Trifecta

It is your first day on your internal medicine rotation! You are super excited and vow to impress your preceptor with extensive, thorough notes.

A 70 year old man is brought into your clinic by his daughter. As they both enter, you notice that he has a slow shuffling gait. It almost seems that he has trouble lifting his feet with each step. He holds onto her arm to keep his balance.

The daughter is worried about her father because she's noticed some changes. She says, "He used to love crossword puzzles, telling stories, and playing with his grandkids, but now, he just doesn't seem interested in much anymore. He watches TV, but his favorite things are the commercials. I think it's because he's having trouble concentrating." You ask the patient a few questions, and he reports that he's been feeling pretty tired and weak lately. He thinks its old age. He's also concerned that he's feeling a lot of urgency in urination and has to go to the bathroom pretty frequently.

Past medical history is significant for an appendectomy when he was 18, Guillain-Barre when he was 30 which required 2 weeks on a mechanical ventilator, MI several years ago. Family history is significant for Alzheimer's on the mother's side and Parkinson's on the father's side. His sister passed away and had frontal-temporal dementia. His brother had lung cancer. He has two kids, both healthy.

Current medications include aspirin, a beta-blocker, an ACE inhibitor, and a statin. He also takes a multivitamin daily. He drinks half a glass of wine with dinner every evening and smokes about a pack a day. He has a 50 pack year history. He went through a mid-life crisis in his 60s when he tried heroin and cocaine. His previous job was a painter.

The patient lives with his wife who helps him take his medications. He does not exhibit any signs of depression. He is able to do most of the activities of daily living, but he cannot walk very well and has trouble remembering where he puts things. He stopped driving after his MI.

When you do a Mini Mental State Exam, he does pretty poorly for his age and education level. In particular, when you ask him to remember a few objects, he cannot recall them 5 minutes later, but he can recognize them if you give him a list. His neurologic exam is normal. In particular, there is no rigidity or tremor.

You pack up your five pages of notes and go to your preceptor. After you present the case to him, he says, "Hmm...let's order an MRI." This is what the MRI shows:

Too bad radiology didn't label the arrows. The preceptor says, "That's a good history you have. In it, there is a triad of three symptoms that point to his diagnosis."

Challenge: Can you identify the trifecta? What's the diagnosis? What's the treatment?

Related Questions:
1. What does the MRI show?

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People Like That Are The Only People Here

This disease is described in a story by Lorrie Moore with the same title as this case. Here is a typical presentation. A four year old African American girl presents with abdominal pain and hematuria. On exam, you find that she is hypertensive and you palpate a firm, nontender, smooth abdominal mass that does not cross the midline. Further workup involves removing a kidney. The pathology is shown below:


You notice the gross specimen shows infiltration by a fleshy tan mass with a pseudocapsule surrounded by areas of hemorrhage and necrosis. The histology shows three cell types.

Challenge: What's the diagnosis here?

Related Questions:
1. What three cell types are seen on histology?

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This Was Not Photoshopped

After finishing medical school, you decide to squander your education and abandon your kind-hearted nature to pursue law school. As the district attorney, you get called to evaluate this case of potential child abuse. This child presented with multiple fractures. You take one look at his eyes and remember fondly back to your medical school days and realize that this disease is...

Challenge: What?

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Burnt Caramel

You're about to leave the path lab when the attending hands you a urine sample. "Smell this," she says.
"Are you out of your mind?" You almost ask. Instead, you say, "As you wish." After all, you really want that UCSF pathology residency.
The urine smells weird, almost like burnt caramel. "Diabetes?" you ask.
"Nope, it is pretty sweet smelling though. It came from a newborn. We need to put him on a special diet to prevent neurological damage."

Challenge: What restrictions will be put on the infant's diet? There are three specific things to avoid.

Related Questions:
1. What is this disease?
2. This disease has higher prevalence in those with a specific religion. What would this be?

Tahoe

A patient comes in with pain, tenderness, and swelling of his thumb, mostly along the ulnar aspect of the metacarpophalangeal joint. He says the thumb feels slightly unstable. You have him pinch his thumb and forefinger, and compared to the other hand, the affected one has less strength. The history is notable for a recent ski trip to Tahoe. Here's an X-ray:

Challenge: What's the diagnosis?

Related Questions:
1. What's seen on the X-ray?
2. What is the historic name for this disease and why is it called that?

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Physiology Basics

A central venous line is put into an 80 year old to monitor fluid status. You notice on the central venous pressure waveform that there are no "a" waves. Your attending tells you that he should be put on warfarin.

Challenge: What would you see on an EKG?

Related Questions:
1. What is the cause of "a" waves on a central venous pressure waveform?
2. Why the warfarin?

Happy Valentine's Day

On your pathology elective, you do an autopsy and find a lung with necrotizing pneumonia; when you look at the lab results for the patient, you find gram positive cocci in clusters.

