1. Nano Quiz(t)
For medical student
Sathienwit Rowsathien, MD, Flg. Off.
Internal Medicine Resident
Chiang Mai University

2. Describe these lesion and Diagnosis…
Cutaneous
telangiectasia
AVM of the left
hemisphere
(Brain)
AVM of the
left lung
(Pulmonary)
Mucosal
telangiectasia

3. Hereditary hemorrhagic telangiectasia
• Eponym: Osler–Weber–Rendu disease
• Autosomal dominant ENG, ACVRL1 and MADH4 mutations
• Abnormal blood vessel formation in the
• Skin, Mucous membranes and end organs such as Lungs, Liver and Brain.
• Curaçao criteria (3/4)
• Spontaneous recurrent epistaxis
• Multiple telangiectasias in typical locations
• Proven visceral AVM (lung, liver, brain, spine)
• First-degree family member with HHT
• Only symptomatic treatment
William Osler, Frederick Parkes Weber and Henri Jules Louis Marie Rendu

4. Describe these lesion and Diagnosis…
Splinter
hemorrhage
Roth’s spot
Osler node
Janeway lesion

5. Infective endocarditis
• Modified Duke’s criteria (2 majors, 1+2 or 5 minors)
• Major
• Sustained Bacteremia (viridans streptococci,Staphylococcus aureus, Streptococcus bovis, HACEK group or only +ve Coxiella)
• Evidence of Endocardial involvement (TTE see Vegetation, New valvular regurgitation)
• Minor
• Predisposing heart condition, Fever >= 38.0 C, Vascular phenomena, Immunologic
phenomena, Positive blood culture not meeting major
• Acute (high Virulence S.Aureus), subacute (less S.Viridans)
• EKG: new conduction abnormalities
• NVE: Acute  Vanco, subacute  Cef-3
• PVE: Early < 60days  Vanco+Cefepime+Genta, subacute  Vanco+Genta
• Endocarditis prophylaxis (PV, previous NVE, transplant, CHD) before Dental&Respiratory procedure
• Amoxycillin 2 g, Cef-3 1 gm IM or Clinda 600 mg 30 min before.

6. Describe these lesion and Diagnosis…
Necrobiosis
Lipoidica
Diabeticorum
Acanthosis
Nigricans
Kimmelstiel
Wilson FSGH
Foot
(Pressure area)
Ulceration

7. Diabetes Mellitus
• FBS >=126,HbA1C > 6.5 or Random >= 200 mg/dl *2 occasions
• 1 if severe + symptomatic (DKA, HHS)
• Type 1, 2, MODY, 2nd causes (Gestational, drugs (PI, Psychi), cushing)
• Polyuria, Polydipsia and polyphagia.
• Aware Complication  Retinopathy, Nephropathy, Neuropathy,
Artherosclerosis, Infections
• Must control comorbid disease (HT keep <140/90, LDL <100)
• Must screening yearly for
• Dilated Retinal exam yearly by ophthalmologist
• Microalbuminuria (spot) goal <30
• Diabetic neuropathy (Monofilament)

8. Describe these lesion and Diagnosis…
Xanthelasma Corneal Arcus
Eruptive
Xanthoma
Tendon
Xanthoma

9. Dyslipidemia
• Tendon Xanthoma  LDL specific (may >300mg/dl)
• Eruptive Xanthoma (pimple) TG specific (may >1,000 mg/dl)
• Xanthelasma  any type of dyslipidemia, Corneal arcus  non specific in older adults.
Risks
Male> 45, Female>55,smoking,
HTN, FHX +ve, HDL<40 (if >60 -1risk)

10. Describe these and Diagnosis…
S1Q3T3, Sinus tachycardia, RBBB, TWI in V1-V4(5), P pulmonale

11. Describe these lesions and Diagnosis…
Hampton’s Hump Westermark sign

12. Pulmonary Embolism
• Dyspnea and pleuritic chest pain, tachypnea
• Hypoxemia with increase A-a gradient
• Simplified Well score
• EKG: most common  Sinus tachycardia
• Gold: CTA if high risk, d-dimer if low risk (< 500ng/ml  excluded PE)
• Work up for Thrombophilia OCP, HRT and Malignancy
• Enoxaparin 1mg/kg SC BID 5 days  long term warfarin INR 2-3

13. Describe these lesions and Diagnosis…
Discoid rash
(Erythematous papule/plaque with keratosis and plugging)
Malar rash

