EtOH 2

A 50 year old with longstanding alcohol use presents with fever of 38.1, yellow eyes, and decreased appetite. On physical exam, you feel a large tender liver and hear a bruit over the liver. His mental status is slightly waxing and waning and he says he doesn't "clot well."

Challenge: This week's cases are pretty easy. What do you expect the AST and ALT to be?

EtOH 1

This week is alcohol week.

A 35 year old alcoholic presents with coffee ground emesis and black tarry stools. "My stomach has been killing me too," he says, "but that's probably from all the vomiting." He notes that when he started vomiting, there was no blood; he only noticed blood after a few hours of retching. He says he's just a binge drinker during the holidays.

Labs show anemia. Upper GI endoscopy shows a hiatal hernia and this:

Challenge: What's your diagnosis?

Image shown under fair use.

One Week Vacation

Hi everyone. I hope you're enjoying the cases and finding them educational. I am going to take a one week break from this blog for winter vacation. I hope you have very happy holidays, and we will be back with brand new exciting cases next week. Please let me know if you have any ideas, comments, suggestions, or feedback. Thanks! Craig

Tears

A 30 year old woman presents with a positive pregnancy test. "How could I be pregnant?" she asks. "I take my oral contraceptive regularly along with the other four drugs my other doctor told me to take." She starts sobbing and you notice red-orange tears.

Challenge: Why did she get pregnant?

I Shrunk the Kids

This is a 5 year old had a "bumpy rash" that started out on his face a week ago which then became red and finally turned into this. The lesions are painful but not itchy. There are no systemic symptoms.

Challenge: What's your diagnosis?

Image shown under Fair Use.

Immigration

A 20 year old man presents with left lower back and flank pain over the last few weeks. He's also noted fever, a limp, lack of appetite, and weight loss. He has recently immigrated from sub-Saharan Africa and has not been receiving medical care. He denies alcohol, smoking, or IV drug use.

On exam, he has severe pain with extension of the hip and limited hip movement. He prefers to be in a position with hip flexion and lumbar lordosis. Laboratory studies show WBC 12,000/mL, Hgb 10 g/L, elevated ESR and CRP. A CT is shown below:

The white arrow indicates where aspiration was done. A routine gram stain and bacterial culture were sent but they are negative. Routine bacterial cultures of the blood are negative as well.

Challenge: What's the diagnosis and what is the cause?

Image is shown under Fair Use.

Difficult

A patient presents to clinic with a skin and soft tissue infection. The provider gives empiric coverage with one agent, 300mg every six hours. The patient is reassured that this one drug will cover all usual skin and soft tissue bacteria. Unfortunately, she presents a week later complaining of severe watery diarrhea 10-15 times daily with lower abdominal cramping. She has a temperature of 38.5 and a WBC count of 16,000. Pathology would show the finding above.

Challenge: What's the diagnosis?

Image shown under fair use.

Gum

Challenge: What antiepileptic is this patient on?

Image shown under Fair Use.

Acting in Vain

A previously healthy 20 year old man presents with sore throat, tooth pain, fever, and chills. His primary care doctor diagnoses him with pharyngitis, gives him some acetaminophen, and sends him home. Five days later, he is brought into the emergency department by ambulance with mental status changes and respiratory distress. His temperature is 40 degrees C, his blood pressure is 105/60, his pulse is 115, and his respiratory rate is 26. He is in acute distress with severe prostration, use of accessory muscles, and active rigors. His oropharynx shows an exudative tonsillitis. He has mild tenderness, swelling, and induration over the angle of his jaw and along the sternoclaidomastoid muscle. After he is stabilized, a CT scan of the chest shows multiple septic pulmonary emboli. A higher slice in the neck shows this:

The patient is started on broad spectrum antibiotics and admitted to the ICU. However, he still remains septic with positive blood cultures. He develops pulmonary infiltrates that evolve into abscesses and empyema. He then gets septic arthritis and osteomyelitis. Cultures grow out an oropharyngeal anaerobe Fusobacterium.

