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Pearls & Pitfalls

63 y/o man with long standing HTN,
hyperlipidemia arrives in office Friday
afternoon with chest pain
 80 pack-year smoker
 1 year ago: cardiac cath: 3v CAD, not
amenable to CABG/PCI – medical
management (beta blocker, ASA, statin)
 Severe pain centrally, to left arm and back

BP 180/110, pulse 90, resp 14, afebrile
 No CHF, new AI murmur
 Otherwise unremarkable exam
EKG

You start ASA, give a dose of metoprolol
 Call Cardiology
What is your next step
(diagnostic/therapeutic?)
Aortic dissection






h/o HTN, “tearing” pain, radiation to back
Can dissect into renal / mesenteric / carotid /
coronary arteries (presents as acute MI, as in this
case)
New AI murmur from aortic dilatation
PITFALL:
no thrombolytics/anticoagulation if dissection
suspected
Diagnosis confirmed with ECHO, CT, MRI
Call CT surgery
Objective: recognize the clinical presentation of aortic
dissection

27 year old man is admitted with chest pain after a
rear-end motor vehicle accident 6 days ago
 belted, 10 mph
 History of HIV
 Occasional thrush, no other opportunistic
infections
How do you
manage this
patient?
1. Tube thoracostomy
2. Bactrim for presumed PCP
Objective: recognize PCP as a cause of spontaneous
pneumothorax in patients with HIV

50 year old man is admitted with chest pain
Objective: identify the blood gas findings in a patient
with acute MI / cardiogenic shock



Becomes confused, clammy
Bp 90/58, pulse 106, rr 22
Which ABG below would most likely fit the clinical picture?
a) 7.40/40/100
b) 7.52/26/90
c) 7.32/52/82
d) 7.30/28/88

You evaluate a 47 year old woman with chronic kidney
disease for hypertension. She has no history of diabetes, no
cardiac problems, and other medical problems. She has
followed a low sodium diet. She does not smoke or drink
alcohol.

She is 5’ 8” tall and weighs 230 lbs. BMI is 35.

Blood pressure is 158/92, pulse 70. The exam is
unremarkable. She appears well hydrated.

Creatinine is 3.2, glucose 90, and the remainder of the
metabolic panel is normal.

Urinalysis shows 2+ proteinuria.

Which of the following interventions is most likely
to reduce this patient’s risk of requiring dialysis in
the future?
a) implementing a low protein diet
b) starting hydrochlorothiazide
c) starting an ACE inhibitor
d) starting amlodipine
e) weight reduction until BMI is ≤ 30

Which of the following interventions is most likely
to reduce this patient’s risk of requiring dialysis in
the future?
a) implementing a low protein diet
b) starting hydrochlorothiazide
c) starting an ACE inhibitor
d) starting amlodipine
e) weight reduction until BMI is ≤ 30
ACE inhibitors and kidney disease


Clearly reduce progression to ESRD in diabetic patients (especially
with proteinuria – micro or macro)
Nondiabetic patients have similar benefit:
–
–
–
–
–



MDRD trial
Benazapril trial
REIN trial
REIN 2 trial
AASK trial
Even patients with creatinines up to 5.0 mg/dL had reductions in
progression to ESRD
Be sure the patient is well hydrated, evaluate diuretic use.
AARBs – similar antiproteinuric effect, but outcome trials lacking
Objective: Rx to limit progression renal disease in a 47
y/o woman w/chronic renal insufficiency




64 year old woman with DM II for 20 years, gout, HTN seen in the office
No S3, no displacement of PMI, no increased JVD, no rales
History of “blood clot,” very high cholesterol (TC 320)
Findings below on BOTH legs:
a)
CHF
b) Nephrotic
syndrome
c)
Objective: identify cause of edema in patients
with diabetic nephropathy

Most likely cause of the exam finding?
DVT
d) Gout
e)
An overly
aggressive
GT3 exam



35 year old woman with malaise, abdominal pain, diarrhea,
nausea/vomiting
Recently
visited here
Objective: understand the most common cause of
traveler’s diarrhea and how to identify it
What are you likely to find on stool gram stain?
a) normal flora
b) large parasites with few eggs, many RBC
c) gram positive rods which are germ tube positive
d) gram positive cocci in grape-like clusters
e) the lost colony of Atlantis

You see a 32 year old man in the emergency
department for fever, stiff neck and malaise. He
has a petechial rash on his ankle. Gram stain of his
CSF shows the following:

