BLACKWELL'S

VIKAS BHUSHAN, MJI llrlivt.r,sity of California, San Francisco, Clws or 1991 Series Editor. Di~~gnostic Radiologi<t

VISHAP, PALL, MBBS Govert~rnent Medical 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 Califcirnia, San Francisco, Class of 1996

PARAG MATEFUR, MD Mayo Schotll oT Medicine, Class nf 2001

JOSE M. ITERRO, La Sallc I ;nivrrsitv. hRlcxicn City

HOANG NGUYEN, MD, MBA Northwestern U n i v e ~ ~ i t v , Clash of 2001

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~les S ~ r i i ~ T;.vc Knsti~~ite

Vipal Soni, Ir(:L4 School nf \frrlirinc. C:la<s nT 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 ~ ~ i 13r.t' 111ar tlir inthrm;~ric~n cunlair~ccl 11crci11 i q arcumrr and compui- Ijlc wilt1 tlie \tnnrlartE~ ge-rnrl.al11 arrrptt-rl at the ~ i inc of p~lhlicnrion. Y~vrrthrlesh~ it i? dim< rdt 10 C I I S U ~ C

that all thr ~nfnrmation ~ v e r r is r r ~ t i ~ clv accllrate I'or a17 crrrtImsrancc<. The p~~l , l i~hcr anrl 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' lhtf vnltln~?.

CONTENTS

Acknowledgments Preface to the 3rd Edition How t o Use This Book Abbreviations

Card io 1 ogy

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 Aneurysm- Ruptured 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

Heme/Onc Immunology Neonatology

N~phroiogy/Urology

Neurology

Obstetn'cs

Orthopedics

Ureteral Inju y-Iatrogenic Varicose Veins Gartner's Duct Cyst Uterine Prolapse with Cystocele Squamous Cell Carcinoma-Lip DiGeerge's Syndrome (Thymic Aplasia) Caput Succedaneum Congenital Diaphragmatic Hernia Duodenal Atresia Hypertrophic Pyloric Stenosis Nephzoiithiasis Vasectomy Acoustic Schwannoma Acute TorticoIlis Aphasia-Wernieke's Astrocgtoma Bell's Palsy Brown-Sequard Syndrome Cavernous Sinus Thrombosis Common Peroneal Nerve Damage Deafness-Conductive Epiphyseal Separation with Ulnar Nerve Palsy 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 e Sleep 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

- Elbow-Median Nerve Palsy (Nonearpal) Elbow-Radial Head Subluxation F? 7

Forearm-Monteggia's Fracture r+< 1 Hand-Boxer's Fracture 1:. \ Hip-Legg-Calve-Perthes Disease F "3

c- >r Hip-Trendelenburg Gait Hip Dislocation-Congenital 7 B

Hip Dislocation-Traumatic > :+?

Hip Fracture C - i Knee-Combined Knee Injury 1- , $

Knee-Osgood-Schlatter's Disease r A + t

~eg-compartment Syndrome F" 1 , -- 3

Pelvic Fracture * A

" - 8

Shoulder Dislocation I I

Shoulder Separation r.-- 4

Spine-Prolapsed Intervestebral Disk Temporomandibular Joint Dislocation r+''f Thorax-Cervical Rb I

Wrist-Carpal Tunnel Syndrome F

Wrist-Scaphoid Fracture I , " <o

Wrist-Slash Injury i .1 Lung Cancer-Lymphatic Metastasis r - 1 Lung Cancer-Pancoast's Syndrome -z,q

ACKNOWLEDGMENTS

T l i r ~ ~ ~ g h o ~ ~ the production of this book, we have had the sup port of marly friends and colleagz~es. Special thanks to our sup- port 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, Tan111 Mathur, Alex Grimm, Sonia S ~ I I ~ C I S and Elizabeth Sand~rs .

Ilrc Irave elljoyed working with a world-class interna~ional pub l i sh in~ RI-OUP at BEackwell Science, irncluding Lnt~ra DeYnrnlg, 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~ce across all of the vignette titles in all eclitions, we collectiveIy thank:

Tara hdamo\rich, Catnlyl Amxckr, 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~nara Callahan. 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~rchanJoshi , 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~l Levett, Warren Levirlson, Eric Ley, Ken Lin,

Pave1 Lobanov. J . Mark Maddox. Ararrl Mardian, Salnir Mehta. Gil Melmerl, Joe Mesqina, liobert Mosca, Michael Murplly, Vivek h'andkarni, Siva Naraynan, Carvell Nguven, Linh Nguyen, Deanna Nnbleza, Craig NodurFt, George Naumi, Darin T. Okuda, Adam E. PaIance, Pan1 Pamphn~s, Jinha Park, Sonny Parcl. Ricardo Pictrohon. R i n L. Rahl. Xashita Randeria, Rat-Iran Rcddy, Bcatriu Reig, Mali1011 Reyes, Jeremy Richmon, Tai Roe, Rick Roller, Rajiv Roy. Diego Ruis, A11 thnny Russell, Xnnjay SahgaI, Urm imala Snrkar, John Schilling, IsabcIl Schmitt, Daren Schu hmacher, Sorlal Shah, Fadi Abu Shahin, Mae Sheikh- Ali, Edic Sl~cn, Justin Smith, John Stulak, Lillian Su, Julie Surldaram. Ritii Suri. Seth Swuctser, ,;lritoriio TaIayero, Merita Tail, Mark Tanaka. 'ric Taylot; Jess T ~ I O I I ~ ~ . S C I R , Inrli li-ehan, Ka)miond Tl~mer, Okafo L:cheilna, Ktic Ilygllatlco, Riclla Vrrrma,John Wages. Alan IVang. Eunice UTang, ,211dy Mrciss, Amy IVilliarns, Brian Yang, Rally Zakr; Ashraf Zaman mcl David Zipf.

For genernnlsly cotlrributing images to the entire Unrlvpound CIinAl-nl I ' p ~ f t ~ Step I wries, we coll~ctively thank the starrat Blackxvell Science in Oxfard, Boston, and Berlin as well as:

Axford, J . iMrcIirirr~: Ostley Mead: Rlackw~l l Science 1-id, 19%. 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 n f~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.

Rerg D. Ad~t-r,nnrvrl l J h Erul Sfca'lls nnd P$l ~irrrl I)irqytosis. EPackwcll Science Ltd.. 1995). Figures 7.10. 7.12, 7.13, 7.2, 7.3, 7.7, 7 3 , "151, 8.1, 8.2, H . 1 , H.5, 9.2, 10.2, 11.3, 11.5. 12.6.

Cuschicri A, Hcnncssv TPJ, Gccnhalgh RV, Rowley DA, Grace PA. trl Stcrqq . Osney Mead: 13lackwell Science Ltd, 19i16. F i ~ ~ r e s 15.19, 18.22, 18.33.

GiIlespie ST-!, Eamf'ord IC lM~dirnl iVlirml7ioIn~ and In fedion at a

Glnrlcr. Osnev Mead: Blackwcll Scicnce Ltd, 2000. Figures 20, 23,

Ginsberg L. Lecturr h~otes on I ~ ' ~ Z I w I o ~ , 7" Edition. Osney Mead: Rlackwell Scierice I,td, 1999. Fig~ll-es 12.3, 18.3, 1P.Sh. - EIliott '1: Hastings Mn D e s s ~ r l x r g ~ r U. I ,PT~~I,~PNO~P.T on ~Mprlirnl

Mirrohiolngy 3" Il,Jitiou~. Osney Mead: 5lackwell Science Ltd. 1997. Kgurcs 2, 5. 7 , 8. 9. 11. 12. 1.1. 15. 16. 17. 19, 20, 25, 26. c - q 2 f , A, :<o, 94, 35, 32 .

Mchta AB, FJoEFbmnd AV. Ho'oprnnroln~ nf a Cl~nrr . . Osnev

Mead: Blackwell Science Ltd, 2000. Figures 22.1, 2?.2,22.5.

Pleaqe let us know if your name has been missed or mi~spelled and we will he happv to make the update in the next edition.

PREFACE TO THE 3RD EDITION

We were very pleased ~ i t h the ovem~helmingly positive student feeclhack for the 2nd edition of our L ' n h p n d C:Iiniru,/ Vii$71,dt~.~

wries. M'ell over 100,000 copies of tllc LTLV books are in print and have beer1 used hy student5 all over the world.

Over the last two years we have accumulated and incorporated over a thousand "updates" and improvement5 suggested by ~ ' O L I ,

our waders, including:

marly additions of specific hoards and wards testable content

deletions of' redunclan t and overTapping cases

reordering and reorganization of all cases in both series

a new master indcx bv case name in each Atlas

correction of a fcw factual errors

cliagnosis and treatment updates

acldition of 5-20 new cases in every book

and the addition or clinical exam photo4q graphs within UCV- An,ntomy

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~r Attm (St+ I ) includes over 250 color plates, divided into gross pathology, microscopic patl~ol- ow (hi~tology). hematolom, and microbinlogy (sinears).

'I'he PICIT-CIinicn? Science CO?M A [lor ( , C ~ E 2) has over 123 col nr pIares, incIuding palien t images, dermatol~~gy, and fundus- copv.

Each atlas image is descriptivelv captioned and linked to its cor- responding S ~ e p 1 case, Step 2 caw. and/or Step 2 MiniCase.

How Atlas Links Work:

step I Book Codes are: 2 = .2natomv Step 2 Book Eoden are: FR = Fmergeilcv hlerllc~nc nS = Hrhav~n~ a! Srlrnre IM 1 = Inremail \ft.rI~clr~e. t'ol. 1

BC = I5tr1c11cnll\lrv 1M:! = lntri nal CIrdirir~e. \bl. 11 M1 = M ~ c m h ~ n l n p . Yol. 1 SlCU = Nrrimln~?; M'1 = M ~ c r n h m l n ~ ~ ~ Vnl. T I nn = OH/(:W PI = Pa~hopliwitrlc~gy. 1'111 T PEn = Pedistnrs

P2 = I ' a ~ l ~ t r p l ~ c ~ ~ n l o p . Xh1. [I SLIR = surge^ v

P.7 = I'a~hcrph~ctnln~. Vnl. TI1 SW = Pavchint~ 1

PT 1 = Pharn~arn loq \lC = MinrGa~t.

Case hlumber \ / A T1--u M-P3-032A ER-03 5A, ER-035B

/ Indicates Type of Image: I I = Hrrn,unlr,gv 7 Indicates UCVl ar UCV2 Series

M = MICI u~hinlncg

PL = C:I osc Pdrhnlnp PM = hllrrnwnprr I 'arho lo~

If the Casr number (092, 035, etc.) is ntlt f~illowcd by a letter.

then there iq only one image. Othcnvisr A. R. C , I1 indicate 1113 10 4 i~na~;es.

Bold Faced Links: Fn order to ~ v o you accps5 to the largest tlurnl~er of irnages po%sibIe, we haye chosen rn rross link the Step 1 mrl 2 series.

IT tlw lilik is holcl-Facccl this indicalcs t h a ~ the link is direct ( i . ~ . , Srep 1 Casc with h e Rasic S c i ~ n c ~ Step f Atlas link). - TI' ~11e link 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.

11'~ 11:1w also irnplemen t ~ d a Cew stn~ctliral changes upon your I - e q ~ ~ e s ~ :

* Each current ancl Cuture crlition of our popular Ant Aid for

IJlr 1!SMfJ< S'lri, J (AppIeton Pr L;lrige/ McGra1t7-f1 ill) and Firs[ Air1 Jrjr t f ip ILCZIIZ St? 2 (AppleLon k lAange/McGraw-Hill) book ~vill he lir~ked LO I he cnrscspoilding UCX' case.

Wu eljxrlinated UCV + First Aid links a.i the? Frequently b e c o r ~ ~ ~ o11t nf date, as thc Fir.r/ Aid 13ooks a r r revised yearly.

The CoIor Atlas i s also speciallv designed for qui~zing- captions are descriptive anrf rlo not give away t1lc caw name directlv.

We hope the updated UCV series will remain a u n i q ~ l ~ and rve!l-

inzegnted study tool that providc~ cclrnpacL clinical con-eIations to hasic scici~ce infurmation. 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 edi- Eion 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, yo11 will rec~ive a 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~ture UCV hook, or working with our teaor in devrloping additional books, please also e-mail us ynur W/rcsllme.

Wc prefer illat you submit corrections or srqgesrions .via elec trotlic mail to UCVteam@vahoo.com. Please incltide "Und~rgro~lnd vignettes" as thc subjecl of' your message. If you 1-10 not hwe access to e-mail, use the I;~IInwing mailing address: Blackwcll Ptlblishi ng, Attn: Eclitors, 350 Main Stwet,

Malden, MA 021 48. USA.

IJikcas Bhushrrn I/i.qhnl PnM Tan 12 October 2001

This series was originalIv clevelopcd tu address the increasing number of clinical ~-i;ignctte que5tions nn medical examinations, including the USMLE Step I and Stcp 2. It is also drsihmed LO

supplcm tn t ancl conydempnt the popalas Fir~l ,4i/f.[m ! l ip

IJS,WIJ:' SIP/) I (Applernn XE Lange/McC;raw Will) and Fjrst Aid /br 191r 1i,Ti2111 .Sf+ 2 (Applrtnr~ k Lange/McCmW Hill).

Each LJCV 1 lmok rise% a series of approsirnatelv 100 "supra- prototypical" cases as a way to condense testable facts and associations. The clinical ~ i ~ p e t t e s in his ser-ieq are cleqignect to

incorporare as man!: reqtable fact5 as posqi hle i tlto a cahesive and nlemorahle clinical picture. The vigziertes represent ctlrnpmi tes d r m n from general and special+ textbooks, refel-cnce hnnks, zhr)~tqands o f IISMLE stvle q u ~ ~ t i o n s and the personal experience of the authors and reviewers.

Al t h o u ~ h each case tends to presrn t all the signs, symptoms, and diagnostic findings for il particular illness. patients gener- ally will not present with such a "complete" picture either clini- cally or on a medical examination. case^ are not meant to sirn~~late a potential real patient or an exam vignette. All thc boIdfaced "hnzzwords" are Far learning purposes at14 are nor nrresuarily expected to he fo~und in arlv nne palient with the cliseasc.

Definitionl; ofLselrrtrd impnrtant term? are plared within the vignettes in (s~11.r t ~ ~ s ) in pamnthescs. O t h ~ r parcnthctical retnar-kls oftell refer rt j the pathophvsinlngy o r tnechanism of cli~ease. The format shonlrl also help stuclents lcarn to present case5 s~~ccinrtlv during oral "bullet" prcsen~~t ions on clinical rotatiuns. TI-IC cases arc rneant to s cne as a cnndensed review, tlclt as x priman? refet-ence. The information provided in this hook has heel1 prepared with a great deal of though^ and care- €111 research. This hook should nut, however. I>r cousiilered as your sole eoiirce of infosma~ion. Correc~inns, suggestions and submissions of new cases are encouraged and will bu acknorul- rrlgerl and iiicorporxterl whet1 appropriate in fl~tur-r editions.

5-ASA ARGs ABVD ,4CE ACTH ,4RH AFI' A1 ATnS .ALL

,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

5aminosalicvlic acid arterial hlood gases adriamyc:cin/bleornycin/~incristi~c/daca~b~ine angiotensin-converting enzyme adrenocr>rticntmpic hormonr antidiuretic hormone aIpha feral protein aortic insufficietlcy acquired i~nrni~nodeficiency syndmmnp acme lymphoc"ic kukernia aIanine transarnii~~e acute myeIogennuq leukemia antinuclear antibody adult respiratory distress syndrome atrial septa1 defect anti-streptolysin 0 aspartate tlansam i naw ;~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~ocytic leukemia chronic myeIogenous leltkemia cpornegalovirus cen trai nervous system chronic ohstl-uctive puln~ona~y disease 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 rlccp vcnoris thrombosis

E131' FCC; Eclirs EF FGD EMG ERCP ESK FE\: FNA FTtZ-,%I3 S F5-( : c;1:1-t

1 GI I;M-CSF

GP' 1 Li\' I1cC HEEKT H n ' I TL4 I IPl HR HKJC; f.lS ID/C:C: rDnv I K rC:T; I hl

.PT RUE 1,DM LES LIT5 LP I ,I' LW-l 1,l't PS

R.IC:IIc MCW MEN

Ep=+tein-Rarr vi.inls clcctmc:rl-cliography echocardiography qjerti(111 lLrac-tion t-sop~~a~op~~rod~1nc1~noscopy c l e c ~ r n i i ~ v ~ ~ g ~ ~ p h y cndascopi~ rrcrogr-;ldr c h o l a n ~ o p a n c r r a t u ~ ~ i ~ ~ h v erythrocyte s~clime~~tatic,n r-atr rcrrcrti expirxtn1-v rwlunle fine irceclIe aspil.ation [luorrsct-nt trrponcn~al an t ihndy ahsorption Inrcrrl v i ~ d c i ~ p a r i ~ glomcn~lar filrration r;~tc

grow111 l~ormonc ~as t ro in trstinal granulocyte macroph;\gc coton\ qtirnt~lat ing li~ctor gvlii ~ o ~ ~ r i i ~ a r y hcpatiti? h L~I-11s hw11;~n cl-turirtnic gc~n;z<lntropt~il~ head. evr.;, rai-9. nnsr, and thr-oar hl~rnnn imtnunocleficici~cv virus

hnman lu~rkr>c),te a~~r igen history of prrserlt illnesc hcan rate lniman t-allies in~lnune glr~hufin hcrcclitarv spher.r>cy~usis identification anrl c hieC colnplain t ii~.;itIin~lrlr~r~cletii rliahelc-3 rnellitus itnm i~nog lnh~~ l in irls~tlin-like jirowth Cactor i13 traml~scul;t~* j~igular T-enous preqsurr Iti~lneys/i~r~ter/t~IacLrler

Iariale deh~rlrr~genasr lower tsophagewl splliilcler li\.er- li~tlction tests

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- ~ m l ~ ~ r n t ' rnilltiple endocrinc ncolslxia

MHC Nl1 h,lOPP

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 - r rP LTA LTCl LTS

pracarbazine Jprc-dnisone tnagnelic rcsonancc (imaging) norl-Modgkin's 1~mphorn:i non-in5uTin-clcpc11dent cliabetev mell i t us nil per os (norhirlg h? ~ 1 1 ~ 1 u t h )

nonste~oiclal anti-inflan~mato~v dri ~g poqteroantei-ior proximal in t erp halangeal peripheral I~loorl snie;w

pr-othrombin time percliiaileotis transIuminal angioplasy pat-athyt-<)id liorn~o~lu partial th rorn boplalirl ~ i m c peptic ulcer disexre r rd blood cell

r-espiralnry rare Rced-Sternbet~ (cell) right vcntricrilar right vent ] - i r~ 11ar hypertropll!~ s ~ r ~ a l l bowrl follow-through sy~ldrorne of inappropriate secret ion 01' ,AnH systemic 111p1is ei~tYlemat~sus srx~raI1y t~~i-lsrnitted disease tliyroirl lrlnctien tesw

tissrie pln5minc~gen actir*;lzor thyroirl-stim ~rlacingy hormone rota1 ir-on-binding capacity transjugular intrah epa tic pr>rtos).stumic shunt ~hyroicl pcroxiclase 1hyrr3icl-stimulating hormone thro~n hatic thrornhr>cytopei~ic purpr~ra urinalysix upper G1

VDRL Venereal Disease Researth Lahnratot? VS vital si%gns TJT yen I 1-icular tachpcal-clia WXC: while blond cell MT'M' Mbl IF-Parkinson-Whitc (.wndrome) S R s-rav

ID/CC A 29-year-old male cornes to the medical clirljc beca~ise of palpitations, wexkne~s, atid fatigue that dr~es no( allow hirn to 19-alk more than five blocks, togethrt- wit11 coldness of his right foot.

HPI He underwent suFgery 4 wccks ago for a punctrating stahwound injury in his right groin that he sus~ainecl d u ~ i n g a fight. n

P XI

PE VS: marked tachycardia. PE: continuous murmur anrl easilv E r

palpahle thriIl over area of woutlrl: skin over wound warm to 0 G7

touch; right Coot rolrl to touch with diminished puke: < tachycardia diminished when pl-ussure appliecl to site of fistula ( RK\~VTIAM's S I C ~ K ) .

Labs CBC/Lytes: normal. LlTs, glucose. BUN, creatinine normal.

Imaging MR/.4n*o: largr A17 connection (fistula) in gruin arra with significant diversion of hlnnrl flnw. IJS: color- flow Uopplel- s l ~ n w ~ rainbow-colorcd turbulence in fistula: high-velocitv and arterial- ized (pulsatile) wavcform in draining vein.

G ~ S S Pathology Ahnurmal communic;itiun between artcry ar~cl vcirl. iri this case

as a result or a penctrating injury.

Treatment Surgical repair if symptomatic and large: angiographic cmbolisation if smallcr. Ultrasound-guicled direct compressiuri i s snmecimrs an option.

Discussion Arteriovenouq fistula rnav clinically prcscn t ar high-output cardiac failure. larrogenic AY fistulas rnav be seen die]- artrriography.

ARTERIOVENOUS FISTULA

ID/CC ,4 I2-ycai.uld furnalc pl-csrn ts ~vi th prr,gi.essive shortness of breath on exertion artd palpitations.

HPI T h e p~tiriit has Ileeti ymptoin fi-ec until now.

PE VS: irregl~lal-lv il-l-egilal- ~ I I I S P . PE: Eel? pal-asternal hcavr: grade 111 /V1 vtolic ejection flow murmur in lcfi second intcl-custal

qpace: widely split, fixed 52 (docs no1 changc ni th breathing).

Labs EC:C;: atrial fibrillation: RSR pattern in riglit pru~~r~rlial leads: riglrl-xis clexi:itioii (rig111 \,en ~ r i c i~lar hyper-1.1-ophy).

Imaging C S R clilxtcd proxinlal pnlmonary nrterics: increased pulmonary vascularity enlai-grrl right atrium anrl right vcntriclc.: small aor- tic knoh. Eclln: paradoxical septa1 movement; left-t (>-right flow Gtr-cliac cathcttrization confir lniltory.

Gross Pathology The iiiost cniiirliclil (r $r.nl iq i t ) fie midseptum, in the area of the Soramen omle (OSI 1 1 . h ~ SI~ .I ,CIUDI IM): tllosr in tllc Tower scptlinl ((n\nrlu PKIMI IZ~) are associatc,d with AV valve iincsnl;~lieu (rnosr cclrnnlurl in D o M ~ ' " ~ ; 11ir1sr ill he 11ppts srpltlin ( s r ~ r l s v i . ~ t l s ~ s )

arc. awx-ixterl wirh anomaln~ls pulmot~ary venous return.

Treatment Sz~rgical or intcrrrntionnl angiographic clos~~rc. of'drfect with pros111r.ric patch. Operalive repair i q r.ecotnmenderl i r ~ all symp i t m ~ a t i c t>;lti~iitq wirh ostitun secunrlutn rlefeclts re~ardless of size of' rlcfrct.

Discussion Oxygerlaterl hlt~url li-rrin l l ~ e l ~ f i a1 rit~rn ~ ~ S S P T into the right

atrium. irlcrcasing r igh~ ventricular ontput ancl pulrnonasy flow. Acyanotic (Iefi-ro-I-i~hr shunt) ; ~tle mnqt cotntnotl congenital 11c;lrr rliscasc in aclults. Scquclae r ~ f untreated acrial scptal clcfrc t~ inrIudc paradoxic emboli, infective endocarditis, ;~nd congestive heart failure.

