Friday, February 26, 2010

Neuro III

You are a pediatrician who is sued by the family of a premature infant who has lateralizing neurologic deficits. This infant was delivered at 30 weeks gestation and had poor Apgar scores. Due to a need for fluid resuscitation and an arterial blood gas, you performed a procedure. The post-procedural X-ray is shown above. Currently, the infant is 2 months old and he is not spontaneously moving his left side. The lawsuit states that you failed to flush the lines before inserting them.

Challenge: What happened?

Related Questions:
1. What procedure was done?

Image is shown under Fair Use.

Wednesday, February 24, 2010

Neuro II

Challenge: You are the radiologist on call and you read this film. The radiology request form says: "70 year old man, back pain worse while recumbent." What's going on?

Image is in the public domain.

Monday, February 22, 2010

Neuro I

Hi! This is another neurology week.

A 35 year old woman presents with a headache that started this morning. It is on the right side of her head, dull, deep, pulsating, with a gradual onset. The headache was preceded by fatigue, difficulty concentrating, nausea, yawning, and pallor. It is worse with physical activity. During the time of the headache, she also gets head pain when brushing her hair. There were no visual disturbances, sensory symptoms, motor weakness, or speech disturbances. She's had the same headache in the past which have lasted anywhere from 24 to 48 hours. They seem to be triggered by stress, menstruation, lack of sleep, weather, hunger, and certain foods or odors. She treats herself by lying down in a dark quiet room. There is a positive family history. She is obese. Her neurologic exam is nonfocal.

Challenge: What is the acute treatment? What is the prevention?

Friday, February 19, 2010

Mind the Gap

A 65 year old Caucasian man presents with bone pain in his back and chest. His primary care doctor ruled out coronary causes and referred him to you. The pain is induced by movement but does not wake him from sleep. His past medical history is significant for COPD, PTSD, and atherosclerosis. He takes a baby aspirin. His family history is noncontributory. His social history is significant for smoking 50 pack-years and drinking a beer a night. He is married, has two children, and is a retired auto mechanic. Review of systems is positive for fatigue and generalized weakness.

The laboratory values are: sodium 135, potassium 4, chloride 110, bicarbonate 24, BUN 10, Cr 1.6, glucose 95. Calcium, magnesium, phosphorus, and albumin are normal. The patient has a normocytic, normochronic anemia of Hgb 11 g/dL. WBC and platelets are normal. An X-ray is shown below.

Challenge: What's the diagnosis?

Image is shown under Fair Use.

Wednesday, February 17, 2010

Four Sheep, Inc.

I have a friend who was contemplating using the title of this case as a name for a company.

Challenge: Tell me about this patient's past medical history.

Image shown under Fair Use.

Monday, February 15, 2010

Found Down

A 77 year old woman was found down by her neighbor and brought in complaining of hip pain. She is confused and cannot give a good history. On exam, the right leg is shortened and externally rotated. There is bruising and local tenderness present, but no pelvic or distal femoral tenderness. The x-ray is shown below.

Challenge: What's the diagnosis?

Image is in the public domain.

Friday, February 12, 2010


The blood smear above comes from a 10 year old presenting with jaundice. There is a positive family history of this disease. On physical exam, you note a large spleen. On labs, you note a severe anemia with a normal MCV and modest reticulocytosis along with an elevated serum bilirubin. An abdominal ultrasound shows cholelithiasis.

Challenge: What's the diagnosis?

Image is in the public domain.

Wednesday, February 10, 2010


This is modeled after a case presented at the University of Iowa Department of Ophthalmology. This gentleman presents with diplopia. The abnormalities are mostly with vertical gaze, especially upgaze; the patient prefers a downward gaze. He may have some upbeat or downbeat primary position nystagmus as well as trouble with convergence and divergence. There is also some bilateral upper eyelid retraction on exam. MRI of the brain shows hydrocephalus.

Challenge: This tough constellation of symptoms makes up what syndrome?

Image shown under Fair Use.

Monday, February 8, 2010

Next Step?

A 60 year old woman with diabetes and hypertension presents with one episode of vaginal bleeding. She said she had menopause several years ago. She is unsure about her medications, but takes something for her "sugars," "high blood pressure," "bones," and "hot flashes." She has no children. She is obese.

Challenge: What is your next step in management?

Friday, February 5, 2010

Renal III

A patient with renal failure of unknown etiology requiring dialysis went to get a pan-body CT/MRI three weeks ago. She is fairly wealthy and paid for as many fancy technological scans as possible in an attempt to identify the cause of her renal failure. Today, she presents with the lesion shown in the first image. These lesions developed symmetrically on bilateral ankles, lower legs, feet, and hands. Then they may progress to the thighs, forearms, trunk, and buttocks. The second image shows a later stage.

CRP, serum ferritin, and ESR are elevated; albumin is low. ANA, anticentromere, and anti-Scl-70 antibodies are negative.

Challenge: What happened?

Images shown under Fair Use.

Wednesday, February 3, 2010

Renal II

Challenge: For each of the following, would you expect these findings in prerenal acute kidney injury or acute tubular necrosis (ATN)?

1. Mannitol administration.
2. ACE-inhibitors.
3. Severe burns.
4. A history of vomiting and diarrhea.
5. Muddy brown casts.
6. Bland urinalysis with rare hyaline casts.
7. Improvement of creatinine within 48 hours after IV fluid administration.
8. FENa < 1%
9. BUN/Cr = 12:1.
10. Urine Na+ = 50meq/L.

Monday, February 1, 2010

Renal I

This is kidney week! The cases will get progressively harder.

The CT scan shown above is from a 20 year old otherwise healthy woman presenting with flank pain, nausea, and vomiting. She does not have any urinary frequency, urgency, or pain. Her temperature is 38.1, and she has costovertebral angle tenderness. Pregnancy test is negative. A urinalysis is nitrite negative but shows WBCs and WBC casts in the urine.

Challenge: What's the diagnosis?

Image is shown under Fair Use.