What therapy is warranted for the household
family members of this patient?
a) no therapy, watchful waiting is appropriate
b) Penicillin V-K, 500 mg orally three times daily x 7 days
c) Ciprofloxacin, 500 mg x1 (adults), oral rifampin x 2 days
(children)
d) meningococcal vaccine, post-exposure dose
e) respiratory isolation, culture anterior nares, no therapy

What therapy is warranted for the household
family members of this patient?
a) no therapy, watchful waiting is appropriate
b) Penicillin V-K, 500 mg orally three times daily x 7 days
c) Ciprofloxacin, 500 mg x1 (adults), oral rifampin x 2 days
(children)
d) meningococcal vaccine, post-exposure dose
e) respiratory isolation, culture anterior nares, no therapy
Objective: recognize drug treatment for the family of a
patient with meningococcal meningitis.
Meningococcal prophylaixs

Indicated for high risk exposure:
– household contacts
– >4 hours spent with patient for 5 of 7 days prior
– dorms, barrack roommates, day care
– mouth-to-mouth

Prophylaxis regimens:
– rifampin (600mg q 12h x 4) – there is resistance to
rifampin in some areas
– cipro 500-750 mg x 1
– ceftriaxone 250 mg IM x 1

35 year old man with this finding on tuberculin skin testing:

He begins treatment. Which of the following will help prevent
symptomatic side effects of therapy?
a) Vitamin B12, 1000mcg monthly
b) Vitamin B3, 1 mg daily
c) Vitamin B6, 50 mg daily
d) folic acid, 1 mg daily
e) Jack Daniels, nightly
Objective: recall the management
of side effects of anti-TB
medications

You are consulted to see a 72 year old man whose
urine output has diminished 48 hours after
aortofemoral bypass grafting. He has Type II
diabetes and hypertension, and has had claudication
for 1 year, which was angiographically confirmed
the morning of surgery.

He appears well hydrated. Blood pressure is 148/84;
otherwise vital signs are normal. There is an S4 on
exam, but no other abnormalities. Distal pulses are
1+ and symmetric.

Serum creatinine is 2.5 (baseline 1.2).

What is the most likely cause of the renal failure?
a) contrast-induced nephropathy
b) surgical error
c) renal artery thrombosis
d) atheroembolism to the renal artery
e) post-op MI with congestive heart failure

What is the most likely cause of the renal failure?
a) contrast-induced nephropathy
b) surgical error
c) renal artery thrombosis
d) atheroembolism to the renal artery
e) post-op MI with congestive heart failure
Objective: recognize contrast nephropathy.



You are called to admit a 50 year old man from the emergency
department for obtundation. The family states he has been
complaining of fatigue for nine months, and two weeks of
vomiting. He has also lost approximately 20 lbs. over the
previous two months.
He has no other past medical history, and takes no medications.
Vital signs:
– BP 96/60
P 88 R 20 T 38.4 C
– On exam, the patient is obtunded but responds to painful and loud verbal
stimuli. He grimaces when you palpate his abdomen. You notice dark
coloration of his palmar creases.

What is the best initial management for this
patient?
a) Broad spectrum antibiotics
b) Vasopressors
c) Glucocorticoids
d) L-thyroxine
e) Thiamine

What is the best initial management for this
patient?
a) Broad spectrum antibiotics
b) Vasopressors
c) Glucocorticoids
d) L-thyroxine
e) Thiamine
Objective: Understand initial treatment for a 50 y/o man
w/fatigability/vomiting/wt loss/obtunded/brown palmar
creases.


You see a 65 year old woman with Type II Diabetes who
complains of exertional pain in the chest for the past three weeks.
The episodes last a few minutes, are not associated with nausea or
dyspnea, and resolve either with rest or spontaneously. She has
no history of cardiac or pulmonary disease. She now presents
with a similar episode of chest pain which has lasted about 35
minutes.
Her exam is normal.
 EKG is completely normal.

