A Diamond is Forever

Happy New Year!

A six month old baby is referred to you because of profound anemia of 4.5 g/dL. He has a snub nose, wide set eyes, a thick upper lip, and an intelligent expression. Looking at the records, you note a progressive normochromic and macrocytic anemia. The WBC and platelet counts are normal. The patient's reticulocytes are markedly decreased. There is increased Hgb F. The bone marrow shows normal cellularity but very few erythrocyte precursors. Red cell adenosine deaminase activity is increased. There is a positive family history for this disease.

Challenge: What's going on?

Happy Holidays

This is sort of a fun case that's taken from the blog A Cartoon Guide to Being a Doctor. Hope you all have happy holidays! I think there will be no case this Thursday, but I'll plan for a case a week from today.

Challenge: How many diseases can you name?

Image shown under Fair Use.

Are We Uncomfortable Yet?

A 35 year old woman presents to you in clinic with a complaint of vaginal bleeding after sex. This has only started happening recently; she says, "I've had dozens of partners in the past and this is new." The bleeding happens during and right after coitus. She does not have menorrhagia, irregular menstrual cycles, or intermenstrual bleeding in the absence of coitus. There is no pain, dyspareunia, or dysuria. Her partner is asymptomatic. She has not seen any doctors ever, and is worried she has an STD. Exam does not show any lesions; the vagina and cervix look normal, without discharge. HIV, hepatitis, gonococcus, chlamydia are negative.

Challenge: What is the most serious potential diagnosis?

Opposite of Midnight

Challenge: What autosomal dominant disease associated with pulmonary valve abnormalities and hypertrophic cardiomyopathy is shown above?

Images shown under Fair Use.

Windowing Your CT

A 70 year old woman with diabetes presents with fevers, chills, flank pain, abdominal pain, nausea, and vomiting over the last week. Labs show hyperglycemia, leukocytosis, acute renal failure, and pyuria.

Imaging is shown above. Panel A is an abdominal radiograph. Panel B is a CT scan in soft tissue window. Panel C is an air window.

Challenge: What are the two most likely organisms that cause this disease?

Image is shown under Fair Use.

Noncon

Challenge: What's going on in this non-contrast head CT?

Image shown under Fair Use.

Walk With Me

What do you think about the following gait assessments in an elderly patient?

1) This patient's toes don't clear the ground; the toes scuff with each step. Thus, the patient uses circumduction of the hip to help toe clearance. When you look at the patient's shoes (because that is part of your regular exam), there is wearing of the soles at the tips.

2) This patient's step is high. There is an audible slap as the foot hits the ground.

3) This patient's gait is described as "stumbling, lurching, staggering, slow, reduced step length, wide-based, reeling, and drunken." Acceleration and braking are impaired, and not only in gait, but with other movements as well.

4) This patient walks as if on ice. He has a cautious gait, slow, with shortened stride length on a normal or slightly wide base. He turns en bloc. There are no other signs of Parkinsonism.

ERCP

Although at presentation, most patients with this disease are asymptomatic, this ERCP is from a patient with inflammatory bowel disease and an elevated alkaline phosphatase. She initially presented with fatigue and pruritis, though other symptoms include fever, chills, night sweats, and RUQ pain. Alkaline phosphatase is remarkably elevated, though AST/ALT are less than 300. She also has hypoalbuminemia, hypergammaglobulinemia, increased serum IgM. Antimicrosomal antibody is negative though a smattering of other autoimmune markers are positive.

Challenge: What's your most likely diagnosis?

Image shown under Fair Use.

Debunked

This 2 year old child has not yet talked but is able to do this. In fact, this is all he likes to do. When you try to interact with him, he does not make eye contact. "He likes to play alone," the parents say.

Challenge: That's all you really need to suggest a diagnosis of what?

Image shown under GNU Free Documentation License.

I Saw This Mismanaged

A 60 year old patient comes in with bradycardia in the 40s. He doesn't have the typical symptoms of bradycardia; he doesn't feel weak and hasn't had syncope, but instead he complains of headache, nausea, and vomiting. His other vital signs include a temperature of 37C, a blood pressure of 170/90, a heart rate of 42, and an irregular respiratory rate ~8. I saw this case mismanaged because the diagnosis wasn't recognized.

Challenge: Who is the man shown above and how is he related to this case?

Image is in the public domain.

Water Under the Bridge II

This is the second part to a two-part case (scroll down to see the first part).

Unfortunately, the patient described in the last case fails to follow up with a doctor. He finally presents with intractable coughing and recurrent pneumonias. He is intubated and a percutaneous gastrostomy tube is placed for nutrition. He continues to get recurrent pneumonias until finally a diagnostic procedure is done involving methylene blue in the tube feeds.