Challenge 1: What antibiotic would you use for this infection? This bacteria secretes a particular type of (Valentine related) toxin - what is it?

Here's a hard one. A 30 year old female presents with abrupt onset of these lesions and fever. You get a dermatology consult which describes the lesions as "erythematous tender papules forming plaques with an irregular pseudovesicular surface, a few centimeters in diameter with central yellowish discoloration." The patient describes these lesions as painful but not itchy. They are found on the face, neck, upper extremities, and dorsum of the hand. The patient says this presentation was preceded by a flu-like illness. Lab tests show neutrophilia with 70% bands, elevated sed rate, and elevated C-reactive protein. A biopsy shows "nodular and dense perivascular neutrophilic infiltrates with neutrophil karyorrhexis and no vasculitis." You put her on antibiotics and there is no response. You then switch her to systemic glucocorticoids and she responds well.

Challenge 2: What's the diagnosis?

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The Acute Scrotum

A 16 year old boy presents to the ER of the children's hospital complaining of severe onset testicular pain of one hour duration. He played a game of soccer several hours ago, but there is no reported injury or trauma. He is experiencing nausea and vomiting. There is no fever, dysuria, or discharge. The patient is not sexually active. You examine the affected testis, which is asymmetric from the other side, and it appears to be attached to the inner lining of the scrotum higher than usual. He says it feels tender. The cremaster reflex is absent. A blood count shows leukocytosis. This boy needs immediate surgery.

Challenge: What is the diagnosis?

Related Questions:
1. What is the cremaster reflex?

*Note: I have been told that you should not say "acute scrotum" out loud.

Not for the Faint of Heart

You get an emergency consult as an infectious disease doctor. A 25 year old girl had presented with high fever and severe headache. She was throwing up every few hours and had trouble moving her neck. She avoided light and sound and acted confused and lethargic. She was treated a week ago, but came in today with a severe rash. She said she felt feverish earlier with sore throat, cough, and malaise.

You look closely at her. It looks like you can peel away the top layer of skin from the lower layers. It's almost as if she's been severely burned. You notice blisters and erosions in her mouth. She says, "I can't eat, my eyes hurt, it hurts when I pee..." Indeed, this rash covers her eyes, her mouth, and vagina.

Challenge: What is the diagnosis?

Related Questions:
1. When she originally presented to the doctor, what did she have?
2. What is the cause of her current condition?

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Swoon

A 55 year old man presents to your cardiology clinic. He says that last week, he had an episode of fainting. He was sitting on the couch watching TV when he became extremely pale. He felt his heart "skip a beat." He then swooned into the arms of his wife who promptly dropped him to the ground. Once he hit the ground, he began to twitch for 15 seconds. About 15 seconds after he stopped twitching, he regained consciousness. After that, he became extremely flushed. He went to see his primary care doctor who referred him to you.

He is bradycardic and hypotensive. You look at the EKG taken by the primary care doctor.

Challenge: This syndrome is named after two Irish doctors. What is the syndrome?

Related Questions:
1. What does the EKG show?
2. What causes the syncope?

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For Whom the Bell Tolls

A diabetic and pregnant patient presents with the above finding with an onset of a day or two. She has trouble closing her eyes. She looks funny when she wrinkles her forehead. Oh, oh, oh!

Challenge: What's the diagnosis?

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Double Entendre

This case is based on a real patient I saw last Tuesday (but I did change details).

I was in the Emergency Department and my preceptor asked me to see a patient in room 17. When I opened the door, I noticed a gaunt-appearing man probably in his forties who began to immediately scream in pain. He was bawling, cursing, howling. I managed to elicit his chief complaint, "It hurts so much," and upon further investigation, I found that he had acute onset steady epigastric pain that began yesterday (he said he stopped drinking several days ago). It was band-like and radiated to the back. He had nausea and vomiting and was restless and agitated. Past medical history was significant for infective endocarditis, osteomyelitis, hepatitis B, and hepatitis C. A police officer recognized him and said he had a record for shoplifting and burglary.

He had tenderness and guarding of the epigastrum. There was no ecchymotic discoloration of the flanks or periumbilical region. But, this was interesting:

Challenge:
What do you think?

Related Questions:
1. If there were ecchymotic discoloration of the flanks or periumbilical region, this would represent two signs, which may be useful for the Boards or wards. What are they?
2. What labs would you like to order?

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Eye of the Beholder

This is an image of the right eye of a 15 year old male. He has been partially deaf since he was born and also has a patch of white hair along his forehead. Indeed, it looks somewhat like the hair seen here:

When you take a family history, you find these symptoms follow an autosomal dominant pattern.

Challenge: What is your diagnosis?

Related Questions:
1. What is the eye finding called?
2. What is the hair finding called?

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Second image shown under fair use.