Challenge: What's your diagnosis?

Image shown under Fair Use.

This Week

This week I will be out of town for residency interviews in anesthesiology. Cases will be posted on time, but solutions may not be. I will try not to get too behind. I hope you're enjoying the cases. If you have any ideas or suggestions, please let me know. -Craig

Lunar

A 12 year old girl is brought in by her mother because she has been complaining about cyclic pelvic pain which occurs with every full moon. "She's been reading too much Twilight," the mother says. The girl denies any kind of abuse. She has not started menstruating yet. Abdominal exam shows mild suprapubic tenderness. External vaginal exam shows a vascular, bluish bulge protruding from the vaginal introitus while the patient is supine. Pelvic ultrasound is shown above; the white arrow indicates the vagina and the black arrow indicates the uterus.

Challenge: What's the diagnosis?

Image shown under Fair Use.

Earthquake Magnitudes

A 75 year old man with diabetes, coronary artery disease, dyslipidemia, COPD, diverticulosis, untreated chronic lymphocytic leukemia diagnosed 3 years ago, and a history of CVA 5 years ago presents with new onset of fever, night sweats, and weight loss. Examination shows abdominal lymphadenopathy, and splenomegaly. Labs show an increased lactate dehydrogenase, anemia (Hgb 10.5 g/dL), and thrombocytopenia (plts 80,000/mcL). Biopsy of a lymph node is shown below:

Challenge: This finding was described in 1928. What new diagnosis does he now have?

Image is shown under GNU Free Documentation License.

Baby Got Back

On a single clinic afternoon, you get four patients with low back pain.

Challenge 1: A 45 year old has sharp or burning pain radiating down the lateral or posterior aspect of the leg to the ankle. There's a little bit of numbness and tingling. What's the diagnosis?

Challenge 2: A 70 year old man presents with urinary retention with overflow incontinence, bilateral shooting pain down the back of his legs, and leg weakness. You note perianal anesthesia. What's the diagnosis?

Challenge 3: A 16 year old IV drug user presents with low back pain after a day of heavy lifting. He has no other symptoms and no other medical problems. Do you image his back?

Challenge 4: A 30 year old woman who is a smoker presents with low back pain after sleeping funny for a week. She has no other symptoms and no other medical problems. Do you image her back?

Elemental

A 35 year old woman with rheumatoid arthritis, asthma, bipolar disease, gastroesophageal reflux disease, cholelithiasis, and polycystic ovarian syndrome presents with tremors and twitching. She says that she might have mixed up her meds last week at which time she started having an irregular coarse tremor, motor agitation, weakness, ataxia, and sluggishness. She doesn't remember what meds she's normally on. Review of systems is notable for nausea, vomiting, and diarrhea. Exam shows sinus bradycardia and hypotension. Labs show a leukocytosis.

Challenge: What happened here?

Image is in the public domain.

Inborn Error of Metabolism

Ah yes, everyone's favorite lecture, the inborn errors of metabolism. You meet a 5 year old with mental retardation who was just diagnosed with ectopia lentis (dislocated lens), which occurs in 90% of these patients; 60% have a inferior or nasal subluxation. There is a family history of this disease which seems to skip generations. The patient is at risk for osteoporosis and thromboembolism. Physical exam shows tall stature.

Challenge: What's the diagnosis?

Image is in the public domain.

Light at the End

A 45 year old secretary presents with pain and tingling of the thumb, index, middle, and ring fingers. She's noted difficulty writing, pinching, and holding small utensils. She's been under a lot of stress lately at the law firm. Physical exam shows mild flattening of the thenar eminence. The two following tests recreate symptoms:

Challenge: What's the diagnosis and what are the tests shown above?

Both images shown under Fair Use.