What is the best initial management for this
patient?
a) Admission, cardiac enzymes, medical therapy for acute
coronary syndrome
b) Reassurance, prescribe GI cocktail
c) Begin aspirin, schedule outpatient stress test
d) Send for CT of the chest with PE protocol
e) Immediate cardiac catheterization

What is the best initial management for this
patient?
a) Admission, cardiac enzymes, medical therapy for acute
coronary syndrome
b) Reassurance, prescribe GI cocktail
c) Begin aspirin, schedule outpatient stress test
d) Send for CT of the chest with PE protocol
e) Immediate cardiac catheterization
EKG in Acute Coronary Syndrome



Initial ECG is often not diagnostic in patients with an ACS
In two series,
– not diagnostic in 45 percent
– normal in 20 percent of patients subsequently shown to
have an acute MI
Patients with history suggestive of ischemia / ACS should
be managed as such despite a normal or non-diagnostic
EKG
Objective: Manage a 64 yo woman w/type 2 DM with 3
weeks of exertional chest pressure and a normal ECG.



A 62 year old man with a history of chronic bronchitis is admitted
to the hospital with lobar pneumonia. He presented to his
physician after one day of cough and shortness of breath. He has
no other chronic medical conditions. Baseline arterial blood gas
is as follows:
pH 7.34
pCO2 68
pO2 60
Vital signs on admission:
– BP 130/80
P 100
R 24
afebrile

Pulse oximetry shows an SAO2 of 84% on room air.

He is begun on cefuroxime and azithromycin, oxygen therapy
(40% by face mask), and IV fluids.

Twelve hours later, he appears somnolent. Arterial blood gas
shows the following:
pH 7.18
pCO2 88
pO2 160


What is the most likely reason for the blood gas
findings in this patient?
a) Worsening pneumonia; non-responsive to chosen antibiotics
b) Antibiotic-induced respiratory depression
c) Exacerbation of chronic COPD
d) Reduction in ventilation caused oxygen therapy
e) Exacerbation of heart failure from excessive IV fluids

What is the most likely reason for the blood gas
findings in this patient?
a) Worsening pneumonia; non-responsive to chosen antibiotics
b) Antibiotic-induced respiratory depression
c) Exacerbation of chronic COPD
d) Reduction in ventilation caused oxygen therapy
e) Exacerbation of heart failure from excessive IV fluids
Objective: Understand the cause of blood gas changes in a 62
y/o man w/lobar pneumonia and chronic bronchitis.


A 48 year old man with no past medical history complains of six
months of pain in his buttocks, especially when walking. He has
had no chest pain or shortness of breath, and no leg pain. He is a
smoker (1-2 packs per day) since high school but does not drink
alcohol. He takes no medications.
Review of systems is positive only for erectile dysfunction; he
asks you for a prescription for the “blue pill.”

Further studies would be most likely to show
which of the following?
a) Central disc herniation in the L4-L5 area
b) A hard, nodular prostate exam with an elevated PSA
c) Colonic dilatation on CT scan
d) Reduced arterial blood flow in the distal legs
e) Loss of the sacroiliac joint space on plain X-rays

Further studies would be most likely to show
which of the following?
a) Central disc herniation in the L4-L5 area
b) A hard, nodular prostate exam with an elevated PSA
c) Colonic dilatation on CT scan
d) Reduced arterial blood flow in the distal legs
e) Loss of the sacroiliac joint space on plain X-rays
Objective: Diagnosis in a 48 y/o man with a 6-month history
of pain in the buttocks w/walking and erectile dysfunction.

An 80 year old woman complains of fatigue and weakness
for the past two months. She has otherwise been in good
health, and takes no medications. Her age-appropriate
cancer screening is up to date.
 She appears well but pale. Vital signs are normal. There is
loss of vibratory and position sense of both legs.
 Initial labs show a hemoglobin of 9.0 g/dL; peripheral smear
is shown below:
What is the most likely diagnosis in this patient?
Pernicious anemia

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

Vitamin B12 deficiency
Megaloblastic anemia (hypersegmented PMN)
MCV often very high (>110)
Other cell lines may be affected in severe disease
“Subacute combined degeneration of the posterior
(and lateral) columns” - neurologic disease not
seen with folic acid deficiency
– Paresthesias, ataxia, vibratory/position sense
Objective: diagnose a patient with fatigue / anemia, a
hemoglobin of 9, and an abnormal peripheral blood smear
You see a patient with knee pain and this joint aspirate. His liver is
slightly enlarged and his blood glucose is 211. How do you work up
the underlying hereditary disorder?
Transferrin saturation (UIBC): Fe/TIBC
[HFE gene]
DX: CPPD/hemachromatosis (hyperparathyroidism,
hypomagnesemia, hypophosphatemia)

A 59 year old man with a history of alcoholism is admitted
to the hospital for cellulitis. He is coherent, and MMSE is
28/30.