Atlas Link LTT-= PEA-002

ATRIAL SEPTAL DEFECT

ID/CC A 25-vearuld male postal worker whn waq stabbed in the chest rh~rit~g- a n~tyging is brought to the cmer-getlcy room in a semi- conscious shte, gasping for air (DWPKEA).

HPI Thc knife penetrated the 1ho1.acic wall at (he luvc.1 of the f o ~ ~ r t h intel-cmtal ?pace alor~g the left sternal borcIcr.

PE VS: hypotension (BP 'JO J40) that does not respond to rehydra- ;o

tion; ir~spira~ory Io~vering oTq5rolic RP hv > 10 mmHg (~rrr.sris S s

r;la~ncrxrls). PE: increase in venous pressure wi I h itlspiratory lilling nf rlerk veins during inspiri~tion (Eirrss~.e.ku~'s SIGN);

R < cI(n-ing drawing 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 ECG: reduced vnl tage.

Imaging CXR: car-cliomegalv, I N I ( ivitli acute heinopericardi~~m , tlte heart shadnw may not enlarge; thus d i a ~ o s i s is clinical. Echo: pericardial fluid; dias~cd ic collapse of right ventricle ailrl atria.

Gross Pathology BIood rrom sitrs of injury fills pericardial sac, causing conlpres- sion of all l~eart rhamlwrs anct pl-ruenting vennns i-etril-11, heart filling, and artcrial Q I I ~ ~ O ~ V .

Treatment Immediate pericardiocentesis ancl subseqllelz t operative thorn- cotomv and pci-icar-dial cFecornprrssion with rrpair of laceration.

Discussion Unlike this case, the ma-jnrir), oi" pat irrits ~ v i t h penetrating cltest 11-auma will have a pnrumothorax or hetnothorax. The triad nf Ecck (hypotension, distant heart sounds, and increased venom pressure) is charactwi~f ic nT cardiac tampolrade.

7 C A R D I A C TAMPONADE

IO/CC A 57-year-oid male is seen l3y the resident on call hecausr hc complains of pain in the p i n area and coldness in the right foot.

HPI He ~lndcfwent coronary angiography that morning for evalua- cion of coronary artery disease.

n- B

PE LTS: tachycardia (FIR 98) ; hypotension (BP 90/60); no fever. PE: m

pallor; right groin examination discloses inarked swelling and g deformation at site of femoral artery plrncture with skin 6

I 3 discoloration (ecchymosis) to middle third of thigh anteriorly < ancl posteriorly (patients are anticoagulated for angiopphy) ; peripheral puIses present I ~ u t diminished.

Labs CBC: low hematocrit. Prolonged clotting. time, PT, and MT.

Imaging US: shows humatuma (no flow, nonpulsatile) and excltides pseucioaneurysrn.

Gross Pathology Large subcutaneous henlatoma at site of puncture. c a ~ ~ s i n g com- pression of femoral artery.

Treatment Evacuation nC hematoma. con~pressive handage. and drainage.

Discussion The external iliac artery passes in close proximiry to tile inp ina l ligament, where it is susceptible to injury during hernia repair. DistaI to this landmark, the artery changes its name to the common ferno~il artery, which is the main blood supply to the leg. In the groin, the netlrovascular bundle suppIying the

lowcr cxtremitv consists of the femoral vein, artery, and nerve, in that order, from medial to lateral.

fl FEMORAL HEMATOMA ^ : I

ID/CC /In S-yeal--old femalr with a history of recurrent pneumonia and low exercise tolerance i s referred to a pediatric carlrtliolo~st for evaluation.

HPI The child was horn prcrnaturely and has a history of recur-rent rerpiratory tract infcctio~~s; her mother had rubella during her

P'eP='cY -

PE Delayed growth and development (fdth percentile); wide pulse premure: prominent carotid pl~lsation; increased JGT; continuous "ma&eryU murmur with systolic accentuation and thrill at second intercostal space at left pwaq~ernal ho~-der: increastd intensill: of apical impiilw.

Labs ECG: increased voltage of I< in V,-V, and S in V,-V,: Icft-axis rlevial ion (left vcn tricular hypertrophv) .

Imaging CXR: enlarged cardiac shadcrw wit11 increased pulnlonarv blood

flow ( left atriurn, left ventricle, aorta, and pulmonary artery). Echo: Dopplcr flow mapping confi rmar ol-y. Angio: definitive.

Gross Pathology Pa ten1 rl~lcrus arturiosus (PIIA) connects the aorta and left pzhonary artery just distal to the origin of the left subclavian artery.

I

Brachiocephallc artery Left subclavian ar tev

Right pulmonary angry -. Ductus arterlosus

Aorta Left

Superior vena cava pulmonary artery

Septum II

Foramen ovale Pulmonary trunk

Septum l

Aorta

Inferlor vena cava

Clmbilrcal arteries

Figure A-006A Fetd circ~~larinn.

"*mr PATENT DUCTVS ARTERIOSUS

Treatment Surk+I or catherer (umbl-ellaj closure. hdomethacin alone mav br successfilI in closing the PDA in rluonates (due to inhibi- tion of synthesis of prostaglandin E2, which normally keeps the ductus arteriasus open prior to birth).

Discussion Acyanotic. Patent ductus arteriasus is suer1 in association with congeni ti11 rubella.

Atlas Link E E I T " 3 PG-A-006

ID/CC rS. fivr;>r-nld child is referr-ed r r, :i pedinil-ir ral-dioln@st for uval i z -

a t i c l r ~ uT dyspnea on exertion.

HPI Sincc birth. Iic l ~ a s had se1~~1;11-iiiin~lr~-lonff "blue spells" rl~iring whirl1 I I P ~ P C ~ T I I ~ S I I ~ I I Y ~ ~ I I I P ~ C , cyn(>tic, and rr\tIrw: at time4 he 113s alsn lost corlscio~~snes~. I-le has hecn ohscrvad lo arisume a squatting position in order to relieve tlyspnea due I r ) physiral eF for1 {irtcrcaws vennlis rettlrn to right hc'art and pl1ltno1iar.v flow).

PE Dclrycd growth: ccntral cyanosis; gi-ade 111 clubbing of fingers:

svstolic* tl~rill p~lp7t1le aloog lefi ~ x ~ i ~ : ~ s t ~ r ~ i a I l>orrlcr (d~ ic tn Y C ~ I I -

tr.iculnr srprill def(3ct): svs~nlir mllrrnur hccl hcartl tliircl leT1 in- c~rcoqtal spare (ptllmon:~ry rtcuosis) : murintrl- disi~ppear-5 d~u-ing qxnntir spell (no hlootl llow ~hrol~gl i wive) : single seconrl heal-t stmrld (only ,42; 5oR. inaudible P:! clue t t ) pulmnnarv sro~iosis) .

Labs CBC: polycytl~rmin. MGs: 11 ypnx~rn ia (Pat ,, 72Yh). ECC:: I-ight- i1xi.c clevis tion : evidrtl re of right ventricular hypertmphy and right at~ial clilntarion.

Figure A-007A Narrrnvrrl puln~onar! ar.leiy, ve~~lric i~lat . septa! delrrt. aorta overlying !>oh rigti1 ant1 left vt~11tr.i~ Icr. :I nd h v p ~ r ~lnptiic rig11 t vrn trirlc.

TETRALOGY OF FALLOT

Imaging CXR: concalitv in region nf main pulnit>r~ar). artei-~: rigllt veu~ricular enlargement (13ocr1-sri.zvto I I LZRT) ; diminished pulmonary vascularity. Echo: shows all Fimr gross li~~dings. c : A,II cl~ac cathett=rizariou conlirmatorv.

Grass Pathology Four defects norrcl: ( 1) right ventricular outflow obstruction (pulmonary \xlvc stcnosis) : (2) large ventricular septa1 defect; (3) "overriding" large ascending aorta; (4) right ventricular hypertrophy.

Treatment Palliative shnn t 01- corruc ti7.c opun hcarr surgery.

Discussion Trti-alogv of Fallot is a lifc-zlir-ea~rning condirion and i~ a catnlnorl callse of cyznosis in rhildhonrl. Synptomatolup is directly pr~)pnrtifinill to the amount c ~ f right ventricular 0 ~ 1 1 -

flow ob~tl-uction. It is caused bv an emhryalogic defect that cariscs antemsuperior displacement of the inFundibular septrtm, ~+osultii~g in 1wequ;h division of'ihe aorta atlrl ~xi l t~~nr~ai-y ~ 1 - t ~ r y .

AtZas Link PG-A-007

ID/CC

HPI

PE

Labs

Imaging

Gross Pathology

Treatment

Discussion

Atlas Link

rZ 2-montIl+Id I'emnle presents with dyspnea, feecliilg difficul- ties. poor p w t h , and profuse perspiration.

Thc cllild had pneumonia when she was 7 days old. at which ~ i m c 11er parLen& we]-e informed of a c*otlgenital heart tnurtnur-.

VS: pulse normal. PE: tio edema, ryanoqis, 01- rluhlling; palpable parasternal heave: apical thrust ancf s?stolic thrill: loud PT com- ponent of 52; harsh pansystolic murmur heard best over left lower sternal border: short apicill dim1 olic rumble ( c l ~ ~ e trj

increased flow across mitral valve.).

IJCG: biventricular hyperwophy with peaked P Tvavcs cltir to right atrial hypet-tropl~y (pulmonary artcry h!perter~sion).

CXR: carcliumcg.aly (all chambers and p~~lt i ionary wterv except r.igli I atri~inl) will1 ii~creaserl p~iltnnctal-~ vascularitv. Echo: large vrntl-ictilar sephl defcct {lTSD): Doppler shows left-to-right clirrc~ion c ~ f shunt (lcft vrr~triclc to right vrntnclr).

Faillwe of fusion of interventridar septum with aortic septum.

Fonr t yp rs of LrSDs: perimeml~ranous (HW). mt~suular ( 10%~).

rupracrista7 (5%). and rndocardial cr~shion defer t (5%).

Stu-qical clr>sii~-e of' large \tSIls s h n ~ ~ l r l I>e pel-formed heforc nppcarancc of irrcvr.rsil>lr puln~onary vasculai. hvperrensinn.

Acyanotic. Ventricular scptal dcfect is a common cardiac malfor- mation that accounts for 25% of all cases of congrnital lirart C I ~ S P : ~ ~ . Small ~lelkc-ts niav r l o ~ e ~ p n n ~ a n ~ o ~ i s l y T h e develop rnrnlt of p~ilmonarv vnsuular hypcrtrnsion m a v Icad rt) reversal (11' the shun 1 (ill to I-igli t-(+left\ and cyanosis (F;ISF:NMF,N(;FK'S

SIT I IR~ I F,} .

" VENTRICULAR SEPTAL DEFECT

Labs

Imaging

Gross Pathology

Treatment

Discussion

A 46-year-olcl female on 1lt.r third postopcralive day rings the nurse because of tlre development uf numbness arottnd her mouth and a h g h g sensation in her legs and Fingertips.

The patient 11aq spastic ccrntrrtcturr of the ket and wrists in outwar-d mtatiorl and flexion, wi ~h her fingcrtipr; touching rach o ~ h e r ((AI<Pc)PED,~~. SPASKI). She had just hiid a total thymidectomy.

13: normal. PE: surgicaI W O U ~ C ~ hcalecl: n o signs of infection or I~clnatnina formation; cr~nrraction of F~cial mtiscles when rapping facial nerve an terior to ear (rnsrrim CH~CISTEK'S SIGN);

carpal spasm after occlusio~~ uf brachial artery with RP cuff (TROLJSSF.,UJ ' S SIC.N) : abductiun anr! flexinn nf foot ~vhen pcrorreal nerve i~ tappcd (P(J\ITIXT P L K( INFAL. SIC:^) (a11 signs of

CRC: normal. Hypocalcemia. ABGs: rlol-ma!. ECG: normal.

CXR/KU R: normal.

Kesectccl thyroid tissue shows ztnaplas~ic carcinoma with incipi- unl invaqion into trachea (a sir~all square r~f antel-iol- dk n.as

resrcred); on car-cfirl exanlination, all four parathyroid glands Cotind 10 1 1 ~ deeply adherenl to the thyroid; n o evidenre nE nerve tiss~ic (bryngeal nerve).

Calcium supple11ient.s.

The parahyeid glands are the rmhrvnlogic rlerira lives or the dorsal endodem of the third and folrrth brachial pouches. T l ~ e glands may bc found anywhere Crom thc sl~perior mecli- asr in t~rn to thc carotid hifi~rcatinn but arc usually located on

he posterior aspect and in close proximity in or embedded in the thyroid gland. L~suallv tl~cre arr turn superior and two i~lFc:r.iol- glands. but superrliirnerary and absent gla1-td3 arc not uncommon.

HYPOPARATHYROIDISM-IATROGENIC

ID/CC (1 newborn male is evaluated Ibv a neonatologist brcause of ~ o s i 5 .

HPI T11r child p~rsents with qailosis that increases with feeding (while thc chilcl uses she m o ~ t t h for eating, no air gocs in the lungs) and is relieved with crying.

PE M'ell developer1 and hydratecl; heart sounds normal: no mur- murs: I ~ t n ~ s clear; no increase in JVP: resident rvas unable to pass a catheter thmr~gh the nose (rliagnnstir frahrre) .

Labs Lab stl~rlies and nennatal scrtcn normal.

Imaging CT: con lirmatory.

Treatment Snrgical correction.

Discussion Newborns are obligate nose breathers. so pat ientq nit11 chnanal atresia cannot inhale cnough air and thus become cyanntic. \$'hen the child cries, air i s breathed into his lungs via the inouth, correcting the qanosis. ,4 normal choana allows cam-

munication hehveen the nasal fossa and the nawpharynx.

CHOANAL ATRESIA

IDJCC An IS-y=ar-old college freshman suddenly collapses in the middle of a dinner at 11is fri-itert~iy house: shortlv thereafter his face turns blue ( c u ~ ~ o s r s ) and he qtruggles cle~pcratcly to

I>reathe.

MPI He had hecn drinking heavily most of the dtcrnoon while cele- hratin~ 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 ~ C also laughing hcartilv while eating.

PE VS: tachycardia. PE: in acute distress, clutching throat with both hatldl;; qwnotic; sweatv, with inspiratory stridor and high- pircherl expiratory sounrls while attempring to hreathe; altered !c-r~cl of consciousness; piece of meat lodged at inlet of laryax; spasm of laryngeal muscles. Patien1 slopped breathing and collapsed.

Imaging XR: latcral V ~ M : of neck may show foreign hndy causing alrwav ol~ststiction (obtained in stable patients with partial ohsauction).

Treatment Manual retnoval OF ohsiructing foreign bodv. rapid back blows, Heimlich maneuver, or emergency cricothyroidotomy (incision tl~roug-h cricoid ligament inferior to thyroid cartilage and superior to dcoid cartilage).

Discussion Preren tion of chnking is the k e e mainly in children; teaching the Heimlich maneuver tr3 lapeople has savrd the lives of marly "raE coronarv" victims.

CHOKING

ID/CC A S4vear-old male complains of acute pain on the left side of his Face whenever he eats accompanied by swelling of the same siclt of his face (ducl to trapping of saliva in the parotid duct); he also complains of l-taving eexpullud "saridy*' milterial with h i s

saliva.

HPZ The patierit has hacl frequent hnuts of infedo~ls parotitis (C'IIRONIC: SLC,~\DENI?-IS~.

PE Fir m, round mass palpable below zygornatic process of temporal bone (stone in parotid duct).

Imaging C1T or sialographp: irregularly enlarged Stenson's duct; may cisualize stone.

Gross Pathology S~oncs composed of a m ~ ~ c i n o u s core surmunded hv calcium and pfiosphat~ sal~ depmition.

Treatment Have patien r suck on lemon to atrempt stone expzilsion through incl-eased salivation. I<emt>val cri' stones (1 I-~HC)T~\') hy duct dilatatinn nr s~~rgical gland removal.

Iliscussion All the salivarv gland4 and tl~icts nrav present wiih stnrtp rnrma- tinn (SIAIX)~.I I 1 tl,e<~s): the condition is Creqnentlv associated wit11 r t>ronic inrection of the glands. Apprnximately 80% of salivary gIand stones are rorincl in the submandibular gland (Mrhal-ton's duct).

ID/CC A 19-year-old woman presents with a painless sweUig just

beneath her hyoid bone.

HPI The swelliag has been getting larger over the past several weeks but has not been painf~~l.

PE Rounded, midline. w-ell-den~arcaterl, painless, fluid-filled mass that is not fixed and moves superiorly when patient mallows (vs. dermoid cysts, whicla do not move) ; no othcr neck masses or Iyrnphadct~~opathy presenc.

Labs Basic lab work and thyroid ftfncrion tests normal.

Imaging XR, lateral neck: may see mass compo~ed of soft tissue with n o calcification. Nuc: ratlioactive iodine may localize in cyst if cyst corltains Cunrtionin~; thyroid tissue.

Treatment Surgical removal of ~hyroglossal d ~ ~ c t , cyst, and midportiotl of m 8'

Ilyoid aftcr confirnzing presence of adequate-furlctioning Z 4 1

tllj~oid tissue rlsrwhere. o -0 I --I

Discussion Cysts may arise rrom the remnant of the thyroglossal duct, an x e~nhr~yolopic structure formed during migration of the thyroid $ from the base of the tong~e (at the foramen cecum) to its final

3 0 r

position in the neck. Thev frequentlv become infrcted. The o I 3

fordrncn cec~iln is the normal rcmnant of the ihvroglossal duct. <

THYROGLOSSAL DUCT CYST

Labs

Imaging

Treatment

Qiscussion

Atlas Link

:I 10-year-nld boy is hrouglzt to the pedian-ician complainirlg r>f h i ~ h fever, sore throat, cardchc, swollen gIands. and prodnctive, greenish-~t~hite, bIood-tinged spu turn.

His mother statcs that the b q has had recurrent bouts of sore throat several times a year Col- the past 5 F r s . crzch lime trearerl r f f r c t i v r l y w i ~ h ant ihiolics.

Mouth parlially open (mvollen pharyngeal tonsil c~l~stri~cls nasophar!-nge;ll isthmus) ; tonsiTs markedly enlarged, hyperemic, and cryptic with spotted area5 of pus; infl:immatioil of I( lrus

t 11hal-ius {pro tech opening of eustachian t111~r: ii~ldit<>rr in ratus

is imn~ediately anterior and inferior to pharsngeal lonsil, and infrction or p h a r ~ n g e d tonsils sprcads up aucli~orv t ~ i l ~ r , causing otitis media).

CRC: neu trophilic leukocytosis. Antistreptolysin titer (AS0 ) high; throat culture st1 ows Phemolytic streptococcus.

XR, lateral neck: thickened retrophww~geal prcvcrtuhl-a1 tissue. CT: pharyngeal or retropharyngeal mass (abscesf) rttav he present.

I'enicillin . Re~opharvng-eal abscess is a serious complicalioti that reqriircs drainage. Evaluale for- tonsillectonlv.

Tonsillrctnniy is performed Iess frrquently now Llun a decarl~ ago: nevertheless, an maltlation rnrist be done w ~ i g l i i ng surgical risks wit11 those of recurrent p-ctreptococcal infrctions and posssihle rheumatic fever. Walduyer's ring consists r>l' the nasopharyngeal tonsils, the palaline tonsils, and tile lingual tonsils.

IDJCC A 35-vear-nld woman i s kr-nllght to the enlergency room by amhutance because of the suddcn appearance of'severe retrosternal pain with radiation to the hack and ahrtornen along ~vih dvspnea; the pain i~ppeared after vigorous vomiting.

HPE Shc wfkrs frnm episodes or hinge eating and self-ind~tced vnm-

iting ( I W I ~ I M I ~ ~ ) .

PE VS: tachycardia (HR 1 10) ; mild hvpotcnsjor~ (BP 100/65); no fever. PE:: i t 1 acute distress; complains of scvert chest pain; no

heart murmurs; left lung field hypoaerated (due to pneumotho- 1-ax); cracklitla sound heard over precordium (HAMVAK'S SIGY

OF I ' N F ~ ' M ~ ~ ~ ~ ~ I ) ~ . - L ' ; T ~ N L I ~ ~ ) .

Labs CBC: le~lkocylosis. Amvlase elevated.

Imaging UGI: extravasation of contrast in to medias~inurn. CXR/CT left pleural effusion and hpdropneitr~~othorax; mediastid emphysema. Esophagoscopy: complete rupture of esophageal wall.

Gross Pathology All layers or the esophaps arc tori1 completely in posterior lateral wall of esophagus on left side (vs. Mallory-ZI7c"iss tear of otlll; superficial esophageal lavers; presents as pnstetnetic m + hl~eding} . % -+

n 0

Treatment RI-<)ad-spcclrum antibiotics, chest tube and surgical repair. rn z

7 Discussjon Postemetic rupture of the esophageal wall (BOFRJ ZMKE'S

A 0

SYNDROMF:) i~ lisl~allv qeen f ~ l l n ~ ~ i n g protracted and forceful r 0 GI vomiting of snlid fond; it is common in alcoholics, bulimics, and -<

pmcpant women and in any cvndi tion tha t increases in tra- ahd(~mini1 presstire. The esophaps has three anatomic constrictions: the cardiac (the most common site of rupture}, thr aortic arch, ancl the cricopharyng-eal.

* BOERHAAVE'S SYNDROME

HPI

PE

Labs

Imaging

Gross Pathology

Micro Pathology

Treatment

Discussion

A ft~ll-term, 3-week-old male is ht-ol~glit to his family physician for his second welIkabv visit, at which time the physician notices lhat the in fan^ is jaundiced (jaundice clid not start i~nmediately aCter I~irth, as is the case wit11 physiologic jaund ice).

On directt-d questioning, the r n o ~ l ~ e r also reports that he has dark urine staining his diaper along w i ~ h passage olC "clay- colored" (AC:HOI.IC:) stools (due to ohstnictive jaundicc) .

lcteric skin and sclera; firm milcl hcpatosplenom~galy; no signs of portal hypertension or liver f~ilure.

Direct hyperbilirubinemia; increased alkaline phosphatase, ALT, and ,\ST: low serlm albumin; increased globidin; lack OF urobilinogen in urine.

US: norinaI. Nuc-HIDA scan: unimpaired liver uptake with absent excretion into intestine over 24 hotus.

Livcr increased in size with gree~~xolol-ed, granulnr surface; p~riportal fibrosis if long-standing; eximhepatic bile duct consists of fibrous cords with no lumen (atretic bilr ducts).

Livcr biopsy shows bile d ~ i c l proliferatinn with dilatation of canaliculi and presence of inspissated bile plugs.

Surgery hcforc 2 mont l~s of age lo prevent liver clamage; Kasai procedure to directly attach borucl to surfice of liver; liver

transplant.

Rif iat-v au-esia is t h e nlost corninan cause of persistent jaundice in infancy and is associated with the presence of rnnre than one spleen (POI,YSPLF:NIA). Differential diapods includes cholc- rlnchal cyst {inxw u~ually palpable). a,-antitrypin deficiency, and neonatal hepatitis. If long~tanchg, liver cirrhosis will rlevelop: other cornpFications include chronic rholangitis, fai-soluble vitamin drfjciencies, and portal hypertension.

CONGENITAL B I L I A R Y ATRESIA " <?.

ID/CC A 37-ycar-oId male is admitted to the ER fo!lowing; the develop- rn en t c ~ f marked lighfheadedness, sweaty palms, palpitations, and nausea.

HPI He has a history of duortenal ulcers that have been unrespon- sivc to medical treatment, for which he underwent surgery 2 months agn (vagocnmy and BilIroth I1 anastotnosis [gastrojej~ostomy] ) .