Challenge: What is the diagnostic procedure? What do you expect?

Water Under the Bridge I

This is the first part of a two-part case.

You are doing an away rotation in China where many people smoke, drink, and eat very little fruits and vegetables. You see a patient with longstanding GERD and gastritis that has been untreated for 20 years. He is presenting with weight loss. Upon further inquiry, you find that he has solid food dysphagia as well as anorexia. Apples, meat, hard-boiled eggs, and bread seem to "stick" in the patient's throat. The patient says his voice has become hoarse.

Endoscopy shows this at the gastro-esophageal junction:


Challenge: What is the diagnosis?

Image shown under GNU Free Documentation License.

Sounds Like the Last Case

A 30 year old woman presents with pain on urination. She is empirically prescribed a course of trimethoprim/sulfamethoxazole but her dysuria persists. On examination, you note painful genital ulcers and tender local inguinal lymphadenopathy. There are multiple pustular vesicles and ulcers that arise after a 4 day incubation period and last 2-3 weeks. In addition, she complains about fever, headache, malaise, and myalgias.

Challenge: What's the most likely diagnosis?

Hermes

The gentleman shown above has an intention tremor, gingivitis, excessive salivation, excitability, insomnia, irritation, and shyness. He is likely to die of an interstitial pneumonitis. His exam shows swollen salivary glands.

Small kids with this disease develop a body rash, swelling, and irritation of palms and feet followed by desquamation, irritability, photophobia, fever, and insomnia.

Other syndromes include peri-oral paresthesias, malaise, constriction of the visual fields, deafness, and ataxia as well as nephrotic syndrome.

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

Two Step

A 70 year old smoker with HTN, hyperlipidemia, and diabetes presents with severe crushing chest pain and calls 911. The EKG en route is shown above. He is given an aspirin, nitroglycerin, and oxygen. On arrival to the emergency department, he is hemodynamically stable. On his way to the cath lab, he suddenly becomes profoundly hypotensive. Your exam reveals no new murmur, clear lungs, and distant heart sounds. Within a minute, he has a PEA arrest and dies. An autopsy is shown below.
Challenge: What happened?

First image is in the public domain. Second image shown under Fair Use.

Rhythm and Blues

Challenge: What's the rhythm?

Image is in the public domain.

Sugars

You are asked to consult on a newborn who is several days old and has persistent jaundice, vomiting, poor feeding, and failure to thrive. She was born at home to a 30 year old healthy G1P1 mother. They did undergo prenatal screening but the patient has not seen any doctors since birth. When you examine the patient, you note a jaundiced lethargic infant with hepatomegaly and hypotonia. The fontanelle is full, and there is some edema and possibly ascites. Two weeks later, lenticular cataracts are noted; if this is not caught early, patients with this disease develop a nuclear cataract where the nucleus of the lens looks like a cloud of dust. Laboratory tests in the infant show a hyperbilirubinemia, abnormal LFTs, coagulopathy, and increased levels of plasma phenylalanine, tyrosine, and methionine.

Challenge: What's a possible diagnosis?

Image is in the public domain.

Milk of Amnesia

You are a newly minted anesthesia resident and are called to assist in the anesthesia of a patient undergoing a painful reduction of a fracture (there is a fracture, I must fix it). You did an induction at the beginning of your shift 12 hours ago and still have half a bottle of propofol in your pocket. You go ahead and use it to induce anesthesia, and there are no problems. The orthopedic surgeon is happy, and you go on your way. A couple hours later, a rapid response team is called and you rush to the bedside to find that it is the very same patient. He's febrile, tachycardic, hypotensive, and tachypneic. He is diaphoretic with bounding pulses.

Challenge: What happened?

Image is in the public domain, from Wikipedia

There is a Fracture, I Must Fix It

This gentleman had a sports accident where he fell onto his shoulder.

Challenge: Where is the fracture?

Image shown under Fair Use.

Polar

Both EKGs above are from the same patient, a 70 year old man with many medical comorbidities. He initially presented to the clinic for lightheadedness, presyncope, and palpitations. He switches into and out of the rhythms shown above.

Challenge: What is the syndrome described here?

Both EKGs shown under Creative Commons Attribution Share-Alike 3.0 License.

Scar (Not Eschar)

This is a particularly challenging case. The images above are from a patient who noted acute onset nonpitting edema of the arm. This later became a symmetric induration with puckering, giving the irregular, woody texture of the skin of an orange peel. The disease spares the hands and feet. When you raise the affected limb, visible indentations appear along the course of the superficial veins. The patient also complains of arthritis. Labs surprise you with an eosinophilia.