Upon admission, his blood alcohol level is 10 mg/dL (BAC
= 0.01). He is begun on antibiotics.

24 hours later, you are called to evaluate him for “altered
mental status.” He is afebrile; no rash is noted. His MMSE
is 27/30, and his neurologic exam is non-focal. He
describes “spiders” crawling on the walls and on his arms,
and thinks he saw his dead mother sitting in the nurses
station.

WBC is normal.

What is the most likely cause of this patient’s
change in mental status?
a) Delirium tremens
b) Vitamin B12 deficiency
c) Acute Wernicke’s encephalopathy
d) Alcoholic hallucinosis
e) Adverse effect of antibiotics

What is the most likely cause of this patient’s
change in mental status?
a) Delirium tremens
b) Vitamin B12 deficiency
c) Acute Wernicke’s encephalopathy
d) Alcoholic hallucinosis
e) Adverse effect of antibiotics
Alcohol withdrawal syndromes



Acute Wernicke’s usually rapid onset after administration
of glucose in patients with underlying thiamine deficiency
Hallucinosis:
– usually visual, but may be auditory
– No clouding of sensorium
DTs:
– Later manifestation
Objective: explain the change in mental status 24 hours
after admission in a patient with alcoholism





You see a 28 year old man with hyperlipidemia. His father, grandfather, and
uncle all had coronary artery disease at an early age, and multiple family
members have Type II diabetes. He does aerobic exercise regularly.
On exam, he appears well. Height 67 inches, weight 180 lbs. (BMI = 28)
Vital signs: bp 126/78 p 52 r 14 t 35.9
His exam is normal.
Labs: TC 270 LDL 190 HDL 36 TG 220
Objective: recognize secondary causes of hyperlipidemia
(hypothyroidism - up to 4% of patients with hyperlipidemia).

You start a statin. In addition to checking liver enzymes in a month, and a
fasting serum glucose, what other lab tests would you order?
TSH

60 year old man, in good health, has a positive
FOBT
 Colonoscopy at age 51 was “normal”
 Sent for colonoscopy – one polyp is found
(pedunculated, hyperplastic by pathology)
 When is his next colonoscopy due, assuming no
abnormal signs/symptoms and negative FOBT in
the interval?
a) 6 months
b) 1 year
c) 3 years
d) 7-10 years
e) Depends upon polyp size
Hyperplastic polyps

No malignant potential
 “routine” screening interval
 Need to differentiate from adenomatous polyp
(ALL have malignant potential)
– Tubular
– Tubulovillous
– Villous (highest potential)

Sessile polyps – harder to fully remove than
pedunculated (but this is simply descriptive, no
relation to malignant potential)

You are asked to see a 23 year old man, s/p repair of a torn medial collateral
ligament, who has become yellow.

He is healthy, with no chronic medical problems, no medications, no exposures or
travel outside the U.S. Up to date with immunizations. No alcohol or drugs.
ROS: recalls similar eye discoloration after “the flu” 2 years ago.
Exam: normal except for eye changes above, yellowish skin discoloration
HBsAg - Anti-HBS + Anti HBc - HAV ab –
AST 40 ALT 36 AlkPhos 110 Bili (T) 3.2 Bili (D) 0.4 CBC, Chem 7 normal




What do you do next?
a)
Reassurance, no testing
b)
CT abdomen
c)
RUQ ultrasound
d)
Liver biopsy
Objective: recognize common benign
causes of hyperbilirubinemia
(Gilbert’s)

A 22 year old woman is seen for a rash. She was on a camping trip in
the Shenandoah Valley one month ago. She has no other symptoms.

On exam, vital signs are normal, and the exam is normal except for the
rash pictured below:

What treatment should be begun?
a) doxycycline
b) erythromycin
c) dicloxacillin
d) vancomycin plus bactrim
e) no treatment warranted at this time

What treatment should be begun?
a) doxycycline
b) erythromycin
c) dicloxacillin
d) vancomycin plus bactrim
e) no treatment warranted at this time

A 22 year old woman comes to you because she is worried about Lyme
disease. One week ago, she went on a camping trip to the Shenandoah
valley. On the morning of the second day of the trip, she found a tick on
her arm, and removed it with tweezers. She stated it was not easy to
remove, but she thinks she removed the entire tick.

On exam, vital signs are normal. There is no redness and no signs of
retained tick parts at the site of the bite. There is no rash.

