Insult on Injury

These biopsies are from a 60 year old gentleman who was admitted to the ICU for a severe COPD exacerbation. He has a known history of COPD, diabetes, and hyperthyroidism, was not taking his medications, and came into the emergency department with hypercarbic respiratory failure one week ago. He was intubated for airway protection due to altered mental status. He has been on high dose IV glucocorticoids for the COPD exacerbation.

He had a prolonged extubation due to difficulty weaning him from the ventilator. Even after he was successfully extubated, he complained of weakness and exam showed a flaccid weakness greater in the proximal than distal extremities affecting all limbs. His facial muscles are also weak, though extraocular movements are intact. Sensation is normal. Deep tendon reflexes are normal. CK is elevated.

Challenge: What is your main concern?

Image shown under Fair Use.

Pre-Op II

You are evaluating a 50 year old smoker for lung resection for localized non-small cell lung cancer. Pre-operative pulmonary function tests include: FEV1 1.8 L, 75% of predicted, preoperative DLCO 90%, predicted post-operative FEV1 is 900mL or 45% of predicted.

Challenge: What is your interpretation of this data?

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

Pre-Op I

This week's cases will be things seen in pre-operative clinic.
A healthy 55 year old gentleman is scheduled for a laparoscopic cholecystectomy for symptomatic cholelithiasis. He has not seen a doctor in ages but is "otherwise healthy." He has never had surgery before. He takes five herbal medications for "general wellness." He has no allergies. He smokes marijuana daily, but does no other alcohol or drugs. His vital signs are all within normal limits. His Mallampati score is II, he has good neck range of motion, and his heart and lungs are normal on exam. Because of his age, a screening EKG is obtained and shown above. The EKG computer says "abnormal EKG."

Challenge: Do you do the case or cancel it for further workup?

Image shown under Fair Use.

The Illusionist

These images are from a patient with a "vanishingly" rare disease which affects children and young adults (age<40). Although almost any bone can be affected, the shoulder girdle, pelvis, and mandible are most common. The lesion is nonulcerative but locally aggressive. You take a biopsy which shows no malignant cells but intraosseous proliferation of hemangiomatous or lymphangiomatous tissue. Osteolysis is present. The disease is not hereditary. Some patients present with pain, swelling, or a pathologic fracture, while others are asymptomatic. There are no specific laboratory findings.

Challenge: Only 150 cases of this disease have been described; what is it?

Image shown under Creative Commons Attribution 2.0 Generic License.

Which Is It?

Jaundice A starts at 3-5 days of life, peaking at 2 weeks. Total bilirubin levels are commonly >5 and mostly unconjugated. This is a relatively benign condition. Jaundice B starts at the first week of life in conjunction with weight loss and dehydration; it is seen more commonly in preterm rather than term infants.

Challenge: What is Jaundice A called? What is Jaundice B called?

Image shown under Fair Use, from newborns.stanford.edu.

Short Blogger Outtage

Hi everyone,

There was a short outtage with the blogging service and so things are a little disrupted, but I should have a new case on Monday. The other thing is that this blog has been an immense privilege to put together and maintain. It began as a fleeting idea in the first year of medical school and has evolved to capturing some of the complexity, mystery, and fascination in medical diagnosis. I've found this entire experience to be incomparably educational for myself. However, I think that I am slowly edging toward closing this blog. It was never meant to be an endless project, and over the course of the last four years, I've explored over 500 medical diagnoses (and to think about it, I'm pretty happy to have read the same number of UpToDate articles for this blog). As I begin advanced training in anesthesiology, I will turn my attention and time to other things. I still have a host of cases to explore so I'll probably keep chugging away for the next couple months but I wanted to give you a heads up. Thank you for your time and your interest, and good luck on all your endeavors.

Craig Chen, MD

Mike and Ike

You are doing home visits and stumble upon this scene. The patient admits to doing IM shots of street drugs. "But it's cool, I clean the needle before I inject." You ask him how he cleans the needle and he says, "I lick it." Unfortunately, he has an erythematous tender area over his deltoid where he injects. "I think I might have an infection," he says. You admit him to the hospital and get an ultrasound which shows a complex fluid collection. Aspiration shows gram negative rods. Unfortunately at that time, he says, "I want to leave. I'm not going to stay. Just give me some oral antibiotics."

Challenge: What is the antibiotic of choice here? What might the organism be?

Image is in the public domain, from Wikipedia.

SummerTop

You are in Uganda doing an international elective and you see the patient shown above. He comes in because of the painful lesion on his shoulder which he got while traveling through warm shaded forests in a large blue van (with open windows). On examination, the lesion is rubbery, painful, and indurated. You are unsure what it is and tell the patient to return in a week.

In a week, the patient presents again with intermittent headaches, fevers, malaise, and arthralgias. On exam, the patient has soft painless posterior cervical lymphadenopathy and splenomegaly.

Challenge: The diagnosis is lethal if untreated, so you better know what it is before it progresses to the next stage. (What's the next stage?)

Image is in the public domain.

Hard as a...

A male infant presents with fatty, foul smelling diarrhea, poor growth (<3rd percentile for height, <3rd percentile for weight), and recurrent infections. His bowel movements are pale, greasy, and voluminous though with time, this symptom may resolve. He also keeps presenting with pneumonias and otitis medias. Labs show a pancytopenia as well as a low trypsinogen level. A sweat test is negative. A bone marrow biopsy shows hypocellular marrow. Full examination shows skeletal abnormalities such as metaphyseal dysostosis, thoracic dystrophies, and osteopenia. Notably, his parents are tested for the disorder he has and they are both found to be carriers of the genetic mutation. Down the line, the patient is at higher risk for myelodysplastic syndrome and AML.

Challenge: What's your diagnosis?