Sudo I

My classmate Alex P. suggested that I do a week of "pseudo" cases. Here we go!

A 65 year old man presents to your office complaining of severe pain and swelling in his left knee. He's had these symptoms 2-3 times in the past but they resolved without medical attention. On exam, you notice a red, hot, swollen left knee. Here's a radiograph:

You tap the knee. The synovial fluid has 20,000 leukocytes, 90% neutrophils. You examine it under compensated polarized microscopy:

Challenge: What do you think?

First image shown under GNU Free Documentation License; second image shown under Fair Use.

Black Box

A 50 year old woman with a history of GERD and gastroparesis medicated with the drug shown above for the last few years presents to your practice. She has new onset involuntary repetitive movements of limbs, lip smacking, tongue protrusion, eye movements, blinking, puckering of lips, and impaired movement of hands.

Challenge: The FDA just issued a statement related to this. What's the diagnosis and what's the cause?

Image is in the public domain.

Kodak

Challenge: This 2 year old has an increased risk of osteogenic sarcoma; what does he or she have?

Image is in the public domain.

Case of the Mondays

A century ago, a factory worker related to the above patent might have presented to you complaining of severe headache, dizziness, and flushing every Monday. The symptoms would get better the next few days until they disappeared for the rest of the week. The following Monday, he would go through the same cycle.

Today, you might prescribe a patient the same drug as treatment or prophylaxis for acute onset chest pain.

Challenge: What drug or chemical does this refer to?

Image is in the public domain.

Inversa

A 25 year old man with obesity presents with the skin finding above. He notes the lesions in his axillae, inguinal area, inner thighs, and perianal and perineal skin. He said it started at puberty with solitary, painful nodules lasting several weeks or months. He was diagnosed with "boils" and "furunculosis" at the time. Since then, he's always had a few active lesions; they are intensely painful; he can barely walk or sit without pain. A few of these skin lesions have become infected over the years, developed into abscesses, and ruptured externally, draining pus. That relieves the pain. Healing of these lesions has lead to dense fibrotic bands and indurated thick-scarred plaques.

Challenge: This disease is actually more common in women (3:1) but this was the best picture I found. What's the diagnosis?

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1 in a 1000

A 24 year old man presents to the health care system for the first time. He is feeling generally well and wanted to have a physical exam before his health insurance ran out. He has no past medical history, takes no medications, and has no allergies. His family history is notable only for breast cancer in his mother at age 40. He does not drink alcohol, smoke, or use drugs. He works at a local restaurant but may lose his job. He was told by his boss that he's socially awkward, has poor judgment, and doesn't learn from adverse experiences. As you talk to him, you note he has trouble sustaining attention. For the physical exam, you have him completely undress (shown below). You note that he has small, firm testes.

Challenge: You send genetic testing to confirm what disease?

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Surgeon Shopping

A 30 year old man makes an appointment in your surgery clinic asking you to fix his nose. He's seen five surgeons already including plastic surgeons, dermatologists, and ENTs, but they refuse to operate on him. He feels that his nose makes him look ugly, and that no one takes him seriously because of it. It's been this way for his entire life, and it's made him depressed and anxious. He can't stop thinking about it; at night, he can't sleep because of it. He says he has no past medical history, but he's been hospitalized several times for suicidal ideation. He takes fluoxetine and alprazolam. He lives alone and says that he cannot go outside in public because people keep looking at him and his nose. He's currently unemployed and gets money from his parents. They don't like his nose either. It's shown above.

What's your diagnosis?

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Malignancy

You are about 15 minutes into a routine laparoscopic cholecystectomy for symptomatic cholelithiasis in a 45 year old woman when you hear the beeping of the heart monitor speed up. You are still dissecting out Calot's triangle and have not yet cut or clipped any ducts or arteries. As far as you can tell, hemostasis is fine. The anesthesiologist says, "We have a problem. She has masseter stiffness, sinus tachycardia, skin cyanosis with mottling, and fever."

Challenge: Without the right therapy, the patient is at risk for hypotension, dysrhythmias, rhabdomyolysis, electrolyte abnormalities, DIC, acidosis, and cardiac arrest. The anesthesiologist should be grabbing what drug?

Image is in the public domain.

Quincke II

This is a continuation of the previous case.

Your patient's clinical condition remains stable and her signs and symptoms begin improving but about 20 hours after presentation, she begins to complain of an occipital headache, nausea, and dizziness. You are on your neurology rotation and asked to consult. She has a history of migraine headaches but this feels different. There is no aura, photophobia, or phonophobia. Instead, she says the headache is worse when she sits up.

Challenge: As a consultant, what is your diagnosis? What is your treatment?

Image shown under GNU Free Documentation License.

Quincke I

This is the first part of a two part case.

A 22 year old college student presents to the emergency department with a temperature of 39 C, photophobia, and confusion. This began about 12 hours ago. She tried acetaminophen with minimal relief. She complains of a severe, generalized headache. Although she has had migraines in the past, this is much worse. She takes an oral contraceptive, smokes and drinks occasionally, and uses marijuana (last use last night). When you flex her neck, you note that her hips spontaneously flex. When her hips are flexed 90 degrees, she cannot fully extend her knees. Here's a diagram of those maneuvers:

She has no papilledema and no focal neurologic deficits.

Challenge: What's your next diagnostic test? Will you give empiric treatment?

Related Questions:
1. What's the leading diagnosis?
2. What is shown in the diagrams above?

Both images are in the public domain.

Cyst III

Challenge: Here is the pathology of an unfortunate patient who died at age 40 from a subarachnoid hemorrhage. There was a family history of such sudden deaths. What's the diagnosis?

Image is in the public domain.

Cyst II

A forty year old woman presents with pelvic pain, dysmenorrhea, and dyspareunia. The ultrasound shows a characteristic adnexal mass:

Here is what is seen on surgery:

If the cyst were broken, you would find a thick brown tar-like fluid. This is not a hemorrhagic corpus luteum cyst.

Challenge: What kind of cyst is that?

Both images shown under fair use.

Cyst I

This is cyst week! If such a thing can exist.

A 50 year old man who spent 4 weeks in rural India, returning about 12 weeks ago presents with one week of acute onset fever (39.0 C) and RUQ abdominal pain. His only other medical condition is severe COPD requiring chronic steroid use. On review of systems, he denies diarrhea. On exam, you do not note jaundice but there is hepatomegaly and point tenderness over the liver. Labs show a leukocytosis without eosinophilia, elevated alkaline phosphatase, and elevated hepatic transaminases.

Here is a CXR:Given those findings, you order an abdominal CT. Here's one slice:

The microbiologist says, "Aha!" He pulls out the textbook you used for first and second year of medical school and shows you this image:

That's the cyst!

Challenge: Now, if you were going to do a needle aspiration of this lesion, there is a "classic description" of the color and quality of the aspirate. What is it?

First two images shown under Fair Use. Third image is in the public domain.