What treatment should be begun?
a) doxycycline
b) erythromycin
c) dicloxacillin
d) vancomycin plus bactrim
e) no treatment warranted at this time

What treatment should be begun?
a) doxycycline
b) erythromycin
c) dicloxacillin
d) vancomycin plus bactrim
e) no treatment warranted at this time
Lyme disease

Treatment:
– Early localized (EM): doxycycline, amoxicillin, cefuroxime
– “more serious disease” (neurologic, cardiac, arthritis): ceftriaxone

Evaluation & treatment after a tick bite
– Rare disease unless tick attached for >48 hours
– Patients who meet all guidelines for antibiotic prophylaxis should
be treated:





Attached tick identified as an adult or nymphal I. scapularis tick
Tick is estimated to have been attached for 36 hours
Prophylaxis is begun within 72 hours of tick removal
Patient was in an endemic area
No contraindication to treatment (single dose doxycycline)



You see a 40 year old woman with fever, weakness, pallor, confusion
Blood smear is below:
Chem-7:
138 100
4.6 20
42
3.7
104

PT 11.6, PTT 28

HIV testing is negative
All cultures are negative
What is the most likely diagnosis?

a)
Objective: recall the clinical
/ lab findings in TTP
AIHA (autoimmune hemolytic anemia)
b) West Nile meningitis
c)
DIC (disseminated intravascular coagulation)
d) TTP (Thrombotic thrombocytopenic purpura)
e) Chronic renal failure with sepsis


37 year old woman is seen for eye and abdominal pain, and
nausea. Her eye feels hard to the touch.
Has this finding:
Objective: recognize clinical presentation of acute angle
closure galucoma
Acute angle closure glaucoma


24 year old woman with acute flank pain, hematuria.
History of weight loss, intermittent bloody diarrhea over past 12
months.
Has this
skin rash:

And this
urinalysis:
What is the underlying illness?
Objective: identify extraintestinal manifestations of
inflammatory bowel disease (Crohn’s) – Calcium oxalate
crystals / nephrolithiasis, pyoderma gangrenosum




78 year old man with BPH admitted with anuria.
Foley inserted, 2100 cc urine in bladder.
Creatinine 4.6
EKG:
Initial treatment?

23 year old nurse sees you for a painful finger:
Herpetic Whitlow
Pityriasis rosea

Which vitamin should NOT be used alone in this patient?
Folic acid (folate)

To which non-ID specialist should you send this patient immediately:
Ophthalmologist (herpes ophthalmicus– nasociliary branch)

What immune system dysfunction might be found in this 19 year old
man with fever, headache, stiff neck, photophobia, and gram negative
diplococci on gram stain of lumbar fluid:
Terminal complement deficiency (neisseria meningitidis)

What is the antibiotic of choice for this 42 year old man who was
bitten by his cat?
Amoxicillin/clavulanate (Augmentin) – pasteurella maltocida

A 45 year old CDC scientist presents with fever, headache, malaise,
vomiting, and this rash:
What is her mortality?
Variola major: 20-30% if unvaccinated (probably much less if vaccinated –
widespread smallpox vaccines stopped around 1972)
Variola minor: 1%

Why do you NOT give steroid eye drops to this 21 year old student
complaining of a painful, itchy eye:
HSV keratitis (“dendritic pattern”)

Name the immunization which may prevent overwhelming bacterial
sepsis in this patient:
Pneumovax (Howell-Jolly bodies)

Pel-Ebstein fevers and this biopsy finding are associated with which
malignancy?
Hodgkin’s (Reed-Sternberg cell)
Acanthosis nigricans
Basophilic stippling
18 year old patient developed this rash after treatment for an upper respiratory infection.
He is febrile, very fatigued, and has tender lymph nodes in the back and front of the
neck. There is a pharyngeal exudate, a few small red spots on the palate, and a
slightly palpable spleen tip. What do you advise him to avoid?
a)
b)
c)
d)
Alcohol
Contact sports
Sulfa-based antibiotics
Contact with children
under age 5
e) Sex, drugs, Rock & Roll
Morbilliform rash common with mono after amox/ampicillin, palatal
petechiae + exudates virtually diagnostic of EBV.
What treatment might
be helpful for this
patient with malaise,
fatigue, anemia,
thrombocytopenia,
elevated PT/PTT and
a positive d-dimer?
All Trans Retinoic Acid (ATRA) – PML (M3),
associated with DIC. Auer rods seen, t15:17
mutation common.