Period

A 30 year old G4P1 woman is concerned that her periods have changed in quality. They used to be regular at 29 days, heavy, lasting 5 days, but since the last few months, she's had minimal to no periods. She doesn't have any vaginal pain or discharge. Her gynecologic history is as follows: at age 18, she had an elective first trimester medical abortion; at age 22, she had a daughter at full term without complications; at age 26, she had a spontaneous first trimester abortion; and several months ago, she had to surgically terminate a second trimester pregnancy due to fetal demise. She has no significant past medical history and takes no medications. She is married but has multiple sexual partners; she does not use protection. She denies domestic violence. She smokes a pack per day. Family history is noncontributory.

A urine pregnancy test is negative. A hysterosalpingogram is shown below.

Challenge: What's the diagnosis?

Image is shown under GNU Free Documentation License.

Three Muskateers

Challenge: Click on the image to enlarge. This EKG has voltage criteria for LVH, non-specific inferior and lateral ST-T changes, and one peculiar finding on the intervals that identifies this as a 3-name syndrome...what is it?

Image shown under fair use.

Electrode

A 25 year old woman is brought in by her roommate because she's "acting weirdly." But the patient denies this. "I feel better than ever," she says. "I'm invincible, I'm awesome, I only need four hours of sleep each night, and that's not even counting the sex, and even though I'm not getting to my job on time, I have all these projects I'm working on, and I have to go shopping, and sure, my friends can't stand me, but they couldn't before anyway when I was all moody and mopey and dopey and down, but that's okay, now I'm happy just going to the gym and working out for 3 hours a day, and besides, this has happened to me once before, a couple years ago, when all of a sudden I decided to quit school and go on a road trip and see the world, and all my friends thought I was tripping, ha, isn't that a good pun? but really I've never taken any drugs or seen a doctor, I'm healthy like that, and ooh, that's shiny." She points at a plaque you won for diagnostic acumen.

Challenge: Making the right diagnosis is important because the rate of suicide attempts is 25-50% (15% die of suicide) in this condition...what is it?

Dinner 3

Despite the last two cases, you're still eating fish for dinner. This time, on a trip to Japan, you try a local delicacy. Within minutes of eating the dish above, you note weakness, dizziness, paresthesias of the face and extremities, and nausea. Since you always carry around a trusty reflex hammer, you test your reflexes and find they're absent. The fear with this disease is paralysis and hypotension. The toxin is shown below. Cool ring structure!
Challenge: What's your diagnosis?

First image shown under Creative Commons Attribution License. Second image is in the public domain.

Dinner 2

You visit the Polynesian islands, enjoying the tropics and subtropics. You catch the fish above and cook it for dinner. Three to six hours after eating the fish, you start having vomiting, diarrhea, and abdominal cramps. Three to 72 hours later, you feel paresthesias, painful teeth, painful urination, blurred vision, nerve palsies, and hot/cold temperature reversal. You take your pulse, 50, and your blood pressure, 105/60. The neurologic symptoms last for days to weeks. Your vacation, unfortunately, is ruined. The toxin is shown below:
Challenge: What's your diagnosis?

Both images are in the public domain.

Dinner 1

How well do you know your toxins? This week involves toxins of a specific kind.

An hour after eating the dinner shown above, you feel flushing, warmth, and palpitations. You note an erythematous rash on the upper torso and face. You take your pulse and it is 115. Within 12 hours, the symptoms have resolved. The culprit is shown below:
Challenge: What is your diagnosis?

First image shown under GNU Free Documentation License. Second image is in the public domain.

Into the Fire

Please see the last two posts for the first two parts of the case. The patient has respiratory distress and needs to be intubated. Here is your routine CXR after intubation.

(Obviously this is a different patient, but the pathology should be obvious.)

Challenge: Despite FiO2 of 100%, the patient's oxygen saturation hovers just below 90%. Why?

Image shown under fair use.

Out of the Frying Pan

The is the second part of a three part CXR case. Please see the previous case for the first radiograph. You initiate treatment for the patient and get a follow-up X-ray. Here's what you see.

Challenge: Explain.

Image shown under fair use.

Dextrocardia

This is the first part of a three part case for CXR week.

Challenge: In the wording of the USMLE Step 2 exam, what is your first step in management?

Image is shown under Creative Commons Attribution ShareAlike 2.5 License.

