Do Sweat the Small Stuff

A 50 year old patient with hypertension, diabetes, arthritis, and obesity gets the procedure shown above. Six months after the procedure, he is doing well; he no longer needs antihypertensives or insulin; he only takes some metformin and vicodin. The surgeons say he can go back to his regular family doctor so he shows up at your office. His only complaints are a new numbness and tingling at the tips of his fingers and toes. His laboratory studies show a microcytic anemia.

Challenge: What is the cause of these signs and symptoms?

Image is in the public domain.

Open Ended Question

You are working in the clinical laboratory and get an arterial blood gas: pH 7.27, PCO2 70 mmHg, serum HCO3 31 meq/L.

Challenge: Your mentor asks you to interpret. Is the patient compensating for the acid-base disturbance?

Wild Wild West

The EEG shown above was taken in a 6 month old child who is brought in because of recurrent motor spasms. You observe a video taken by the parents which shows symmetric movements starting as sudden brief contractions of muscle groups lasting a second followed by a longer tonic phase lasting 2-10 seconds. Some involve sudden flexion of the neck, trunk, arms, and legs; others involve extension of the neck and trunk with abduction of the legs. Occasionally the eyes show nystagmus. Changes in respiratory pattern occur commonly. The parents say the attacks occur in clusters up to a peak, then decline until they stop. When you consult the chart, you also note neurodevelopmental delay.

Challenge: What syndrome is described here?

Image shown under Fair Use.

Not A STEMI

A 60 year old man with hypertension, arthritis, and multiple myeloma presents with constipation, anorexia, weakness, and nausea. As per usual ER protocol, he gets a CT abdomen which shows kidney stones as well as the multiple myeloma. He also gets an EKG, shown above.

Challenge: What's going on?

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Hangman

A 42 year old woman undergoes screening colonoscopy because she has a positive family history for cancer. The patient's mother died of endometrial cancer; her sister has colon cancer at age 39; her grandmother (on her mother's side) had ovarian cancer and colon cancer; her uncle (on her mother's side) had transitional cell cancer of the ureter. Her colonoscopy is shown above.

Challenge: What do you suspect?

Image is shown under GNU Free Documentation License.

Old Timer

Challenge: Why does this patient have what looks like ping pong balls in his lungs? By the way, he got this treatment in the 1940s.

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Odd Set of Risk Factors

A 30 year old man comes in with fevers, chills, malaise, and myalgias. He has no significant past medical or surgical history. He takes no medications. He has no allergies. On review of systems, he notes dysuria, perineal pain, and cloudy urine. He also has urinary dribbling and hesitation. He initially thought this was a urinary tract infection and took a 2 week course of amoxicillin-clavulanate (Augmentin) but his symptoms persisted. He is an avid bike rider and has been training for 8-hours a day. He is not currently sexually active. He denies smoking, but drinks a beer occasionally and smokes marijuana occasionally.

If a biopsy were taken, the image above might be found.

Challenge: If this is more than a UTI, what is it?

Image shown under Creative Commons Attribution Share-Alike License.

Wrong Place, Wrong Time

Both of these can be diagnosed with fetal ultrasound and materal serum AFP. Obstetrics, pediatrics, and surgery all play key roles in diagnosis and management.

Challenge: What congenital anomalies are seen here? (They are two distinct entities)

Both images shown under Fair Use.

Canada? Canada!

A 40 year old man comes in with a soccer injury. He twisted his ankle in a game and has ankle pain. On exam, he can bear weight but limps. There is tenderness at the distal 6cm of the posterior edge of the fibula.

Challenge: Do you take ankle X-rays and why?

Image is in the public domain, from Wikipedia.

Demon

A 30 year old man is brought in by police for a suicide attempt; he was found on a bridge, ready to jump. He says he wants to commit suicide because of symptoms exactly as those shown above: severe left orbital 10/10 pain occurring 6 times a day. All he can do is pace about or rock back and forth in his chair, waiting for the pain to stop. It's so excruciating that the affected eye waters and he gets congested. He's thought about committing suicide multiple times when these attacks start, especially after enduring them for a week, but each time he gets to the bridge, the pain stops for a few weeks.

