Vasculaire beelden Quiz
2018 Q: What is the diagnosis?
1. Digoxin poisoning 2. Hyperkalemia 3. Pericardial effusion 4. Right fascicular block Q: What is the diagnosis?
Answer:
2. Hyperkalemia.
The electrocardiogram shows a regular rhythm, with a widened QRcomplex in a sine- wave configuration, and there no discernible P waves. The T waves were fused with the widened QRS complexes to form the sine-wave pattern (sinoventricular rhythm).
Serum potassium level was 9.1 mmol per liter. His condition stabilized after the administration of calcium chloride, bicarbonate, glucose, and insulin therapy, which was followed by hemodialysis A 71-year-old woman presented with 5 days of right retroauricular pain that radiated to the retrobulbar area, with accompanying putrid nasal discharge, body chills, double vision, and swelling of the right eye.
Physical examination revealed right ptosis, chemosis, a visual acuity of 20/32, limited eye movements in all directions, and hypoesthesia in the ophthalmic branch of the trigeminal nerve Physical examination revealed right ptosis, chemosis, a visual acuity of 20/32, limited eye movements in all directions, and hypoesthesia in the ophthalmic branch of the trigeminal nerve
Contrast-enhanced magnetic resonance imaging showed a partially occlusive thrombus in the right superior ophthalmic vein (Panel C), cavernous sinus (Panel D), inferior petrosal sinus (Panel E), and internal jugular vein (Panel F) (white arrows). Moreover, there was pus in the right sphenoid sinus (red arrow in Panel D) Septic Cerebral Venous Thrombosis
blood cultures and sinus aspiration material grew Enterobacter cloacae complex. no obvious predisposing factors for acute sinusitis and not immunocompromised. treatment with surgical débridement, antibiotics, and anticoagulation and recovered completely.
Sinus infection can spread through direct extension or travel from mucosal veins through a valveless system of diploic, cerebral, and emissary veins to venous sinuses, the latter being the most plausible cause in the present case. Q: This 23-year-old man was involved in a motor vehicle accident. What is the diagnosis?
1. Aortic dissection 2. Cardiac rupture 3. Diaphragmatic rupture 4. Pneumothorax 5. Vertebral fractures Q: This 23-year-old man was involved in a motor vehicle accident.
What is the diagnosis?
Answer:
4. Pneumothorax
The presence of a deep, lucent, right costophrenic angle on supine chest radiography is an indirect sign of a pneumothorax. In addition, a pneumothorax with associated rib fractures and subcutaneous emphysema is evident in the right chest. The patient's endotracheal tube needs to be withdrawn further into the trachea. Q: This patient presented with a 1-day history of fever, acute painful symmetric polyarthritis, abdominal pain, and hematemesis. What is the diagnosis?
1. Bacterial endocarditis 2. Henoch-Schönlein purpura 3. Rheumatic fever Q: This patient presented with a 1-day history of fever, acute painful symmetric polyarthritis, abdominal pain, and hematemesis. What is the diagnosis?
Answer:
2. Henoch-Schönlein purpura
Henoch-Schönlein purpura is an acute immunoglobulin A (IgA)-mediated leukocytoclastic vasculitis associated with cutaneous purpura, arthritis, abdominal pain, gastrointestinal bleeding, orchitis, and nephritis. The diagnosis was confirmed in this case with a skin biopsy. The patient recovered with supportive care. Q: Which coronary artery is occluded?
1. Left anterior descending 2. Left circumflex 3. Left diagonal branch 4. Left main stem 5. Right Q: Which coronary artery is occluded?
Answer:
4. Left main stem
ST-segment elevation in leads V1, V2, V3, I, aVL, and aVR and ST- segment depression in leads V4, V5, V6, II, III, and aVF, findings suggestive of occlusion of the left main stem of the coronary artery. The patient recovered following revascularization. Q: What is the diagnosis?
1. Diaphragmatic rupture 2. Lung abscess 3. Marfan syndrome Q: What is the diagnosis?
Answer:
1. Diaphragmatic rupture
Chest radiography performed after the administration of contrast material through a nasogastric tube confirmed that the stomach lay within the left hemithorax, confirming the diagnosis of diaphragmatic rupture. The patient recovered after emergency surgery Q: What is the diagnosis?
1. Gout 2. Paronychia 3. Scabies Q: What is the diagnosis?
Answer:
1. Gout
The patient's serum uric acid level was elevated. Multiple bright-yellow needle-shaped crystals, consistent with gout, were visible in a skin scraping. Q: What is the diagnosis?
