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?

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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?

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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?

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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?

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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.