14. Systemic Lupus Erythematosus
• Serositis, Oral Ulcer,
• Arthritis (non-erosive),
• Photosensitivity rash,
• Blood (leukopenia <4,000, lymphopenia <1,500 or thrombocytopenia <100,000),
• Renal (RBC cast or Protein uria >0.5 gm/day),
• ANA, Immunologic (dsDNA, smith, Anti Phospholipid),
• Neuro (seizure or psychosis),
• Malar, Discoid
• 4/11

15. Revise (2012) SLICC for Research

16. Systemic Lupus Erythematosus
• Control symptom
• Prednisolone low dose (10-15mg)
• HCQ
• NSAIDS
• Lupus Flare/ severe flare
• Steroid high dose (1mkd)
• Mycophenolate  LN
• IVCY  LN, CNS
• AZA, MTX, CsA, Rituximab, Belimumab  limit used

17. Describe these lesions and Diagnosis…
Webbed neck 45X

18. Turner syndrome
• Ullrich–Turner syndrome "Gonadal dysgenesis“
• Absence of an entire sex chromosome, the Barr body, sporadic
• Low set ears, Low hairline, Amenorrhea, Webbed neck,
• AS(Bicuspid),Coarctation of aorta,
• Horse shoe kidney,
• Lymphedema, Short stature
• Treatment
• GH
• Estrogen replacement therapy

19. Describe these and Diagnosis…
ST segment
elevation V1-V3

20. Brugada Syndrome
• Nocturnal Death Syndrome
• 3 type of EKG
• I. Coved ST segment elevation >2mm in >1 of V1-V3 followed by a negative T wave.
• II. >2mm of saddleback shaped ST elevation.
• III. I or II morphology but <2mm ST elevation
• Treatment: ICD

21. Describe these lesions and Diagnosis…
Pneumatocele at RLL

22. Staphylococcal Pneumonia
• May be post viral or HAP/ HCAP
• Consider MRSA  Vancomycin
• Prediction of severity
• SMARTCOP
• SBP < 90 (2), multilobar, albumin <3.5g/dl, RR >= 30, Tachycardia >125, Confusion,
O2sat <90% (2), Arterial pH <7.35(2)
• CURB 65
• Confusion, BUN >19 mg/dl, RR > 30, BP< 90/60, Age >=65
• >=3 point need ICU

23. Describe these lesions and Diagnosis…
Kayser–Fleischer ring

24. Wilson’s disease
• Mutation in ATP7B  copper overload
• Neurologic Wilson’s  Parkisonism (hepatolenticular), KF rings
• Diagnosis by
• Increase 24 hours urine Cu, decrease of serum Ceruloplasmin
• Treatment
• Copper chelation with Penicillamine + B6, Zinc

25. Describe these lesions and Diagnosis…
Plasmacytoma
Rouleaux
Formation
Plasma cell
Bony erosion
“Punch out”

26. Multiple Myeloma
• Clinical CRAB
• Hypercalcemia
• Renal involvement (Ig light chain, RF or infiltrative)
• Anemia
• Bone pain
• Symptomatic MM criteria (3/3)
• M protein in serum/ urin
• Bone marrow clonal plasmacytosis >10% or plasmacytoma
• ROTI  lytic bones, Ca >11.5g/dl, Cr >2mg/dl, Hb <10
• Treatment by induction chemo + supportive treatment

27. Describe these lesions and Diagnosis…
Golden S sign

28. Lung cancer
• Golden S sign = reverse S sign of Golden
• RUL atelectasis
• May be from central mass obstructing the upper lobe bronchus
• Suspicion of a primary bronchogenic carcinoma
• Central lesion  Squamous, Small cell
• Peripheral  Adenocarcinoma(KRAS), Large cell
• Adenocarcinoma  most common in non-smoker!
• Endobronchial growth symptom  cough, hemoptysis and dyspnea
• Paraneoplastic  ACTH, ADH release, Eaton Lambert  SCLC,
PTH-rP  Squamous, Clubbing finger  non-small cell,
Hypertrophic osteoarthropathy  Adenocarcinoma

30. Spot parasite Diagnosis
Isospora belli oocyst Hookworm ova Ascaris fertilized ova Capillaria
Cyclospora Cryptosporidium

31. Intestinal parasitic treatment
• Isospora  Self limited, AIDS  TMP-SMX
• Hookworm  Ivermectin 200ug/kg/day for 3 day, Albendazole (400) 3 days
• Ascaris  Albendazole (400) single dose
• Capillaria Albendazole (400) 10 days
• Cyclospora  TMP-SMX DS bid 3 days, AIDS 10 days
• Cryptosporidium  Self limited, only supportive, AIDS Atovaquone,
Paromomycin???

32. Good Luck
For tournament and Exam