Suddenly, the patient screams in pain and starts clutching the side of his head saying he is having an attack. On exam, you wonder if he has a unilateral Horner's syndrome. You're not sure because he does seem to sweat. His eye is pretty red and you wonder about conjunctivitis. The patient can't give further history but says it'll get better within the next 15-30 minutes. The rest of the exam is unremarkable, except for a pack of cigarettes in his shirt pocket.

Challenge: Other than danger to self, what's the diagnosis?

Image is shown under GNU Free Documentation License.

The Grecian Bend

Hi everyone. I hope you have a happy Thanksgiving week. There will be no case on Thursday because of the holiday, but this is a great case - will post the answer next Monday.

This posture, seen with female socialites in the late 19th century, looks similar to workers building the Brooklyn Bridge in 1883.

These days, you don't see much of that disease. But instead, you see something related to the liquid shown above. You're on a plane flying from San Diego to New York when you hear an overhead page, "Are there any doctors on board?" Reluctantly, you hit your call button.

A few minutes later, you are rushed to the aisle-side of a 30 year old gentleman. "I knew I shouldn't have gotten onto the flight," he says. "In the airport, I just had the sense that something was wrong, I was tired, everything hurt, I had no appetite, and I had a splitting headache. Now, my elbows and shoulders hurt, and my chest itches. My arms and legs feel weak and they're tingly too."

When you examine the patient, he has full range of motion of his joints, pain is not exacerbated with movement, and there is no erythema or swelling of his elbows or shoulders. He does have some erythema on his chest and some mottling with cyanosis. His neurologic exam is significant for some mild weakness of the extremities. His pulse is 80. He doesn't feel febrile. You try to take the blood pressure with the airplane's sphygmomanometer and stethoscope but can't hear a thing. His respiratory rate is 18.

Challenge: You forgot to take a social history on this patient. What are his hobbies?

First image is in the public domain. Second image is shown under Creative Commons Attribution Share-Alike License.

Stigma

This patient notes that the lesion by his eye is numb. He also has hypopigmented lesions on his nose and testicles. All of these lesions have decreased sensation. On exam, you also note that he has no eyebrows. In fact, advanced forms of this disease can be associated with saddle nose deformities and hoarseness. On examination, some nerves appear enlarged and tender such as the greater auricular nerve, common peroneal nerve, and ulnar nerve.

Challenge: Thinking of the geographic distribution of the abnormalities, what's your diagnosis?

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Overanxious Parents

At a two-week visit, parents bring their newborn into your office, worried because she has had a few days of bloody mucoid vaginal discharge. A week later, this has resolved.

Challenge: What's the physiology?

Gender

Two children present with the same disease.

A 5 year old boy is evaluated because he has gotten two urinary tract infections in the last six months. He is toilet trained and never has any problems. However, a renal ultrasound shows a dilated ureter.

A 5 year old girl presents with constantly wet underwear. She is toilet trained and has normal voiding habits but has persistent moisture in her underwear. When she sits in her parents' lap, this wetness is more pronounced.

Challenge: What's going on?

Image is from Wikipedia, shown under Creative Commons Attribution Share-Alike License.

Earthquake

A 70 year-old patient is referred to neurology clinic, and before meeting the patient, you review the chart. This EKG stands out to you. Initially, you think it's one rhythm, but then you take a look at every single lead.

Challenge: What is the patient referred to you for?

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Fentanyl

A young man with no past medical history comes in after a motor vehicle accident. His primary and secondary trauma evaluations show a couple fractured bones and some ecchymoses. There are no other injuries. Both the resident and the attending each write for 100mcg fentanyl IV push for pain, and the nurse ends up giving 200mcg all at once. Suddenly, the patient has trouble breathing. He's awake and alert, so it doesn't appear to be respiratory depression from opiates; instead it seems that his tidal volumes have significantly decreased.

Challenge: How does the patient's chest wall feel and why?

Image shown under Fair Use, from usfca.edu.

Lemon

Happy Halloween!

A young man presents with early systemic manifestations of a curious disease occurring one to two months after its initial onset. He comes to the medical system because of palpitations. You take an EKG and note something very peculiar. He goes from first degree AV block to second degree AV block to complete heart block to first degree AV block over the course of minutes. The patient works at a national park.

Challenge: A lot of clues in this case point to what disease?

Image is in the public domain.