Challenge: What is your diagnosis?

Both images shown under Fair Use.

Satellite

This child who had a recent ED visit for acute sinusitis presents with swelling and erythema around her eye. Eye movements are painful. You note chemosis, proptosis, and mild globe displacement on exam. It is difficult to test visual acuity since she complains about seeing double. She refuses extraocular movement testing.

Challenge: What's the diagnosis and what are the bugs?

Image shown under Fair Use.

Hardware

Challenge: A simple question but: what is the device shown here and where are its leads?

Image shown under Fair Use.

Rooftop

Challenge: Diagnosis?

Image shown under Fair Use.

One Week Break

Hi everyone,

Thank you for following along case of the day. This is one of my favorite educational things to work on each week. Unfortunately, residency is absolutely exhausting and I think I need to take a week off from this blog, so no new cases until next Monday, October 4th.

Thanks,
Craig Chen

Goiter

This is a biopsy from a 50 year old woman who presented with tremor, sweating, heat intolerance, palpitations, anxiety, diarrhea, and inability to sleep. On exam, you note tachycardia, a wide pulse pressure, hypertension, a prominent stare and lid lag (but no proptosis). Surprised, you find a pelvic mass and ascites. There is no goiter and an iodine uptake test shows minimal uptake in the thyroid.

Challenge: What's going on?

Image shown under Fair Use.

Bubble Bobble

This near-term baby is small for gestational age and presents with bilious vomiting 30 hours after birth. You note gastric distension on exam. He did pass meconium earlier.

Challenge: What's the diagnosis? What syndrome is this seen in?

Image shown under Fair Use.

Not Quite a Cancer

As has been the case for many of my patients this month, a 30 year old man is admitted to the medicine service for "social reasons." That is, he doesn't have much wrong with him medically, but he is homeless and says he cannot walk, and although you do not think he warrants a hospital bed, you give him one anyway. Unfortunately, he makes quite a ruckus, yelling at nurses, throwing tantrums, demanding sandwiches, etc. One night, you decide to calm him down with a bit of haldol, and then a bit more. This seems to work for a bit, and after a few days, the social worker seems to have found a place for this patient to go. Yay!

You are about to discharge him when the nurse says, "he's acting up again." "Oh no," you think. You sort of dismiss it, but the nurse insists: "he's in an agitated delirium." You go see the patient and indeed, he is confused. You touch his arm and realize he's completely rigid. He's rigid throughout all ranges of motion. Yet he has a bit of tremor as well. When you touch him, you realize he's hot and diaphoretic; the nurse takes a temperature and it's 41 degrees Celsius. You ask for all the vital signs and find that he is tachycardic, hypertensive, and tachypneic.

Challenge: I guess he can't be discharged. What happened? What did he take this time?

Invertebrate

These lesions are very common in children, but if a multitude spring up in an adult, you have to assess for HIV (or other form of immunosuppression). Common areas of involvement include the trunk, axillae, antecubital and popliteal fossa, and crural folds.

Challenge: What is the etiology of this lesion?

Image shown under Fair Use.

Nerve II

This is the second part to a two-part case; please scroll down to see the first part of the case.

The aforementioned patient is admitted to the hospital and therapy is begun. After a week of therapy, however, you are called to the bedside for a seizure. The patient is having a tonic-clonic seizure which responds to benzodiazepines. However, she also has hypotension and clinical signs of heart failure, requiring a transfer to the ICU. Diagnosis is made with standard lab tests.

Challenge: Whoa, what happened there?

Nerve I

This case is adapted from an example on UpToDate. It is the first part to a two part case.

A 20 year old woman with no past medical history presents with weight loss of 10kg over 6 months. She began watching her diet after taking a nutrition class. Her diet now consists of a cup of coffee for breakfast, an apple with a diet coke for lunch, and an organic leafy green salad with a cup of coffee for dinner. She says she hydrates herself well, especially since she runs 5 miles a day. She has one bowel movement a week. Her LMP was 3 months ago, though she denies sexual activity. Her EKG is below.

Challenge: What's the diagnosis?

Image shown under Fair Use.

Big

This is from a blood culture of a 50 year old HIV positive patient who has never been on antiretrovirals, now with a CD4 count of 4 (nadir) who presents with fever, night sweats, abdominal pain, diarrhea, and weight loss. Labs show anemia, elevated alkaline phosphatase, and elevated LDH.

Challenge: Diagnosis?

Image is in the public domain.