1. Coarctation of the aorta 2. Lung cancer 3. Pneumothorax 4. Substernal goiter Q: What is the diagnosis?
Answer:
4. Substernal goiter
The chest radiograph demonstrates tracheal deviation. Ultrasonography of the neck revealed a large goiter with the right lobe extending into the anterior superior mediastinum. Man 69 jr, hartfalen bij voorheen forse hypertensie, nu 4 pillen! Bloeddruk spreekuur: 145/81 mmHg ABM, 91% geslaagde metingen DagGem: 108/67 mmHg NachtGem: 92/52 mmHg Dip: -15/-23 % C/
Casus 11 Man 69 jr, hartfalen bij voorheen forse hypertensie, nu 4 pillen! Bloeddruk spreekuur: 145/81 mmHg ABM, 91% geslaagde metingen DagGem: 108/67 mmHg NachtGem: 92/52 mmHg Dip: -15/-23 % C/ te goede bloeddrukregulatie met 4 middelen? Er is een duidelijke wittejas- hypertensie
Casus 11 A 58-year-old woman presented with a 6-week history of intermittent passage of bright red blood from the rectum, as well as progressive fatigue and dyspnea.
Her medical history included recurrent episodes of spontaneous epistaxis since childhood, but she had never undergone a full evaluation.
Physical examination revealed telangiectasias on the labial mucosa and nail folds
Lower gastrointestinal endoscopy revealed arteriovenous malformations and telangiectasias of the colon hereditary hemorrhagic telangiectasia, or the Osler–Weber–Rendu syndrome
In addition, her mother was reported to have frequent epistaxis and similar skin lesions.
Laboratory test results showed severe iron-deficiency anemia
Radiologic evaluation revealed no pulmonary or cerebral vascular malformations.
Genetic testing was performed, and the results were positive for an endoglin gene mutation Q: What is the diagnosis?
1. Cirrhosis 2. Superior vena caval obstruction 3. Transposition of the great vessels Q: What is the diagnosis?
Answer:
2. Superior vena caval obstruction of the great vessels Vrouw 28 jaar pilgebruik aanvalsgewijze koude pijnlijke vingers
Wat is de diagnose?
Wat adviseert u t.a.v. de ‘pil’? Raynaudfenomeen
Maurice Raynaud, 1862
Q: What serologic test is most likely to be positive in this patient?
1. Anticentromere antibody 2. Anti-double stranded DNA 3. Anti-ribonucleoprotein antibody Q: What serologic test is most likely to be positive in this patient?
Answer:
1. Anticentromere antibody
Systemic sclerosis is the most frequent condition associated with secondary Raynaud's phenomenon and is typically associated with anticentromere antibody. This patient's ANA titer was greater than 1:1280, with an anticentromere antibodypattern.
Q: What is the cause of this patient's dyspnea?
1. Mitral stenosis 2. Pneumonia 3. Pneumothorax 4. Pulmonary embolism Q: What is the cause of this patient's dyspnea?
Answer:
peripheral wedge-shaped opacification abutting the pleura, signifying pulmonary infarction distal to a pulmonary embolism. The patient had a thrombus in the left main pulmonary artery. Q: What diagnosis is suggested by the results of this coronary angiogram?
1. Diabetes mellitus 2. Fibromuscular dysplasia 3. Marfan syndrome 4. Polyarteritis nodosa Q: What diagnosis is suggested by the results of this coronary angiogram?
Answer:
4. Polyarteritis nodosa
These findings on coronary angiography are most consistent with severe generalized coronary arteritis. This 63-year-old man had been given a diagnosis of polyarteritis nodosa 3 years earlier and was receiving prednisolone maintenance therapy when he presented with cardiac arrest. Although severe cardiac involvement in polyarteritis nodosa is unusual, it can result in myocardial infarction and confers a poorer prognosis. Despite treatment, the patient died a few months later Q: What is the diagnosis?
1. Paronychia 2. Dermatomyositis 3. Endocarditis Q: What is the diagnosis?
Answer:
2. Dermatomyositis
Dilated and tortuous blood vessels with areas of atrophy, telangiectases, and bushy loop formation along the fingernail bed are most consistent with dermatomyositis. Periungual telangiectases also occur in patients with scleroderma and systemic lupus erythematosus. Q: What presentation is most likely to accompany this angiographic finding?
1. Binocular visual loss 2. Hemineglect 3. Urinary incontinence 4. Verbal agnosia Q: What presentation is most likely to accompany this angiographic finding?
