Happy Memorial Day!

Hi everyone,

Thank you again for following along these cases. I am going to take a case of the day holiday today because I am out of town for a friend's wedding.

Thanks for understanding,
Craig

Dollars to Euros

A 26 year old woman presents with epilepsy from an unknown cause. She has already seen two neurologists who have been unable to make a diagnosis. For the last two years, she's had daily episodes of witnessed seizure-like activity. The episodes last around 5 minutes with variable motor activity; she thrusts her pelvis out, writhes and trashes, rolls from side to side, or arches her back. During an episode, these motor symptoms wax and wane. Her eyes are always squeezed tightly shut. She sometimes makes vocal noises. She has never had incontinence, cyanosis, or tachycardia with these episodes. She awakens rapidly and reorients quickly without a post-ictal headache. She sometimes recalls what happened during the seizure. No one has noticed any episodes while she is asleep. Antiepileptics have not worked to decrease the frequency of symptoms.

Physical exam is remarkable for profound weakness of the patient's left arm. She barely moves it antigravity and can't exert any force against resistance. When you ask about it, she just shrugs and says "whatever."

Challenge: What's going on?

Cut It Out

You are the pathologist receiving this specimen from the operating room. This patient had encephalopathy, GI bleed, weight loss, and early satiety. Labs show thrombocytopenia, hypoalbuminemia, hyperbilirubinemia, and prolonged PT and PTT. AST, ALT, alkaline phosphatase, and gammaglutamyl transpeptidase are all elevated. A chart biopsy shows that these abnormalities have been going on for years.

Challenge: What serum marker is often elevated in this disease?

Image shown under Fair Use.

Whodunnit?

A patient is brought in from a skilled nursing facility. Four hours ago, she was given somebody else's pills but the nurse has run away! No one knows what she was given, except that it's probably a common nursing home medication. She was brought in because of a witnessed seizure about three hours ago. She has recovered from the seizure but has altered mental status with delirium. Her vitals show a heart rate of 40 and a blood pressure of 90/50. There are no focal neurologic deficits. Her labs show a glucose of 40 and potassium of 5.5; otherwise electrolytes, BUN, and creatinine are normal. Acetaminophen and salicylate levels are undetectable. Chest X-ray is clear. EKG is shown above.

You secure airway, breathing, and circulation. You give dextrose. You start atropine but the heart rate and blood pressure are minimally responsive.

Challenge: What's the antidote to this ingestion?

Image shown under Fair Use.

Burn

Challenge: If all these patients were also deaf, what would be your diagnosis?

All images are in the public domain.

Double Diagnosis

A 40 year old man with hepatitis C presents with a subacute onset of fever, nonproductive cough, and shortness of breath. These symptoms have been getting progressively worse over the last few weeks. Other than hepatitis C contracted from IV drug use, he doesn't know about a past medical history. He hasn't seen a physician in years. He takes no medications. He occasionally drinks, smokes, and does IV drugs. Review of systems is positive for fatigue, chills, chest pain, and weight loss.

Physical exam is notable for a temperature of 38.3 C and respiratory rate of 26. His heart rate and blood pressure are normal. The rest of his exam including cardiac, pulmonary, and abdominal exams are normal. A chest X-ray is shown below.

LDH is elevated. An induced sputum is done with inhalation of hypertonic saline. The slide is stained and shown below:

Challenge: Unfortunately, two separate diagnoses can be made here. What are they?

Related Questions:
1. What does the CXR show?
2. What does the second image show?

Both images are in the public domain.

OCPs

Today's case is not a diagnostic dilemma, but rather a patient education question. A 25 year old woman comes to your clinic because she is interested in starting combined oral contraceptives.

Challenge: Which of the following will she need before starting the pill: a breast exam, a pap smear, an STD screen? When should she start taking the pill? What are the contraindications to combined oral contraceptives?

Image of OCPs is from Wikipedia, shown under GNU Free Documentation License.

No Case Today

Hi everyone,

Since today is medical school graduation for me, there will be no case of the day. Enjoy the day off! There should be a regularly scheduled case on Monday. Thank you all for your participation. I have thoroughly enjoyed writing these and I hope they are fun and educational. I'm not sure when I will end this blog, but I will keep it going for the next month at least.