Diagnostic Arrow Sign

A 60 year old man with Crohn's disease undergoes a colonic and low anterior resection that is uncomplicated. He shows up to his follow-up appointment 6 days later and complains of low grade fever, prolonged ileus, moderate pain, and feculent drainage. Exam shows a mild tachycardia. Imaging is shown above.

Challenge: What's your diagnosis?

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Ancient History

This image is from a ward in 1918, filled with patients with the same disease. This disease typically presents with abrupt onset of fever, headache, muscle ache, malaise, cough, sore throat, and rhinorrhea. Exam shows hyperemic mucosa and mild cervical lymphadenopathy, but little else. Complications include persistent high fever, dyspnea, bilateral reticular or reticulonodular opacities, secondary infection, rhabdomyolysis, encephalitis, transverse myelitis, aseptic meningitis, and Guillain-Barre syndrome.

Challenge: What is the molecular mechanism by which such pandemics occur?

Image is in the public domain.

Hurricane II

This is the second part of a two-part case; please see the prior post.

You confirm your diagnosis and begin treatment which is shown above (given as an IV bolus of 1-2mg/kg over 5 minutes). The patient does not get better after a few hours. In fact, he seems to get worse; he's more dyspneic. You decide to send another panel of labs, and when they come back, you note that the hemoglobin has dropped 3 points and the blood smear shows:

Challenge: What happened?

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Hurricane I

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

You are on call covering a whole hospital of medicine patients when you get a call from a nurse that a patient who recently had an upper endoscopy has a sore throat. The patient is a 50 year old African American gentleman with hypertension and alcohol abuse who presented with coffee ground emesis. His EGD was negative. The plan on the sign out is to discharge him the following day. His labs look fine. You decide to write him for benzocaine 20% topical throat spray and his symptoms resolve.

Once the floor quiets down, you go to sleep, and at midnight, the nurse pages you and says the patient now has a headache, fatigue, and lethargy. You figure he's just not sleeping so you give him acetaminophen and zolpidem. You go back to bed.

At 3am, a code blue is called and you rush down to find...this patient. The code blue was called for respiratory depression and hypoxia. You note an oxygen saturation of 86% and the patient is minimally arousable. You go ahead and get an arterial blood gas, shown in the image. The patient's ABG is the tube on the left; a control ABG is on the right.

Challenge: The results of the ABG are pending, but your initial diagnosis is...what?

Image shown under Fair Use.

Worth Your Salt

Challenge: Worldwide, what is the most common cause of this condition?

Image shown under GNU Free Documentation License.

Ambiguous

You deliver an infant who has ambiguous genitalia. The child is born at 38 weeks to a 32 year old G1P1 Caucasian woman. The parent declined all prenatal screening and testing. At birth, a karyotype is 46,XX. You note clitoral enlargement, labial fusion, and formation of a urogenital sinus. She is at risk for early puberty and short stature.

Challenge: What is this autosomal recessive disorder?

Split Spine

I apologize - this case was meant to be posted in the morning.

This child, shown on her back, was born to a mother who had prenatal AFP screening that was positive. The child has bowel and bladder incontinence and does not seem to move his feet.

Challenge: What's your diagnosis?

Image shown under Fair Use.

Cherry

A middle-aged patient presents with these on the trunk. They bleed profusely if cut. They blanch with pressure.

Challenge: What's your diagnosis?

Image shown under Fair Use.

One After Another

The patient shown above, in his 20s, underwent surgery to remove both his adrenal glands.The symptoms shown above improve but then he develops the finding below a couple years after surgery.

Challenge: What is this syndrome? Why does it happen?

First image shown under Fair Use, second image shown under GNU Free Documentation License.

Two Sides of the Same Coin

Back to real hardcore diagnosis:

Case 1: A soldier returning from Afghanistan presents with the skin lesion shown below.

It began as a red papule and evolved to the lesion shown above. There is no surrounding induration. The lesion is completely (and surprisingly) painless. There is some local adenopathy. Without treatment, this lesion will resolve spontaneously, leaving only a residual hypopigmented depressed scar.

Case 2: A photographer who travels worldwide presents with subacute insidious fatigue, malaise, fever, and weight loss over months. The spleen is markedly enlarged but minimally tender. Labs show a severe anemia. The patient notes his skin has "darkened" over the last few months. Without treatment, this disease is lethal. Bone marrow aspirate is shown below.