19 year old man with weight loss, diarrhea
 Recurrent “bronchitis”
 This exam finding:
Objective: identify the diagnostic test of choice for
cystic fibrosis

What is the diagnostic test of choice?
Sweat chloride – elevation supports diagnosis of cystic fibrosis

48 year old man with cough (bloody), alcohol abuse
 X-ray:
Objective: recognize TB as a causes of upper lobe
pneumonia

What is the diagnostic test of choice?
Sputum for AFB (TB)

46 year old woman with HTN and this X ray:

Gram stain shows this organism:
Objective: recall common causes of meningitis in adults

During treatment, she becomes confused. What do you do next?
Lumbar puncture (pneumococcal meningitis)

67 year old woman with ESRD has these lesions on
exam:
Objective: identify lab findings in patients with chronic
kidney disease

What is the most likely finding on lab testing?
a) normal PT/PTT, platelet count 25K
b) prolonged PT and PTT, normal platelets
c) PT normal, PTT elevated, platelets 400K
d) PT/PTT normal, platelets 130K

You see a 27 year old woman for an annual visit. Her blood pressure
is 176/88. She is otherwise healthy, no significant family history, no
drugs, tobacco or alcohol. Her only exam abnormality is shown on
the next slide.
You begin working her up for secondary causes of hypertension.
What would you be most likely to find?
a) Creatinine 4.1, creatinine clearance of 18 cc/hr
b) Na 152, K 2.8, adrenal mass on CT
c) Diffuse atherosclerosis of right renal artery on duplex ultrasound
d) Vanillomandelic acid levels of 2,200, metanephrines 1,750 in a
24-hour urine collection
e) A “string of beads” appearance in the distal two thirds of the left
renal artery on renal angiography
Objective: recognize the most common cause of secondary
HTN in young women (fibromuscular dysplasia)

You admit a 55 year old, alcoholic man s/p tonic–clonic seizure. He is
hemodynamically stable, and post-ictal. Chest X-ray findings are below:
Objective: understand the antibiotic management of
aspiration pneumonia
What antibiotics do you begin?
a)
Clindamycin
b) Metronidazole
c) Amoxicillin
d) Cefuroxime + azithromycin
e)
No antibiotics, watchful waiting
f) GORILLAcillin, 8 grams hourly until rash
spreads to entire hospital floor



An 80 year old woman complains of fatigue and weakness
for the past two months. She has a history of frequent skin
infections, which have responded slowly to treatment.
Currently, she takes no medications. Her age-appropriate
cancer screening is up to date.
She appears well but pale. A few petechiae are noted on the
posterior pharynx.
Initial labs show a hemoglobin of 9.0 g/dL; peripheral smear
is shown below:
What is the most likely diagnosis in this patient?
Myelodysplastic syndrome

Malignant hematologic disorder with abnormal / inefficient
cell production
 Infection common (abnormal WBCs)
 Anemia, fatigue
 Petechiae (thrombocytopenia)
 Classification:
– RA
– RARS
– RAEB
– CMML
– RAEB-t

Pseudo-Pelger-Huet anomaly shown

A 19 year old man complains of knee pain for 2-3 months.
He recalls a motorcycle accident 3 months ago, where he
“layed down his Harley,” and had multiple contusions and
abrasions, but did not seek medical care. He has no chronic
medical problems, does not use drugs or alcohol, and takes
no medications. Review of systems is positive only for
occasional “sweating” episodes.

On exam, vital signs are as follows:
110/70 80 14 38.9° C
There is pain with active and passive range of motion of the
right knee, but no overlying erythema.
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
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X rays show periosteal elevation near the tibial plateau.
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What is the most likely diagnosis?
a) Osteonecrosis
b) Avascular necrosis
c) Osteomyelitis
d) Osteosarcoma
e) Stress fracture

What is the most likely diagnosis?
Causes of periosteal elevation:
a) Osteonecrosis
b) Avascular necrosis
c) Osteomyelitis
d) Osteosarcoma
e) Stress fracture
1)
Osteomyelitis
2)
Osteosarcoma
3)
Hypertrophic pulmonary
osteoarthropathy
4)
Familial pachydermoperiostosis
5)
Caffey’s disease
6)
Scurvy
7)
Sarcoid
Objective: diagnose a young man with knee pain three
months after trauma