Sick 3

You are the pediatrics night float - that is, the resident covering all the patients for the other teams - and you get called because the day team forgot to read an EKG. It's shown above.

Glancing at it, you get worried. You read the short sign-out on the patient: 7 year old, cycle 2. What kind of sign out is that? They didn't even put in a diagnosis. Ouch. You go see the patient.


Wow. Okay. You glance through the chart and the only legible note says the following:
Cycle 2
Ifosfamide: 800 mg/m2 over one hour IV per day on days 1 through 5
Mesna: 200 mg/m2 IV per day on days 1 through 5 at 0, 4, and 8 hours after ifosfamide
Methotrexate: 150 mg/m2 IV over 30 minutes on day 1, then 1.35 g/m2 IV over the next 23.5 hours, for a total dose of 1.5 g/m2
Leucovorin: 50 mg/m2 IV 36 hours after initiation of methotrexate, then 15 mg/m2 every 6 hours until serum methotrexate concentration <0.05 micromolar
Vincristine: 2 mg IV push on day 1
Cytarabine: 150 mg/m2 per day by continuous IV infusion on days 4 and 5
Etoposide: 80 mg/m2 per day IV over one hour on days 4 and 5
Dexamethasone: 10 mg/m2 PO per day on days 1 through 5

The nurse notes the child has been having nausea, vomiting, diarrhea, anorexia, lethargy, and muscle cramping.

Challenge: You're the unfortunate person on call. What's your preliminary diagnosis?

Related Questions:
1. What does the EKG show?
2. What is your treatment for the EKG abnormality?
3. Given your limited history, what do you think the child's primary problem is?

First image is in the public domain; second and third images shown under Creative Commons Attribution ShareAlike 2.5.

Sick 2

You're making midnight rounds on your surgical ICU patients when you notice one of your patients has a tense abdomen. This is a young guy who was involved in a motor vehicle accident several days ago. He underwent emergent abdominal surgery for splenic laceration, liver laceration, and bowel injury. He was persistently hypotensive but responded with aggressive fluid resuscitation.

Now you note progressive oliguria, increased ventilator requirements (for hypoxia and hypercarbia), hypotension, tachycardia, an elevated JVP, and peripheral edema. You clamp the Foley, instill 25cc sterile saline into the bladder via the aspiration port, and attach an 18-gauge needle with a pressure transducer into the aspiration port. It reads 30mmHg.

Challenge: What's your diagnosis?

Image is in the public domain.

Sick I

No more of that outpatient nonsense; this week, we have three sick patients.

A 60 year old man with a history of treatment refractory multiple myeloma just received an allogeneic bone marrow transplant from an HLA matched donor 3 weeks ago. Prior to bone marrow transplant, he received high dose cyclophosphamide and total body radiation. Post-transplant, the patient is on cyclosporine and prednisone. Since you know the literature, you know this is not the ideal approach to multiple myeloma; there is a 20% early mortality and 30-50% overall mortality; UpToDate does not recommend myeloablative transplants for myeloma outside a clinical trial setting.

Alas, the harm has been done. The transplant team is calling you to admit the patient to the intensive care unit. The patient has been febrile to 41 C for two days. He complained of chest pain and dyspnea. He had one episode of hemoptysis. He was cultured and started on broad spectrum antibiotics and amphotericin B. The antibiotics have not helped. Here is the CXR:

Lower extremity Dopplers are negative for DVT. Here is a slice of the CT chest with the "arrow sign."


Challenge: The cultures are cooking. The transplant team wants to know if you have a diagnosis, and more importantly - a proposed treatment.

Both images shown under fair use.

Dots

The picture above is a warm-up. The challenge is below:

Challenge:
Which images scare you?
[ ] First image
[ ] Second image top left
[ ] Second image top center
[ ] Second image top right
[ ] Second image bottom left
[ ] Second image bottom center
[ ] Second image bottom right

First image is in the public domain, second image shown under fair use.

Billie Jean

Here's my Michael Jackson tribute (don't worry, it's not propofol toxicity). This disease peaks in the 20s-30s affecting the extremities and face around the mouth, eyes, and nose. It also appears in skin areas at places of trauma like shoulder straps, waistbands, and collar areas. The lesion is not raised.

Challenge: What's your diagnosis?

Image shown under GNU Free Documentation License.

Nails

Since I was on dermatology last week, this will be skin week.

A patient presents to your clinic complaining of morning stiffness of the hands lasting over half an hour. His joints also hurt, but the stiffness and pain improve with use. On physical exam, you note some joint line tenderness and effusions, mostly involving the distal interphalangeal joints. The image is shown above. He has some pitting edema of the extremities. He was also treated last week for uveitis. Note the nail involvement; below is a textbook example of mild (left) to severe (right) nail findings.

