have? How do you treat it?

- Prinzmental (variant) agnina - No, rare - Nitrates are main tx - calcium channel blocker for long term treatment

You are seeing a 45 year old female patient in the ER after she woke up with severe chest pain in the middle of the night. EKG shows ST elevation, but all of her labs (myoglobin and troponin) are normal. What do you think is going on? Is this common? How do you treat?

- Dilated cardiomyopathy (DCM) - Multiple causes - in this case, diabetes and HTN - It is the most common cardiomyopathy (95%) - Echo to confirm LV dilation, CXR to confirm cardiomegaly - ALL on b-blocker and ACE. Other treatment depends on other risk factors/symptoms.

A 65 year old patient with diabetes and uncontrolled hypertension comes to your clinic. They have recently noticed difficulty breathing, edema and fatigue. PE shows rales, elevated JVP, and an *S3 gallop*. What do you think he has? What caused it? Is it common? What diagnostics will do you? How do you manage?

- Aortic dissection - Multiplanar CT - Urgent surgery followed by B-blocker to reduce blood pressure

A 65 year old woman with a history of uncontrolled HTN comes to the ED with severe persistent chest pain radiating down her back. Both her EKG and troponin levels are within normal limits. What do you think she could have? How do you diagnose? How do you treat?

- Aortic stenosis - Calcification of normal valve - Murmur radiating to the carotids - YES - when there is angina, syncope or CHF - Only valve replacement if symptomatic or severe

A 68 year old woman with HTN comes to your clinic with increasing dyspnea and syncope a day prior. She does not have a history of angina, and has had gradual dyspnea. Her PE shows BP of 145/65, P83, R14. There is a 3/6 systolic murmur best at right upper sternal border described as "crisp and high pitched", radiating to the carotid arteries. What do you think she has? What likely caused it? What PE findings did you look for? Do you get an echo? Valve replacement?

- Hypertrophic cardiomyopathy (HCM) - Left ventricle grows inappropriately thick - No - it's genetic - Yes- it caan cause sudden death, especially in athletes - No symptoms, no treatment - just no excursion. B-blockers initially. Then surgical myectomy/ lots of surgical procedures.

A 19 year old man comes to the ED with new syncope while playing football. PE shows BP of 120/65, P75, R12. With auscultation you hear *a loud S4* and a 3/6 mid-systolic, rasping crescendo/decrescendo murmur best at LLSB. What do you think he has? What is going on? Could he have prevented it? Is it serious? How do you treat?

- Premature atrial contraction - Generally benign - The caffeine and stress (also triggered by nicotine, alcohol) - Anyone can get it, but incidence is higher in certain heart disease populations - Typically not necessary

A 29 year old PA student comes to see you with complaints of palpitations. She is otherwise healthy with unremarkable past medical history. She describes the palpitations as a strong beat or a flutter followed by a slight pause. Sometimes she feels dizzy with them. She has noticed an increase in symptoms with caffeine intake. Upon PE she has regular rate and rhythm with a couple premature beats. What does she have? Is this serious? What probably triggered it? Who gets it? How do you treat it?

- Mitral valve prolapse - Early age onset (women onset ages 14-30), fatigue, chest pain (non typical angina), difficulty breathing, mid systolic click. - If asymptomatic and MVP is not severe - REASSURE. - If chest pain, Beta-blockers. Mitral valve repair if severe

A 45 year old woman comes to your clinic with occasional palpitations, and years of non-cardiac chest pain, fatigue and difficulty breathing. Her cardiac exam reveals a regular extra sound in mid-systole, followed by a 2/6 systolic murmur. What do you think she has? Why? Is it serious? How do you treat?

- Occlusive disease of the lower extremities caused by atherosclerosis (peripheral artery disease) - Calf pain = any vascular level or superficial femoral artery - Foot gangrene, or ulceration leading to amputation - Conservative care (stop smoking, exercise treatment) and endovascular surgery (used for superficial femoral). If severe - revascularization or amputation.

A 62 year old male smoker comes to your clinic with complaint of cramping pain when he walks his dog. When it started 6 months ago it didn't bother him, but now he just walks down the street and the symptoms start. Upon PE, you see changes in hair distribution on the lower extremities and reduced popliteal arteries. What do you think he has? Which artery? What complications are you concerned about? Treatment?

- Atrial fibrillation - Yes - 5 fold increased risk for stroke, 3 fold increased risk for HF, 2 fold increased risk for both dementia and mortality - What you would expect - age, TN, DM, hx of MI, CAD, HF, obesity, sleep apnea, smoking... - Irregular R-R intervals - Management depends on a lot of things - but you want to control rate/ rhythm and prevent clotting. In his case, start him on warfarin, and a beta-blocker to control heart rate

A 78 year old mal patient with HTN, T2DM, and hx of CVA comes to see you for routine management of his HTN and DM. He reports "feeling a bit more tired than usual" x 2-3 weeks. Also dyspnea on exertion, BLE edema, denies palpitations. PE reveals irregularly irregular rhythm, trace bibasilar crackles and 1+ BLE pitting edema. What do you think he has? Is this serious? What are the risk factors? What is on the EKG? How do you treat?