Challenge: Maybe these serve as hints: What is the Hindi name for the second disease? What insect acts as a vector? What's the diagnosis in each case?

First image is in the public domain; the second image is shown under Creative Commons Attribution Share-Alike License.

Doesn't Bind GABA Receptor

A 25 year old woman with bipolar disease attempts suicide by overdosing on gabapentin. She's taken about one hundred 400mg tablets.

Challenge: What's your antidote?

Scheduling Glitch

Many apologies - the last case did not get posted as scheduled (the Blogger interface was updated recently so I've been adapting). It is now up, but I'll post the following case this Thursday, and then we'll be back on schedule.

Craig

You're in Court... II

A 50 year old gentleman with CAD, HTN, hyperlipidemia, DM, diverticulosis, hypothyroidism, and opiate dependence in remission is scheduled for a 3 vessel coronary artery bypass graft tomorrow. His medications include metoprolol, lisinopril, atorvastatin, levothyroxine, naltrexone, and aspirin. He has a two flight of stairs exercise tolerance. His exam and labs are unremarkable. The patient stopped his aspirin 7 days ago. You tell him to hold his lisinopril and naltrexone tonight. He takes his metoprolol on the day of surgery.

Challenge: You're in court... Why?

Image is in the public domain, from Wikipedia.

You're in Court... I

This week's cases are about pre-operative evaluations gone wrong.

A 70 year old gentleman presents to the pre-operative clinic because he is scheduled for a repair of a 6cm abdominal aortic aneurysm. His other medical problems include HTN, DM, COPD, arthritis, GERD, and obesity. He is an active smoker, though trying to cut down. His medications include losartan, metformin, tiotropium, albuterol, fluticasone, omeprazole, ibuprofen, and aspirin. Due to his arthritis and COPD, his exercise tolerance is one flight of stairs slowly. However, when he climbs a flight of stairs, he gets mild substernal chest pain which stops when he rests. It has been going on for several months but has not changed in character, severity, or frequency. EKG is NSR with LVH. Troponin is negative. Because of his reactive airway disease, adenosine stress test is contraindicated. You order a dobutamine stress test prior to his vascular surgery and refer him to cardiology.

Challenge: You're in court...Why?

Image is shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

Don't Treat a Number

A patient (usually seen in children, but described in adults) presents with fever, hepatomegaly, splenomegaly, nonspecific rash, lymphadenopathy, and neurologic symptoms. Labs show cytopenia in two cell lines, high triglycerides, low fibrinogen, elevated liver enzymes, and decreased coagulation factors.

Challenge: Everything above is pretty nonspecific, but what if the patient had a ferritin level of 20,000 micrograms/liter? What would your leading diagnosis be?

Image shown under Fair Use.

Labor Day Weekend

An umbilical artery arterial blood gas is obtained in a 34 week newborn right after a prolonged delivery to a G1P1 30 year old mother. The ABG reads: pH 7.25, pCO2 50 mmHg, HCO3- 23 mEq/L, and base excess -3 mEq/L.

Challenge: What's your interpretation?

Image shown under GNU Free Documentation License, from Wikipedia.

Know Thyself

A patient with leukemia undergoes an allogeneic hematopoietic stem cell transplant and is discharged on cyclosporine and tacrolimus. He presents to his followup appointment one week later with the arm shown above. He initially thought he had a sunburn on his neck, ears, shoulders, palms, and soles, but then it progressively got worse. It changed from an erythematous maculopapular rash to a confluent swelling with bullae. Review of systems is positive for severe diarrhea and abdominal cramping. The bowel movements started as watery but progressed to bloody. Liver enzymes show an elevated bilirubin and alkaline phosphatase.

Challenge: What's your diagnosis?

Image shown under Fair Use.

Alphabet Soup

This is one of the more difficult EKGs I've found. This is seen in a young patient with no past medical history presenting with vertigo. Her electrolytes were normal. Cardiac enzymes were normal. Cardiac cath was normal.

Challenge: What do you see? Where's the lesion?

Image shown under Fair Use.

Pouch of Wrath

A 10 year old child is brought in by parents because her teacher has noted that she has visual impairments. You note decreased peripheral vision on exam. On her growth chart, you note that she is 3% of her expected height and weight. She has no signs of puberty yet. The only complaint she has is headache. Laboratory testing shows decreased growth hormone, GnRH, and TSH.