Unfaithful Mortals

A newborn with Hirschsprung's disease in the neonatal intensive care unit presents with respiratory failure. ABGs show a mildly elevated PaCO2 during wakefulness and markedly elevated PaCO2 during non-REM sleep. He seems to forget to breathe when sleeping. You test him with inhalation of CO2 and he has no respiratory discomfort.

Challenge: What's your diagnosis?

Image is in the public domain.

Ostreidae

This oyster-catcher with alcoholic cirrhosis in the Chesapeake Bay presents during the summer with the wound infections shown above. The wounds look pretty bad, so you keep him in the ED for a few hours. Over that time period, he becomes hypotensive, tachycardic, and obtunded; you admit him to the ICU for sepsis. Blood cultures grow out the bacteria shown in panel C.

Challenge: What's the bug?

Image is in the public domain.

Elaine Benes

You do an away rotation in obstetrics in Turkey and saw several cases of the disease shown above, which is rarely seen in the United States. 60-75% of these newborns are deaf, 10-20% have cardiac malformations, and 10-25% have CNS defects.

Challenge: What is it and why does it not exist in the United States?

Both images are in the public domain.

JNC-7

I have a tendency to hunt down rare and fun and bizarre diseases, but we shouldn't neglect common solid family medicine diagnoses as well.

Challenges: According to JNC-7 guidelines,
1. What would you use to treat the otherwise-healthy African American gentleman with the BP reading above?
2. If instead, the same patient has chronic kidney disease and a BP reading of 165/102, what would you use?
3. You recommend dietary sodium restriction (100mEq/L). What kind of BP response can you tell the patient to expect? Choices: No effect on SBP, 5mmHg reduction, 10mmHg reduction, 15mmHg reduction, 20mmHg reduction.

Image shown under Creative Commons Attribution 3.0.

To Quench

You are on an away rotation in India. A father brings his child, shown above, to clinic. The child has been severely constipated. On exam, his height and weight are severely diminished, he is bradycardic, hypotensive, and hypothermic. He has thin, dry skin with redundant skin folds and hair loss. When you treat this condition, the child becomes ravenously hungry.

Challenge: Specifically, what is the disease called?

Image is in the public domain.

Galleon

This blood smear is from a 20 year old man complaining about acute onset severe chest pain with nausea and vomiting. He is febrile, tachypneic, and hypertensive.

Challenge: Here's a multi-step classic boards question for you - if this man had instead presented with osteomyelitis, what organism would you suspect?

Image is shown under fair use.

Oncology Consult

This gadolinium CT of a 30 year old patient shows a well-circumscribed capillary-rich benign neoplasm. Unfortunately, he is at risk for developing multiple such tumors, usually infratentorial. His past medical history is notable for retinal detachment due to "bleeding from a tumor" several years ago. He is also being seen by ENT doctors for some sort of problem with his temporal bone which has caused hearing loss and tinnitus. Family history is notable for father dying of clear cell renal cell carcinoma at age 60. The grandfather also had the same cancer as well as pancreatic cysts.

When you present this patient to the attending, he asks you whether the patient has episodic headache, sweating, tachycardia, and hypertension.

Challenge: What's going on here?

Image shown under Fair Use.

Hematology Consult

As a hematologist, you are asked to see a 25 year old female with easy bruising and heavy periods. She says she's always been an easy bleeder with nosebleeds lasting 30 minutes and severe bleeding after wisdom tooth extraction. After she delivered her last child, she had heavy bleeding during the peripartum period and then 7 days after delivery. Her ob/gyn referred her to you. She denies any soft tissue or joint swelling. She denies using any NSAIDs or aspirin. Physical examination is normal. The pattern of inheritance is shown above. Her CBC including platelets is normal.

Challenge: What's the diagnosis?

Image is in the public domain.

