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?

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Foxes and Sheep

A 40 year old patient presents with nonspecific malaise, weight loss, and right upper quadrant discomfort. He has hepatomegaly on exam. Labs show a leukopenia, mild eosinophilia, and borderline liver function tests. A CT and fecal smear are shown below.

Surgery is performed and an intraoperative specimen is shown below.

Challenge: What's the diagnosis? Why handle that thing so carefully?

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Nature and Nurture

A 9 year old boy is referred to you by his 3rd grade teacher because she's worried he has absence seizures. "I had a child last year with absence seizures and this boy is displaying the same thing. I talked to his 1st and 2nd grade teachers and they agree. He's often daydreaming and forgetful in daily things. He can't sustain his attention in tasks or even when playing. And his grades are suffering; he makes careless mistakes and doesn't pay attention to details. I'm worried about him. When we have a test, he forgets his pencil. When we're reading, he forgets his book. He's just so unorganized."

The mother protests. "They expect too much of my son. He's always been like this, but he means well. Sure, he never finishes his chores and I have to sit with him for him to do his homework, but he's smart enough; he understands everything. His strengths are elsewhere. He's always so curious; whenever he sees something interesting he'll just drop what he's doing and go investigate. The one thing that frustrates me is that he sometimes doesn't listen even when I'm talking to him directly."

You ask about seizure-like activity and no one has noticed anything. His problems seem to be more chronic rather than episodic. A full physical exam including neuro exam is normal.

Challenge: What's your most likely diagnosis?

Purpurea

A 50 year old woman with renal insufficiency presents with fatigue, vision changes, and GI symptoms. She has blurry vision with "weird colors." She complains of nausea, one episode of vomiting, and several episodes of diarrhea. Review of systems is positive for headache and dizziness. She seems slightly confused. Her vitals show a bradycardia. Otherwise, her exam is unremarkable. EKG is below.


Here's the offending molecule:

Challenge: What's your diagnosis? What's the flower shown above?

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Used to be an Insecticide

Cases are now Monday and Thursday rather than Monday, Wednesday, Friday. See announcement below this post.
A 25 year man is brought into the emergency department by his friends because he is "acting weird." The patient is irritable, angry, and restless. He says, "I can't concentrate or sleep. I'm anxious and sad. I keep eating. I quit 3 days ago, but I can't handle it. This is too much. My friends say I'm going to gain weight and get depressed too."

Challenge: What did he quit?

Image is in the public domain.

Change in Frequency

Hi Everyone,

As some of you may know, I am starting my residency training soon. I was unsure whether to continue this blog given the time constraints of residency, but I decided that it's still educational and fun for me so I will continue. Unfortunately, I need to decrease the frequency of posts from 3 cases a week to 2 a week; each takes me at least half an hour to research and write, and saving that extra time each weekend will be really helpful.

For now, new cases and the answers to the preceding case will appear on Mondays and Thursdays. I think the composition of cases will shift towards adult internal medicine as that is what I'll be seeing and learning, but I will try to keep a diverse mix. The next case will be posted at noon PST today.

Thank you for following along,
Craig

I Never Heard of This Disease

I was browsing UpToDate as I usually do on Thursday evenings and came across this disease. Note, if I don't identify gender in the first line, then it is not an epidemiology clue.

A 40 year old southeast Asian presents to your clinic with yet another episode of right upper quadrant abdominal pain, fever, and chills. Reviewing the chart, you note that he's had these same symptoms many times in the past along with a few episodes of pancreatitis, two liver abscesses that required drainage, and cirrhosis. In social history, you find out that he is poor and lives in a rural area. He does not drink. Physical exam shows jaundice, right upper quadrant tenderness, and hepatomegaly.

A RUQ ultrasound shows ductal dilatation, stones, and hepatic abscesses. CT and cholangiogram are shown below.You treat the patient with fluids, antibiotics, and biliary drainage, but so many stones keep coming out; they're mostly pigmented. Nevertheless, there is no evidence of hemolysis. Endoscopy is limited because of the strictures. Finally, you get surgery to do a cholecystectomy with common bile duct exploration and T-tube drainage.

Unfortunately, the most common causes of death in this disease are sepsis, liver failure, and complications from cirrhosis. There is an increased risk of cholangiocarcinoma.

Challenge: What is this bizarrely named disease?

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Not Good

Challenge: Well...that's not good (yes, it's an EKG). Assuming it is not artifact, what's the differential diagnosis (H's and T's)? What is your next step in management?

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Pelvic Pain

A 35 year old woman presents with sudden onset right-sided lower abdominal and pelvic pain. She said the pain started when she was "exercising," but upon further inquiry, it occurred when she was having sex. This was accompanied by light vaginal bleeding. Her past medical history is significant for appendectomy at age 20. The only medication she takes is aspirin for knee pain.

On exam, temperature is 38.1, heart rate is 75, blood pressure is 115/85, respiratory rate is 12, O2 sat is 99% on room air. On abdominal exam, right lower abdomen is moderately tender to deep palpation. On vaginal exam, an adnexal mass is barely palpable on bimanual examination. There is minimal cervical motion tenderness.

A serum hCG is undetectable. CBC is normal. Urinalysis is normal. Blood culture, urine culture, and cervical studies are negative for infection. Ultrasound shows an adnexal mass and fluid in the pelvis. A CT is shown below.

Challenge: Oral analgesia as an outpatient is the treatment for this condition if uncomplicated. What is it?

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Nine-Banded Armadillo

This gentleman presents with multiple skin lesions over his entire body. They are erythematous macules, plaques, and nodules. He has generalized nerve damage with decreased sensation throughout. He has a "claw hand," "foot drop," and "claw toes" as well. The treatment for this is a multidrug regimen including rifampin.

The alternate title for this case is "MMMBop."

Challenge: You have to check him for G6PD deficiency before starting which drug?

Image is in the public domain.

Warsaw

Challenge: These two physical findings are seen in what syndrome or sequence? The abnormalities are on the same side of the body.

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