Challenge: What's your diagnosis?

Image shown under Creative Commons Attribution 2.0 License.

From First Year of Medical School

Challenge: What is this test, and what is it for?

Image shown under Fair Use.

An Eye for Details

Yikes! This is an older patient who has diabetes, hypertension, atrial fibrillation, chronic constipation, and a recent URI who had no eye symptoms and was quite unaware of this finding until he looked in a mirror. His visual acuity is unchanged. There is no photophobia, discharge, or foreign body sensation.

Challenge: What's your diagnosis?

Image shown under Creative Commons Attribution Share-Alike License.

From Latin for Glue

Challenge: What has this patient been eating?

First image is in the public domain, second image shown under Creative Commons Attribution Share-Alike License, third image shown under GNU Free Documentation License.

NSFW

This man presented with severe pain of his butt with spread of the disease to the anterior abdominal wall, penis, and scrotum. The patient also has diabetes and peripheral vascular disease. Blood cultures grow out both aerobic and anaerobic organisms. You page urology stat.

Challenge: What's this eponymous diagnosis?

Image shown under Fair Use.

Number the Stars

This 19 month old girl was brought in for 4 days of fever to 104 degrees (40C). She was slightly irritable, but otherwise active, well-appearing, and alert. The mother was concerned about the fever, but this morning the fever broke abruptly. However, you do notice this rash, starting on the neck and trunk and spreading to the face and extremities. It is blanching, flat, and not itchy.

Challenge: What's the cause of these symptoms?

Image is in the public domain.

Sweetbread

A patient comes to your office complaining of longstanding depressed mood for at least several years. He feels "depressed" on "many days," and this is accompanied by poor appetite, poor sleep habits, low energy, poor self esteem, and poor concentration. However, he does not feel this way for "most of the day nearly every day for two consecutive weeks." Instead, it appears to be more of a chronic feeling rather than an episodic one. He does not have psychomotor agitation or retardation, thoughts of guilt or worthlessness, thoughts of suicide, or symptoms of mania.

Challenge: What do we call this?

Two Passengers

A 30 year old G2P1 woman at 28 weeks gestation is taken to the emergency department after a car accident. She was T-boned by a car which hit the passenger's side, but likely she was on the driver's side. On arrival, she says she "can't catch her breath."

The patient is afebrile. Heart rate is 100, blood pressure 100/60, respiratory rate 14, O2 sat 100% on room air. Extremity exam shows mild peripheral edema and a small water hammer pulse (rapid rise and brisk collapse). The JVP is easily visible. The apical impulse of the heart is at the fourth intercostal space, midclavicular line; it feels relatively hyperdynamic, though not sustained. Heart sounds are easily audible including a widely split S1, an S3, and a 2/4 systolic ejection murmur over the pulmonary and tricuspid areas. There is also a venous hum.

EKG shows a left axis deviation, left atrial enlargement, and an inverted T wave in lead III. The CXR shows mild cardiomegaly with increased pulmonary vascular markings. Hemoglobin is 11, hematocrit is 31, WBC 14,000, platelets 250. ABG shows a PaCO2 of 32, PaO2 of 107, and calculated HCO3 of 20. Creatinine is 0.4.

Challenge: The attending says, "I checked out the fetus and the fetus is fine, but tell me about the mother."

Image shown under Fair Use, from chronicle.pitt.edu.

Typo

You are cross-covering 80 floor patients overnight and a nurse calls you for one of them because her monitor keeps having the finding shown above. You look at the sign-out given and it's a 40 year old woman admitted for abdominal pain. The last set of labs were:
WBC 11, Hgb 11, Hct 31, Plts 210
Na 134, K 4.1, Cl 101, HCO3 22, BUN 12, Cr 0.9, Glucose 220, Ca 10, Mg 1.7, Phos 4
b-HCG negative
UA with 1+ leukocyte esterase and 5-10 WBC.

You stop by her floor and jot a quick order in the chart on your way to the call room. An hour later, you hear a rapid response being called for this patient. When you run to the bedside, you hear the nurse saying, "She isn't responsive. Her vitals are HR 62, BP 102/68, RR 6, O2 sat 94% on room air."