21

Parents bring in their 1.5 year old infant for the fifth time this year because of recurring fevers. "It seems like every month for 2 or 3 days, our child doesn't feel well," they say. "I think I had it," the dad says, "and my dad too, and my sister, and my aunt. My sister actually died of a clostridium infection when she was a child." You look into the patient's past medical record, and 3 weeks ago, the child presented with pharyngitis, and 3 weeks before that, with a bacterial skin infection, and 3 weeks before that, malaise, and 3 weeks before that, gingivitis.

On exam, you notice significant gingival disease and chronic mouth ulcers. The child looks otherwise normal, with a normal growth curve, no dysmorphic features, and no hepatosplenomegaly. Labs are surprising. At each visit, the child's ANC (absolute neutrophil count) is around 200-400. But labs drawn at "well-child visits" when he is not sick show a normal CBC.

Challenge: What's your diagnosis?

Young Woman with Abdominal Pain

A 30 year old woman presents with abdominal pain, your favorite chief complaint for that demographic. The pain is in the epigastric and RUQ areas. You note hepatomegaly with no Murphy's sign. Her urinary pregnancy test is negative; she protests, "I take my oral contraceptive religiously, like I have for the last fifteen years." You find that she's visited her primary care doctor multiple times with no diagnosis. Finally, you succumb to CT scan.

Whoa! You did not expect to see that. This CT shows a large complex enhancing mass of the left lobe of the liver with displaced vessels (small arrowheads). A smaller low attenuation mass is also noted in the right lobe of the liver.

While coming out of the CT scanner, she screams in pain and collapses. Her blood pressure is 60/palp. You start resuscitating her aggressively and the surgeons take her to the OR immediately. They find gross blood in the peritoneum.

Challenge: By textbook, this lesion is usually solitary in the right lobe of the liver, but this patient's history makes her prone to more complex lesions such as this one. What's the most likely diagnosis?

Image shown under Fair Use.

Territorial

Challenge: Localize the lesion.

Image shown under Fair Use.

Gem

Sorry about the late post today!
These ghoulish crystals are seen in an alkaline urine of a patient with dysuria.

Challenge: What organism(s) do you expect?

Image shown under Fair Use.

Belly

This gentleman with longstanding hepatitis C, hypertension, and diabetes presents with a temperature of 100.4 F (38 C) and mild abdominal tenderness. His wife says that he's been a little confused lately. Labs show a leukocytosis, azotemia, albumin of 2. You put in a needle and take out fluid from the belly. These fluid studies show:
Albumin 0.2
Total protein 0.5
Glucose 80
WBC 600
RBC 2500
45 % neutrophils
40% lymphocytes
15% monocytes

Challenge: What's your diagnosis?

Image shown under Fair Use.

Next Step

Yes, I've shown a similar EKG before, but I had to write this case last minute. A 70 year old man who has never seen a doctor before presents with chest pain and the EKG shown above.

Challenge: What's your next step in management?

Image is in the public domain.

Sorry!

Hi everyone! I apologize - no case today mostly because I haven't had time to put one together. I shall try to have a case ready by tomorrow morning, solution on Monday. Thanks! -Craig

Common Welsh Surname

Both images show the same finding in a young athlete who describes acute onset pain on the lateral side of his foot, anterior to the ankle. He was playing basketball at the time. He has difficulty bearing weight. Examination shows edema and ecchymosis.

First image shown under GNU Free Documentation License; second image shown under Creative Commons Attribution Share-Alike License.

Tic-Tac-Toe II

This is part two of a two part case. Please scroll down to see the first part.

The 70 year old gentleman presents to clinic several months later with recurrent urinary tract infections. He also says he has a weird symptom: when he urinates, he sometimes pees air. Physical exam is unremarkable.

Challenge: What?

Tic-Tac-Toe I

This is the first part of a two-part case.

A 70 year old man presents with left lower quadrant abdominal pain of several days. He's had this in the past but previous episodes were mild and he's always ignored the symptoms. This time, though, he also has nausea, vomiting, and constipation. The patient has left lower quadrant tenderness with a palpable mass and abdominal distention. He has a mild fever and leukocytosis. LFTs and amylase are normal.

Challenge: This patient is not Asian. If he were Asian, how might the symptoms differ?

Image is in the public domain.

The Ayes Have It

This is the fundoscopic exam of the left eye of a 30 year old man with no symptoms. He has 20/40 vision in this eye. Extraocular movements are intact. Visual fields are intact to confrontation. Pupils are equal, round, and reactive to light. Color vision is intact.

Challenge: What's your diagnosis?

Image shown under Fair Use.