Answer:
1. Binocular visual loss
The patient developed vertigo and binocular visual loss during cardiac catheterization.
Cerebral angiography revealed total occlusion of the distal basilar artery consistent with cardioembolic stroke. All neurological abnormalities resolved following selective intraarterial thrombolysis. Q: What is the most likely diagnosis?
1. Angioedema 2. Facial palsy 3. Parotitis Q: What is the most likely diagnosis?
Answer:
1. Angioedema
The patient presented 2 hours after the beginning of an episode of progressive swelling. She was using fosinopril for years already. Q: This patient has diabetes. What is the diagnosis?
1. Diabetic bullae 2. Eruptive xanthomas 3. Pustular psoriasis Q: This patient has diabetes. What is the diagnosis?
Answer:
2. Eruptive xanthomas
The lesions were reddish yellow, pruritic, and painful and were present on the backs of both legs and on the buttocks and knees.
A blood specimen was lipemic and the triglyceride level was high. Q: What is the diagnosis?
1. Gonococcal arthritis 2. Rheumatoid arthritis 3. Tophaceous gout Q: What is the diagnosis?
Answer:
3. Tophaceous gout
Needle aspiration of the swelling yielded a white viscous fluid with numerous urate crystals identified on polarized microscopy. Q: This patient presented with renal failure. What would be the expected finding on renal biopsy?
1. Cholesterol crystals 2. Crescentic glomerulonephritis 3. Renal cortical necrosis 4. Tubulointerstitial nephritis Q: This patient presented with renal failure. What would be the expected finding on renal biopsy?
Answer:
1. Cholesterol crystals
This patient presented with renal failure five weeks after coronary-artery bypass grafting.
It is likely that atheromatous plaques were disrupted at the time of arterial manipulation, resulting in progressive subacute renal dysfunction, livedo reticularis, and digital cyanosis.
Examination of a specimen from a percutaneous kidney biopsy revealed obstructive cholesterol crystals Q: What is the diagnosis?
1. Angioedema 2. Cholesterol embolism 3. Compartment syndrome 4. Raynaud disease 5. Subclavian vein thrombosis Q: What is the diagnosis?
Answer:
5. Subclavian vein thrombosis
The swelling and red discoloration of the right arm and hand were caused by a subtotal occlusion in the subclavian vein close to the clavicle. This resolved after treatment with oral anticoagulation. Q: This patient presented with a 10-day history of left foot discoloration that resolved with elevation. What is the most likely diagnosis?
1. Arterial insufficiency 2. Erysipelas 3. Peripheral microembolization 4. Phlegmasia cerulea dolens Q: This patient presented with a 10-day history of left foot discoloration that resolved with elevation. What is the most likely diagnosis?
Answer:
1. Arterial insufficiency
Buerger's symptom refers to dependent rubor after elevation and is suggestive of arterial insufficiency. The foot is not edematous.
Erysipelas and peripheral microembolization would not typically resolve with elevation.
Phlegmasia cerulea dolens presents with a bluish discoloration following deep venous thrombosis. Q: What is the diagnosis?
1. Scleroderma 2. Thromboangiitis obliterans 3. Calciphylaxis 4. Osteomyelitis Q: What is the diagnosis?
Answer:
3. Calciphylaxis
The radiograph demonstrates severely calcified arteries and the loss of soft tissue at the tips of the index and middle fingers. A skin biopsy was consistent with calciphylaxis. Q: What is the diagnosis?
1. Rheumatoid arthritis 2. Cirrhosis 3. Psoriasis 4. Endocarditis Q: What is the diagnosis?
Answer:
4. Endocarditis
Typical subungual ("splinter") hemorrhage and numerous petechiae on the skin of the abdomen are seen in a patient with staphylococcal endocarditis. Q: What is the diagnosis?
1. Deep venous thrombosis 2. Necrotizing fasciitis 3. Scleroderma 4. Digital ischemia Q: What is the diagnosis?
Answer:
4. Digital ischemia
This patient developed severe digital ischemia during treatment for shock complicated by disseminated intravascular coagulation. Q: What is the diagnosis?
1. Ehlers-Danlos syndrome 2. Pseudoxanthoma elasticum 3. Marfan syndrome Q: What is the diagnosis?
Answer:
1. Ehlers-Danlos syndrome
Hyperextensibility and hypermobility are features of Ehlers-Danlos syndrome, and result from abnormalities in collagen synthesis. Q: What is the diagnosis?