PE \'.$: mild hypotension; tacliycardia; no fever. PE: abdominal exam discloses well-healed upper midfine incision wit11 no hematom-as, tlelliscence, or ~igrls or infection; no peritoneal signs.

Labs Hypoglycemia (50 mg/dL) . CBC JLytes: normal. LETS, amylasc nor-ma!.

Imaging CT: no fluid collections in suhphrenic, sul,hepatic, o r pelvic spaces.

Treatment Low-carbohydrate, hfgh-pmtrin, small, frequent, dl-y ineals.

Discussion A complication of duodenal surgery, dumping syndrome is d~le to the rapid, ~~nirnpeded passage of high+smolarity rood to the 0 - jej~mxm, wit11 onset half an hour aftur meals (there is also a

B Cn -4

delayed rq~e) . Symptoms appear relaled to the development of m 0

hypoglycemia. The blood supply LO the distal stontach- m z duoder~um is derived from the gastrocluodenal artery, a branch --I rn

OF t11p collimon hepatic artery. The pancreaticoduodenals are n 0

bratlcl-les of the gastroduodenal, as is t h e right gastroupiploic. r 0 C;r

which courses through the greater curvature to join the left 4

gas1 rn~piploic artcry, a branch of the splenic artery. The hranchcs uf the celiac axis are the left gastric, splenic, and common hepatic arteries.

DUMPING SYNDROME

ID/CC A 57-vear-old white male complains of deep, burning retraster- nd pain (I I ~ . L ~ W ~ B L ~ R N ) that worsens when he lies down,

HPI The patient i s a heavy cigarette smoker and alcohol drinker. He also complains of regurgitation of so~~l- m;~tertal on and off Tor years. Hr. has been overweight fcjr the past 10 vears and has

recently experienrecl insomnia.

PE Obew and mod~rately nrrvous; slight diwomfort on palpation of epigastrium.

Labs CBC may show rlnemi a if ulcer is preqeir t .

Imaging UGT: gnstroesophageal jtmction and part of stomach protrude above diaphragm. EGD: may show esophageal ir-rfl;linmatint~.

Micro Pathology Esophageal mucosa with varial~l t degrres of inflammation.

Treatment Mkiglzt losl;. cessation of smoking. avoid lying down after- meals, prokinrtics, H, rrccptr3r. hlockers, pro1 on pump in hi hitors,

qu rgesy.

Discussion Most hiatal hernias are sliding (the srnii-racli herniate5 intn the thorax ~ogetl~el- w i ~ h the gastt~es~pl lagea! junction, producing

Figure A-018 Protrusinn of thc stomach above the rliaphmpn, causiilg l~~l l-shaped supraphrtnir dilatation.

HIATAL H E R N I A r-

reflux), but they may also he paraesophageal (the gastm- esopha~eal. junction remains fixed below t11r diaphragm with no reflux; symptoms are due lo pressure). Complica~ions aworiated with pataesophagcal hiatal hernias arc s~nngltla tion, ohstr~tc- tion. incarceratior~. and hrmorrhk~gr. Chronic untreated pstroesophageal reflux disease secondary tr, a sliding l l i a ~ ~ l hernia mav lead to Barren's esophagus (columna~ metaplasia of' the distal esophagus), which i s associated with an increased risk of esophageal adenocarcinoma.

H I A T A L MEFNIP,

lD/CC A Mav-old male is brought to the emergency room with bilious vomiting, ahdomind distention, and failure ta pass stools.

HPI The full-term hahy faiIed to pass rneconium in the first 24 hours afier birth hut did so i~nmediately following a rectal exam.

PE A k d o m ~ n distended and tytnpanic; loops oCintestine palpable; increaqed anal tone; rectum empty; clzild passes Foul-smelling ~t0o1 following I-ectal exam.

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 ~ ~ p t cI~ar~ges ~ I E caliber between gxnglienic and a911glinn ic segments: fail t~l-e to evacuate barium.

Micro Pathology RcctaI biopsy rcveals ahnormal developmenr n i Meissner's and Auerllac11's plexuses with aganglionosis in myenteric nerve and suhrnucosa: hypertt-ophv of nervr fil~ers in Meissner's plextis.

Treatment Stu-gical excision of agar~gIionic segment and anastnrnosis to

anal canal.

Discussion Hirw hsprung's disease is due to railure of mip-atian of' cells of the embryonic neural crest to the howuE ~ 1 1 1 of distill segment5 with absence of*pamsympathetic ganglion cells in the anal and rectosigmoid areas. lrading to Functional (not anatomic) obstruction and colonic dilatation proximal to the affected segment. I t niav be associaterl with Down's syndrome and ~ ~ r i n a r y anomalies. The pl-esrnting wmptom mq. he acute enterncolitis with watery, foul-smelling diarrhea.

fi HIRSCHSPRUNG'S D ISEASE

TD/CC X 45-ycar-oIcI female prcscnts with pain and compiaitls of heaviness and a "twnar" in her abdomen; she also has a fever.

HPI Eight wreliq ago rhe harl heen I~ospitaIized for epigastric pain, nauwa, and rnmiring due to acr~te pancreatitis.

PE VS: Ipvet-. PE: pallot-; epigastric mass tender to palpation; Inass

not motile and scems to he deep-seared; no change of overlyirlg skin; tlu peritoneal signs.

Labs CBC: elevated WBCs. Amylase and lipase elevated (although n o t 10 extent of her. firsl. aclmission) ; AST and i4ZT slightly elevated: bilirubin moderately increased. UA, normal .

Imaging CT/US: large cystlike fluid cnllect ion in close proximity to pos- terior wall OF stomach, origi-inatit~g in pancreas.

GKISS Pathology Collertion arennme-ricl-t fluid aro~itld pancreas walled off Ily inflammatory adl~esions of peritoneal ~urfaces, large bowel, and diaphmgin; no tsue capsule or epithelial lining (~s~:rnc)rf i~r) .

Treatment Imaging-pided intervention for placement of drainage cathctcr. Sometinies slu-gical drainage required.

Discussion Pancreatic pseudocysts are a compljca tion of pancreatitis that occur in about 3% of cases. Tlie pancreas has a hcad, neck, body a i ~ d tail. The mail1 pancreatic duct (nrlc-t. OF WIR~UNG) drai rru into the ampulla of Vazer loget her with the comrnon bile duct. The accessury duct (nrlcx nr S L i ~ ~ c ~ ~ ~ ~ ) drains Innre prox- imallv or in to onp of the above-mentioned ducts.

PANCREATIC PSEUDOCYST I - I

ID/CC

HPI

PE

Labs

Imaging

Treatment

Discussion

Atlas Links

A 56-year-old male bus driver is rnsl~ed to the emergency room with generalized, excruciating abdominal pain that began in the epigastric area aftcr he atc a large meal; 11e also cr>inplains of nausea and vomiting.

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 psir ic dcer and treated with antacids and H2 receptor blockers.

VS: tachyrardia (HR 1 10) ; mild hypotensinn (BP 100 J60) . PE: weary and in acute distress; marked, generalized abdominal trndrrncss. predominantly in cpigasmic area. with positivs. rebound tenderness; n a peristalsis heard; abdominal rigidity ( ~ 1 1 1 ~ 1 0 peritonitiq).

CBC: neutrophilic Ie~tkoqtosis. Slightly elevated amylase.

XR. ahdonlen: generalized small bowel loop diIntation. CXR tnav F I ~ W intraprr-toneal rubdiaphragmatic free air.

Surgical removal of ulcer or c los~~re of perforation in gastric

wnll, peritorleal lavage and drainage. Antibiotics Cur pcrironi tis.

Treatment for Flr l i co l l~r t~r pyhn' on clisch arge.

Perfom~iou i s cornmorl in the gastric antril~n or lesser curva nlre. The pqmic conteilts n1av spill into the lcsscr or greater sac. The boundaries of the lesser sac are the hepatoduodenal Iiga- ment, caudate lobe of liver. d~rodenum, and inferior vena cam. The lesser sac communicates with the peritoneal cavity via the foramen of Winslow. Anterior duodenal ulcer4 ran rause perf* sati on, while posterior duodenal ulcers are associated wit11 hcrn- orrhage ~econdarv to ulcer erosion in to the gaqt t-oduodenal artery.

PEPTIC ULCER-PERFORATED

ID/CC

HPI

PE

Labs

Imaging

Gross Pathology

Treatment

Discussion

Atlas l ink

A 47-yeasoId male is brought by ambulance to t h ~ cmergcncy roorn vomiting copious amounts of blood ( x ~ : w s n ~ H E U ~ ~ M E S I S ) .

He has a history of heavy alcoholism; h e has gotten drunk at least thrre times a werk fnr many vearq.

VS: tachycarclia (T-IR 103) ; hypotension (BP 90/4C!) {cllie ro hypoiwtemia) ; no fcvcr. PE: marked pallor; thin, wastrd, delil-i- nus man with strong alcohol smeU on breath; pupils reactivr a~ td equal; enlargement of parotid glands; no focal ne~~rologic sign^; abdomen enlarged due to aqcitic fluid; spider angiomas over abdominal skin: palmar erythema.

CBC: low hemoglobin (7.3 mgJdL) : leukocytosis. increased ALT and AST; mild hvperl~ilir~ibinemia.

Esophagoscopy: active bleeding of markedly dilatcd and tortii-

ous suhmucosal veins (BLEEDING V ~ R I G E S ) .

illcoholic hepali~is gives rise to fibrosis (CIRRHOSIS) of the livcr, rr.hich inmaws portal vein resistance. With the dcwlopmen t of portal hypertension f > 10 ~nmHg) , 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-in ferior gastric (navel caput medusae), and the retroperitoneal-red vein svstem.

ScIcrothcrapy. In emergency bleeding. balloon ~mponade, entloscopic cauterization. ligation, IV vasopressin, surgery. Consider spFeilorena1 or transhepatic portal-svstemic shunt.

The portal vein i5 formecl hv the joining of the mesenreric vein and the splenic vein; tributaries include the left and right gastric veins. On occasion the inferior meseriteric vein drains into the superior mesente~ic vein rather than in to the splenic vein.

PORTAL HYPERTENSION

ID/CC A newborn rnalc. haky prchents with inahilily to accept food: he chokes, coughs, and vomits with each attempt to feed him.

HPI Fr~n;ilal ultrasound sF~owtld excess a m ~ o t i c fluid ( 1 3 c l r , S ' H \ ~ R , ~ M N I ( 15) and no fluid in stomach.

RE Ft111-t el-in hahv; excessive salivation; ahdomen diste~~ded and t!mp;ir~Itic: catheter cannot be passed into stomach: chest exam nnrmal.

Figure A-023A PI-ouirnxl cnrl of ~ h t . rsoljtlagr~s enrlinq in a I d i r ~ c l prmcli anrI sexmen1 con~nl~rr~ic;~tii~q wi t l ~ the rrarh~a.

F- TRACHEOESOPHAGEAL FISTULA

Imaging CXR: coiled feeding catheter in upper esophageal pouch; gastric air bubbIe present.

Gmss Pathology The most common type of rracheoesophageal fistula is that x~sociated with a hlinrl proxi~nal esnphageal pmzch and a distal esophageal pouch that communicates via a fiqtula with the Ir~wcr ~rachea.

Treatment Treat aspiration pneumunia. Keep esophageal pouch empty b y constant s~~ction. Surgical repair i I S early as possible.

Discussion Anomalies are due to defective differen tiation oI' primitive foregut into the trachea and esophagus, defective growth of endodrrmal cells leading to atresia, and incomplete firsion of the lateral walls of the forc'pt during separalion of the trachea from the foregut. Thcre may hc esophageal atl-esia without trachcoesophagcal fistula and tracheaesophageal f i~n~ la without esoph;tgeal atresia. Maternal polyhydramnios is associated with esophageal/duodenal atresia and anencephaIy (t11 e fetus can 11 ot

swallo-rz~ amniotic fluid), whiIe maternal oligohydramnios is associated 14th bilateral renal agenesis and postdor urethral valves (fetal vritle is allsent or obstructed).

ID/CC A 7&year~ld hypertensive male was hrought to the emergency room I ~ e c a ~ ~ w of the sudden development or severe, tearing abdominal pain that radiated to the back.

HPI He lost consciousness when he waq being transported to the 11ol;pital in his rteighbor's car.

PE VS: hypotension (BP '713/30); tachycardia (HR 110): marked tachypnea. PE: ronfirsed, disoriented, and in a delirious state; skin cold and claminy; peribuccal cyanosis: pulsatile mass in abdomen; rvllile cen tl-a1 lincs were bejng placed, patient snfel-ed a fatill cardiac arrest.

Imaging abdomen: diagnostic; arteriography i~acfiil for planning sr~rgical trcatrntnt.

Gmss Pathology At~i i~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 .4rherosclerosis (Marfan's syndrome pati~nis shaw rvstic npcrosis of the tunica media).

Treatment Immedialr surgical resection and grarting, Patients with asymp- inmatic ahilorninal aorric aneurysms > -5 rm us~tally undergo elective ~urgical resection.

Discussion Atheroscferosis is the most comnlon cause of ait>dotnitlal aortic ;ineut.ysm (lucalized dilatation of its I~irnen). Other cauqeq

include syphilis and ttaunra. Aneurysms are most common in males. partir~~larly the clclerly. They arc ~ ~ s u a l l y located helow r i le lrvel of the renal arteries,

? ABDOMINAL AORTIC ANEURYSM-RUPTURED

ID/CC A iT5vear-old woman prese~irs with groin pain, vomiting, and abdominal distention Tor R honrs.

HPI Shc has also noticed "a Ilunp" in the Ieft groin.

PE VS: normal. PE: abdominal exam reimeals mild ahrlominal distenrion, increased howel sounds, and diffuse tenderneqs to

palpatinn (withour any rigidiq. guarding, or rel~ound lendernev,); tense, very tender, irreducible, mrrnded mass in Ieft groin inferolateral to the puhic ruherclc.

Labs CRT;/LVI~S: normal.

Imaging KLrB: dilated small 'bowel loops with multiple air-fluid levels; rounded area of intesi inal gaq over3ving left groin area.

Treatment Incarcerated and strangdated hemias warrant emergent surgery; otherwise. manual redudtion followed by elective herniorrhaphy is tlze rreatmrnt af choice.

Mscussion The defect in ftmoral hernias is ~rsually much smaller than in inguinal hernias, which makes incarceration Jstrang~~Iation more likelv. The incider~ce nf fernnraI hernias is higher in females and rhe eldertv.

FEMORAL HERNIA-STRANGULATED

I D JCC 1 1 58-year-cllrl ollese Inan presents 10s an evaluation ol" a "lump" in the anal area of 3 davq>dt~ratinn, ra11qing acute, mnstant pain t t~ar inrrcascs d1ir.irlg defecation.

HPI He i s a S Y T I O ~ C ~ ivit11 a chronic cough anrl is overweight. He i t 1 ~ 0

st~fft-r s fro111 proststtic hyperplasia Illat forcrs him ttr strain in n i . r l~ i rn i n i ~ i a t r 1nict~1ri1i0.11.

PE Patient r17alks very slowly with both ?ear apart anrl sits down in r'liair .;irlewavr; extert~al r ~ c l a l ex;lm r.pvp;~ls prewnce d ' a

rounded. 3c-111, purple mass in thr anal verge i l ~ a t is tense and extremely painfill to the touch: ititeri~al digital rectal exam impcr~cible C ~ I I P tcl acllte pain: maw Ir)caIi7~rI to nuter anal region.

Labs CBC: ?light Irrtkou~tosis.

Gross Pathology Dilil~<>~I. ~ngorgcct vein wit 11 clot.

Micro Pathology Ariite illflam~natorv neliwophilic infiltrate

Treatment Acute tlii~ornl~c~sis \vill suhride ~pon~ai ieo~is ly in mnqt cases with sitz baths, atrti-it~fla~nn~atorie~~ local sternirls, xncl laxatives. If rccul-l-rn't, snrgic;~l rcscction is warrantccl. IF ;ic~~iely painf~tl or if rniict-l-vativr rreatmpiit Ii~ils. exciriora wiih local aneqthesia mav

IIC clone.

Discussion Exlernal hcrnorrllc~ids arr dilatations of' the ;in;ll veins fmtw the inii.rior hemnr~rhoidal ~jlexlcs, which drains it110 thr internal

pudur~dal veins. Intcrnal hemorrhoids lie a l~ovr the mucocura- nerlus junction (pectinate line) ancl helong to [lie wperior

hemol-1 hoitlal plexus, wliich dt;linr inro the pol-tal vein through rhc inferior rncsrntcric vein. Intcrnal hcmerrhoids arc painless (\.iscel-al in t~erratiotl) anrl are covererl hy Inucosa. Extcrnal hcmorrhoirls arc piiinfr~l (somatic innrr-ralir,r~) arlcl nl-e covered 1~ skin.

Attas Link '11 1 ' 1 I SUR-028

" HEMORRHOIDS-THROMBOSED EXTERNAL

ID/CC .A 73-year+ld male i 5 r-efkrred 10 a wrgcon bccausc of a pxinf~tl mass in the left ingriinal area: [ he milw prntrildes wit11 straitling and dbappears at rest.

HPI The palie111 has Fretluet~t brjl~ts or constipation ( i . e s~~l ting in increased inm-abdominal pressurr.) .

PE Rrctal exam shows mar-ked prr~s~atic cr~largcn~en t (st rairsing at ~nictliritinn is pl-eilispoqing ticlor); in wpinr p o ~ i t i o ~ ~ , left inguinal region dnrs not di.~cIose any apparent pxthologp-, I~u t

when patient stands 2nd is askrcl to c r l~~gh , a mass is felt in the ing~~ inn l canal that ran he rasilv rrcIucec1.

Treatment Sirrgical repair: IT eatmerlt for prostatic hyperplasia comrs first.

Discussion Direcl 11er11ias are mnl-e frrqlwntlv seen in rldcrlv people with weak abdominal wall musculature; they protrude directly throu~h the floor of the muscular inguinal canal, whirl1 is the 11-ansrrcrsalis fi+sci;l (inljidr Hrsselbach'~ triangle). On srrotal ex;lrnination, wir h the finger introduced in the inguinal canal thrn~lgh the external inguinal ring, thc Ilrrnin is S i l t i n the putp of the fingcr (indirrct hr.~+ni;~.; AT-c- fell i l l the l i p of the fingrr). VIP Iin~itr; nf Hesselbacll's triangle are thc dccp (inferior) epigastric arter!: latcral rectus T I I L I P C I P I I O I . ~ P ~ ; 3nd inguinal ligarncnt. Direct herniils mav cui~rrtin tlrinary hladder that ran be darnaged during s11rp;er-l;.

Atias Link r_I1A:1_- SUR-029

* INGUINAL HERNIA-DIRECT

ID/CC .% P,%eal--nEd male weight liftel- come5 to the emergency room I~ecause of a painful lump in the right scmtal area that began cal-licr in the morning.

HPL Hr is hualrhv with an unremarkable pas1 medical history; h e Srcqucntly cngagcs in strenuous physical labor,

PE Z'S: tachycarrfia. PE: abdomen distended and h l p a n i c with inrl-eawrl peristaltic mnvemenls; render tn palpition with no rehnurlcl tendcr~irsv (intestine i 5 ohstr~~ct~c l with backward accum~rlatiun c , I gas and k c w ) ; tender, tense, and painful mass in right i n ~ ~ l i n a l area that continues thror~gh extcrnal inguinal ring into strrotum; masq clops not tranrillu~ninate.

Labs CRC: neutropt~ilic l e u k o u ~ ~ o i s (intestinal loop is sufrering iscl~cmia). Incr.rawd BUN: normal creatinine (dehydration due to in tra-akdorn inal sequestration ) .

Imaging KLTR: dilated sm;lll bowel locjpv will1 air-fluirl levels in steplarlrlcr pattern; mass in right scrotum.

Treatment Surgical tl-eannenlt tn Cree inteqtinal lonp and repair hernia.

Discussion Indircct inguinal iicrnia is thc most common type of hernia i 13

ma1r.s (usirally va~mg) and frrnales. T l ~ c h e r ~ i i n rnmes out thro~~gh tlzc internal inguirtal ring with thr spcnnatic cord anti hrq tirntly prr )tr,utles into tlir scroti~rl~ t h ~ . m ~ p h l11e extrrnal ingt~inal ring. Indircct hernias lie lateral-superior to the inferior epiga~tric artery, outside Hesselhach's triangle. Inclirect inguinal hernias are most cr)mmonly dlic tcr a congenitally patent processus vaghalis.

INGUINAL HERNIA-INDIRECT

lD/CC t\ 2-yearald boy is ! , m ~ i ~ h t lo the en-lergency room I>? his par- ents l~ecausr of a n increase in the size of his beIIy and persi5tent vomiting.

HPI Two weeks ago the hnv had bright red blood in his stools For 4 davs.

PE VS: tachvcarciia. PE: pallor in co11,j tuictiva; abdomen distended and *panic with incrpawl howel sn~lnds: on palpation. aT>rfonzen i s tender with small, sau.sa~-shaped mass in right lower quadrant (due to inmssu~ception l .

Labs CBC: normochromic, r~orniocytic anemia; nelltl-nphilic 2cukocv- tnsis. Tncreased BUN: crratini~~r ~ ~ o r n ~ a l .

Imaging KLlB: air-fluid Icvcls with small howcl Inop rlistenrion. Nuc:

prvsencc of ectopic gasltric mucosa confirmed.

Gross Pathology Five-cen timeter-Iong divertirulum situated on xntimesen~eric border or ileum located IiO cm from ilt-ocecal \.nIve. nit-erticultim fnnns tip of'an in1 uwllwep~inn.

Micro Pathology Con tai 11s ectopic acid-secrehg gastric mucosa irrlrl pancreatic tiswe.

Treatment S~rl-gical excisio~l.

Discussion Mcckul's diverticulum i~ the mosl colnmon congenjtal anornalv ot I h r GI tract; i t consists OF a diverticular sac oat~sed hv persistence of the vitelline duct nl- yolk sialk. The five 2'q 19

m rlescrihe it: 2 inchec long, 2 feet from thr ileocccal va l~e . 2% of' z m th r p o p l ~ l a t i ~ n , first 2 years of life, 2 v r s of cpithelil~tn. I t tnav m

he Lwwnptom;ltic or mav give rise to intuss~~scrptiotl and $ VI

intcstin;~l okqrr-uction, rlivel-tic~lli~is (indisting~~isf~ahle from c ;E)

ap~endiciris), nr hleerling. CI m ;D <

Atlas Link LT_ml PG-A-032

MECKEL'S DIVERTICULUM

IDJCC A 73-vca~old mail is hruughl lo the E:K Frnm his nursing hnme because of thc sutldcn developmpnt r)C intcnse abdominal pain.

HPI Thepaticntstatcs~l~at t11epainissevere;tndevenworsethan his prior MI. He Ilas a history of similar hut less severe rrrampy abdominal pain aftw meals (inrestinal angina); he i s a Iieaw

smoker.

PE C'ln palpation. abdomen is only moderatclr teiider atlil dislend~d rvirli IIO parding; peristalsis not heard (pain is out of proportion to clinical Findings); rectal exam shows blood.

Labs C13Cl: markcd lcukocyto~js (27.700) with neutrophilia; IIO ane- mia. h ~ y l i s c . motlerately high; CK elevated.

Imaging KUB: marked distention of borvlcl loops to splenic flextire; p q in

bowel wall. BE: thumbprinting or howcl wall ( d t ~ e 10 ~l~l~rnucosal hrmorrhagc- arid edema). hlgio: vascular occlusion by embolus.