Genetics Consult

This week's theme is "von." Whatever that means.
You are on the genetics consult service (you're at a tertiary care hospital) and are asked to see a 6 month old infant with seizure. Physical exam shows a protruding abdomen and hepatomegaly. Laboratory tests show hypoglycemia, hyperlipidemia, and a lactic acidosis. The infant was born to a healthy G1P0 30 year old mother but since birth has had poor growth. The pattern of inheritance is shown above.

Challenge: Given that this is "von" week, what's the diagnosis?

Image is shown under GNU Free Documentation License.

Smear

A 70 year old Caucasian man presents for a routine yearly physical. He's been doing well, without problems, happy that he lost 15 lbs. without even trying over the last few months. Sure, he has a bit of fever and night sweats, but who doesn't? "At least it's not as bad as menopause," he says. He has a little fatigue, but it's just part of getting older, he thinks.

Exam shows cervical lymphadenopathy; you feel firm, round, discrete, mobile nodes. You might feel a spleen and a liver edge too. Routine CBC shows a leukocytosis, mild anemia, and mild thrombocytopenia. Here's the blood smear:

Challenge: What's your diagnosis?

First image shown under GNU Free Documentation License; second image shown under fair use.

Fishy

A 30 year old African American woman presents complaining of vaginal discharge. It is unpleasant but not painful. It is fishy-smelling and occurs after sex. She has multiple sex partners, but denies being at risk for STDs or HIV. She is a smoker. On exam, you note thin off-white homogenous discharge. Vaginal pH is 5. The wet mount is shown below.

Challenge: What do you prescribe?

Image shown under Fair Use.

Named by a Flemish Anatomist

This case was requested by my friend Kate. I hadn't heard of the diagnosis until she mentioned it; about 1000 cases have been reported in the medical literature.
This patient noticed a swelling in the mid-lower abdomen. Although it was painful, he could "push it in" when he's lying on his back. Within the last day, though, it's become much more painful; he's vomited and hasn't had a bowel movement. On exam you note that the mass is covered by an intact external oblique aponeurosis. It is lateral and inferior to its defect in the space posterior to the external oblique muscle.

Challenge: Specifically, what's your diagnosis?

Image shown under Fair Use.

Saturn

An 18 year old woman presents with a very weird chief complaint: drooling. She's also has inappropriate uncontrollable grinning and slurring of speech. She is brought in by her college roommate who is very concerned. "Even though she's smiling, I think she's depressed," the roommate says. "She never wants to do anything, seems to have no motivation, and sometimes, thinks people are after her. Is she paranoid? Her personality's changed. And I think her grades are a lot worse." On exam, you note a tremor, rigidity, and a clumsy gait.

Challenge: What's your diagnosis?

Image shown under Creative Commons Attribution 2.0 License.

Popeye

This older gentleman was working out when he noted a "pop" and pain in his shoulder. He's been having moderate anterior shoulder pain with radiation over the anterior upper arm. He noted bruising and swelling after the incident. The pain is worse with lifting, pulling, and doing overhead arm motions.

Challenge: Assessment?

Image shown under fair use.

Cath Lab?

You're taking home call as the cardiology fellow when your sleep is interrupted by beeping of your fax machine. You get the EKG shown above; darn the quality of those faxed copies! The resident calls with the story: a fifty year old gentleman with hypertension, diabetes, dyslipidemia, and gout presents with several minutes of substernal crushing chest pain radiating to the jaw and left arm. This pain is accompanied by dyspnea, nausea, and diaphoresis. Troponins are negative. The EKG is shown above. Apparently, this man had a perfectly normal EKG one year ago.

Challenge: Do you drive into the hospital to cath this guy? If no, why not? If yes, where is the lesion?

Image is shown under Creative Commons Attribution-ShareAlike 3.0 License.

Zebra

The newborn shown above is being treated for a rare genetic disorder. He was the product of a normal spontaneous vaginal delivery at 38 weeks to a 30 year old G1P1 mother with no medical problems. He presented at 2 days of life with jaundice. Blood tests showed a total bilirubin of 25mg/dL (direct bilirubin of 0.1). Liver function tests were all within normal limits. Coombs test is negative. Stool color is normal. In social/family history, you learn that there's consanguinity in the parents.

