Gutenberg

This 1680 painting and these photographs both depict the same disease. These patients are often born by C-section due to breech, decreased fetal activity, and polyhydramnios. Prenatal ultrasound might show unusual positioning of hands and feet. As neonates, patients demonstrate profound hypotonia, feeding difficulties, a weak cry, and genital hypoplasia. Toddlers are slow to acquire their motor milestones, and starting between age 1-6, they become obese from eating a lot. Patients are often short and have growth hormone deficiency. Most patients show some behavioral problems and learning difficulties.

Challenge: What's your diagnosis?

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

Piddly

A 22 year old woman comes into clinic complaining of lower abdominal pain, worse with jarring movements, which started just after her period finished. It's been going on for a week. The pain does not localize to any particular side. The patient also has some fevers, chills, and vaginal discharge. She denies nausea, vomiting, diarrhea, dysuria, or change in bowel habits. The patient has multiple sexual partners and uses an oral contraceptive. She has no past medical or surgical history.

On exam, the patient is afebrile. Abdominal exam shows tenderness in the lower quadrants with rebound. Bowel sounds are diminished. Pelvic exam shows endocervical discharge, adnexal tenderness, and cervical motion tenderness. The pain and tenderness do not lateralize to any side.

Ultrasound is shown below:

















The ovary is marked OV and the arrows point to the Fallopian tube.

Challenge: What's your diagnosis?

Image shown under Fair Use.

In the News

Challenge: This X-ray has been in the news lately. I thought it was pretty cool. What's going on here?

Image shown under Fair Use.

SOPA and PIPA

No case of the day today. I instead encourage you to learn about two bills before Congress now, called Stop Online Piracy Act and Protect IP Act. These bills would make websites and blogs like Case of the Day impossible. I use images from many different websites, all for educational purposes, which could be illegal under interpretation of SOPA and PIPA. If you enjoy Case of the Day, then I encourage you to advocate against these bills.

We will return to our regularly scheduled case on Monday. Thanks!

-Craig Chen, MD

Near and Dear

This is a rare neurodegenerative condition with a characteristic non-contrast CT scan shown above. Its phenotypic presentation is variable with features of parkinsonism, chorea, dystonia, cognitive impairment, and/or ataxia. Patients are between 20 and 60, and there is a familial form inherited as an autosomal dominant disease.

Challenge: What is it?

Image shown under Fair Use.

Sapling

Challenge: These are examples of what kind of fracture seen in pediatrics?

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

Intern Fatigue Syndrome

A 25 year old medical student is concerned because she has chronic daytime sleepiness. She keeps a sleep diary but sleeps exactly the same amount as classmates without chronic sleepiness. The patient is often so sleepy that she falls asleep suddenly at inappropriate times. Often when she takes notes in class, she just writes off the end of the page; she's also missed her highway exit several times. She feels most awake in the morning and right after naps.

Furthermore, just when she is falling asleep and occasionally when waking up, she has vivid frightening hallucinations. They are visual, tactile, and auditory. Immediately after awakening, she sometimes feels that she is paralyzed and cannot move for a minute or two.

Review of systems is positive for weakness only with laughing. Weird? Weird! This weakness happens mostly in the face, neck, and knees and is associated with strongly positive emotion. It lasts only a minute and does not interfere with consciousness. She does not snore and is not obese.

Challenge: What's your diagnosis?

Up High, Down Low, Too Slow

You are the anesthesiologist on call and get paged by labor and delivery for an urgent C-section for failure to progress. You meet the patient for the first time in the operating room; she is 30 years old, G1P0 at 39 weeks, morbidly obese with gestational diabetes. Given her morbid obesity, you elect against general anesthesia and decide to place a spinal anesthetic instead. You position the patient, place local lidocaine, and go in with a standard spinal needle at L3-4 (you think; the morbid obesity makes it hard to feel landmarks) but are unable to get into the subarachnoid space. You try again one level higher at L2-3 and manage to get into the CSF. You inject 1.8mL of hyperbaric bupivicaine and 10mcg of fentanyl.

You lay the patient down and achieve surgical anesthesia quickly. The obstetricians begin working but because of the large pannus, they ask you to put the patient in steep Trendelenberg and have two nurses hold back the pannus as they work. Soon the patient becomes hypotensive. You run in fluids wide open and put a roll under the patient's right back to take pressure off the vena cava. The surgeons are getting into some blood loss, but not enough to explain the hypotension. She continues to remain hypotensive but is not particularly tachycardic. You ask her how she feels and she starts complaining of nausea and dyspnea. Her respiratory rate drops to 10, then 8, then 6. You end up intubating her emergently.

Challenge: What do you think happened?

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

Moon

A 30 year old woman reports sudden intense right lower quadrant abdominal pain after going to the gym. This pain was also accompanied by some light vaginal discharge. She presented to urgent care where she had normal vital signs. Physical exam showed moderate tenderness to palpation on the right lower quadrant with minimal rebound and guarding. Pelvic exam showed mild cervical motion tenderness and slight adnexal fullness. Laboratory studies are normal and a pregnancy test is negative. Urinalysis shows pyuria. A CT abdomen/pelvis is shown below.

Challenge: Lots of things present this way; what is your diagnosis?

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