Cross Pathology Smgiral ~ p ~ c i n ~ c n reveals cotnpletelp black ancl i~ecro~ic ileum ai~d~jcjunuin; multiple clots in superior mesenteric artery (SMA) branc hu?.

Treatment lrnmcdiatc surgical in tcl.\,en~ inn ir massive: intrrt'er) tional ai~gio- grapllic th~-orn l~o l~s i~ iT Cocal.

Discussion Occlusive cIiscas~ of rhe h o r z ~ l mav be due to thromhosir or cinl>oli, giving rise to lire-thrr-atening inrestinal infxctio~r. The ShIA is a clircct hrarlch of the aorta and suppIies the right side of thc colon, the appendix, anrl the jejr~rlurn ;tnd ilelrm (its hrai~cheb are 11ie ~nirlclle colic. right colic, arrd i!eocolic). The itifetior. tneqenteric artery (MA) alsrl hr-;~ilches from t l~c aorta and sripplirs tht. lefi colon, sigmoid, and upper r-ectz~m through i t9 hraii~hes (IeCt coIic, sigmoid, and wperior hemorrhoidal).

fl MESENTERIC ISCHEMIA

IQ/CC A '1-~ueek-nlrl male i s hrougt~t to the f;amilv cloc;tnl- brcause his parent5 t~nticrrl a "lump near the child's buttocks'" the lump son~urimcs disappears hut invariahlp reappears when rEle chiIcI cries.

HPI Hc is the first-horn child of a healihy Hispanic cotiple. The pse~mancy and tIclir~crv were lineven tf ril.

PE VS: no frvcr. PE: no abdominal mwws palpable; no neurnlogic qignq; zipon examiniition of left lumbar area, nothing was noticed until child criec2, at which point a 2-cm-diamuter, rolmded mass was felt on edge ol'iliac crest.

Labs RaGc lab work norm~al: ~rreening for inlieri ted metabolic deficirnries normal,

Treatment Sm-gical.

isc cuss ion Petit's tri:~ngle i s for-merl h v the iliac crest iihferiorlv, thr. poste- rior 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 HERNIA

lD/CC A 33-year-old gas station attencIant is brought to the emergency room after sustaining a bulIet wound on the back of his leg.

HPI He panickcd and ran when confronted by hvc1 muggers on a dark. deserted street (shot from behi~ld) .

PE Lert foot is cold; inability to dorsiflex foot; overlving ski11 cynnotic; no dorsalis pedis pulse palpahle (artery lies hetween

tendons of extensor llalliicir; longus and extensor digitorurn langus); entrv wound located on poplitral rnssa and exit wound on anterolatcral portion of knee; lower third of thigh and tipper third 01-leg tense, .swollen, and painful.

Imaging XR comminuted (multiple fragments) fracture of tibial plateau. h g i o : traumatic Wansection of poplited artery.

Treatment Emergency surgical repair of artetv.

Discussion The popliteal fossa is a diamond-shaped zone houndcd 011 the lateral superior tnargin by rhe biceps fernoris musclc, the medial superioi- margin by thc rcnlinlen~branous muscle, and the inferior margins hy the gastrocnemius muscle. I r I~arbors the poplitcal artery and vein ( I - ~ C T C the lesser saphenous vein clrains) , tibial nerve, peroneal nerve. and obturatot- and ikmorocutaneous nerve branche~. Tramtic knee cli~locsttions

POPLITEAL FOSSA TRAUMA

EDJCC A 37-year-nld remale comes to t iw emergency room because of the sudden development of pain in B e right <groin area and a tender mass of 2 ho~rrs' duration.

HPI She is a heaIthy mother offour with no pertinent mcdical historv.

PE VS: tachycardia; mild hypertension (clue to pain). PE: patient in pain: chest and abdomcn normal; no signs of intestinal ohstniction; small, ror~nded, very tense and tender mass felt; on palpation of right groin area, mass is not sed~icihle and causes

intense pain.

Labs CBC: marked neu trophilic Ieukocycosis.

Imaging KUR: normal appearance of gas in rectum; no signs of intestitla1 obstruction.

Treatment Immediate surgery to reIease ischemic, ga~ngrenous bowel and hernia repair.

Discussion Richter's hernia refers to a type nf hernia in which only one wall of the intestine ( u s ~ ~ d l y the antimcsentcric border) is trapped by the constriction ring of the hernia; ia can occur with l'emoral, inguinal. or timbilical hernias (more common in the femoral type hecause of the narrow orifice). Since gas and feces may still pass through thr. nonconstricted area, s i p s of olwtruction are usualIy ahsen t. Femora1 (crunl) hel-nias, found medial to the Femoral vein in the femoral canal. arc more common on the right side, more cotrimon in womm, and prone to strangulate early. The Femoral ring is formed by thc inguinal ligament, the lacunar (GIMRERVAT'S) ligament, the Femoral vein (easily darn- aged during repair). and the pelvic border.

RICHTER'S HERNIA

ID/CC R T%year-olrl Temalc corneq ro the emerge~ency room cornplaitling of acute abdominal pain that is colicky in naturc, dung with pain in between contractiorw and inability to pass f l a w .

HPI She s~ll'f'ers €rot11 chronic constipation and takes Iaxativeq every day

PE IS: tachycardia (I-IR 97) ; borderline hvpertcn~ion (BP 140/95) : t'rvcr (58.1 "C) . PE: dehydration with clry mucotls mr-~nbrancs; abdomen markedly distended md painfill wit11 guneralited ~ym-

tone on p~rcussion and absence of perisraltir movements,

Labs CBC: neutrophil ic leukocpsis. Increaserl RUN; nrlrnlal crea ti- nine: amylaso mildly clc\~atcd. GTX: increascd specific gravity.

Imaging KCR: massive distention of sigrnoid colon. RE: bid's-beak appearance of contrast at point of vol~,'~~Ius.

Gross Pathology Sigmoid excessively mobile and twisted over its own mesentery with massive distention and thinning (paperlike qualitv) of intestinal wall.

Treatment Sigmoicloscopic decompl-ussion; with failure. surgical operation.

Discussion Vnlvulus (twistitla) of the colon is mote frequent in the elderly and most commonly orcurs itr the stgmoid area: thc sccond most common site is the ccclrrn. Closcd-loop intestinal okstr~~c- f i o ~ i t ' t ~ s ~ i t - s and, if per-sistunt, ]nay lead t o ganzrenr anr l perrnra- tion with peritonitis. Bloodv colonic clischarge with shcclding uf dark colonic muuosa suggusts colonic necroris and warrants, ernergrnr wtrgical resectiun uf r~ecrcltic howel.

9 SIGMOID VOLVULVS

ID/CC A 2Syear-old tnale is hrougl~t to the ernergen7 room i11 a con- fused state after being iilvolvccl in a high-speed rlorvnhill skiing accident.

HPI We complains of severe abdominal pain radiating to the left scapula.

PE VS: marked hypotension (BP 70J.50). PE: cold, clammy skin; acute distress; generalired abdominal tcndetness and rebound tenderness with guarding, especiallv in Iefr ilpper quadrant; pair1 in left scapula when foot of' bed is devated or an palpation of left .rubcostal reffion {&HR's SIGN) (due co presence of free in rmperitoneal blood tl~at irritates diaphragm) : dullness to per- cussion un lcft flank and dullness to pcrcltssion on sight flank that changes with position ( B A L I ~ ~ F ' s SIGN).

Labs lAow hematocrit; peritoneal tap grossly bloody. Uh: negative.

Imaging CT/US: he~natnma surrounding spl~en with obliteration ofL splenic outline; peritoneal flnid.

Treatment Immcdiatc blood and volume replacernen t; emergency surgical splcen removal (srr E ~ C T O M Y ) or. when possible, rplenorrhaphy (SPI.ENIC SUTURE). Postsplenrctomv patients slloulcl receive pncu- mococcal vaccine for prophylaxis.

Discussion The splcen is the mosl commonlv in,jui-ecl organ in blunt a b

dominal trauma. So~lletimes a few clays will pass hetw~en a trauma and syrnptomatolog (I)I..IAWD SPLENIC R U ~ I R E ) . With splcnic enlar-gement, wen minor trauma can cause rupture.

SPLENIC RUPTURE

ID/CC A 1 3-year-old boy: is hrmigh t to the ernergcncy rorm l jr? his par- ents a rc r an accident at school: hc was walking along n $[eel ~ ~ ' n i - d rail whcn he slipped and fell, straddling the rail.

HPI H e was in extreme pain initially. 1121 home the pain subsided

'iotneWt~at. Upor1 2 wination, a few dmps of bloody urine wcrc pi-utlilcucl. Tlte child also nolicerl qwelling 01- his scrontrn.

PE VS: racl~ycardia (HR 1") ; frvcl- (3K.3"C). PE: pa~i~t lr in pain: grni tal examination ruwi11s vru.it< of' blood on meatus, ecchymosis. and painful swelling of s c r o t u m and perheal region: abdominal exam cliscloses a rounrlrrl, tcndcr rnlal-gerncri 1

un the suprapubic area that is ~ ior l~r io~i le arid dull 10 percuqsion (hlarld~1- is frill).

Labs CHC:: leukocytosis (1 7,0003 with ncutrnphilia. Slightly increased R U N wirh nc>rmal rrpatinit~e. C.4 was not possihlc in thc ER {duc to inahiliv to void; i~lsor-tine Fcrlrv cathrter w;+s rantraindi- cx led b~cauve of pl-ohable m-elhral rlanlage).

Imaging Ure~hmgl.aphv: extrxva5ation t~rirle inro scrota1 ri~stie and perincum (rupture of urethra).

Treatment Surgical rrpair, trmpur;lrv cvsrostoniv.

Discussion The n~;iIc u re t l~m i.: dkided inlc, sevel.al pt,rtinn<: rhe pr-oqtatic (wiclest), t -~eml~ixnnns (narroivest), h u l h n ~ ~ s (in the hufh part of the corpus sponposrtm) , and sponp portions (Iongvsr, withit1 the C ~ I - ~ I I F s p ~ i ~ g i o ~ t ~ n i it'irlr), enrlinq in the fbssa naviculnris a n d meatus. IY i t t~ fnrr~f111 rnn~trirtion of the tlrerhra against thc pubic arch, n urr.thr:il ruptrlrt. may enstlr. The Iascial plane5 i 13 rhe region rli rect urine to flow allreriorly ro the louse arrolar t i s s ~ i r of rhr scrotum arlcl silperficial perinril space. This qpce lies belween r h e inferior ihscia of he t~rngeuital dinphmgm nnd the s1q3rrficial peri11eal I'awia.

7 STRADDLE INJURY

ID/CC A 42-year-olcl fcrr~alr on the p n e c o l o e ward cumplains OF a dull, aching pain on her left Bank as well a3 riausea and vomiting on lier t tiirrl postoperative clxy; [the in tern notices that the palient has alsn heen olipric o~ernight.

HRI Shc recen rly unrEer\vent a tc~tal abdominal hysterectomy due ro large uterine fi hmids.

PE VS: l o w p d e fever; BP normal. PE: @ent well hydrated; no

pallor notrd; surgical woumct is tnidli~le infratlnlbilical; dressing noted to be wet with urine; al~clome~l has muscle g~rarding; peri~talsis diminished without ubviol~s peritoneal signs.

Labs CBC:: le~~kocytosis with neutrophilia. BLT and crearinine i~icreased. T.yte5: normal. UA: proleinuria and rnicm~mpic llernaturia.

Imaging Lxcretor~ uro-qapliy: blockage of urine at level of lefi ureter and intra-abdominal leakage of urine from right ureter.

Treatment Exploration and surgical repair of rlrrtel-s wi rh end-to-cnd arm+ lr>mosis or ?' stent.

Discussion The ureters mrty be injurer1 r l~~ i ing h?~stel-ec tomy Thc crilical point comes di~ritlg; ligation of the uterine vesscIs at the vicinity of the CPHT~X. Thc ureter crosses underneath the uterine arteries

* URETERAL INJURY-IATROGENIC

IDJCC A 43-vuar-ald female complains of numhness and swelling of the legs; qhe also ha5 muscIe fati-gue in the afturnuvt~q wi~li a feeling of heaviness in t h r Inwei. exrt-em i ties aswcia~erl wirli cutaneous lumps and humps.

HPL Sht. i s overweight, works behind the corintcr at a fast-food I-rsLmran t (associated 1virI1 prolongrd sta~lding) , and h a given birth to five chilclrcn. Hrr symptoms are alleviated when she elevates her l e p by placing them t>n ;i chair.

PE Ohese: rliffiri~lry I>reart~ir~g after clinlhing a flight nT stairs; facial pletliorn; examination of lo~vcr extremities rrvrals swelling with dilatation of veins in territory n l greater saphenous vein.

Treatment Low weight, elastic stockings. dimiu is11 prnlongcd stanclin~, SLlrRCry (<apf~c.nucturriy).

Discussion The greater uapl~ei~cl~is vein start., at he atiterior aspect of the

rncclial inailuolus, origii-tating in thc dorsal venous arch of the Foot: it asc~~lclx in the ar~~ercsrncdial portion of tlie k g and thigh tu drain in the frrrloral vein just hefore rhe inguinal ligament. Tt has ilunlernus cnnltnunicating veins with the deep vcnous nf.;tcn1. Prinl;u+v varicoqities ilrr a rev 111 of incompetence of the valves in the s a p h e n n ~ ~ ~ vein o r in the communicating rein<.

thus increasing hydrustatic prussrlru and pr.oducir~g dilaratinn arid tortuous veins. Sccondiu-v varicoqities ;ire a r ~ s ~ l l t or nhstl-uction ol'tt~e r leej~ venom svstem ~ v j r j ~ t ~ resultant increased flow and pressure.

Atlas Link TT'T? MC-364

7 VARICOSE VEINS

I D JCC A 3 1-yearilld white female comes to her- Fatnilv physician for a routine physical examination.

HPI He]- rl~edical history is unr-emarkal3le. She has hcen on birth control pill4 for the past fi months.

PE Three-cen t i i t fusiform fluid-filled submucosal mass along lateral wall of vagina on speci~lum exam; no discharge; cervix

ilormal; on palpalion, no pain or mobilization; no pelvic masscs on bimanual palpatiorl; I-eclal exam normal.

Labs Rvu tine lab rxarns n n r m ~ l ; pregnarlcv test negative.

Imaging US: rranslahial approach shows k r n cyst in v;lg-ina.

Micro Pathology Simple. cyst wilh serous fluid, lincd with a single layer of col~tm- nar epitl~eliun~.

Treatment Surgical excision if large or syrnpi ornatic.

Discussion Mos~ vaginal cysts larger than 2 cm are Gartner's duct ~ysts, whir11 are of mcsonephsic {WOI .FFIAV) duct origin (due to incompIute cIostre during embryonic life) and are Found along i l~e anternlateral aspect of the vulva or vagina. Thcy may a l~o he

I'ound in the broad ligament.

GARTN ER'S DUCT CYST

ID/CC A 54yei1r-old nursc complains of a E~rq sensatinn in her lower abdomen that worsens when she lifts heavy objects. together with hack pair1 at~r l increased Ii-eqllencv of' ui-i nation with a burning sensatio~i (due to a1 tererl location of bladder, ailhsequent stagnation OF ~irine, and thns bacteria! proliferarion).

HPT She has given birth to five children, all by vaginal delivery. She co nlplairl s nS urine leakage while coughing, sneezing, or running (STIZFSS I N ( : O ~ I I M F V I :F.). Her menses are irregular. hut she has otherwise hren in good health.

PE Downward bulging o f anterior wall of vagina (CWTOC:I<I.E) with 1 0 ~ s of urrthro\cqical angEe exacerlxiled Ijy straining; protrl~sion of cervix (PRC~LIPSE OF ~ T E R L ~ S ) .

Imaging Xiding cvs~ourethroffram: hladdcr dropping l3elow syrnphysi~ putris during voiclin~; loss of un-ethrovesical angle.

Treatment L%laddrs rew~spension sllrgery.

Discussion LTtrrinc prr~lapsu i> nls~vally a result of the stserchi ng or peIvic s~ ippor l in~ strncttlres during delivery coupled with years of grnci tational weight and m~nopausal lorn nC muwle tone. Pelvic Ilnnr slipport is given hv the levator ani inuscle and its fascia, which continues with thr urogenital diaphragm, endopelvic ra~cia, and cardinal ancl l~terosacral lipmetlts.

UTERINE PROLAPSE WITH CYSTOCELE

Labs

Ernaging

Grass Pathology

Micro Pathology

Treatment

Discussion

Atlas Links

A GG-\:ear-old rliah~tic higll-~cllonl hirlloq teacher goel; to a Fllr- geon for an cvaluatinn or n smalI nodule on his lower lip.

The norl~~le i l a ~ heen tl~crc fur o w r vcal; and hc wclnders if it might he re1;lted to his llahil of chewing tobacco while watching bas~hall Fanre5 aftrr w-hc)ol.

x -- rn

Ind~~ralcrt, ill-defi~lcd, vir,laceous, rlc)~imo~ile mars fell in IOM~PT 3 m

lip: uiilargernent nf submental lymph nodes (wli irh drain the =. 0

rnedial ~>or-lion of t h e lower. lip) arlrl suhrnandibular lymph Z rn

nodes (wl-tich di;lii~ the Iaiel-a! pnl-tinn of r t i r a lower lip): enlarge- Inenl oI deep cervical lymph nodes neat. omohvoid m~~scle .

Sitrgicnl pi~tholow specimen rnnsirtl; elf a wrdgr oI'lowrr lip wiih an ulreraterl lesiml a ~ l d rnI!ecl edges.

Si~rgicaI reinoral nf nnrlule on lip and radical neck cli~section (removnl of ~ubmandihillar gland [adhcrrcl to ; i f f tc td s u b rnandi hular nodrs] . sccrnoclriclomastoid muscle, omo hyoirl, accessnry nerve, and in~errial J z 1g111ai. \.pi tt ) .

I n l p ~ r t a n t rqions in tile anatomy nf'sqnamous cell carcinoma nf the lip I I I C I U ~ P the s~thrnanrlil>r~lal- triangle (hchvccn tl~c base of the mandihlc and the antcrior and po~tulior hcllics of thr tliga\tric); the mttsctilar triangle (omollyoici, s~ernocleidomas- toid. fnprlian Eitle. rnntait~ing snme deep cervical Imp11 nodes): thc carotid rriangli- (stcrnoclrido~n:istoid, omohvoid, posterior belly ol' digr~slric. con tainir~g internal jugular vein at~cl deep cervical noclrs): ; l r ~ r i tlte PC,~~PI .~O!- cervical ~ r - i a n g l ~ (ttapezil~s, strnroclridnn~astoid, ornol~void, containing dccp ccrlical nodes near accewnry nrt-re).

* SQUAMOUS CELL CARCINOMA-LIP

I O J C t A I P-ruuckuld male in Fat11 is brought to the hospi~al Tor e ~ d u a - tion of recurrent oral thrush and t R L 5 .

HPI The cllild had seizures (due LC, Ilypocalccmia) s h o x ~ l y aftcr birth. I4is mother is an Il' drug uscr.

PE Full-trrm in rant: jittery; incl-easecl muscle tone; ur;11 1I1r11sh; midfincia1 hypoplasia.

Labs Hypncalcemia; T-cell count markedly low.

Ernaging CXR: absent thymic shadow.

Treatment Tranrpiant of an immature fetal thymus: meat upportu11is;tic infections: irradiatim~ of Illnod producrs.

Discussion DiGeorge's syndl-ome is duc to a11 em bryologir dcfec t ctiaracter- izcd hv lack nf rlev~lopnient of the third and fourth pharyngeal pouches. It is associated ~ i t l l lack of thymus and thur 110

cell-incdiatrcl irnrril~niq (henre recurrcnl viral and fungal inkc- tions) as well as wit l a congenital hcart defec tq. The associated lack of parathyroid gtands rcsults in livpocalce~nia. leading to

DIGEORGE'S SYNDROME (THYMIC APLASIA)

ID/CC ;2 newborn female presents with a r~onplllsatile mass on the left .iicle oF11rr head: an irr tern is called to ;~ddresu the mother'q colic-et-n~.

MPI The in t ~ r n has been tl-ving [to reassure t hp chilrl's mnther that he]. rhilrl's rot~ditiot~ i'; benign, Imt hi< re:issurnrlce5 hirvc bren LO nu avail. Thc rlclivcrv was unrvcntful except fnr a pmlongrrl expulsive perind.

PE Ncwlmrn fc~nalc in no aclltr dis~rcss; 1-10 cyatinais or pallnr; n o signs ol rarrliopulmon;u-l~ involvement; scalp exam cliscloses skin rlisct~lol-at inn wi ttl ecchymosis and rliff~lsr swelling of soft tissue in left parietal arca involving most nf the left parictal bone and unc-third of the rig11 t parietal bone (crosses suture lines).

Labs C:RC:/I,vt es: nnrmal.

Imaging XR, 5kllll: no fract~~rt. or r~vcrlapping of bones at srrtzu-eq: large scalp maw unrelated to skull clcarlv lius acr-uss sutures.

Treatment Observation.

Discussion Ci~p~ir s~tccedaneum refers tn a benign edema or the soft tissues

of the head during ddelivcry: it charxctel-iqticallv crosses the midline and cranial suh~las and is riot assr~cialerl tvith an onrlerlyir~g fi-act11 re. The diiTerer1i iaI dizgnosis includes crphal hrmatoms. rvltich does not prcscn t wit11 C C C ~ I ) T ~ ~ O S ~ S , is som~tinics associated with a fracture. docs not cross suturr line5 (a~l~pcrictstral hlcccling is limiter1 to one hnne), anrl may take F P I I P ~ ~ I 1 1 o 1 1 r ~ to heco n ~ e eviclent (caprlt i q imtnecliateIv srcn) .

* CAPUT SUCCEDANEUM

ID/CC A neonatologist is ca!led into the nursery for an emergency; a newborn hahv girl has hecome dyspndc and turned blue (cymo~rr.) upon her arrival from the delivery room.

MPI The ytitient i s the product of a normal delivery. Her mother did not receive any prenatal care.

PE Full-term fernaIt. baby; cyanosis: severe dyspnea wilh olwious intercostal retractions; small and scaplloid abdomrn; absent breath sound.? anrl positive peristaltic bowel sounds: in left chest; heart sout~ds heard best nver- sight h ~ m i t hol-ax (clue to cardia- mecliascinal shirt).

Imaging CXR: coils of air-filled stomach or bowel seen in left hemithorax. displaciri g treart to r igh~ sick . Prenatal diagnosis can Ile made by ultrasonogl-aphy.

Gross Pathology Left pulmonary hypoplasia; left posterolate~.al congenital diaphragmatic hernia uilh failure of fr~sion of pleuroperi toneal canal.

Treatment Res~~sc i tate and stal~ilire neemale, intubatiotl, aqsisted ventilation follo~verl kv ~urgical repair.

DTscussion Congenital diaphragmatic lterrlia usually rcprcsents failnre of the pleul-operiioneal canal LO close cclmpletely ( F ~ K A M E N OF

S p ~ n a l cord

Vertebra

Rib Aorta

pleuroperttoneal Mesentery of oesophagus

Cef t pleuroperitoneal

lnferror vena.. membrane

Contr~bution from body wall

traosversum Oesophagus

Figure A-044 Muscular structure composed of the sepninl transver- rum, dorsal rsophageal meqrntrry, hncly~vall, ancl plcuroperitoneal rnernlxar~e.

7 CONGENITAL DIAPHRAGMATIC HERNIA

BOCHU,ULIC), leading to protrr~sion of [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 congen- ital bur usrlally do not produce symptoms so early and are located antcriorlv (11s. Roclida~ek's postcrolateral location). Pulmonary hypoplasia is the tnort common cause of death in infants w i ~ h diaphragmaric hernia.