Challenge: Prior to the treatment shown above, nearly all infants with this disease died of kernicterus. What is the disease?

Image shown under fair use.

Horse

A G1P0 woman at 10 weeks gestation presents with right lower quadrant abdominal pain. She also has some nausea and vomiting, worse than her normal "morning sickness." She's lost her appetite, complains of general malaise, and has fevers and chills. On exam, palpation of the left lower quadrant causes pain in the right lower quadrant. Her WBC count is 15,000. You order an MR, and a T2 weighted image is shown below. The pathology is noted by the arrow. GS refers to the gestational sac.

Challenge: What's your diagnosis?

Image shown under fair use.

Dentistry

A 40 year old dentist presents with the skin lesion shown above, pain, and low grade fever. To make the diagnosis, you remove the blister roof with a no. 15 blade, blot excess fluid, then scrape the base with a scalpel blade. You spread the material on a slide, add 95% methanol for 5 seconds, air dry for 1-2 minutes, then add a nuclear stain for 30-60 seconds. Finally, you wash with distilled water and restain with methanol. Here is what you see:

Challenge: What's the diagnosis?

Related Questions:
1. What stain was that?

Both images shown under fair use.

Full Moon on the Quad

A week after "Full Moon on the Quad" a Stanford freshman develops malaise, headache, low grade fever, sore throat, and "swollen glands." He then takes "an antibiotic" that his roommate has and breaks out with this rash:

Challenge: What's the initial disease? What antibiotic did he take?

Image shown under fair use.

Follower of Artemis

This is a T2 weighted MR image of a patient with bilateral loss of pain and temperature sensation in his hands and fingers. His upper arms have preserved pain and temperature sensation. He has no deficits in light touch, vibration, or proprioception. Good thing you tested all the sensory modalities!

Challenge: What's your diagnosis?

Image is in the public domain.

Blender

This is an incidental finding in a patient with a ball-cage prosthetic valve for a remote history of refractory endocarditis.

Challenge: Why this finding?

Related Questions:
1. What do you see on the smear?

Image shown under fair use.

Dinosaur

A 25 year old man presents to your clinic with low back pain that improves with exercise but not rest. It had an insidious onset and occurs at night. He also has buttock, hip, shoulder, TMJ, and posterior thigh pain. He had an episode of anterior uveitis a month ago. Review of systems is notable for fatigue.

Physical exam is remarkable in that the patient is stooped; you note loss of normal lumbar lordosis, increased flexion of the neck, and increased thoracic kyphosis.

Challenge: What's your diagnosis?

Image is in the public domain.

Carinii

A 20 year old man is brought in by police with agitation and combativeness. On exam, he is tachycardic, hypertensive, and hyperthermic. In general, he is a diaphoretic, flushed man. Neuro exam shows vertical nystagmus even while the patient is awake as well as hyperreflexia. HEENT exam shows miosis and hypersalivation. Psych exam reveals he has acute new-onset schizophrenia, psychosis, audio-visual hallucinations, and paranoid delusions.

Challenge: You avoid the complication of rhabdomyolysis because you recognize this diagnosis as...what?

Image is shown under GNU Free Documentation License.

Happy Labor Day

This case is based on a "pearl" article in UpToDate.

A 25 year old previously healthy G1P0 at 30 weeks gestational age presents with uterine contractions. She was admitted to the hospital and started on terbutaline, a beta-2 agonist, for premature labor. The contractions stopped for 12 hours, but resumed 12 hours later, and she had a normal spontaneous vaginal delivery. The following day, the patient develops cough, dyspnea, and pink frothy sputum. She is transfered to the intensive care unit for mechanical ventilation. Her exam showed tachypnea, sinus tachycardia, no JVD, no murmurs, rubs, or gallops, and diffuse crackles. ABG is 7.50/ 30/60 on 40% FiO2. CXR is shown below.

Challenge: What is the diagnosis and the cause?

Image shown under Creative Commons Attribution-Share-Alike 3.0