Craig

Previously Healthy

A 30 year old previously healthy man presents with high fever, tachycardia, hypotension, and severe localized pain of his left lower extremity. The leg has tense edema, red-purple erythema, crepitus, blisters, and bullae, but the pain seems to be greater than he should feel with these findings. The pain has been rapidly increasing over the last day or two. C-reactive protein is 180 mg/L, WBC is 30,000/uL, Hgb is 10 g/dL, sodium is 132 meq/L, Cr is 1.6 mg/dL, glucose is 190 mg/dL. Gram stain is shown above.

Challenge: What's the diagnosis? What's the bug?

Image is shown under Fair Use.

An 18th Century English Author Had This Disease

A 7 year old child presents with "weird" movements and utterances. Throughout the day, he will have involuntary facial grimacing and shoulder shrugging. The symptoms wax and wane. When he concentrates really hard, he can suppress them, but otherwise, he feels an irresistible urge before the movement and great relief afterward. He says he can tell when they're coming on. His teacher has sent him home from school multiple times for saying "bad words." Review of systems is positive for restlessness, insomnia, enuresis, somnambulism, nightmares, and bruxism. His parents have observed his weird movements in his sleep. A head MRI is negative.

Challenge: The person shown in the image above also had this disease. What is it?

Image is in the public domain.

Asthma III

A 36 year old presents with several months of fever, weight loss, malaise, fatigue, and a new wrist drop. All of his medical problems started about 16 years ago, he says. He was diagnosed with allergic rhinitis when he was 20, eczema when he was 24, and asthma when he was 28. At age 32, he was admitted with pulmonary opacities, an eosinophilic pleural effusion, and peripheral eosinophilia. They didn't know what to make of it, diagnosed him with an asthma exacerbation, and sent him home.

His asthma is poorly controlled on moderate doses of inhaled corticosteroids. He has required several courses of systemic glucocorticoids to control his symptoms. He's had multiple exacerbations requiring ED visits, hospitalizations, but no intubations.

His allergic rhinitis has been evaluated by an ENT and the endoscopic image is shown above. The white arrow points to the middle turbinate and the red arrow points to the nasal septum. The black arrows represent the findings. The patient also says he gets recurrent sinusitis.

Most recently, the patient complains of the skin finding shown above on his elbow. It is tender, nodular, and subcutaneous. On exam, you also note a foot drop.

Challenge: Making the diagnosis is important as cardiac complications can be serious. What do you think this is?

Images shown under Fair Use.

Asthma II

You are a pediatrics intern on your first day of clinic. Now you get third year medical students running around for you! You send a medical student to see a 2 year old who is "fussy." The medical student comes back about an hour and a half later, fumbling through pages of notes. He says this is a 2 year old with no significant past medical history and a normal birth history who presents with irritation that started about an hour ago. He was in his crib, unmonitored, when he began to cry. The parents don't know what was wrong and brought him into urgent care. The child has had a nonproductive cough.

You wonder why that history took an hour and a half to obtain. You also wonder what's on the five other scribbled pages of the medical student's notes. Oh well.

The student reports a definite wheeze, but he only heard it on the left side. There were decreased breath sounds on that side too. You're not sure why, but the medical student got chest X-rays, shown above. The right CXR is expiratory and the left CXR is inspiratory. The CXR does not improve with bronchodilators.

The med student hedges on the assessment and plan. The differential diagnosis, he says, is asthma definitely, and also...

Challenge: Your student hesitates, waiting for you to fill in the more likely diagnosis which is what?

Image shown under Fair Use.

Asthma I

This week is not only pulmonary week, it is asthma week.

The CXR and CT shown above are from a patient referred to you because she has asthma that just won't go away. She is 30, but she had asthma since she was a child. Every year, she gets a few exacerbations with bronchial obstruction, fever, malaise, cough productive of brown mucous plugs, and occasional hemoptysis. Her blood counts always show peripheral eosinophilia. Wheezing is present. These episodes are only minimally responsive to bronchodilators such as albuterol and ipratropium, but they respond well to systemic steroids. Pulmonary function tests show airflow obstruction, air trapping with a reduced FEV1, and increased residual volume. Improvement is minimal with a bronchodilator. A skin test shows reactivity to Aspergillus antigens, serum antibodies against Aspergillus are positive, and serum total IgE is elevated >1000 ng/mL.

Challenge: The referring doctor asks what antibiotics he should use for this infection?

Images shown under Fair Use.