ID/CC A l-day-old male infant ( i 7 . s . pvIoric sirnr~sis. which i q xsqociated with 3-week-old infants) has persisten r bilious vomiting (vs.

pvloric ~tenosis, which is n o n h i t i o ~ ~ ~ ) when his motller attempts

10 feed him.

HPI Hr. was horn a1 36 w c k s of gestation and w e i ~ h e d 2.3 kg at birth (vs. f~~ll-tcrm for pvlorlc steriosis). His morhrt. harl excess amniotic fluid ( ~ n ~ k F W I 3 ~ k h . l ~ l o s ) .

PE VS: ~arhvcarrlia. PE:: dehydrated: no ja~rnclicc present; on che41 ar~scul talion, con tinuouc machinery mtlrmur- @tent c luct~~s artrriosus) present: single palmar crease and ~ypical Cxcies of Down's syndr-ome; abdomen distended, tympanic tn pcrcussio11. and painhil: nr, mass Celt; no visihlr pcristarsis; narrnal-lookirlg mcconillm on rcctal oxam.

Imaging KUB: gaseous tlila~a1ior-1 of stnniarh anri dundenurn ("nur30r,~ I3ITRKI F").

Treatment Sl~rgical repair.

Discussion Iluodenal a~resia i s asqociatecl with ~ t l i e r inusculoskelutaI and \iscrral abnarmaIitic<, notal)ly Down's syndrome, as well as with congenital heart disease. It n-pically present5 with bilious vomiting on the F i t day of life.

DUODENAL ATRESIA

ID/CC A 3-week-old male is hrcmght to the pediatricia~i for projectile, nonhilious vomiting t I ~ 1 h e ~ p n totl,w s11or.rlv afl'rur feerlin~.

HPI He hiis ZIPPH rpffrlrgit-aring h o d and has l ~ a d occasional hoirts oi-vt~miting fm- 1 week. The chilcl is thc first-barn son of n 28-~~ar-old white feimalc and i s the p r o d ~ ~ c ~ t of ;+ 1101-ma! r1eliver.y. His mother had hypermphic pyloric stenosi5 w1lt.n she was bar-n.

PE Letharqc. moderately dehydrated hahv: low weight for age; wrinklecl. "old man" appcarancc: visible peristalsis ii-c)m l ~ f c llpprr qtiarlrint tcnm~-rl right llppel- q~larlt.ant Fol Ion-cd by projectile vomiting: hard, rnohilr, nonlendr~; olive-like mm felt z in epigastriwrn d c ~ p to right rcc~us nlrrwle. m

0 Z

Labs Lytcs: hvpokalrmia: hyonatrcnria. ARCS: hyporbloremir alhdu- 3 o siq (rllre ro loss ofg-astl-ic hudrochlnric acid in votnitus). 6

C) < Imaging PIS: pylorus mrrscle thickening (target sign of pyloric st et~nsis) :

rlongated pvlnric canal; ~zridcncd pt lor-us. UGI: pylnr-ic ~ 2 1 1 1

iliickening; elongated and rial-rrwrd ~lv lnr ic channel (%TRAM.

SIC;N) ; vianrcntsly perisialf is stntnacl~ with almost no ga5h-i~

Gross Pathology Diffiise hypertrnph y and hyper-placia or smooth nlusclc involvi~~g pvEnric sphincter; muscular thickening r-xtenrls proxi~~~al lv IO

;In trum ;inrl end.; w h e r ~ r l ~ ~ o d r t ~ t 1111 hegin$.

Treatment Carl-ection nS Il\~iil and cllectrofvtr abnormalities, nasognstric rl113e decompressinn. Surgical wlicf of pvloric ohst rtlct inn (R~XISTEDT ~ \z~Ro\ I \T .Y~c) \~Y) .

Discussion Hvpertrnphic p~loric sto~iosis rlsu:illv preseilts "verks afzer birth. although it Inav 11ut hecoinr appal-rtnt 1111 ti1 s~veral tnorlt hs of' age.

HYPERTROPHIC PYLORIC STENOSIS

ID/CC ,\ 48-yea~old male cornpu ler prugrdmmrt is kzougli t to the emergency room with intermittent, e x m c i a h g pain in the right flank: rhe pain radiates to his inner thigh and testicle and is accompa~lierl by nausea anrl vomiting.

HPX Orfcs a pcriod of a frw hour<. the pain migrated toward his p i n . I t lasrerl for 30 minutes anrl then stoppcd for anothur 30 minutes before n~ddenlv recurring (due to periodic pesiqtal~ic 111r )tion nf' 1.1re~er).

PE hhdomirlal exam shows no rebound tenderness (vs, peritonitis 07- ;~ppenldicitis); guar-ding i q present; painrul and difficult urination ( n k s ~ l ~ m ) ; blood ill urine (HF:MATI.KI~); patient is rrstlesv and keeps witching position (vq. peritonitis. in which p a t i c ~ ~ t lies still bccause of pain).

Labs t!A: hematuria; I>;lcteri~~ria; leukoryturia.

Imaging ILT or CT urngram: fiTli~rg rlefects in umtcr and renal calyces due to stoncs. Obstruction proxirrial tu storle.

Treatment HvrZratinn, analgesics, antispasmodic?: many patients pass stones syontat~eoz~sly; treat metabolic ahnormalitius: pcrcutarleotls stonc extraction (PEKC:LT.~NEO~S KEPI-IROLITH~TCIMY), shock wave storle f r a ~ p e i i taiir )n (+,x I KACOKPOKI.AI. L.ITHCITRIPSY) , or surgical rcmoval.

Discussion Renal ir-act stones may produce one or the most severe forms of pain known duc to obstruction arid s~nooth mtiscle 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 A 4.5-year-old man. ~tle farher of swen children, comes to a ram- ily planning clinic fnr acl~-ice regarding birth control.

HPI Afcer carefi~llp weighing all possible alternatives with the doctor, h e decides to 11avr a vasectomy.

PE Physical exam unrcmarkahle cxcepl for an old McRurnev appendectomy war; no coutraitwlications fnr surgery.

Imaging CXR: within normal litnits I'or age.

Treatment 1';wvctomy (complications include scrota1 hematoma. infection, spermatic ~ a n u l o m a , sperrnatocele, an<? spontaneous recanalization).

Discussion \'asectornv is an increa5inglv popuIar rnethocl of permanent birth contrd (regzarded as such, although repnrrs of up to 70% successftll reversal exist, mostly in men under 30 years of age who ~lnderwer~r the proceclltre lesg rhan 7 years ago). The Iayess to clit d ~ r o ~ t g l l are skin, superficial scrota1 fascia ( n , w o s msc;r,$), external spel-matic fascia. cremasteric fascia and muscle, internal spermatic f'wcia, pwperitoneal fat, and ~rlnicavaginalis. The d~ictus defer-enr is tied in n w place5 and transccted.

IDJCC A 59-\!ear-old femalc comes to her family physici;m hecause of left-side hearing loss, ~iutnbness over the lefi hall' of her Face, a n d unqteadiness of gait of ahorit 1 innn th's duration.

HPE She nlsa rornplnins of intermittent vertigo and ringing in the ear (TINNITI!S). She has no history of earachc, car clisclaitrge, or eri~ption aver the pinna.

PE P a t i ~ n t Calls lo left when star~rling with eyes closed ( F ~ s I ~ .

K~~MIJ~:I~L;'s SIC ; Lirnclus normal; gait wide and ataxic; whrtr runi11g L'ork is pli~ced in midline of skull, patient reports that she hears best on right sidr (Wcher test laterafizec t c ~ the right, i.e., he normal sidr, becanse r he leh suffers a senrori~lc~~ral loss); caloric testing SIIOIVS left canal paresis.

Labs Ar~diometry shows sensorinenrd hearing loss un left side that is mow pronounced with high frequencies.

Imaging CT/MR: cnntrasren hanceil cerebelIopontine (CP) angle mass cxtcrlding into internal auditory canal.

GTOSS Pathology Slow-growing sc hwann nma nf eighth nerve.

Treatment S l ~ r ~ i c i ~ l rmn~ov;tl.

Discussion :Zcoustic schwanno tnas art= Schwann cell-rleriv~d neoplasms that comprise about three-fourths of CF-anglc nec~plasms, They arise mainly frt ,111 the vestib~11a1- divisiori of CN V'III. Other CI'-iati~Ie inawrq include ~neningirrina, arachnoid cyst, and epiclermnid tntnot Bilateral acnustic schwannomas are seen in type 2 neurofibmmato sis (NF-3).

Atlas Link DJ- LA PG-A-049

ACOUSTIC SCHWANNOMA

ID/CC A 42-year-old man presents ro his fararnilv doctor rnrnpjaining tof pain and stiffness on one side of his neck that precIudes normal moi~pmpllts.

HPI Tlir patient is obese and sedenlarv and never exercises. His paill startccl after he wenk outside and shovelet-I rhe firqt m o w withor~t ws~rming up (sudden, ~ i g o r o l ~ s plysiral rserrise) .

PE 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 XR. cervical spine: no fract~iro or siil>litxation

Treatment Muurle ~ .e laxar~ts . KSMDs, local h a t , masxilge.

Discussion Acittc torticullis is causer1 by acute spasm of neck muscles due tn

irlfl atn t~ratorp changes Iwcause of ~tnclue straining; thc rnuscl~~, that arc. usuallv invol\~d arc the trapczilis, suprahpinat~is. thorn- I~oicl, splcnius capitis, Icvator scapt~la, s c a l ~ n ~ ~ s rnedilis. qplenius cervicis, and, in severe cases, transverse li~a-imenr. allowing subluxation nf one vertrhra on another. Tortjcolliq may also bc congenital due to unilateral fibrosis of the steniocleido~nastoid

ACUTE TORTICOLLIS

ID/CC A -57-year-nlcl rig11 t-handerl male is Ix-ought to the emergcncv I-OOHI 13v his relatives hccause t l ~ y noticed that altl~ough he speaks flt~rrltly. he has beg1111 ro use inappropriate words and phrases to rprer to ol-dii~al-y n l j e c t ~ and event? in his daily lifc

HPX I Ic suflers fi-om chronic hypertension that has been treated with calcium channel hlnckerr.

PE 1'5: hypertension (BP I i 0 / 120). PE: confusion; constructianal ncurolugic deficit; Bahiirski's reflex prcscnt.

Labs KEG: a f > ~ ~ o r ~ n a l brain activity in leR ter-nporal lolw over supra- marginal anrl marginal pri.

Imaging CT/MR: infarct in left tnirldl~ cerebral at.tc-1-)* t eyrir or-y.

Treatment Supportive. Speech therapy.

Discussion IVel-nick's ("receptive") aphasia is a disorder of spcech that is cluc to a lcsion in the superior temporal gyms that occurs w i h ~nidtllt ccrebral xi-wry occ l~~s ion . Speech is fluent hut nonsensical. a11d I here i s ;11~n at) iiiahili~y to ~~nrlerqtand spoken 01. written Ia i~guag~. Nonfluent ("expressive") aphasia (BROCA'S .krti/~rc\) is chi~rdctcrized by thr i l~~b i l i ty fc~rtn words: patients knnw what thev want In 5ay h ~ ~ t are lt~lahle to clo so. IU~atever thev do say, houvever, is appropriate ancl rneani~~#~ul. This diwrder rcsults frarri a Iusiori ill the ir~furior frorllal gyrus.

Figure A-051 Demonstration of ir~voluritary tlorsiflexio~i of thr lees in rcspolnsr to stroking

, , , , ",,, G , A , A , on the sole of the fool 1: ': ; , , ,il

(A-Rahinski's sign) and altcrna- , , , ,

j::$ tivrs: anterior tihiat surface , <

I . ,$ (bOppenhrinl3,r sign), and

l;lier:~l tn:xlleolt~s (GC:hadrlock's sign} or to tir~nlv ahdk~ctirig (lie

, . ,, , , , , , " , , , , " A , , , A , , , , " , , ::,,;!

I , ; -\

, , , , , , A , , A, , , , , , + , , , , , fifih cligii Tor 2 s~coi~ds. A , , , , , , ,<

, , A ,

, , , , , , , , , 8 k.:; >,,--,,,< ; , : ; " , ", , , , ., , .. (n-Srru~isky's sign).

blCq c - APHASIA-WERNICKE'S

lD/CC A 7-year-olrl girl is hl-oiqht hy her parents to the pcdiatric umer- gencv drpartrnen t hecarl~e or a severe headache t11:t~ does not respo~ld to treatment wit11 analgesics.

HPE Her fa~lier is cot-rcerned aho-iit "weird movements" of thr girl's ryes (NIS I-AC;~TLIS).

PE M'ell dcvelopecl and nourished I~ut confi~sed with ataxic gait;

chest and abdominal exams unrem;~rkahlc-; fiinduscopic exam reveals left papilledema (due to incr-ei~sccl intracranial pres- snrc) : nvstagmus also noted; patie111 exprrienced prqjectile vom- iting during examination (also due 10 increased intracraniaf p"es""'e ) .

Imaging MR/CT: cystic posterior fossa tumor.

Gross Pathology Grayish cystic mass; zones af necrosis, hemorrhage, and calcifi- cation; cerebral edema.

Treatment Surgerv, chpmothcrap): radiotherapy

'Discussion hsrrocvton~al; are slo.rt,-growing malignant tumors that originate from neuroectodermal neuroglia. In ch i l tlrpn I hey are usually located iri the cerrbelltirri (posterior fossa), whereas in acl~lults z

m the)' are located in the cerebrum. OCten cvstic in cl~iIdrcn, heir c A growth mas calrsr increasecl intracranial prc~sitr.e. seix~rt-es, and o r

h y ~ l r n s ~ p l ~ a l t ~ ~ . The posterior cranial fossa is limited antrriorlv o Gi

the dorsum sella, laterally Iw thc parirtal bones, and posteri- < or117 hv the occipital bone; it contains the fm-amen rrlagnum h r l h e spinal cord as well aq rhe jug71lal- fornmetl anrl rhe internal acoustic meatus.

Attas Link U PG-A-052

ID/CC A 43-ycar-old diabetic male comcs to the emergency room fear- ing 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 The pi-evinuq night, Elis wi€e 1101 iced thac he was sleeping with his right eye open and lha t the righi sirle nT t i i q race was droop- ing. That morning, the patient couId not cop drooling on the right side of his ~nouth. He has no1 c losu l~~ monitored his blood Sllrdr for sr\,cral months.

PE Kight-siderl Facial tnl~sclc.i flaccid: t ~ t ~ d e r rnrcerl rlonlre of right cvr, cycball rotates l~prvard (BEL.I.'s P I I E N O ~ ~ E V O N ) : cognitive function normal; ~ ~ l ~ r n patient is askcd to smiIc, right side of innuth rcrnains flaccid (B).

Cabs CRC/ I ,vt PS: nnrtnal. Myp~rglvcen~ia; Z.FTF: nol-inal.

Gross Pathology lnflarnmation of GN VII in thc v i c i n i ~ of the shdr>mastnid fr>ramt.11.

Treatment Steroids, artificial tears or eve covering.

Discussion Bell's palsv is seen as a cornplicatiou of diabe~es. AIDS. Lvme diwase. rumors. ancl sarcoirlosip but i~ most co~nmonly irlio- pathic. InvoI~ernen t 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 ~ S llpper 1noro1- nrlsrnll pathology (11ppe1- mator neurons have ct-nqq-innet-i~tion to the Cnrehead). It is sclf-limited in mast cases (~picaI1y rrsolves in F, to 12 ~nonths). with only a small pclrentage oTcases i-es~~ltinfi: i l l permanent disfiglrr.munt. It is lIiougl~t to rrprrsunt a viral cranial polyneu-

* BELL'S PALSY

Figure A-053A Drnlnnstmtion

01' ~~rurnlogic drficit secol~dary I

tr, a cr;tnial nervr lesion- . . unable to close r i ~ l l t ryc dur in

m .

ol-himlaris nclllns muscle palsy.

my-

& \

'I

Figure A-053B Detnnnstra~inn of n v ~ ~ r o l o f i c deficit secondarv rn a cranial nerve Frsion-low of tipturn of right angle of

? '

:- $<i mouth on heitig asked to smile -. clue to orl~iczilaris oris muscle

"3. palsy.

>.., 1 ' : I

, . <, A,:, , , A

> + ; " ^

,,<,A

+ A , , , ", +

, ", , <;"> , , < * < < ', , ' ' , ,,

,+ , ,,,,, , A ,

, , ,,, ,, , , I - , , , , , , < ,,

' g . , , Figure A-053C Denio~~strittion ! ol~ilcl~rolagic deficir secondi~ry

i ' toacr~~~ialner~~elcs ion- loss OF liarisverse f r ond wrinkling on l~pwal-rl Rue due to right ri.011 talis rn uscle palsy.

ID/CC A 45-pear-old man i s broughl by ambulance lo the emergency department of rhe local cortlrn unity hospital cotnplaining of hbility to move his left leg.

HPI He was stabbed in the back 2 houl-s ago while defending his wife frotn a nlligger.

PE Modcrdtr bleeding; stab wtlund at Irvcl of the positlrior cervical spinous prominence (C"7) on leIi sicle; loss of position sense of lefi leg; weakness of finger- flexinn: extet~sion or left finger: in- ability to sense vibration of nming fork along left lower limb; loss of pain and temperature sense in con~alateral lower limb.

Imaging MR: liematoma at level ol'C7-TI i n left hair of spinal cord.

Gross Pathology Hemisection and compression of spinal cord at level of C7.

Treatment Surgical removal of hematoma.

Discussion Rsown-Skpard syndrome consists of ipsilateral upper and lower motor paralysis helow the level of the injury (corricospinal tract),

ipailateral cumncous anesthesia, ipsilateral loss of vibrations and proprioception (dorsal colurnil) , and contralateral loss of pain

A B C

Sensory deficit

Figure A 4 5 4 A Lnqq nnf tibratoy se~~satiori on flip =me qide as h e spl~lal lesion.

9 BROWN-SEQUARD SYNDROME

and trmpcrature sense helow the Iwel of thr lesion (spi11otha1i1- mic tract). It is risually clue to a pench-ating injr~sy to the spine, resuli ing in functional hemisection of the spinal cord.

Sensory deficit D E

Figure A-054B Loss uf pain. pi~lprick. ard tennpe~ ;ilure sensation or1 the srtle couualareial to the spinal lesion (describer1 in coniunctin~~ will1 F i p ~ r A-034.4, ;tq rlissnciat cd ar~rsthesia) .

ID/CC .4 45-vear-nld hov-scour ins~ructnr I- turns fi-om a 2-wrpk c a m p ing trip with a high Fever. a sewre headarhe, and a pus-rded boil on his right cheek that appcar~d after he cut himsclf on a tree branch.

HPI The patienr has a long hiqtory of diabetes mellitus that has been 11-ea~ed with irtsulin. He also complairls of in tertnittent vomiting, nau5ea, and episorlec o l deliri iim. His hearlaclie i 5 particularlv severe on the right sidy.

PE \ ;St fever. PE: neck muscles stiff; right cheek swollen and red ~ i t h area 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~~nction or

right extraocular eye muscles; 'tingling and burning (P~XRFSTI-EESIA) of right upper quadrant of facc.

Labs Stnj~hylocurcus nlcrPrrs on blond and wound pus culrttt-e.

Imaging CT/MR: b c k of cavernous sinus enliancernent: clot in cav- ernous sitltls.

Gross hthotogy Septic venous thromhosiq l>locking tributaries of orbit; cyelid edcrna ancl discoloration.

Treatment Agerewive cmirse of TV antibiotics b G)

Discussion The infection b ~ g a n at the in$~iry sire and progressed along the -< 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.

CAVERNOUS SINUS THROMBOSIS

IO/CC A 34-year-olrl rorlstr~~ctinn wol-k~r- i.s 1,roilghr 1r1 a cl in ic arirr. a

fl!ing pic-ce or s1lr;tpnel cut his l e g < j ~ ~ ' i ~ h ~ l o u ' I he lateral surface of the head of the fibula: the paticn t also cornplnir~q of numb- ness and tingling along the dorslun of his foot and thc lateral qiirfacr. of hi.: leg.

HPI Ffe complains of Inss or qrahiliry when walking and inability to

domiff ex his foot ( F C K ~ I ) K ~ I ~ , ) . [-It= nllzst raise El ig i 11j11t-erI leg higher than not-rnal during walking to prevent his toes ~YCEII I

hilti rlg thr grc>imd. and his foot slaps against the ground w h e n walking (steppage gait rl11e to tinoppc>svrI actinn ol'plantar flrx- ars; n~rlscles innrrvaterl I n prror~eal n e i w are pa~xlvzed: extm-

sor digitorurn longus, tihialis anterir)r, extensor h:llIri~is long11s).

PE \t'r,unrl in proxi~niry ot head of Rbtila { ; ~ l . ~ a whcl-P rhe common fihular riel-vr i s most ~nperfirial as i t wraps arnunrl rlre head of the f?hula) : diminished cutaneous sensation nicer antt=rolateral aspcci of leg and cIor.s~rtn or root (cutaneous h ran rhe~ or thc uupf=r-fitial fibl~lar nerrr .;ul>ply t h i s arr%i): i~~al~i l i t ) ' 10 extend toer (pal-alv~iq or t ihiali~ atllerinl; peroneti5 Inngl15 and tit-evi5).

Imaging XR, I r ~ : fractrn-r of hu:~cl of fibula.

Treatment Spring-loadecl b~-;ice of foot to prcvcn t Foot drop during walking m1cI tn provide i~drlitinnal ~tal>iliry.

Discussion The common peroncal ncrve is hi.cquuntly inj~lrcrl due to tr;iam;i of the ilppel- leg (..a,. krokrti Libula) owing tn i i q ulrperficial location arounrl ttlc lateral sur.face of t tie head of the fibula.

Figure A-056R I h.rnnl-isrration nl p o . c ~ ~ i o n IIJI. ixhwcsincnt nTlowrr

rsir-rrr~ilr; t l e ~ p lerirlor~ reflexes-patcll;lr rct1r.x.

COMMON PERONEAL NERVE DAMAGE

Figure A-056% E)ciiloi~s~i-;ui<>~~ ut pos~lior~ i ( . ~ ; ~ s v t s s n ~ c ~ > t r-)I- 1orvc1- r ~ s t r c m i ~

cIerp lrnrlun I-eflexes-,Achilles reflex.

ID/CC Tlle parents of a 9-year-olcl bov are called into his teacher's n f f ~ c e to talk ahalit academic proMems tlze child has been having; the teacher suspects that the child cannot hear properly.

HPI Since infancy, he has had recurrent ear Sections ivi ~ 1 1 discharge.

PE Otoscopic exam s l z o ~ ~ perfomtion of right tympanic membrane; when n~ning fork is placed in midline of skull, patient reporls he hears best on right side (Urr.n~.lr msr IA.~FRAI .IZES UIC;HT) ; bone conduction greater than air conduction in right ear (rosma RIT,I-IT R~NNE TEST).

Imaging XR, cranium and sinus cavities: within rlormal limits.

Treatment Myringoplasty is definitive treatznen t.

Discussion This i~ a case of' conduc~ive (not nerve-associated) deafness in the right ear secor~rlary to a tympanic mernhrane perforation. Normally, air cond~iction is greater than bone conduction (i.e., it pves a negative Rinne test), whet-eaq the reverse is [he case in conductive deafness. The Weher test lat~ralizes to the affected ear in cases of conductive deafness and to the normal ear in cases of sensorineural hearing loss. Tnlterprehtion of the two tcsis togethcr can identify the type of hearing loss.