1. Cholesterol emboli 2. Acute arterial insufficiency 3. Deep venous thrombosis Q: What is the diagnosis?
Answer:
3. Deep venous thrombosis
This patient was diagnosed with phlegmasia cerulea dolens, an uncommon manifestation of deep vein thrombosis (painfull blue edema). Q: This 59-year-old man presented with a 10-month history of Raynaud's phenomenon, fever, abdominal pain, and hypertension. What diagnosis is suggested by the findings on his angiogram?
1. Takayasu's arteritis 2. Wegener's granulomatosis 3. Systemic lupus erythematosus 4. Polyarteritis nodosa Q: This 59-year-old man presented with a 10-month history of Raynaud's phenomenon, fever, abdominal pain, and hypertension. What diagnosis is suggested by the findings on his angiogram?
Answer:
4. Polyarteritis nodosa
The angiogram reveals multiple microaneurysms involving the renal artery. A biopsy of a subcutaneous nodule was consistent with polyarteritis nodosa. Q: Twelve hours after urgent coronary angiography, the appearance of this patient's feet had changed. What is the most likely explanation for the finding?
1. Endocarditis 2. Raynaud phenomenon 3. Heparin-induced thrombocytopenia 4. Cholesterol emboli Q: Twelve hours after urgent coronary angiography, the appearance of this patient's feet had changed. What is the most likely explanation for the finding?
Answer:
4. Cholesterol emboli
The bluish discoloration of the toes with livedo reticularis that appeared after coronary angiography suggests a diagnosis of cholesterol emboli. Therapieresistente hypertensie
• Man 42 jaar • Moeilijk behandelbare hypertensie • Als kind ‘slecht in voetbal, maar geweldig in de ringen’ • LO/ souffle over het hart, bloeddruk in de benen lager dan in de armen Coarctatio aortae
Man 53 jaar
DM2 Roken
Claudicatioklachten
E/A index Links: 1,3 Antwoord:
Mediasclerose bij diabetes mellitus
N.B. E/A index vaak normaal bij mediasclerose
Xanthelasmata zijn pathognomonisch voor familiaire hypercholesterolemie
Onjuist
Peesxanthomen Man, 68 jaar
Welke afwijking ziet u op zijn CT- scan?
Welke klachten heeft de patiënt? Tabel 1. Symptomen van acute longembolie bij 260 patiënten [12].
70 jaar 40-69 jaar < 40 jaar
(n = 72) (n = 144) (n = 44)
Aantal (%) Aantal (%) Aantal (%)
Dyspnoe 56 (78) 113 (78) 36 (82)
Pleurale pijn 37 (51) 83 (58) 31 (70)
Hoesten 25 (35) 60 (42) 20 (45)
Zwelling been 25 (35) 48 (33) 6 (14)
Pijn been 22 (31) 38 (26) 9 (20)
Palpitaties 9 (13) 22 (15) 4 (9)
Wheezing 7 (10) 17 (12) 7 (16)
Angineuze pijn 7 (10) 19 (13) 3 (7)
Hemoptoe 6 (8) 6 (4) 14 (32)
A 59-year-old woman with hypertension and diabetic nephropathy presented with a sudden onset of dyspnea after discontinuing her medications
Koga T and Fujimoto K. N Engl J Med 2009;360:1539 Lipidenprofiel: wel of niet nuchter bloed laten afnemen? European Atherosclerosis Society en de European Federation of Clinical Chemistry and Laboratory Medicine uitslagen laten beperkte verschillen zien tussen een nuchtere versus een niet-nuchtere bepaling van het lipidenprofiel een nuchtere bepaling is alleen nodig bij een forse hypertriglyceridemie of bijvoorbeeld wanneer een nuchter glucose moet worden afgenomen • A 36-year-old man presented to the emergency department with substernal chest tightness of 6 hours’ duration.
• The chest tightness was initially intermittent but became persistent 1 hour before presentation.
• He was a current smoker with a smoking history of 10 pack- years.. •
• occlusion of the proximal left anterior descending coronary artery?
• the patient underwent immediate coronary angiography, and the procedure revealed 95% stenosis of the proximal left anterior descending coronary artery • troponin I level rose to a peak of 7.19 ng per milliliter (normal value, <0.06) 14 hours after the procedure.
Wat zegt deze patient tegen de internist?
1. “Dokter, als u eens wist hoe weinig ik eigenlijk eet!”
2. “Dokter, mijn vrouw kookt toch zo lekker!”
3. “Dat lijkt maar zo, dokter… dat zijn allemaal spieren!” Einde
“Dat lijkt maar zo, dokter.. dat zijn allemaal spieren”