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.