DEAFNESS-CONDUCTIVE

I D JCC A 9-venrald hov complains of pain in his left elbow lthat began after he feu off his bicycle, hitting the grouncl elhow first.

HPI He also has nl~mbness on the medial side OF his hand (due to

damage of' [lie ulnar nerve at the rncdial cpicondvle-olecranon yoove) .

PE 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~is nltlscles are innermtetl t h e ultlar ~lerve).

Imaging XR, P I how: separation of epiphysis of tnedial epicor~dyle (children under IG have t~nf used epiphvseal plate).

Treatment Isolation of clhow after reunion of frdckirecl ends: physical ther- apy for hai~d rnovernen~ (crusher1 ncne will regenerate).

Discussion Of all injl~ries to long bones during childhoacl, approximately 15'3 to 20% invrjlve the g~*owth platr. A y-owing hone subjected to a s l learin~ force mav cause the epiphysi~ to separate from the growth plate, prnducing ~ignq and wmproms ofa liacture. Imprnper healing of the growtll plate may 1-esult in Iengtl-t or bowing cleformity.

ID/CC A I -wl-ek-old child is brought to the pediatrician bccause his mother noticed that the child does not move his right arm r l ormallv.

HPI His deliwry was dvs~opir and prolonged wit11 a breech presentation.

PE Child well nourished and developed; no focal neurologic deficits; light arm extended, internally rotated, and in adduction; prenation of Forearm ( ~ V A ~ R ' S TIP POSIT[OK\.).

Labs hasic wnrkup and newborn screening nortnal.

Imaging XR: no fracture of cIaviclc nl- arm.

Treatment Physiotherapy, nervc repair in selected cases.

Discussion Erb-Duchenne palsy involves the upper brachial plexus (C5-Cti), tisuallv by addnction traction of the m with hyperextension of the neck. At times the phrenic nerve [nay he

ERB'S PALSY

ID/CC 11 45-qear-old female is scheduled to undergo a Iefi parotidectomy d ~ ~ c l to a tumor.

HPI Upon a w a k e n i ~ ~ g from anesrhe~ia after removal nC the gland, she was asked to smile hut could not dn so prnperlv.

PE Surgical wound ct)vered hy sterile gauze with no apparent blued- ing; small drain it1 place; when patient i s asked to wrinkle fore- head, patient's left side woz~ld nut rvrinMe (affected side); left comer of mouth does not rise tip as right one rloex when pa- t 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 slloub teeth.

Gross Pathology Sl~rgical specimen consigts of a malignant adenocarcinoina of parntirI gland; a I).5cm-long portion of facial nervc wns found resected. enmeshed in carcinomatous lobules.

Treatment Facial nerve can he sun~red ol- grafted with suraF nerve il'lesion is voluntary or involun~rv hut cannot 11r overlooked: otherwive, physiotherapy.

Discussion M~tscles innervated by the facial nwve include most of the mus cles that move the race and scalp, inclliding the huccinator and zF - -

rn t h ~ posterior hclly of the digastric. The Llcial nerve gives taste c ;D sensation to the anterior two-third? of the t o n g ~ e . The pal-oticl o r

gland consists of two lobules, rhc anterior and posterior: the o I 3

facial nerve ancl its branches (ceriical, buccal, qgomatic, 4

trmpoml, and mandibular) coursc between thc hvo after exiting

FACIAL NERVE INJURY

ID/CC ,4 Pti-year-old professional cyclist visit5 a sport? medicine doctor corn plai tiing of weakness in the right leg and lack of sensation ( ~ ~ N E S I - H E S I A ) in h e anterior area of his thigh.

HPI Eight v:euI;s ago, he fell from his bicycle during a race and suf- fered 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 Patient has significant weakness with extension of his right knee; ~rhen patient is asked to stand, there i s ohviouq instability despite x-rav consof idation of fracture, and d i g is impossible (due 1 0 weak hip ilexion).

I Imaging XI?: healed pelvic Fracture.

Treatment Phwiother-apy, ~ur~gical exploration and repair in selected cases,

Discussion The quadriceps femoris muscle is innervated by dlft femoral nerve. When there is a nerve injury, as is the case in penetrating wounds or pelvic frncturrs, the patient is unaMe to extend the knee and thrt-e i s anesthesia in the anterior area of the lower extremity from the thigh to the foot.

FEMORAL NERVE PALSY

ID/CC A '18vear-r~ld man wit11 tuberculol~s adenitis of the neck is being twaced with a m~~ltiple drug regimen; 2 days ago he developed "strange movemen&" of the tongue and cannot stick his tongue out normally.

PE Mhen patient is asked to protrude his tongwe, it deviates to the left (rlcviatiuil of ahr tungliu to t h r affectrd side i s caused hy dle rinopposed ac tinri of t he con tralarer-al geninglossus muscle,

which is normallv innerva~ed): left ride of tonqre atrophied and flaccid with Fasciculations.

Labs HTV positive; PPD (tuberculin skin test) positive.

I Treatment Trexi callse (TR, tumnl; etc.): physiot11er;zpy

Discussion flaccid paralvsis accompanied IJV atrophv of t h e tongue de- notes a lniver motor nenrt)n lesion of rhc liypoglo~s~l riel-VP.

Cauqes includc parotid ancl casr~tid body tuIrmrs, ~ubetculous adcnitiq. ancl metastatic neck tumors.

Atkas Link E m 1 2-A-061

Figure A-061 l ) t ~ ~ ~ ~ c ~ ~ ~ \ ~ ~ a ~ ~ ~ t ~ ~ b < I c t ~ ~ [ , ~ ! I I ( , I . ~ ( . 0 1 t l i ( 11 I I I torque

o~~iw'iu1 ~ + l e v ~ ~ ~ i c >I) r > t ~lir r o n p r ro t h c rigt~r indicaung an ipsilaieral I:K \ 'TI ltiwrr motor tirllrnn Ir<ion.

HYPOGLOSSAL NERVE PALSY

ID/CC A newhorn chilcl is noted on his first complete phvsical exami- nation to have h i s right hand in a "claw" position.

HPI H e is the son nf an lFCyea~--nld rernaIe who was attundcd at

homc. by a midwife; he was hurl1 with shorllder dystocia.

PE In adclition to claw hand, examination disclose% p~rpiIlat-y con- stric tion (vlcnrs) wi~h rishr-dr-oopinx welid ( i~rosr . ; ) and lack or sweating (,tusrr~~osrs).

Labs Nconatal enzrme drficiency screening and basic Inh work oormal.

Imaging XR: no Cract~il-e nf clavic!e.

Treatment PI-lysiotherapy. ncrvc repair in seIected cases.

Discussion IUumpku's palsy is an abduction injury affecting the lower brachiat plexu%, whereas Fib's i s an adduction injury affecting the upper brachial plexus. Panlysi~ of the lower brachial plexus primarily affects the C7, C8, and TI mats and pmcluces paralysis of the m~isclcs innerv;lterl bv them (e.g., ulnal- nerve, claw hand). Concomitant damage tn the .sympathetic fibers of T1 mav produce Homer's syndrome (\iro.;rs, rrr)sn, ;ZNI+II)KC)SIS).

7 KLUMPKE'S PALSY

ID/CC A 65-year-old woman complains of prngressirre difficulty abducting her arm beyond 45 degrees.

HPT She r~nderwcnt a mastectomy 4 months a ~ o for breast cancer. Refore her surgPry. the patient had fuII rangu of rno~ion in he]- arm.

PE Win-ged scapula noted whcn patient push~s against wall (sen-atus antmior paralv~erl by zlrrve damage and therefarc unable to fix scapula against chtxl wall).

Treatment Physiatherap);.

D i ~ c u s ~ i o n I n the course or surgcal: axillary ltmph nr>dr di5section during mastectomy, the long thnmcic nerve mav be injured.

Atlas Link C1. ~ ~ ~ - 0 6 4

LONG THORACIC NERVE I N J U R Y

-

ID/CG: ,475vear+ldman complainsoCdifficultydawing (n\.irrs.\cr~) and speaking ( I>WARTHRI.Z) (due to corn pression of CN IX, X): Lhese s y p t o n ~ ~ have pr~~qessivcly worsened over the past several months.

HPI I Ie has a140 noticed increasing pain during urinatic~n { D ~ S U R ~ A )

ovcr lhe past several months and difficulty starting the flow of urine (a consequence nf prc~.itatic carcinoma).

PE IVeakness oC right p h z ~ ~ , y n ~ r i l and laryngeal muscles; atrophy of sternocleidomastoid muscle and trapedus rntlscle (comprcssion of CN XI}; rectal exam rcvcals rock-l~ard, fixed rnass in proslate.

Uvr

la vated

la not . ,

Fr'gure A-064 Dernnnstration or ne11roIoh.i~ rleficits rerogni7rrl hv exanlina- tion nf thc ~~\~i la-midl ine u\.c~la at rrst and cle\-;ited ut~ i la with r l o c3tljatir,n while tllr patrcnt says "ahhh" I~hormal); ~n.r~la rlcriared tn (he nolmal side at rest 3 r d elevated with rl~viation to the n o ~ m a l sirlr whilr the patient says "aIihh" (unilateral CN IX. S plcgia); rnid1111~ ~ ~ v u l a ai rev1 and elevatrd rrjih

tleviation to thr normal side while the patient sav~ "ahIih" (~~ni ln t~ . ia l C5r' IX, X paresis); nlidli~ie t~vula at rest and no inovelnerlt utlile ~ h r patient say? "ahhh " (I~ilatrsal 1X. X plegia) .

MASS I N JUGULAR FORAMEN

Labs Mm-kedlv increased serunl-specific prosta~ic antigen; increased acicl phosphatase and alkaline phospha~ase.

Imaging CT,ncck:rnassinj~~gulaxfomen.

Gross Pathology Metastatic prostate carcinoma impinging- on CN IX, X, XI at level af jugular foramen.

Micro Pathology Transrectal hiopw shows high-q;lrle prastauc adenocarcinoma.

Treatment Prostate carcinoma t seated bv orchiectnmv and hormonal rnoclaIities: radiation.

Discussion Prostate carcinoma produces metastases in the axiaI skeleton with d ~ e possibiliv of involvetn~n c at all levels of the spine as well as the cranial bones.

MASS I Y J V G U l A ? F 0 9 A M E N

ID/CC An R~ear+Id maIe presrzits with progressive dyarthria, dgSphagia, and weakness nf the right side nf his horlv of 'I months' duration.

HPI The child has no history of fevei-. vaccinations, rxantl~em, dog bites, or travel outside h e United Statel;.

PE Fundus normal; atrophy of left side of tongue; joint position and vibration sense seduced on right side; spastic right-sided l~cmiparcsis; face spared; d ~ c p tendon reflexcr brisk on right sidr: extensor plantar response noted on right side: no cerebellar s i p s present.

Imaging CT. hhcad: lcft medial medullary enhancing mass with edema.

Micro Pathology Infiltrating glioma.

Treatment Inop~rable tumor I>ecause of s~trgically inaccewihl~ ~i te; irradiation is the primary form or treatment.

Discussion Midli i~e stslictr~l-es are invnlved. including CN XI1 ( I ~OT,L .OSS~IL . ) , pFmi rlal motor tracts, the medial lemniscus (pmprinceptive senqatinn), and he medial longi~udinal fascic.l~lus (connects various CN nuclei}. The hallmark of brainstem lesions is ipsilateral cranial nerve pal^ with contralateral hemiplegia. Lesions of the midlmain produce partial c>phtha lmople~a and contralate~al herniplegia. Legions of the pons p r o d ~ ~ c e ipsilateral paraIysis of conjugate gaze or

inlurnnclcar uphthalmoplegia, contralatcrd hemiplepa, and loss of position and vibratory scnscs. Lesions of the medulla produce paralysis of the rong-ue on the same side and paralysisis of zhr con~alatcriil limbs; lhr face is spared.

ID/CC A 9-month+Fd infant is hrought to hir falnilv physician hecause E I ~ P parents arc wwrricd that the child's head appears too Large.

HPL The mother- had ar t appwentlv unuvcntf~rl prt.gnilncv and drliv- erv. At hirth the chi l r l '~ hodv weight atlrl head circumference were at the fi5th percentile (normnl).

RE Lrthargic anrl irritahfc: anterior fon tanclle bulging; 1~1;hen PI-PSSP~ FI ighrly, i t immediatelr pops hack (incrca~ed intracranial presqure): head circumference enlarged (an infant's head enlarge: \$+i tli increased ill tracmnial pressure, since ft~sion of cranial sutures i s incomplete).

Labs RPR in mother negati~e (Tor ~vphilis) .

Imaging MR. hrad: daated lateral ven~cles; dilated third ~entricles: stenosis of cerebral aqueduct (noncommunicating hydro- rephalas).

Gross Pathology Cong~nital oh~tructiun of aquedrict of Sylvius duc to asach- noidiris, with marked ventrictllar dilatation anrl atrophy of ccre- I~ral t i~sue (most common site of congenital obstrucrion is at the aqueduct).

Z rn Treatment Surgical inserrion of shunt either from lateral ventricle to infe- C

rior vena cam or directly l rn~n third vet~tl-icle tn subarachnoid n 0 r

space. 0 m <

Discussion .;tlrno?t half of infants 7l; i t l . I IlydroccphaIus will 31;lve Arnold- Chiari syndrome (hvdrocephalus, svringornvelia. platvhasia, and myelomeningocele). Other causes include infections (TORCH), hnt it can a l ~ o he idiopathic. as in this case. Not~cornmunicati ng (ohstrnctivc) Ilydrucephal~rs results f r o~n obslrr~ction lo CSF flow within the ventricles. causing dilation uf ahe ~cntricles upstrcam of tl~c hrock. Communicating (rionoh~rrtrctive) hydrocephalus results from failure of CSF reabsorption in the suharac l~nnicl space.

OBSTRUCTIVE MYDROCEPHALUS

ID/CC A 50-year-old obese man corncs to see liis physiciat~ at the 11rgiiig of' hi< wi (P; ~ I I P state5 that her hushanri sleeps restlessly and Iias headaches upon awakening (cluc to inabiliry to breathe wI1Ilc ?Iceping).

HPI Hc is a hr-rgvy smoker. His wife cr)mplains that his Ioud snoring is Leeping l ~ c r up at niglli. The patient also feels very ired during S I I P ctay rlespite the fact that he gets 10 hours c l i slucp each night.

PE ITS: hypertension (RP 1 fiB/ 100). PE: patient markedly obese with bull's-neck appearance; tongue large; nasal septum deviated to lefl; heart sounds reveal arrhythmic rate (pl-olotiged anr)xin): I ~rngs hy[~cwentiIared: pitting e d ~ r n a in legs.

Labs CBC: palycy~hemia (compensatory cffort for hypvxia). LFT? and th!roid function tests nm-mal. ECG: p-elnature ventricular co11t1-artionq.

Imaging Polvsnmnography: cyclic apt~eic episodes.

Treatment I.n\ing weigh1 is rncjF1 iinpr)rcat)t rn~a\zu-e. ildjwat~t therapy is prolriptvline. ni~sal positive prrssiire ma&, repair- of septum, nxllgen.

Discussion Ohstr~~ct ivc slrep apnea is seen i l l middle-aged males who arc usually mol-hidlv ohcse, smokcrs. ancl I-typertensive. I1 i s due to a n timber of causes, mainly obesity pharyngeal malformations, dl-z~g~, and alcohnl. Patirn~q pre~ent ryrliral perioris or hy~or~en- 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 X 65-scar-old male visits his farnil! medicine cliilic hccallse of slowing of voll~nrary ~nrwemen t s ( I < K ~ ~ ) ~ x I ~ ' T S I A ) . unstable p i t ,

ancl rn~lsalar rigidity.

HFl IHc also complain5 OF tremor at rest that worsens when his $-andchildren come to the hausc ancl make it 101 or noise (emotional tension).

PE Sehorrheic clermatitis on scalp; infreq\~~nt blinking, ui th masklike (flat) facies; rarrliopul~nonary and aI>rlo~ninal cxamina~ion wi 111 in normal limits; muscle rigidity with passive movernen ts ((:or ;~VHT.EL R I C I D ~ ) ; pill-rolling movement of' hands ancl fingers (~rr.srmc, TREMOR) (VS. cet-rhellar tremor-inte~~tion 1 remor).

Labs Serut3-l copper levels normal (vq. Wilson's disease).

Gross Pathology Depigmentation of substantia nigra.

Micro Pathology Decreased dopamine concentxation in st~bqtar~tia tligra, locus ccruleus. and striat~lm ( L E ~ C C L R R 4h-n ( ACII3ATE NUCLEI); i n ~ a - r y trlplaqmic inclusion bodies (L1l:wzrl. I I ( I I ) I E ~ ) in suhstantia nigra.

Treatment Eromocript i t.ie (dopaminc agonist), an ticholiner~cs, levndopa z - - rn

(to prodlice rlopamine), selepline (selective MAO-B enzyme c n

inhibitor). o 6 c-i

Discussion ,Ysc> caller1 pal-alysis agitans, Parkinson's disease is an idiopathic < rlisnrder wit11 a male prerIornina~~ce: it is characterized by decreas~d dopamine due to basal ganglia degeneration, mainly in tlzc suhslantia nigra, with a resultanr relative exccss of acetyl- choline. Sincc doparnine cannot crass thr blood-hrairl harrier. lrvudopn, a dnp~mine precursor, i q given; levodopa crosses Ihe

I~loodhmin harrier and is converter1 tn doparnine in the brain.

Atlas Link IT' .CLL PM-A-069

.I" PARKINSON'S DISEASE

ID/CC Durinx her first postope~ttive vivit, a 2ft.yfi1r-olrl [enlate corn- pIain~ to hcr surgenn or hoarseness.

H P I Shc had ju~t ~ ~ n d r r g n ~ l e n total thyroidectomy far papillan! ~hvi.oirl r;wcer.

PE C'S: tlnrrnaf. PE: surgical wound hralcd: 110 s ig ls of ilifrc~ion or hematoma fbrn~alit lr~: nn fi~cal nr~~rt,logic rl~ficin: C:hvostek's :11irl T l - o ~ r s ~ e a ~ ~ ' ~ ~ i g ~ ~ s i l l > ~ e ~ l ~ (checkii~g fnl- I~ypocalceillia clue to

posqil~lr p;~rathy-oirl rcmr)vaI) ; unilateral vocal cord palsy with hoarseness n c ~ t ~ d .

Labs C13C/I,yrm: no!-mal. I;lurow, 131:N, rl-eatiriine normal; no Itvp.pncalccmia.

Gross Pathology 'rhe nerve was cliamageci during thyroid s u r ~ ~ e r v w h i l ~ siiturirtg I F I P t ~ lno~l t,cssels of the inferior polr of llle tflvroitl.

Treatment Spccc FI t'tir~-apy.

Discussion T h ~ r e :we two recurrenr 131-yigeal nrrves (alw c;lllerl inferior 1:lryngc;ll). hot11 of which are hranct~es of 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 ;~scrnrling in the t~~chcorsophagcal groovr iin closc proximity to thc th~-roicl gIancl trb end up in the 1nry-m. IT t l ~ c left rrcurrent I;~r.vn<r;ll nrrvo i h involecd. onc shoulrl cor~sirler mass lesiorir such as enlarger1 Ir~~nph norips in rile a o r t i c o p u l m o ~ window.

* RECURRENT LARYNGEAL NERVE LESION

ID/CC ,4 2-week+Id child is referred to the pediatric surgeon because of a fl eshv maw in his lower hack [hat ha5 heen present since Kith.

HPI He is lkre second-born child of ;i 9Syear-nld womarl ~ h o did not seek prenaraI c a r u~llil d ~ e rime of deEivurv (i.e., she took no folk acid during prugnancy) .

PE 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~~bmacral area.

Labs CRC/I,vtes: normal.

Imaging XR: lurnbar- spine defect in L5 i ie~~ral arch: lamina unfused; ~yiclened canal: soft tissue mass w e n on latenil film. MR: mass communicales with spinal canal.

G ~ S S Pathology Failure of Fusion of' nei~ropore: spinal cord (neurocc todel-tn clerived) and nieniugcs (mesor!crni derived) are 01 11po11c hcd: ski11 (ec~orl~rm) , muscle (mvo tome), and hone (rclerotome) I I ~ not developed over surCnce pruperlt; ependjml;tl, I I I ~ I I ~ ~ ~ ,

and marginal layers or primitive spinal cord llav-e ~rlot developccl. r rn C ;D Treatment Early sm-gery. o r 0 CI

Discussion Spina bifida is the most common de\.~lnpmcn~al defect of the < central nervous system: it involves incomplete fusion of the dorsal vertebral arches ancl is often aswciared rc-ith

hydrocephalus. There are screral degrers, Crom spina bifida occulta. wllel-e 110 defect i q seen and che skin is inract. to

~net~ingocele ancl ~nyelorneningoccle, wl~ere leptomcningeal and 11eitra1 tiswe may protrt~de through a defect in the cIura matel; hone, mcl skin, usually in thc lumbasacral area. Lack of folic acid [luring preylatlc?, is associ;itrcl with spinra hifida. 1t is also associated wil h elevatccl mater.~~al srrum a-fi'topl-oI~it~.

Atlas Link nIU7 MC-263

ID/CC A 55rex-old woman rnmpIains of intermitteilt I~outs of excruciating stabhing pain on tile lrft side of hw 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 f i r s t cxperiencerl this paill 2 months ago, while she was chewing gum. Shc also reports that cold drafts trigger the attacks.

PE HEENT cxam rlormal: no Ivrnphadenopathp found; no ~ ~ ~ l l l - ~ l ~ g i c almnr~~~alities; no tenderness of affected region (VF. sinus infection or nthel- infla~nmation).

Imaging MR: occasionallv shows tllickcned enhancing trjguminal nerve.

Treatment Carhama7epine7 phrnymin, alcohol injection of r~ervc, sur*caI

exploration.

Discussion Trigcmind neuralgia is also known as "tic douloureux." If present in a young individual, multiple sclerosis ~ h o r ~ l d he sl~spectecl. Altho~igh imaging studies usually vieId no positive findings, surgical explvration of thc posterior Fossa in patients w h o d n not respond to medical tllerapv freql~ently reveal5 abel-ranr blood vessels pressing on nerve root (amenable to

TRIGEMINAL NEURALGIA

ID/CC A 69-yar-old male prusunts with a persislent headache, inrl-ea~ing clumsiness, ancl kequrn L tlot~n or nausea and vertigo aF well as difficulty swallowing (~TPI - I - \ ( ; IA ) .

HPI HP has no histol-y of' trauma, ~accination. fcwr. or exrrt~them. T-Tis Ea~uiIv reports that Ile also has difficulty articulating some words {r~wn~rr T IIZI,~).

PE T'S: BP normal. PI:.: alert and oricntecl; mild hoarseness (duc to

ipsilateral vocal cot-d paralvsis) wivjitl~ sonle dil firulty swallowing oral sect.~tions (CN TX, X): right side of face rrve;lI~ ptosis, miosis, and anhidrosis (HOKWK'S ~ N ~ R C I M Y ) ; pronounced bilaleral nystap1~3 in all directions o f ~ w , e (CN VIII); duci-eased sri~siriviry co ligl~t toi~di and pain o n right sick of f ac r (CN V); right-sidcrl incorl-ect appreriation of clis~ar~ce in linger-to-nosc movements ( n \ s ~ ~ . n r ~ ) ; impaired pain scnsa~ir>n in left (conlralarel-al) ~ i d c of hod? {spino~hnla~nic tract).

Imaging MR, brain: inrarction in rig111 1ar~raI medullarv arcil. h ~ g i o : right posterior inferior cerebellar artery occlusio~l.