Challenge: This illustrates a JCAHO (Joint Commission on Accreditation of Healthcare Organizations) violation...what happened?

Image shown under Creative Commons Attribution Share-Alike License.

No Case Today

Hi Everyone,

I rarely take a break, but I got behind so there's no case today. I'll find a good one for Thursday, so check back then. If you have any good ideas, feel free to post them in reply - I will see them and comments aren't automatically public, so it's a good way of sharing that factoid you just learned or case you just saw.

Craig

Anti-Fruitarian

You are in General Surgery Clinic and you see a woman who has allergies to kiwi, banana, peach, avocado, chestnut, fig, bell pepper, tomato, and white potatoes. You roll your eyes. You ask what happens, and she says her throat swells up, she feels lightheaded, and she breaks out into generalized hives. She pulls two Epi-Pens from her pocket. She is scheduled for a laparoscopic hernia repair.

You present this case to your attending who, prior to being a surgeon, completed a medicine residency and an allergy and immunology fellowship. "Ah," she says, "11% of these patients will be sensitive to something in the operating room. And conversely, 35% of people who have that sensitivity show one of those food allergies." She draws the diagram shown above.

Challenge: When you call the operating room to schedule this case, you make sure they know she could have a reaction to...what?

P.S. Despite being Californian, your attending does not use organic locally harvested sustainable eco-friendly kiwi-skin meshes for her hernia repairs.

Image shown under Fair Use.

Chole

A patient underwent the procedure shown above four days ago but returns with fever and abdominal pain. Labs show a leukocytosis and elevated bilirubin, alkaline phosphatase, and gamma-glutamyl transferase. A trans-abdominal ultrasound shows a contained collection of fluid in the gallbladder fossa.

Challenge: What went wrong?

Image shown under GNU Free Documentation License, from Wikipedia.

Free Living

A young adult is rushed into the emergency department with acute onset headache, fever, neck stiffness, nausea, and vomiting. She notes that things taste and smell funny as well. Labs show a leukocytosis with elevated PMNs. A lumbar puncture has elevated opening pressure, PMN pleocytosis, increased protein, decreased glucose. She's started on appropriate antibiotics for bacterial meningitis, but she suffers progressive deterioration with seizures, ataxia, cranial nerve palsies, and confusion. Imaging shows cerebral edema, leptomeningeal enhancement, and areas of hemorrhage and necrosis. Finally, she falls into a coma and then dies. Lifecycle stages of the organisms recovered are shown above.

Challenge: How is this disease acquired?

Image is in the public domain.

Inconsistent

A 60 year old man with hypertension, untreated colon cancer, and a history of NSTEMI presents to the emergency department with immediate onset dyspnea two hours ago. He is short of breath at rest. He has a cough with streaky bloody sputum and associated chest pain while coughing or taking a deep breath. He has two pillow orthopnea. He says he has been taking all his prescribed medications but forgot to bring in a list. His social history is significant for being mostly bedbound due to obesity and living alone.

On exam, vital signs are heart rate 70, blood pressure 110/70, respiratory rate 26, and oxygen saturation 90%. You hear a regular rate and rhythm. He has rales and decreased breath sounds. He has some jugular venous distension. His ABG is 7.50/30/68. His CXR is unremarkable. His EKG is normal sinus rhythm with several old Q waves.

Challenge: When you present your most likely diagnosis to your attending, he says that the heart rate isn't consistent. How do you explain the patient's heart rate?

Thrower

This five year old child appeared normal at birth, but started having problems in the third month of life. At that time, she had developmental delay and recurrent respiratory infections with chronic nasal discharge. Although her growth was fine for the first year, this slowed by the second and third year to minimal. Her developmental milestones peaked at multiword sentences and walking at age 3, but has started to regress. Parents are concerned that her trouble walking is because of joint stiffness and contractures. Past medical history is significant for frequent ear, sinus, and pulmonary infections with thick secretions.

On exam, you palpate both the liver and the spleen as well as an inguinal hernia. The eye exam is noted below, and indeed, her vision and hearing has declined. While she is in the waiting room, she falls asleep and you note some sleep apnea.

Challenge: Unfortunately, the average life expectancy is 5 years and nearly all patients die before 10 years if they have what disease?

Images shown under Fair Use.