- atrioventricular block - "If the R is far from P Then you have a first degree. Longer longer longer ... DROP What you've got is WENKEBACH If some P's don't get through You're looking at a Mobitz II When Ps and Q's don't agree It's definitely 3rd degree." (he has a third degree, or complete heart block) - pace - complete and type II if symptomatic pace first degree and type I

A 78-year-old man with a history of hypertension presents to his primary care physician with 1 episode of dizziness while watching television. On physical exam, his heart rate is measured at about 40 bpm. A 12-lead ECG is obtained showing sinus rhythm at about 75 bpm and complete heart block with a wide junctional escape rhythm at about 40 bpm. On further questioning, the patient admits to increasing fatigue and dyspnea on exertion for the past few weeks. Notably, the patient has bifascicular block at baseline (right BBB and left anterior fascicular block). What is going on? What are the three types of this block, and which one does he have? How do you treat them

- black widow - give opioids and benzos for pain and muscle spasm - apply ice and loose compression - Yes, but it should be reserved for seriously ill babies and elderly

After PA school you want to move somewhere new. You pack your bags and head to Los Angeles, California. Working at an urgent care clinic, you see a 16 year old brought in by his mom. He has been working in the back yard moving a pile of old decking this morning. He doesn't really remember being bitten by anything because he was working really hard, but suddenly started having really bad pain in his hand and severe stomach cramps. PE reveals well nourished boy in severe discomfort and guarding of the abdomen. VS: BP 146/88, HR 85 RR 18 What do you think is going on? How do you treat? Is there an antivenom?

- Sinus sick syndrome (alternating tachy and brady) - SA - Permanent pacing is the only available therapeutic modality for persistent bradycardia owing to nonreversible causes.

An 85-year-old man presents with fatigue and episodes during which he feels he is going to pass out. He has no known heart disease. In the ED his ECG is normal, but a 24 hour halter monitor shows sinus bradycardia with a rate of 30 bpm and on a rhythm strip he has up to 5-second pauses. What is going on? Is this an SA or AV block? How do you treat?

- Pityriasis rosea - Unknown - possibly associated with herpes - Oral antihistamines or topical corticosteroids - spontaneous remission in 6-12 weeks - Psoriatic arthritis

I had this one big spot on the right side of my chest a week or so ago. It suddenly erupted this week and kind of looks like a Christmas tree on my chest. There isn't anything on my face. What is this? What causes it? How do you treat it? Any complications?

- Contact dermatitis - Irritant - Cut down on the hand washing - Avoid irritants, it will heal in two weeks - Topical class I-II steroids with oral prednisone

I have been working as a PA in a derm clinic for a year now and I'm always terrified I'm going to get herpetic whitlow so I wash my hands constantly. Now I have this. It's itchy, only on my hands, and has been getting worse. What do I have? What kind is it? How could they have prevented it? How do you treat it? If it's really bad, would you treat it differently?

- Condylomata acuminata - Human papilloma virus - Visual inspection and PAP in women - No cure - treat symptoms topically (warts) - Tell your friends to get the vaccine, anyone who is sexually active can get HPV

I have loose and flappy skin tags on my penis! What do I have? How do we test for it? How do I treat it? Any instructions?

- Tinea capitis - Scraping - Systemic anti fungal - Gris-peg in kids

I have scaling, and painful inflammation on my skin. My hair has been breaking off resulting in these brittle, grey stumps. What do I have? How do you test it? How do you treat it?

- Dyshidrotic eczema - Topical high-potency corticosteroids

I have these really itchy, clear tapioca-like vesicles on my hands and feet. They just suddenly appeared. What do I have? How do you treat it?

- Tinea corporis (body ringworm) - Dermatophyte infection - KOH prep - OTC topical antifungal

I have these ring shaped rashes on my arm. They are itchy and red with a scaly border but the middle looks clear. When I put cortisone cream on it, it seemed to get worse. What do I have? What type of infection is this? How do you test it? How do you treat it?

- Verruca plantaris - Usually HPV 1 - Liquid nitrogen or salicylic acid

I have these warts on my feet... they are flat and show up in groups. What do I have? What causes them? How do you treat it?

- Basal cell carcinoma - Nodular - Surgical excision/Mohs - Very little risk of metastasizing

I have this pearly pink bump under my eye. I thought it was just an age spot, but now it is effecting my vision. Every time I pick at it, it bleeds. As the savvy PA you are, you perform a biopsy. What does the patient have? What type is it? What is the best way to remove it all? What is the risk of not removing it?

- Squamous cell carcinoma - Wear more sunscreen - Moh's - Low rate of distant metastasis

I have this pimple that wont heal and keeps bleeding. As the savvy PA you are, you know pimples don't bleed like that and you perform a biopsy. What does the patient have? How could they have prevented it? How do you treat it? What is the risk of not removing it?

