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?

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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?

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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?

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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)

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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.