Pharmacology I

A 90 year old man with HTN, HL, a-fib, COPD, kidney stones, BPH, GERD, osteoarthritis, h/o GI bleed, gout, and dementia is admitted from the nursing facility where he lives to the hospital because of shortness of breath and cough. CXR shows a lobar pneumonia. Sputum induction grows MRSA. He gets severe red man syndrome with vancomycin so he is started on the drug shown above by the resident. This cyclic lipopeptide depolarizes the bacterial cell membrane and is approved for skin and soft tissue infections as well as bacteremia with MRSA. The resident remembers to write for weekly CKs and to check for peripheral neuropathy and myopathy.

Challenge: However, this patient won't get better. Why? What's the mechanism?

Image is in the public domain.

Apologies

My sincerest apologies for a hold-up in cases. I really don't know what happened. They were written and ready but simply did not publish correctly. I've tinkered with them a little and hopefully all the bugs are out. Thank you for following this blog and continuing to learn with me. I really appreciate it.

Family Medicine for $200

You are playing Jeopardy! and pick the category "Family Medicine for $200."

Alex Trebek reads, "A 60 year old post-menopausal woman is prescribed this medication 'for bones' but her physician neglects to tell her how to take it; she takes it with a sip of water before going to bed and gets severe esophageal pain..."

Challenge: You hit the buzzer and say, "What is...?"

Image is in the public domain.

Screening

Luckily with screening, this autosomal recessive disease is caught early. Initially, neonates are asymptomatic, but as they start taking in breast milk or standard infant formula, they begin to have developmental delay. Ultimately, they can have moderate-severe mental retardation. Brain imaging shows white matter lesions. A quarter of patients may have epilepsy. Other findings include abnormalities of gait, sitting posture, and stance as well as hyperactivity. Skin findings include light pigmentation and eczema. The body and urine can sometimes have a "mousy" odor.

Challenge: What disease is described here?

Image is in the public domain, from Wikipedia.

What's This? II

Challenge: What do each of the four arrows point to in this patient who is in the cardiac intensive care unit for acute MI and cardiogenic shock?

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What's This? I

Challenge: These are noninvasive alternatives to surgical management for what diseases?

Image is in the public domain.

Pan-Positive Review of Systems

You sigh when you look at your clinic appointments for the day. You have been seeing a 29 year old woman for several years, and she always has the same chief complaints. You haven't been able to figure out the diagnosis despite a battery of tests. She always has headache, belly pain, back pain, and chest pain. Her headache is not characteristic of migraine or cluster; it responds a little to acetaminophen. She has had a negative CT abdomen/pelvis, no response to a PPI, and a negative upper endoscopy. You initially held out on back films but finally caved in, and of course, they are negative. She's had a negative EKG, CXR, and stress echo. She also complains of nausea, bloating, irregular menses, difficulty swallowing, and a "lump in her throat." These symptoms are interfering with her work, which she really likes. She has no odd animal, occupational, or environmental exposures. She only takes acetaminophen at recommended doses. She does not drink, smoke, or use any drugs (which you have confirmed with a urine toxicology). She hates coming to the doctor, but simply wants to get well.

Challenge: This constellation suggests what diagnosis?

The Greek Heart

A passenger in a motor vehicle accident is brought into the emergency department by ambulance. On arrival, the only complaint she has is left shoulder pain, worse with inspiration. Exam shows a positive seat belt sign. Plain films of that extremity are negative; CXR notes rib fractures. The FAST exam and a CT scan are positive, and the patient goes to the operating room.

Challenge: Given the limited information presented here, what was the most likely injury? What is the sign described here?

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