- Psoriasis - Complex genetic disease - increases with times of stress and cold - Lots of different ways - topical steroids, topical vitamin D, photo therapy, moisturizer

I have this pink raised patches of scaly skin. it is dry, cracked, flaky and sometimes bleeds. I have also noticed a weird denting in my finger nails. It's gotten worse now that the weather is a bit cold and PA school stress is building. What is this? What causes it? How do you treat it? Any complications?

- Actinic keratosis - No, but if untreated it can become SCC in situ --> SCC - Cryotherapy, laser surgery, topicals

I have this scattered, course reddish lesions on my forehead. They are not itchy, and can be tender if I accidentally irritate them. What are they? Is it cancer? How do we treat them?

- Erysipelas - Leukocytosis in the blood - IV or oral abx against staph or strep (amoxicillin)

I have this sharply demarcated bright red spot on my face. It feels hot, it's painful and I started having fever and chills. What do I have? How do you test it? How do you treat it?

- Lichen simplex - STOP ITCHING, occlusive bandages at night, glucocorticoids

I have this solid plaque on the back of my neck that is INSANELY itchy. It feels so good to itch, I can't stop. What do I have? How do you treat it?

- Tinea barbae - KOH prep - Griseofulvin

I have this thing that looks like an ingrown hair under my nose. It looks like a pimple with a white head. What do I have? How do you test it? How do you treat it?

- Stevens Johnson Syndrome (<10%) / Toxic Epidermal Necrolysis (>30%) - Skin biopsy - Like a major burn in a burn unit - stop medication, nutrition and fluid support + IV corticosteroids and poss. immunoglobulin

I started a new medication and now a large portion of my skin is peeling off. What do I have? How do you test it? How do you treat it?

- Tinea unguium/onychomycosis - Nail clippings - but can take a long time to process (soaked in KOH) - Treat if there is discomfort, difficulty exercising, or if they are immunocomp. TOES: terbinafine for 12 weeks. FINGERS: ultramicronized griseofulvin. -- topical not very effective.

My toenails are all yellow! They have also gotten thicker which makes them difficult to cut. What do I have? How do you test it? How do you treat it?

- Superficial thrombophlebitis - Common inflammatory-thrombotic disorder in which a thrombus develops in a vein located near the surface of the skin (as opposed to a DVT) - Local heat and NSAIDs is typical treatment - LMWH is recommended if thrombophlebitis is >5 cm

You are on your inpatient rotation and check on a patient who had a PICC line placed 3 days ago. She tells you she has a new dull pain in her left leg. Upon physical exam, you see a region of induration, redness and tenderness on her leg. What do you think she has? What is going on? How do you treat?

- Chronic veinous insufficiency - Severe manifestation of venous HTN - DVT - Compression stockings, avoid prolonged sitting/standing, elevate legs - Avoid surgical stripping

You are riding the MAX on one of the first 60 degree days in Portland - so everyone is in shorts and t shirts. You notice the woman sitting across from you has swollen ankles and what looks like bruising with thickened skin around her ankles. She is wearing sandals and her feet look normal, but she has an ulcer on her ankle as well. What do you think she has? What is this a manifestation of? What does she likely have a history of? How do you treat? What treatment do you avoid?

- Renal parenchymal disease - Urine protein, GFR, renal imaging (ultrasound) - Treat the HTN to prevent progression of renal dysfunction and discuss renal dietary management

You are seeing a 16 year old female patient with a chief complaint of fatigue. You notice the MA recorded her blood pressure as 160/90. When you recheck it, you get the same finding. What is the most common cause of secondary HTN in patients <18 yo? What further testing will you do? How do you prevent this from getting worse?

- Acute STEMI - Complete occlusion of coronary artery - Fibrinolytic - Catheterization

Your patient is admitted with unstable angina and "crushing" chest pain. The EKG shows ST elevation. Labs reveal elevated troponin. What is going on? What likely caused it? What medication treatment should you use? What other treatment is typically indicated?

- Acute coronary syndrome/NSTEMI - Partial occlusion of coronary artery. - AVOID fibrinolytic - Antiplatelet and anticoagulation therapy - Catheterization

Your patient is admitted with unstable angina. The EKG shows ST depression. Labs reveal elevated troponin. What is going on? What likely caused it? What medication treatment should you avoid? What medication treatment should you use? What other treatment is typically indicated?

- Right sided heart failure - Systemic fluid overload - CBC, UA, fasting lipids, CMP, TSH, EKG, BNP/NP-proBNP, CXR - Diuretic + ACE + statin - Reduce salt intake, modify exercise

Your patient presents with fatigue, GI distress, edema, distended jugular veins and ascities. Upon physical exam, her liver and spleen are enlarged. What do you suspect she has? What is going on? What initial tests will you run? How do you treat? Lifestyle changes? ***update with FM 4