Two for One

Two patients are admitted with the same diagnosis in the summertime, the bug shown above. A third trimester pregnant woman presents with flu-like symptoms, fever, chills, and back pain. Urinalysis is negative. The blood culture grows out the bacteria shown above. Unfortunately, her newborn is greatly affected by the transplacental infection and develops disseminated abscesses in the liver, spleen, lungs, kidney, and brains as well as papular and ulcerative skin lesions.

An 80 year old man develops a subacute course of fever and confusion. There is no nuchal rigidity. A lumber puncture shows a pleocytosis and >25% lymphocytes. CSF protein is moderately elevated to 170 and glucose was mildly decreased. The gram stain is shown above.

Challenge: What organism is shown above?

Image is shown under Fair Use.

Not Enough Information

You are outside at a picnic when a person shouts, "Do we have a doctor here?" You rush over to see a young man with visible dyspnea. He is using his accessory muscles and audibly wheezing. You notice the rash shown below. The person also has periorbital edema and conjunctival swelling. A bystander says that the person is otherwise healthy and has no past medical history and takes no medications.

Challenge: What is your next step in management?

Image is in the public domain.

When I Look in a Microscope, All I See Are Eyelashes

An 80 year old man with a past medical history significant for depression presents with fatigue. About 5 months ago, his wife passed away from colon cancer, and since then, he has had a dramatic change in diet. He doesn't cook for himself and eats mainly fast food. He has also started drinking more alcohol. His exam, including neurologic and psychiatric exam, is completely normal. Labs show anemia, elevated serum bilirubin, elevated LDH, and a low-to-normal absolute reticulocyte count. WBC and platelets are low. The blood smear is shown below.

Challenge: What's the most likely diagnosis? Second most likely diagnosis?

Image shown under Fair Use.

Bruit II

See the previous post for the first part of this case.

You decide to perform surgery on the gentleman described in the previous case. The surgery goes smoothly without any immediate complications. One week after the surgery, however, he begins having unilateral headache on the same side as the surgical repair, improved with upright position. Then, he has two episodes of focal motor seizures, witnessed, followed by a stroke with CT evidence of intracerebral hemorrhage. Imaging of the vessel itself does not show thrombosis or restenosis. This is not hemorrhagic conversion from an embolic stroke.

Challenge: What happened? What is this syndrome called? What is the pathophysiology?

Image is in the public domain.

Bruit I

This is the first part of a two part case.

This is an angiogram from a patient who presents with repeated episodes of 15 minutes of hand and arm numbness. This occurs on the left side and occasionally includes numbness of the cheek. These episodes have been going on for a while, about once or twice a week, all with similar symptoms and time course. They all resolve completely. Finally the patient's wife convinced him to come in and see you.

Challenge: What's the cause of the patient's symptoms (ie. what's the anatomic location of the lesion)?

Image is in the public domain.

Growth

A 15 year old boy is brought in by his mother because he hasn't had his growth spurt yet. She's worried he's not eating enough. Otherwise, past medical history is significant for deafness and a cleft palate. He is doing well at school, but was told by the school nurse that he has red-green color blindness. On review of systems, you find out that he can't smell anything. On physical exam, you note Tanner stage 2, no body hair, and no increased bulk of muscles. His voice has not deepened. Labs show a low testosterone, LH, and FSH.

Challenge: What's your diagnosis?

Now a Chronic Disease

Challenge: These outstanding clinical images are from NEJM, shown under Fair Use, in an article describing a 53 year old gentleman with hypercholesterolemia, hypertriglyceridemia, insulin resistance, and an infectious disease being treated by what class of drugs?

Aegypti

The map above shows the distribution of a disease in 2006. There are many different presentations of this disease including asymptomatic infection. Those with symptoms often have an incubation period of 3-14 days before presenting with fever of 5-7 days, fatigue, headache, retroorbital pain, myalgias and arthralgias. Children sometimes present with GI or respiratory tract symptoms. Labs often show leukopenia, thrombocytopenia, and elevated AST.

The dreaded presentation, however, includes shock, hemoconcentration, marked thrombocytopenia, abdominal pain, vomiting, fever of 2-7 days, and spontaneous bleeding. If you inflate a blood pressure cuff on these patients between the systolic and diastolic pressures for 5 minutes, you'll find petechiae.

Challenge: What's the disease?

Image is in the public domain.

Asymmetry (as opposed to a symmetry)

This image is from a 32 year old woman who presents with acute dyspnea about 2 weeks after an elective c-section. She has leg pain at the site indicated by the arrow. An EKG is shown below.

Challenge: Many things may be on the differential, but the most likely diagnosis is what?

First image shown under Creative Commons Attribution Share-Alike License. Second image shown under GNU Free Documentation License.