1. Photo Quiz: “To the Man with a Hammer…”
Paul D Simmons, MD
St Mary’s Family medicine residency – 8 aug 2017

2. Describe what you are seeing
Describe what you are seeing. This nail finding is associated with several chronic illnesses. Name one.
Terry’s nails: CHF, T2DM, advanced age, liver disease

3. Describe what you are seeing
Describe what you are seeing. This nail finding is associated with a kind of chronic organ failure. Name it.
Lindsay’s nails: CRF – due to increased pigment deposition

4. What can you conclude about your patient’s recent history?
Beau’s lines – transverse ”creases” in the nail suggestive of recent serious illness (sepsis, chemo, malnutrition).

5. Describe what you see. This nail finding is associated with hypo-_______________
Muehrcke’s lines – hypoalbuminemia due to nephrotic syndrome or protein malnutrition

6. Describe what you see. Why is this bad?
Acral lentiginous melanoma – because it’s melanoma.

7. What do you see? Name one benign and one serious cause.
Splinter hemorrhage – trauma, or SBE.

8. What lifestyle change has this patient made?
Quitter’s nail – patient quit smoking a couple of months ago. Distal, but not proximal staining.

9. Name three causes of this nail finding:
Lung cancer (“beware the yellow clubbed digit”), pulmonary fibrosis, empyema; RL shunts, endocarditis, pericarditis. COPD DOES NOT CAUSE CLUBBING.

10. This patient is a respiratory therapist. What is your diagnosis?
Herpetic whitlow. From contact with oral secretions containing HSV.

11. What kind of arthritis is this? Name the eponymns for extra credit.
Osteoarthritis. Bouchard’s (PIP) and Heberden’s (DIP) nodes.

12. Extra credit (non-nail question): Which peripheral nerve is damaged?
Median nerve: controls the 1st & 2nd lumbricals, three thenar muscles (abductor pollicis brevis, flexor pollicis brevis, and via a distal branch the opponens pollicis). Additionally there may be thenar atrophy. Patient can’t flex the DIP of the first and second fingers, thus the flat OK sign.
Patient asked to make a fist.
Patient asked to make “OK” sign with both hands. (R abnormal)