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?

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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?

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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?

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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?

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Gum

Challenge: What antiepileptic is this patient on?

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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?

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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?

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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?

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