Advanced Maternal Age

This is related to a case suggestion I got from "CodeDog." Thanks!
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A 40 year old woman 12 weeks postpartum presents with irregular vaginal bleeding. Physical examination shows an enlarged uterus. A beta-hCG level is elevated. Imaging shows bilateral ovarian cysts as well as hypervascular heterogeneous mass in the uterus with areas of necrosis and hemorrhage.

Challenge: This is a tough one, what's your impression?

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Notes

A husband brings in his wife at postpartum day 5 because the wife has had wild mood swings from elation to tearfulness for the last 2 days. She has a distant history of depression but did not take medications for it. You advise conservative treatment and when you see the patient a week later, her symptoms have resolved.

Challenge: Diagnosis?

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VBAC

This week is ob/gyn week!

A 30 year old G3P2 who had two prior low vertical C-sections is at 39 weeks, 3 days by LMP and attempting a vaginal birth after cesarian. She was in latent labor for over 48 hours and elected for pitocin induction. She dilated to 10cm, was completely effaced, and began pushing. About 30 minutes into pushing, the fetal heart tracing showed variable and late decelerations along with fetal bradycardia. Despite epidural anesthesia, the patient complains of severe abdominal pain. She becomes tachycardic and hypotensive. The tocometer stops picking up uterine contractions. An immediate cervical exam is unable to identify the fetal station. The diagnosis is made at laparotomy which shows this:

Challenge: What do you see?

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Cutis

This 65 year old male presents with the dramatic skin changes shown above. He has new onset fatigue, weakness, gingival bleeding, and ecchymoses. Recently, he's had multiple infections as well. Fundoscopic examination reveals hemorrhages and exudates.

Challenge: What procedure do you need to do for definitive diagnosis?

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Avian

This is a classic picture of a barium study in a patient presenting with trouble swallowing solids and liquids and difficulty belching.

Challenge: The diagnosis is easy. What is it? What does the word mean in Greek?

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Iatrogenesis

You're doing a medicine rotation when you get consulted by trauma surgery. The patient is a diabetic with known heart failure who got into a motor vehicle accident one day ago. Several serial CT scans yesterday afternoon ruled out any surgical emergency and he was admitted for observation. He was not hypotensive or in shock. This morning, his creatinine reaches 4mg/dL. You call his primary medical doctor and find that his baseline creatinine is 2mg/dL. He has not gotten any new medications.

Challenge: What's the most likely diagnosis?

Dental

This physical finding was first noticed when a patient was 10. He had early complaints of frequently sprained ankles and difficulty running and keeping up with peers. He was always clumsy when walking but is still able to ambulate. Recently, he's noticed atrophy of the hand muscles too. There is a family history of this disease following an autosomal dominant pattern. The life expectancy of affected individuals is normal. On exam, you note loss of proprioception and vibration in the lower extremities.

Challenge: What is your diagnosis? (Why is this case called "Dental"?)

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Embryo

This is an easy case, but I wanted to share the beautiful picture above, and the diagnosis is a crucial one to make.

A 20 year old woman presents with abdominal pain, breast tenderness, frequent urination, nausea, and shoulder pain. Her LMP was 8 weeks ago, but she's noted some vaginal bleeding. She has a history of pelvic inflammatory disease. Her sexual debut was at age 16. She has no surgical history.

Challenge: A pathologic image of this disease is shown above. What is it?

Image is in the public domain.

Are You Hep to the Jive?

A patient comes in with abrupt onset fatigue, malaise, nausea, vomiting, anorexia, and abdominal pain several days ago. Today, he noticed dark urine, light stool, and pruritis. Social history is notable for travel to one of the red countries on the map below about 30 days ago. He denies drinking, smoking, drugs, and risky sexual activity. On exam, you find mild jaundice and a RUQ abdominal mass.

Challenge: Knowing the epidemiology of this disease, what's your diagnosis?

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On Call

At around 3 in the morning, you get called by the nurse with a question about a trauma patient. You're covering for that service and groggily, you flip through the list of patients. It is a middle age man status post motorcycle accident 2 days ago with bilateral femoral fractures. The nurse says the patient has dyspnea, tachypnea, and hypoxemia. He has also been confused and has a new rash on the head, neck, and anterior thorax. His platelets are fine.

Challenge: You stumble into the elevator and on your way up, you make the diagnosis. What is it?

Note: I tried really hard to find a picture of the rash, but simply could not get one. Sorry!

Merit

This lesion was at birth in this young child. Laboratory tests show a severe thrombocytopenia, hypofibrinogenemia, elevated fibrin degradation products, and a hemolytic anemia.

Challenge: What's the diagnosis?

Image is licensed under Creative Commons Attributions 2.0 License.

I'm Not Pregnant

A thin 16 year old female cross country runner presents to student health because she hasn't had a menstrual period in several months. She had menarche at around 14, but her periods have been irregular. She fervently denies any possibility of being pregnant; she is not sexually active. She has no significant past medical history. On review of systems, she notes feeling cold and dizzy at times. She drinks a great deal of caffeine but eats very little. She is 163 cm (64 inches) tall and weighs 43 kg.

Challenge: Two legs of a triad have been described here. What's the third?

Par 3

All of the three following cases have the same gram stain above. Note that the organisms are curved.

Challenge 1: A 40 year old man presents with burning epigastric pain worst 2-5 hours after food and also at night. What's the organism?

Challenge 2: A 40 year old man presents with cramping periumbilical abdominal pain and profuse diarrhea and frank blood seen in the stool. He also has nausea and fever. The diarrhea is self-limiting, lasting about a week. What's the organism?

Challenge 3: A 40 year old traveler to Africa develops massive watery diarrhea, described as watery with flecks of mucus. There is a mild "fishy" odor. He also experiences watery vomiting, abdominal cramping but no pain, and no fever. What's the organism?

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