Challenge: What's your diagnosis?

First image is in the public domain. Second image is shown under fair use.

Hitman

A bedbound nursing home patient is recovering several days after a orthopedic hip surgery. Routine serial CBC's show a declining platelet count about 10 days after the surgery. The nadir is about 60,000 platelets/microliter. There is no evidence of bleeding.

Challenge: The "hitman" is shown above. What is it?

Image is in the public domain.

Oink Oink

A college student at UCSD after partying too hard over spring break presents to student health with a few days of fever, chills, vomiting, diarrhea, cough, sore throat, rhinorrhea, nasal congestion, malaise, and headache. Ridiculous! He does have a test coming up but he insists that he's really sick. His past medical history includes poorly controlled asthma which required one emergency department visit in the last year and obesity. His temperature is 38.3C=101F. One of your hobbies happens to be electron microscopy; here's what you find:

Challenge: Most likely diagnosis?

Image is in the public domain.

Decidua

A 30 year old G1P0 woman with hypertension at 28 weeks gestational age presents to the emergency department with vaginal bleeding. She also has acute onset back and abdominal pain and uterine contractions. The uterus feels pretty rigid and tender. The mother admits she smokes and just used cocaine. Here is an ultrasound; unfortunately, one of the labels got smudged:

Challenge: What's the diagnosis?

Image shown under fair use.

Bamboo

Here's a picture you put up in your pediatrics office for the kids. Isn't the 7-month old panda cub cute? Note: This is a tough case, initially planned to be two parts, but it's Friday!

An 8 year old girl presents to your pediatrics clinic complaining of abrupt onset fever, sore throat, headache, abdominal pain, nausea, and vomiting. You look into her oropharynx and see this:

On exam, you also note tender and enlarged anterior cervical lymph nodes and palatal petechiae. You swab the tonsils and posterior pharynx and send it off for culture. The blood agar plate is shown below. Disc A contains bacitracin.

Oh, but there's more! The patient's mother brings her in a week later because of acute onset of tic-like movements. She also has obsessive-compulsive behaviors like counting and cleaning. On examination, you notice choreiform movements. You prescribe antibiotics and the symptoms improve.

Challenge: What is this strange movement disorder?

Related Questions:
1. What did the patient initially present with?
2. Describe the colonies on the blood agar.
3. What laboratory tests would you send to confirm the diagnosis?

First image is in the public domain; second and third images are shown under fair use.

Old Men II

This is part two of a two-part case; see the previous case for related information.

After you make the diagnosis, you start the patient on various medications but he is still symptomatic. You then refer to urology who decides to do a surgical intervention. He is scheduled for a standard transurethral resection of the prostate. In the PACU, the patient is noted to be confused, disoriented, twitching, and hypotensive. Standard labs are sent and the sodium comes back 95 mEq/L. The osmolal gap is 40 mosm/kg.

The image above shows the tiny bits of removed prostate.

Challenge: What happened?

Image shown under fair use.

Old Men I

This is the first part of a two-part case. This part is easy; the next one is tricky.

A 70 year old man with type II diabetes presents to a regular doctor's appointment complaining of a gradual onset of urinary symptoms. "I have to pee way more than I used to. I'm not drinking more water, so it doesn't make sense. I usually wake up 4 times at night to go to the bathroom. And not only that, when I want to pee, not much comes out and the stream is pretty weak." He does not complain of any neurologic symptoms, hematuria, or pain. There is no history of urethral trauma or surgery. The only medication he takes is a baby aspirin and metformin. There is a positive family history.

Challenge: The pathology is shown above. What's the most likely diagnosis?

Image shown under fair use.

Bowlegged

This is an AP x-ray of a 2 year old child who has delayed closure of the fontanelles, some parietal and frontal bossing, and soft skull bones. You see odd beading along the anterolateral aspects of the chest. Laboratory tests show elevated alkaline phosphatase.

Challenge: What's the diagnosis?

Image shown under Creative Commons Attribution ShareAlike 1.0 License.

Made-Up Disease

A patient with a subarachnoid hemorrhage admitted to the intensive care unit has been stable for several days. But about 5 days after admission, routine labs show an elevated hematocrit and hyponatremia (130 mEq/L). The plasma osmolality is low, the urine osmolality is high (350 mOsm), and urine sodium is high (45 mEq/L).

You go and see the patient. Due to a baseline poor mental status you can't get much subjectively. But your exam shows hypotension, decreased skin turgor, and dry mucous membranes. Worried about hypovolemia, you administer isotonic saline. This leads to a dilute urine and correction of the hyponatremia.

Challenge: This may be an unfair case as "some authorities contend that [this disease] does not really exist." What disease am I talking about?

Image is in the public domain, from Wikipedia.