I Treatment Treat causativc factors (at~~emscler~sis, emboli) I o prevent fur- t her. dan~agc; rch;il,il i tation. E

m Discussion Also kno~vn as the yn tlrotne or p o ~ ~ c r i o s inferior cei-e bellar o r

artery occl~~qinn ancl lateral rn~du1lai.y synclromc, N7alIen brrg'~ o tl synrlrnme rcsults fi-orrl occlusion of the vertebral artery or its ;=

WALLENBERG'S SYNDROME ' <

Figure A-073 Drmo~lstrarion of neurolocjc clefirii rharacterized h v right-stdecl ptosiq. miosis, an-

hidrosb, and ennpht11;tlmos (Hornel-'< synrllmrnc secunrlary In i~~tnlvcrnrnt or the cer~ i ra l

s y r n ~ ~ x l h ~ t i r chain tihc-rr).

branches (posterior i nferiol- cerebellar) to the laterdl medulla. Findings w e consistent with involvement of structures that lie in the territory of i t 5 distribution: the dorsolateral quadrant of the medulla.

IO/CC A 33-year-old female comes lo the emergency rourn wit11 sudden-onset left lower abdominal pain together with nausea anti vomiting; she passed out near ~thc fi-on1 door. of the I~ospi tal.

HPI Her last menstrual period waq 60 days ago (she 113s been regular and has rlevur ~nissetl a perinrl). Shc also has a I~is torv of pelvic inflammatory disease.

PE VS: hypotension; tachycardia. PE: cold, clammy &in and ma1-kcd pallor (?i?~povnlemia) ; on pal palion, ahdomcil s11ow.c musr ! P

spasm and guarding as well as tenderness of left iliac I'nssa;

pelvic exam cannot be performed hccause of'excessive pain: needle punctnre of poqt~rior cnl-dc-~ac zia vagina (c:t v ~ o c c ~ ~ s ~ s ) sllows frpe inrrapelitonral nondothg b!ood (due tn rupture).

Labs CBC: hcmatocrit low; mild lertkocytosis. Pregnancy test positive. [!A: normal.

Imaging US: ectopic pl-rgnancv in arnpu1l;ll-y region of the lefi Fallopian nlhe with echogenic fluid in cul-de-sac.

Gross Pathology Gestational rac with traphoblast in arnpuIlat-y region of left failnpian mhe.

Treatment Sragical exploration ancl hemostasiq.

Discussion Ectopic prcparlcy refer5 to extrauterinc locations or the fetus; it

may be tubal, abdomind, or in traligan~entous (brrbad ligament ) . Riqk ractors for ectopic pregnancy incIt~dr pelvic inflammatory o m disease, prior ectopic pregnancy, tubal pelvic surgery. and w -+ exposure to leratogeils (e.g., DES) . In order- of frequency tuba1 rn

4

E pregnancieq cornnlonly occur a ( the ampx~lla, isthmus, ftmbriae, r,

or interstitiurn. The blood supply to the tuhes comes from t h ~ V,

ascenrlirig bl-anche~ oCthr uturiile artel-); a brancll of the ii~ternnl iliac artery, and thr ovariat~ artery, a dii-ect l>ratlch of the aorca (brisk I11~eclitig).

A I ECTOPIC PREGNANCY-RUPTURED

ID/CC A 22-yua1--oId wonlan who is in late Ii~hor IAequests anesthesia t~ecatisc st~e has now given up on a "natural birth" delivery (wir hr HI! r>l,st~tri~ at~~stliesia-at~algesia) .

HPI The obstetrician in chargc clccicIes to perform a plideilclal l~ lock.

PE I-Ieacl d h a h y already on perineum, and mothcr is having con- tractions every 5 minlltes; FetaI heart t-ate 140/min with no

apparent d istres5: doctor identifies ischial spine with index fingcr and iiijects a needle I h rough ~arrospinous ligamenr hct~vccn hahv's head and vagina: applies anesthetic (after er~slrrirlg lhar the needle has riot pierced a pt~rlenda! vessel with risk of' llemaloma fnrmat ion) in vicinitv of each ischial spine (7 lL%NC;\''II:lNAI. P I II)IIND4l. YI:Rl'l? fil.o( :K).

Labs Prenatal lah studies tvitbin r~ozrnal l imits, i t ~ r l ~ ~ r l i n g cnagulation

teqtq.

Treatment Pudendal nerve hIock done (complications may incl~~cle hemntoma formation, sv~te~nic toxtcil~ when ii~jected intsavasc~t- farly, nncl locati~ed infections).

Discussion The ~>udendal 1icrl.e provides both motoi- wld sensorv it1nerva.a- tion lo tlle pelineal region: i t passcs out of the peIvis through the gl-ea~er sciatic Eora~nen, wraps around tllc rxtrrnaI srlrface of rhc: isdiii~l spitjr, and enters the pelvis spin thro~rgli the

Icsses sciatic foramen (crt~ssing thc sacrospinuus ligamerit) . The nerve travels within the fascia uf ' t f~c internal ohrur;~tor

PUDENDAL NERVE BLOCK

lD/CC A 1 &year-old ohesu male comes to the emergency room from playing haskctb-dl because of acute pain and s w e m of his dght ankle.

HPI MThiEe playing, he landed awkwardly on his right foot, which was inverted, prod~lcing i~nmediate acute pain, ir-iabilitv to waIk, and swell ing.

PE Right ankle joint mollen with ecchymosis in most of lateral side of hot; acutely painful to touch, mostly underneath fibtilal- end; no bony crepi~us felt; distal tcrnperahlre, pulses, and ensa at ion normal.

Imaging XR, ankle: no fracture; lateral rnalleolar soft tissue swelling.

Treatment Immobilization until pain ancl srvelling subside (usually 3 to 5 days).

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 ligatnen t 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 SPRAIN

ID/CC :\ 2$-~c;ir-r>lrl funiille conlev t o s r r thch orthoperlia 4tlrgeon hrcal~se nT inability to extend her right wrist and li ngel-s.

MPI Shc suffcrcd a middle third humeral rract~u-e 4 wt-eks ago while snow-skiing.

PE CVriv c,ri right sitlr ir "llangii~g" (U,WI\-I U I ~ O I ) ) : inability to dosiflex hand Dyer Crwear-tn: inabiliry lo r l ~ v a ~ e rhi~rnl,; anesthesia on dorst~m of hand over thumb and first three digitq.

Imaging XR: mitlcllc t llirrl of rig11 t I~umcrus s l ~ o ~ v s -s~r;t~~s~c-r~e ~ K * ; ~ C ~ I I I . P

with c;tllus ti,rtriatir>n.

Treatment Clnrerl rerl~trtinn ;111rl Il;~rqing rasl o r "I-'"-sl~;~perl ~pl inc . Wr i~ t irnmol>ili7arion. S111-gird radial riel-vp cxplol-ation if nerve rt~nrllrrtinn ~tltdie5 are ahnol-m;~l for several rn r )n~ l~s .

Discussion The I-iiciial 11c.1-vu co1rrsc.i through thc spiralir~g groovr- localerl in tfi t- midrlle third nl'thc hutnet-:~l shali, prerli\[losing it In I~sions. li;trIial nerve palw mav I>? r lelav~d hv nir~ntf~s or r\,rn !.r;lr.s ( d l ~ c r o trappir-q of thc- ncrvr. i l l osqcolrs c ;~ l l~ i s or Ycai lissue).

Figure A-077A nernr lnq~n'nt inn r r l I>;i~i(. motor csarniiiatiorl of

the tntlial ncr~r-ar~irrr rxtrn- <ion ;IT WT~FI ;IIICI finarm.

ARM-RADIAL NERVE PALSY

Figure A-077B Demons-itin11 o! h;rsic palmar srnwry exa~~~i~ la~~on-rar l ix l nerve tlirtr.ihution (.4): ~~Irlxr nervr rlistrihutio~~ (Bj.

I ID/CC A 1 &year-nld I~igh-school track-team member experiences intense pain in his right collarbone; he also notices a prominence ~711rru the midclle third arlci outer t hirr1 of his right cla\bicle meet.

HPI 'The patient tripped over a hurdle and fell on hi outstretched hand.

AE Markcd tenderness and deformity at rite of fracture; right arm hangs lower than Ieft; arm medially rotated and painful (medial roratnrs of arm are stronger than lareral rotarors).

Imaging XR. clavicle: fracture of ck~viclc at middle third: lateral portior~ drpl-ossed.

Treatment Reunion of fracture by tipre-of-eighr bandage or clavicular spiczi cast, with afrected arm placecl in a sling for comfort, and isolation of arrn movement.

Discussion Fractures are usuallv located where the middle and outer third3 ( ~ r the clavicl~ meet. The m ~ d i a l segment is displaced upward hy thc sternoclcidornastoic1sti rnr~scle. while the distal end is rlepr~sserl 11? the weight OF the shozlId~r.

CLAVICLE FRACTURE

ID/CC A 44-year-old rxuc~~tive -eco~nes to see his pl~ysician for burning pain in his right elbow.

HPI H e is an avid tennis player. For the past sevcral weeks he has ~xpei-ieilcrd a sharp pain in the right elhow (his playing arm) during practice.

PE Mhcn askcd lo localite pain, pa t i~n t points tu lateral epicondyle of humcrus (El: on palpation, area is warm and exquisitely tender; pain increases with wrist extenshn against resistance; no lrlhow defer-mitl;, swelling, or refines-; distaI pulses normal; no spnat3ry disturbances.

Imaging X R , elbow: no frarture or dislocation.

G ~ S S Pathology Uninn ol'tendon and ~rnclerlyiiig perinsteuin chronicallv inflamer1 ivi tli ~mrlinj tis, sylovitis, granulation i issue for ma ti or^, ancl hone resorption.

Micro Pathology Angiolihrohlastic proliferat ion and degenerative fibrosis of the estcnsoi- carpi rddialis brwis tendon.

Treatment Discontirr~~e ~ e n r ~ i s Ibr 6 ~vcuks: NSAIDs, local heat-cold, topical steroids, sllrgery in sclcctccl cnqes.

Discussion The lateral rpicondyle of the humerus serves as thr 01-ig-in for ~ h c extensors or the wrist: tllc extellsor cal-pi radialis breviu,

d Figure A-079 Demoncrratinn

-i+ j of ~ l e s of elhow palpation- - 2 trirdial rpirondvlt. (A): cuhital 1H

I imn~tel (B); oleciation and over-

p. I v i n ~ hurra {C); ulnar/huineral 6 .b + 1 7 . articulntiol~ (D); latrral -F~:+ epicor~dyle (E ) .

ELBOW-LATERAL EPICONDYLITIS

.. - - - -

estrtlsor rligitorum, extcnsor rligiti minimi. 2nd cxtensor carpi ulniiris. All arc innermted hv the radial nervc. 111 t h i s condition, alw known as te& elbow, thc <train of repeated extension of the wrift aqainst a Col-ce, as in playing tcnnis: or tliro~ving a hase- hall, places consideri~hle stress C~TI the si P. T,;~trl-al epicondylitir tnost co~nlnonlv arects the extrnsor carpi radialis hrevis tendon. OrI~cr- causr5 of lateral elhow pain includc pclsteriol- in~~r.c~sseorls nerve compressinn and radiocapitrll;~r ;~rtlir-iris.

lD/CC 1-2 23-year-old crnss-country motorcycle racer visits an orthopedic surgeon hecause of weakness in bk right hand.

HPI Six weeks ago, he sliffered a fall during training that resulted in an elbow fracture.

PE Mhen patient flexes his wrist, it deviates to the zhar side (due to unopposed action of the flexor carpi ulnaris; he median nerve innervate4 the flexor carpi raclialis, which i s re~pnn~ihle for fluxing the wrist and devialing i t radially): when patient is a\kcd to clasp his hands tc~geti~er, right index finger cannot be flexed (OCHSNFIZ'S TI:'~T) (due to inactivitv of the flexor digito- rum suhlimis): paticnt cannot flex thumb (due to inactivity of the flexor polliuis Ton~us) and cannot oppose rhumb (due to

inari ivity of tlie oppunens pollicis brecis. iiitl~rvated solely by the median nerve); fotn-th and fifth Fingers are flexed with thumb and index finger extended (BFFU'EDICTIOV R~IYD).

Imaging X R kealing of el bow fi-aczul-e.

Treatment Phvsio therapy: surgical exploration if nerve crwnpression by frac- ture c d l u s is suspectecl.

Figure A-OSOA De~rlo~~strntiol~ o t 1 3 , 1 \ 1 ~ motor examination of the me- dian nerve---OK" sign (flexior~ of thumb and ~econd digit).

ELBOW-MEDIAN NERVE PALSY (NONCARPAL) 7 P

Discussion The media11 nerve innervates the flexors nt h e twist and lingers as welI as the ferrarm pronators. The ulnar nerve innervates the flexor ral-pi l~lnaris, which, in addition to flexing the r t ~ i s t , also deviates it inedially.

Figure A-080% De~not~stration of hasir pal~nal- srnsnry examination- ulnar nerve distribution (A): median nerve d1~1ribu~iot1 (B) .

ID/CC A '1-year-old girl i s brought to the pediatric cmcrgency room crying with pain in the left elbow.

HPI While the child wa5 having a temper tantrum, the Father forcefully pulled her by the hand.

PE Child is hoIding right forearm in pronation and ebow in flexion; no swelling, ecchymosis, olrrviotls deformity, or hone crepit~is.

Imaging XR (AT and lateral), elbow: no fracture or dislocaliotl; child stopped crying righr after lateral view w a s taken.

Treatment GentIe supination of Corearm with elbow ill 90 degrees of flexion often reduces snhluxation during positioning for Iateral-view x-rays.

Discussion Also called nursemaid's elbow, subluxation of the radial head occurs when the extended and pronilred arm is pulled, tearing the annular ligament.

ELBOW-RADIAL HEAD SUBLUXATION

ID/CC A 5)-yr.;ir-old male is brought tn thc ER with coinplaints of paill atld irtahility lo usc his lrft forcarm.

HPI Ht= was l~lirr while ~ r y i r ~ ~ to ward off an a s sa t~ l t b!. a dl-tinken r o o m ~ n a t ~ .

PE PF,: unable to pronate and supinate left forearm: swelling arnuncl the el bow: neu~.rrlogic exarrl normal.

f maging XR. lefi forearm: fracture of upper half of ulna with dislocation or the radial t~ead.

Treatment Open reduction and plating followcd 1 ~ y 4 to 6 ~~etrbis in plaster.

Discussion This i.; .a tiacturr of the upper third of the ulna with disIocatiun o I ' t he rarlial hear1 1-aiiserl 11y i t F,1l7 011 an o11rs11-etched Iia~irl, will1 thc forearm Forccd into exce~siw pronacion. It mav also result froxn a direct l ~ l u ~ v on the hack of the upper forua~m. Neurologic examination is importarit in ~ I I ; I ~ radial iirr vc injzlry may he asq~ciatecl wi 111 Moiileggia'~ Fr~cLure.

7 FOREARM-MONTEGGIA'S FRACTURE

ID/CC X 19-ycar-old gas station aacndait comes to a local clirlic corn- plainirlg of persistent. irlcrensing pain on the ulnar side of his hand.

HPI Hu was involved in a fight \ki th a truck drivrr I! days ago.

PE Prriorbital ecchymosis 011 Ieft side nit11 no eye in~rolvemenl: rratimatic absence ol' left upper- central incisor; ~'igl~t hand swollen; c hal-act et-istic depression of head oF fifth metacarpal tv1ie11 lookirlg a1 f i s~ anteriorly; patient cannot flex pinkie I~ecaine it elicil\ pain o n tifth metacarpal.

Imaging SR: transverse fracture of fifth metacarpal neck with palmar angzllai ion.

Treatment lierlnce anrl apply rpl int o t ~ ulnar side or hand.

Discussion Boxer's firactur.e is a common fracture when something hard is hit with a closed fist.

HAND-BOXER'S FRACTURE

IO/CC A 6-year-old male is referred to an orthopedic surgeon by his pediatrician because uf thc recent onset of a limp tliar has persisterl for more than 2 weeks 1vi111 no apparent cauqe.

HPI He also complain5 of pain in the right p i n with radiation to the inncr thigh ancl knce.

PE Child is well dei~eloped ancl nourished; average wuigh t and hcight for agc; chcst and abdomen show no pathology; on palpation ovcr right coxofemoral joint there is tenderness and muscle spasticity.

Imaging XR: small femoral head epiphysis; sclerosis of flal~rrletl femoral hcad cpiphysis. MR: marrow edema ancl fracture line in remora1 head epiphysis. Nnc: abnormal uptake in femoiaI l~pad.

Gross Pathotogy Collapsed, soft, anrl friable articular cartilage in Femoral head.

Micro Pathology Awscular nccrt,sis of proximal femoral epiphysis*

Treatment Petlie walking. cast (ahcl~ictiot~ Ilraci~lg), nlrgery (femoral .rrersus acetabular osteotomv) .

Discussion L,eggXalve-Pet-tl~es disease i q a rvpe of avascular necrosis that occurs in the femoral heads of children bctwcen the of 3 and 10 years, affecting males more than fernaleq. I t is selfllimited over a period of up to 3 years: roughly half of affcctud chi1drcn mill have residual deformity.

F*l HIP-LEGG-CALVE-PERTHES DISEASE

ID/CC A mother brings her 3-year-old chi ld co an orthopedic surgeon for oval uation of' his gait; she says the child "waddles" when he rvnlks.

HPI The child had rlifficulty learning 11ow to walk and has always heen rather unstahlc in his gait.

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~ci ors h~nction normally to prevent pelvis from tilting over when leg i s winging).

Labs Sa-eer-t for inheri~ed metabolic cliseases negative: basic lab work normal.

Imaging XR: hip dislocation.

Treatment I4'alking stick or cane in leCt hand to prevent hip from tilting over to left side when left lcg is swirigft~g. Sllrgery

Discussion Unilateral hip dislocatiorl causes Trendcle~lburg gait, with tilting of the trunk toward the affected side in each step. The sliperior ~ l r~ lea l nerve exits the <ciatic foramen ~uperior to the piriformis niliscle. 'Thiq nerve inncrva~es the gluteus mcdius, glutel~s min- imus. and tensor fascia lata, which arc medial rotators oC thr thigh and abd~rclol-s or the hip when the high is fixcd. The itlfe-

rinr gluteal nrrve ancl arrery as well as the sciatic nerve exit the sciatic foramen inferior to thc piriformis muscle co supplv t l ~ e

gluteus maximus.

HIP-TRENDELENBURG GAIT > A <

ID/CC A Y-we~k-old haby girl is Ilrnug11 t in For a wellxhilcl checkup.

MPI The haby was deiiveretl I,? C-section after a full-term pregnancy rom~Ticarerl IIV breech presentation.

PE 1a:xarnination of the lower rxtr-ernilies reveals asymmetry of thigh crrcaqes anrl unequal right and left leg length, limitation of abd~~ction on left qide, inward deviation of'rnrrf'not (metatarsus arlrl~~ctlts assnciated wi i II DT)H). ancl uneven knee level w11e11 both knees are flexed and k t arc placed nn the examining table (Gill F~IZZI'S srcn.) ; lrft hip "pops ant" whm longit~~dirlal: presuure is applied with 111r hip in adduction (B$I<~.~>II*'s slc;~); another pop fell while abducting ant1 adtlucting th? flexecl hip (C)K'II )~AVI'S sic;^).

Labs Normal uewhor~r scr-ecn

Imaging US, hip: didocation of left hip with irlqtahiliry and ahnormal acecahul~tnr morphology.

Treatment Ilace the hip joint in flexion and abduction (with a Pavl ik har- ness 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 D~wlnprnenlal dvsplasia oF t h e hip (previouslv callrd congenital hip dislocatio~l) affects girls more -er,ften than boy (9: 1). Thc inridence increases ~ 4 t h l>r-eech presentation and in balies with a hmilv I~istory of DD1.I. Complications include avastrular necrosis of the femoral head.

Attas Links m-51 PED-O51A. PED-051B

H I P DISLOCATION-CONGENITAL

ID/CC A 23-year-oid mate is rushed eo the ER following a motor vehicle accident.

HPI He was on ihe passunger side of a compacr car when he sufferec! a head-on collision with a pick-up truck. His knee impacted against the dashboard.

PE VS: normal. PE: alert, awake, and in moderate disrr-esq; no evi- duncc of trauma to head, cheqt, or abdomen: right leg visihlv shortened, internally rotated, adducted. and in slight Flexion; olhcr associated in,juries include an obvious patellar fracture and a knee laceration; no neuro-vascular deficits noted.

Labs CBC/Lytes: normal. PT, PIT t~ormal. U h : normal.

Imaging hip: posterior rlislocation oE the right Semoral head.

Treatment Early mduction I'oll owed by immobilization. Surgica t correction may he necessary when clmed reductinn fails or irdictated bv associated fractures. Associated injuries (peliic fractures,

bladder nrpture, liver lacerations, or pneumothorax) must aIso he saught and treated.

Discussion Hip dislocations am anatomicallv c1assific.d as posterior (most rotnmon) , anterior (about IO%), or central (associated with metabolic bone diseaqe). In anterior dislocations, the hip is in external rotation and abduction. Emly complications include injurv to the ~urrounrling nerves (sciatic, femoral, or obtumtor) arid pelvic organs. Late complications inclztde avascular necrosis of the femoral head (early reduction is the most effecrive rncans nC prevenr ion) an tl early degenerative arthritis.

ID/CC An 85-year-ald woman is taken to tkr emergency room after

falling wliile climbing our of the bathtub; slte has pain in her lcft ~ o i n and cannot move her left leg.

HPI She suffers from diabetes, hypertension, and osteoporosis. She is c~lrrcntly being treated wit11 calcium supplcmcnts and calcitonin.

PE Frail. elderly woman with poor mriscle tone and low body weight; left leg externally rotated at resl (lateral rotators: piri-

formis. 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 XR, plain: intertrochanteric rt-act~~re of Cemur: osteoporosis.

Treatment NonrlisplacerI anrl minitnaIly dispIaced fractures can be treated by pcrclrtaneous pinning vs. screw fixatiorl of the affected hip, whi le displaced fract~n-es (associated with a high t-iqk of ar~ascular necrosis) are treated with a hip hemiarthroplasty (femoral heail p~-~>s~hes i s ) .

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 Fcmoral neck Fracturr is f r ~ q ~ ~ n t l ~ srcn in elderly post- menopausal tvclrneli with osteoporosis. The mechanism nf frac- lure is often a trivitd force. causing subcapital fract~~res, irnpa~terl or not, as well as pr-etrochanteric, intertrochanteric, or c.xtracapsulai- fi+actures. Pnt i e~~rs with hip l'ractures are at high risk fbr rlevelnping cleep venouq thrombosis postoperatively: r h ~ ~ s , pmper prophylactic measures ( e . ~ . , seq~icntial cornpres ion stockings, anticoagulation) must he takcn.

ID/CC X 17-year-old hi#li-sclint>l sn~denl is brought to the emergency 1-00rn straight from a footllall game hecalise of acute, severe pain in the left knee and inability to walk.

HPI He could not gut back up on his feet nfter being "chop-blocked" Iw a linenzan from the side during a football game.

PE Leg sligh try flexed; rnarkecl tenderness otl medial aspect of knee (clamagc to medial cnlla~eral liprnen t) and a11 [prior knee joint spacc (damngc to m e d i ~ l meniscus): positive anterior h w e r sign (ruph~red antrrior cruciate lipment); marked b e e effusion.

Labs Aspiration of affected knec rwcals I-etum of grusslv bIuodv fluid (HE MAHTHROSIS) .

