Histo (Part 1)

This is the biopsy of a supraclavicular lymph node in a patient with unexplained fever, weight loss, and night sweats. The serum LDH is up. You note these malignant B cells with prominent nuclei and basophilic cytoplasm. The nuclei are mostly round with vesicular chromatin and nucleoli apposed to the nuclear membrane.

Challenge: What is it?

*Note: The next case is related to this one.

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Typical Case

You are finishing up your family medicine rotation and feeling good about all the typical cases: allergies, URIs, UTIs, asthma, hypertension, diabetes, obesity... Confident you can handle anything, you meet the last patient of the day.

He is a hunter who says that he has nausea, vomiting, vertigo, blurry vision, drowsiness, and malaise following a trip to the Arctic Ocean where he hunted and ate the animal shown above.

Challenge: You must have learned this one in medical school. What's the obvious diagnosis here?

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Thumb's Up

A three year old child is brought in by parents with abrupt onset fever (39.5C), sore throat, dysphagia, and drooling. This has only been going on for the last 12 hours, but the child looks toxic. WBC is elevated at 25,000/mm3 with increased neutrophils and bands. The child complains that he can't breathe and feels like choking when he inspires. He is anxious, restless, irritable, and his speech is muffled but not hoarse. The child is sitting with his arms back, trunk leaning forward, neck hyperextended, and chin thrust forward. No stridor is heard. The child has not received any vaccinations.

Challenge: What is the causative agent?

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Geriatrics

An 80 year old woman living in a retirement home presents with generalized weakness. She says she can't get out of bed because she's just too tired every morning. It's been going on for several months. The onset has been gradual and she can't recall any inciting factors. At the nursing home, she has her own room and says that she goes days without talking to anyone. Her husband passed away several years ago. At that time, she had an MI. Currently, she has severe arthritis which gives her chronic uncontrolled pain. She is on high dose anti-inflammatories, a statin, a beta-blocker, an ACE-inhibitor, and alendronate.

The nursing home attendant also says that the patient has not been eating very much, been losing significant weight, and has stopped doing her daily crossword puzzle. She's been sleeping excessively and moves a lot slower than usual.

Challenge: What's on the top of your differential?

Plum

This child presented with end-stage renal disease due to bilateral dysplasia. The history is notable for multiple urinary tract infections and episodes of pyelonephritis. There was one instance of urosepsis. Pulmonary problems include recurrent bronchitis; GI symptoms include chronic constipation.

Challenge: What is the diagnosis?

10%

This is a biopsy from a patient with episodic headache, sweating, tachycardia, and hypertension.

Challenge: What's the diagnosis?

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MVA

A patient rolls into your ER in the characteristic position shown above. Unfortunately, he was a passenger in the front seat of a car which got rear-ended. A neurologic exam shows hypesthesia over the dorsum of the foot and weakness in dorsiflexion. You get an X-ray, shown below.

Challenge: What happened?

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Goop

You examine a 3 day old newborn brought in because of the eye finding shown above. The baby was born at home without any prenatal care.

Challenge: In the hospital newborns usually receive what for prophylaxis against this disease?

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Nausea and Vomiting

A 50 year old female presents to the ER complaining of severe nausea, vomiting, and headache which all started today. She also gets halos around lights in her vision and severe eye pain.

*EDIT At 8:00 PM. It sounds like this one is tricky. Upon further questioning, you learn that the halos around the lights did not precede the headache and are currently happening. Your preceptor rifles through some books and finds you a "classic" picture of this disease:


Challenge: Diagnosis?

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Another Idiopathic Disease

This week is eye week!

An obese 20 year old woman presents to your clinic with a headache. She describes it as pulsatile and awakens her at night. The pain is worse with eye movement. There is some nausea, vomiting, transient visual disturbances such as visual loss and double vision, and tinnitus. You do a neurologic exam on her and find that she cannot abduct her eyes and she has decreased visual acuity. The opthalmic exam is significant for this finding:

The rest of the neurologic exam is normal. A lumbar puncture is performed and pressure is >250 mmH2O (increased) but otherwise CSF is normal. Neuroimaging does not show a hydrocephalus; ventricles look normal.

Challenge: What does this young woman have?

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LOTR Sign

A 30 year old woman comes in complaining of knee pain after a Lord of the Rings marathon. She gets anterior knee pain after long periods of sitting. The same pain also happens when she climbs hills, runs, and walks on uneven surfaces. She sometimes complains of a noisy knee. She is not an athlete.

Challenge: This does not seem like a whole lot of information, but the most likely diagnosis can be made based on this simple history. What is it?

Safeway Sign

A middle age gentleman presents to your clinic complaining of pain in both legs when walking and standing still, relieved by sitting or lying down. On further questioning, you find that when he shops, he has to lean forward onto the shopping cart to relieve the pain. He also has discomfort, sensory loss, and weakness in both legs, but it is somewhat asymmetric and involves the entire leg. It is not in the distribution of any single nerve. There is associated mild low back pain. The neurologic exam is grossly normal.

Challenge: What's the diagnosis?

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Signs

This week is signs week!

An 80 year old man presents to your clinic. He doesn't have any complaints, but on exam you find the following:

-A widened pulse pressure
-The head bobs with each heart beat
-You can hear a "pistol shot" pulse over the femoral arteries
-When you partially compress the femoral artery, you hear a systolic and diastolic bruit
-You notice pulsations of the capillary beds in the fingertips or lips
-When you have the patient open his mouth, you notice pulsations of the uvula
-Even when you look into his eyes, you see pulsations of the retinal arteries and pupils
-You manage to feel systolic pulsations of the liver
-You manage to feel systolic pulsations of the spleen

What a crazy exam. You rule out anemia, fever, thyrotoxicosis, and AV fistula.

Challenge: The diagnosis is easy. But how many of those signs have names?