Imaging MR, knee: anterior cruciate tear: tor11 medial ~neniscus; rupture o f medial collateral ligamcn t; join t rftiision.

Treatment Surl7ical gralt replacement of the anterior cruciatc ligament (ACL), suture of rnudiaE ligament and repair of medial meniscus.

FigureA-089 l ~ t ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ i ~ ~ ~ ~ t ~ ~ ~ l ~ l ~ ~ ~ ~ . ~ l ~ ~ ~ ~ ~ ~ ~ ~ t ~ ~ ~ t ~ ~ ~ ? - p l a c ~ p ~ s ~ i v ~

valqr~q strrss on thr knrc to assrss hinrtinn of thr mrdical collateral liga~nent.

? KNEE-COMBINED KNEE INJURY

'Discussion Unhappy triad (lesion of the ACL, medial meniscus, and medial collateral ligament) is a common occurrence when the knee receives a blow laterally while the font is firmly planted and the knee slightlv flexed, resulting in massive tension on these suuctures and tearing.

lD/CC A 13-yearuld male is rcfcn-ed to an orthoprdic surgeon 13:. his ~>~din l t i c ian because of pessjste~lt swelling and pain below the knee illat i s in~crmittcnt in nature.

HPI He is a snccer fa11 and haq hcen playing soccer every afternoon in anticipntion of the upcoillii>g World Cup. T h r paticrlt also repom incre:~wtl pain jurt below r he knee while going rip and dnwl stairs.

PE Athletic-looking, fit teenager: exquisitely painful area of swelling 4 c ~ r ~ I~cIow knce,joint (tibid tuberosity); when patient exlet~ds leg agiiinrl resistance. pain is elicited r r r i r i ~ i - e a ~ ~ c l .

Imaging XR. knee: sli~1:llt awlsio~i of t i bial tube-rclc with nsseotlq reqorp- lion ni~d new bone formarion. res~ilting in a fragmented appeal-- atlce oT the secondary ossification center:

Treatment Avoid activities that placc prcssurr on area directlv or axially, suclt as h e e l i n g and junnping. Hamstring strerching and ice Inawage art. helpfill.

Discussion The par elfar ~crldon inserts in the al~resiof- tihial tu herosity, which hy the encl or pu herty has an ossification center. With I-epe;i ted aauma, the t i bial titlm-cle i s avulued a n d c11l ofT rroln L ~ P blood supplv, suffering avasdar necrosis, The course of 0ynod-SchSa ttrr's rlisease il; self-limited, I,llt irl some patient5 a painC~il hens fi-agmenr remains w-i th nonunion.

Figure A-090 Demonstr.lsion of anterior knee bncln~arl+ir~fi-dp;~tellar ~ I I S V I ("4); l>rrpatellar l ~ ~ ~ r s ; ~ (Bj: palella {C): <~tpix-pa~clTar 1>11r<a (D); antri inr tihial spiur ( E ) .

Imaging

Gross Pathology

Micro Pathology

Treatment

Discussion

A 35-year-old computer programmer complains of severe, persistent leg pain after beginning an inrense fitness program involving long-distance running and weight lifting.

T h e pain is on the anternlateral aspect of tlic right leg radiating from jwt below the knee to the ankle.

Poor muscle tone: pain cor.responrlq to anterior compartment of right leg: region is swollen, tense, and warm; anterior tibia1 pulse weak (rearing ol ~nusclus, inflammation, a~irl erlema with small hemorrhages lead to necrosiq) ; sensory deficit in foot; immediateyy ;after exercise. patient has pain on passive extension of toes. with subjective numbness and tingling in foot.

CT JMR: edema and possihlu hematoma of anterior compart- ment rnl~scles.

Grayish discoloration of muscle with edema.

T.;chemia ancl necrosis of muscle and nervr fibers.

Fasciolomy (cutting of raqcia) if in tracompartmen tal prpssure is > 30 mmHg after exercise.

The an tel-ior compartment of the leg has rigid boundaries (tibia, tihula. cs~rral Fascia, anterior interrnusculal- septum) that

can trap blood, contribute to increased pressure, and thus lead to an ischemic process. Acute compartment syndrome may be cauqed by a crush injury or fracture to the involved extremity. In this case, the p a t i ~ n l has chronic exertiond compartment syndrome, which can be seen with unusually vigc~rous exercise. A qequela of Corearm cornpartmerl t sytidrorne is Volkmann's ischemic conlracture, which results in a stiff, noofr~nctioning "claw hand" from nlusclt. necrosis and r-est~lting fibrosis.

LEG-COMPARTMENT SYNDROME

ID/CC A 17-year-old boy is rushed to the neilrrest emergency room after l>eing involvetl in a highspeed motorcycIe accident.

HPI I-Ie was treated for shock in the arnh~~lance wirh ct-ysralloids, pressors. and oxygen.

PE YS: tachycardia; hypote~lsion; no [ever. PE: pariei-tt in acute dis- tres5; respiratory sounds heard in both lung fields: prri tnneal lavage negative; pain tvi th pressure on iliac crest4 anrl tmchan~rrs hilaterally; blood present at urethral meatus (para- medics correctly avoidecl inserting a Enlev cathrter) ; abdomen shows no perironeal signs.

Labs CBC: hemoglnhin and h~tnatncrit low; leltkocflosis. UA: high ~pecific p-arity: Ilematuria.

Imaging XR, pelvis: fractlire of pelvis hilateralh. Retrograde ~lrcthrogm- phy: membranous urethral rupture with extravasation of con-

11-a~t mrdia outside the peritoneal ca~lty. CT: large henlaloma smrot~ndi ng reginn nf pelvic frac~t~rm.

Treatment Treat shock. Drain urinr collection. Suprapubic cystustonly; delay urethral repair. Pelvic sl15penqinn; l>lood replacement. Unstablu peliic fract~~res may require emergent stxhilization wit11 a pelvic external fixator.

Discussion Griicrzlily, cornpouncl l ~ s i o n s ar r to he expcctcd. Bladder and urethral Lesions are comrnnn in pelvic fi'ac~~ires. Nso, rractlires of the pelviq may conceal a large volume nT blood.

PELVIC FRACTURE

ID/CC D l ~ r i n g anti-Gulf War protests in Ohio, a 2 3 - y e a ~ l d rnan was fnrcef~~llv dragged away by the arm becal~se he waq blockirlg the entrance- tu thc inccting.

HPI While in the potice car on the way lo heatlquarlers, lie corn- pIain~d or pain in the shouldet- ancl inability to move his arm.

PE Pain in shotilder, deformity {lack of norn~aI rounded contour nf shoulder), and inatjility to move arm; depression easil! palpabie under acrr~mion; hr~meral h a d palpibIu through axilla. After reduct ion of' the CLisIocatio~~. pa tie11 t complains of numbness on the lateral aspect of the forearm and weakness in biceps muscle F~mdon whrn comparcd to uninrwIvuc1 sicle.

Labs Basic lab work normal: no iracc nf alcrlhol ill hlond: no dl-ligs in urinc.

Imaging XR: depr-e~sion Fracnrre or the ponerolaceral articular rurface of humeral head (H11.r -S4(:iis I .F ' s~(>K) ; axil l a y virw of ~ I P I I C ~ humcral ,joint 5hou.s h~~mrral head lo he anterior to glenoid fossa.

Treatment Before reducing the rlislocation, one mllst Iook For powihle nc~~rologic-vascular damage.

Discussion The glenohumeral jo in t is trequen~ly dislocated d ~ l p to its poor o s s c o ~ ~ s stabilil): Anterior dislocations (the humcr;~l hcad

Figure A-093 I h I IMI I I~ I I ,IT t o t ? 0 1 :i111ct ior ~ I J O L I I ~ L ~ I . lar~clti~a~ ks- Lruacoirl pl-ocras (A): acrorniucla~iclilar articulation (B); 1,itipital tcnrlon, (C:); strrnoclndcnlar articulation (n) .

b ? W , P SHOULDER DISLOCATION

nr~rnlaI1v lies in front of the cm-nrnid pl-ncrss of 111~ scaptila) usu;llly rcsult from a SaIl o n t h e m-111 in forced abrl~lction and exterlsion. Musculocutaneous ntrrve in$ury i s possible (it supplieq [ l ~ c cor;tcc~bracIrialis as rvcll as the brachidis ailrl biceps rnriacles and provides s e ~ l s a ~ i o n 1 n the lateral area of the lurearm). Posterior shoulcler dic;locar ions are much less cotiimon and arc sccn fullowing electric shock it~juries and g r ~ ~ i d rnal scizurcs.

I D JCC -4 35-year-old ice-lluckcy p1avc.i. is br-ought t (3 the rinergencv room after c~~ffrring a violent blow to his shoulder dlrring a p m c ; his righi arm hangs nnticeal~ly lower than the left and tla~re is a pml-touncerl bulge ( the cla\icle qtick~ cnit) at thc tip of l i i 5 ~holllrler.

HPI I'ErIeo replav nf rhc galtie reveals rhar the pati~nr was benrling forward 1% hen an opponent speared into the superior portion of the patient's ammion.

PE P~tient in pain; shoulder ha5 f'alletl artv;iy I'mm clavicle (due to weight of arm); no low nl'srt~sation in arm; on palpation, ten-

riel-ness in acrnrnioclarric1~2at~ and col-ncocla~~iculilr~jc~ints; when external rnrl of clavicle is pressed. it retui-ns to original site

(PI %NO KEY SIGN ) .

Imaging XR. d~oulcfer (stress view): 1O-pnuncl weight suspended from prl-

tient's tvris~ cauqes mal-kerl ~ep;lration at acromiocla~icular joint wit 11 acrotnial depresqion.

Treatment RerIucrion ;~nrF immohilii-atinn; surgerv necc.isary only if cord- coacmmial ligament is r~rpt~rrcrl (gr-adc 111) (Ir if patient has perl;i?tent shoulder pain.

Discussion Mso known as ;I s l lo~~ldcr separ.ltion. arrornir.~clavir r l l x l i p - mcnt clislocation may be coinplete or partial. The acromioclavic- irlar lig;~nlenr pt-eren~s anrerior-postel-inr rlisplaccmcnt of thr cl;lvi~Ie, while the coracoclavicular liganlenl pl-evrrlts vertical displaccmcnt of Lllc clavicle.

* SHOULDER SEPARATION

ID/CC A .l%-\re;t~--uld mall con~plains of lower back pain that began after IIP lifted heavy objects while l~elping his son move out or the famiIv home.

H P I HP is ovcrweigh? and ha5 not had any repliar e x ~ r s i ~ p ~C)T the par1 t 0 years. 'The is aggravated by movement, coughing, and sneezing; it radiates down h i 5 b~ittocks, thigh, and posterior calf.

PE Sensory loss over dorsal aspect of foot and I:tt~ri~l aspect of leg (L5 dermatome); weakness of darsiflexors of Font; nn palpa- tion, left sciatic notch i~ tender: positive Lasepte's sign (straigl~ 1

Icg-rai~ing test ) : deep teilclon rcfleses normal.

Imaging MR. lambar spinc: Focal hcrniarcd disk cuntrally at L+L5 touch- i n s 25 I-oot.

Treatment Phy4ntherapy I~erl rmt: ac~lpllrlrimrr; rhil-opractir thcrap. if sy-mp- tom5 are nlilrl. Consicler surgical lami~lectnmv or Iminotomy if pain I - ~ c o m e ~ prop-essive or neurologic dcficits arc present.

Discussion I-Ierniation ol the irltel-vertel~ral rlisk (most commonly occurs at L5-S 1 ) can Icad to irnpingemen t on spinal tlervt. roots. The

I . , . -

stlation of the straight

ontcomc in this patirnl who even ro a Herion

of almost ! I 0 rlrgrees.

* SPINE-PROLAPSED INTERVERTEBRAL DISK

rrgion of atlestlle5ia can be used to rlerlracc the specific lcvcl oi'

nerve impingcnlcnt. C:r.ntml disk herniation at thc. L4-L5 love1 will cause compression of tilu L5 ncrw mot, whilc pcriphural disk herliintion at L4-C.5 can affrtt thr. L4 ncrw root. Sig~ls and FYHI~ ! ( 11119 of 1,4 HPT.YV r-no( romprrssioii i rtcl~tde ;m ahnormal patellar deep tendon reflex, n~~rnhuoss owr the mrdia8 aspect ui the leg, and wrakn~sl; or rile tihialip :~ntet.ior. n ~ u ~ c - I F (root rlorsI- flexion). I ,5 nerve root comprewimi carlse\ n i ~ m h n e ~ s rnrel- thc Zateral aqpeci nI' the leg anrl w e : ~ k n ~ s ~ of the Putensor hatlucis Inngus.

ID/CC A 20-year-olcl college slr~clent complains of acute, severe pain on both sides of his face Just in front of his ears t l~ar began while yawning ancl 1adiate5 to hoth ears; he cannot close his mouth, and hc is unable to speak clearfy.

HPI He was nntil thc pi-CEPII~ cnmplaint, and l l ~ i s is the first time these 5ymptnrns have occui-red.

PE Pi-r, I rusin 11 nC lower j an,; dimpling of skin in temporomandibular joint area.

Imaging XR: mandibular condyles clislocated ar-iterinrly from letnporal fossa.

Treatment Grip mandible tirmlv in hands with tf~~unl>r placed behind sec- ond i-nolar; push mandible inferio1,ly and posteriorly in quick, singlr n~orion ( \ I A M ~ . ~ . R E D ~ C T I O K ) .

Discussion TIIP cli~lical diagnosis o f remporomandibularjoin~ dislocation i s usually madc o n the spot. The plrysiciat~ may elect to correct the diclncarion 11nde1- genenl arles~heda, hut this is generally

TEMPOROMANDIBULAR JOINT DISLOCATION - 1

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sy~dromcs. These entities compress ncurovascular Ftructures

;~~irl thus give rise to similar signs and symptoms. Cervical ribs of varying. ~ixrls are present in a small percentage nf the normal populatioil hut in some cases may in1phlfi.e on lower brachial plexus branches or subdalian vcsscls.

ID/CC A 4Gyra1--old woman comes to her hrnily physician cornplait~ing ofApain, numbness, and a tingling sensation ( P~KT:S .T~ -~E .S I~S) o n the palmar aspect nf her rigli~ rhumh. her second ancl third fin- gel-5, and t1ie radi:~l side or h e r rourtli lingel- (fir111 finger is alwq-5 spared) : her artacks occur primarily at night.

HPI She has wnr-ked rot. several vear.: in the "dam e n ~ r v " rlepartn~ent crf a computer firm (atr activity associated with prnlongerl, repeti~ve movements of the wrist).

PE Waqting of thenar eminence: weakness of thutnh while opposing to fifth di@t (weakness of oppotlerls pollicis) : tapping over- radi;it qide of palmaris longits tendon produces a tingling sellsation (Trur.~.'s SIGN): increslsecl sensation ( I ~ ~ R E S T F T E S I A )

over p;ilrn;~r S~IIF of thtlrrlh LO r i n ~ Fingers; fo~ced flexion of wrists reproduces cJmptornr. while exrensiota relieves them (~ 'HAT.F,~ 's 7'r'W).

Labs Nerve cur~cluction stuclies of median nerve show rlecrea~ed con- rlucr ion velnciiy atlil increawrl lalei7cy as tlerve en tel-s I~and.

Imaging MR: thickening and edcma of median ncrrc or of acljace~lt tcndons.

Treatment Extension splinting of affcctcd wrist and NSAIDs. Injection (>I' canal tvitli lidocainu ancl corticclsteroid~; airpical clecnmpre~~ion of iranwprse carpal liramert~ (carpal runt~el r-elexqe) if not

responsive to local injcctians.

Discussion Carpal h~nnel s!rndro~n~' is a tvpc of stcnusing tcnvs~moritis 131al is sccn in p~oplc w h o use their hands in a rcpetitire fjshiorl (r.~., [hose rvl~o ure 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 !I 19-yar+Id college nnder-grad comcs to an urgeril care center at a ski rcsort bccar~sc of pain in the wrist.

HPI Iie has suffered repeated -falls while snowboarding (failing forward with ontstreicl~ed palms).

PE Hyperesihesia and marked tenderness in anatomical snliff box .( C) (hounded by the extmor pllicis ion-ps arld the extensor

pollic& brevis; the scaphoid and hpeziurn hones lie in lhr flrlor)

Imaging XR, wrist: 110 definitc fcaot~n-e (a small fracture of the scaphoid may not appear on x-ray for srve-r;tI weeks until the damaged borie in thy rt.gio11 is ~rnd~rgoing resorption). Special rarliograpl~ic tiews of the ~caphoic! a? well aq CTT, MR, or nuclear irledicin~ scans may be ohtainecl for di~~gnoqis if~trnng- clinical suspicion exists.

Treatment ImmobiIizaliorl in a Ir>ng-area thunlb rpica cast, which inln~nki- li7es 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 oCavasm11ar necrosis, rnainiv in disl>lacerl proximal poIr fracnrrrs, since tlie scaphoirl bone. like the talus and femoral hrad, has a very tenuous bloocl srlpplv.

Figure A-099 Demonnmtion nfsr~rlhrc landrnarh for sitrs d ~hurnl, dl4tu1ctien-MCP joint (A): insertion of h e ulna. collateral lipmen1 (B) ; anatomical s n u f f box-caphoid frac~ure (C); IPjnitit (D): MCI'jaint base.

WRIST-SCAPHOID FRACTURE

ID/CC An 1 H-year-old Fitnale high-scl~nol student is brought to the emergency room after slashing the palmar side of' her left wrist at the ckin lines of flexion wit11 a rmor blade; shc is t~nable to

flex her wrist or oppose her th~unb.

HPl She l~ad been severely rlepressrd for- wv~ral months because her hoyfrieild had hem weiiig other wnmen.

PE Mnclerate hleccling (superficial branch of radial artcry}; inahil- iry 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~iction still possible by abd~~c ta r pchlicis l o n ~ ~ s , innervated by radial nerve.

Treatment Surgical hernostasir and repair of severed smictures. Psychiatric treatment.

Discussion The media11 nerve p;isscs deep to tllc flexor retit~ac~ilrim: it innervates t h e thenar and lumhrical muscles ant1 supplies sensory hranches to the laterat palmar surface, thc sides of digits 1, 3, and 3, and the lateral side of d ip t 4. The rendon of the palmaris Iongis lies medial, parallel, and sriperficial tn the median riel-w. The ten structures that lie within the carpal tunnel include thc four flexor rligitorllm superficialiq tendons, tfir four fluxor digitorurn proftmdus 1.etidons. tlie flexor pollicis longus tenclon, nnd !he median nerve. The palmaris longus tendon, l~ltlar nerve. and ulnar artery all lie rolar to the tmnwerse carpal ligament, wl?icll fnrms the roof of the carpal

WRIST-SLASH I N J U R Y

ID/CC A 65-vear-old Vie1 nam veteran complains of pro~~essivcly wors- ei~irig hoarseness and persistent cough,

HPI He hal; smoked one pack ol'cigarettes each d a y for 45 years. lie is currenrly being Lrr~ltcd Fnr e~nphvrema.

PE S~tprarlavicttlar- t~odus hard and enlarged (cancrr has inr tasta-

sizcd to these sentillel node$); ltmg fields filled wit11 dissenii- naz~cl crackIcs and 1- ale^: chesl barrcl-shapccl (ul~clrrlvit~g er~~pl~vrenia) : c111 hbing of t?nger.ri or1 hot11 hands: patches of velvety hyperpipentation (AC:,IN I Hr)srs NIL:RI~A~.;S) of both lower Icp: purpunr s l ~ > t . s seen on chest a i d arms.

Labs CBC: srcoiidai.y polyqthemia and le~~kocv~osic.

Imaging CXR: k m mass at lcft lung hiIm ruith thickenii~g of paratra- chcal stripes a n d hilar fi~llr~css.

Micro Pathology S p u ~ u r ~ ~ c)tology and lymph tlnde Ijiopsy sllow small-cell carcinoma.

Treatment Uppendq on stage: surget.y. radir~tlicrxpv. chernot tleuxp): tleoad- juvnnt anrl imrn~wc~ ~ l ~ c ~ ~ p v . Overall, xi-ormrI 9% 5-ycar s~urvival rate.

Discussion Lymphatic drainage of the lung goes lo t l ~ c . hruricl~opnlnlc~~~arv nnder (at hila or iungs), ~r~ :~rh~obr -onchid norles (s~tperior ant1 inl'eriot- setc around trnrllea and inain I~ronchu~) , pxmtraclieal ROT~PT, and bronchon~cdiastinal Ivmph t runk (which form at the jur~ction of tile I rnct~col>ronchial node^, the anterior mecliasti- nal tiodes, ;lnrl the parastcrnal rlodes). Only when pleural aclhe- \ic>ns arc ~ ~ r c s e n t r l r , the asillary nocles clt.airl the lurlg. The lower Inlw or the left lung drains Ln rlie right tracheohl-onchial nodes. Srnal! cell (OAT CELL) carcinoinas r~~etar tasizc early to lymph

1 * LUNG C A N C E R L Y M P H A T I C METASTASIS

ID/CC .A 63-ycar-old woman nmIlo is a I l r i~ \~ smoker comes to thc cmer- gcncy room wit11 srvcrt swelling on the right side of the neck, arm, ancl rare (r~tnpl-essiot~ ol' superior veils cafi~) ~ I J ~ C ~ ~ I L ' T

will1 srvel-e [ la in in the right arm.

HPI 'I'he ~~re l l i ng I1a~ gotten prngrcwivcIy worse over the paqt sevel-al 7

months. In arldition. hcr voice. has ht-conie home nrTer- the samr c period of timc (the rctlrr-rc11t lar-?r~~eal nerve is 11aral77ed due to cotnpre5sir~n hv tllc tunlr~r).

S Z > ;El <

PE Reduced radial pl~lse 0 1 1 right sirlc (arterial flow i~ hlor.ked by t~irnor) ; engorgement of right jugular vein (venouc remr-n is hlcll-kctl duc 10 i r n p i n g e ~ r ~ r ~ ~ t apical rtlmor.); light ptosis (dmc~pi rig) nf' right eye1 id, miosis (cnnrrartinn nf plrpil) , and anhidrosis (I;~ck of' qrve;~ting/I;lcrin~i~tion) ( I IIIRNI.IR'S S\TDR(IWF;

c l~~t= t o qvnl-mtlletir ~h:lin r~rnp~ess ion) : wasting of first dorsal interosseous mllscle of right hand (supplied by TI): pain and i n~~sc lc atrophy (invulrcmcnt o f hraclifal piex115) nf right arm.

Labs CDC: xnemia, L .v t~s : nnrlnal. EL'S :und crcatininr llormal: LFTs ncirrnal.

Imaging CXR: Itmg tllmor in right apex, dcsh-uving first rib.

Gross Pathology Apical Innx tumor 'tias irivi~drd ccrvicxl u!vmpatlletic plexus and wrln cava.

Micro Pathology Bt-nnchial washings i ~ n d Pap~rii tolaou nf qplt t 11 tn qhow sqna- rlions cell carcinorrla.

Treatment Deprnrling on stilgt'; surgery rr;lrlictl~ei.;~py, rl~eniotherapv, net>ac!j~ want and irnm~inotlierapv.

Di5c~ssion P;i t ~ c n i ~ s ~ ' s wndr.c~rti~ i s ~ll.odaced 1311 anv tumor in close proximity to the thoracic idet x ~ i d bv the coiiqeq~~en I

cr~mprrssion or thc I>rzlclibl plcs~is anrl hnr h I lir vrnous retzlrn and ar-tck~l flow.

41 LUNG CANCER-PANCOAST'S SYNDROME