Gnawing

A 70 year old smoker with hypertension, hyperlipidemia, diabetes, peripheral vascular disease s/p femoral-femoral bypass, coronary artery disease s/p 4 vessel CABG presents with recurrent episodes of abdominal pain. The pain is dull, crampy, epigastric, usually beginning within an hour after eating, lasting about two hours. He has tried famotidine and pantoprazole without any relief. It is worse with ice cream, french fries, and fried chicken. Review of systems notes nausea, vomiting, early satiety, and weight loss. The patient is worried about cancer. Exam reveals a cachectic man with an abdominal bruit, but is otherwise unremarkable. There is no tenderness or pain to palpation. Routine laboratory tests, chest and abdominal radiographs, endoscopy, and colonoscopy are all negative. Lateral angiogram and angiogram with contrast injected into the inferior mesenteric artery are shown below.

Challenge: What's your diagnosis?

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Route

You are delivering twins to a G1P0 34 year old woman at 38 weeks with a prolonged labor. Because of uterine atony, you write an order in the chart: "Methylergonovine 0.2mg x1 now." You are called ten minutes later because the patient's blood pressure is suddenly 180/100 and she has a facial droop and a weak arm and leg.

Challenge: What happened?

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Gentle

The adolescent shown above comes to you for a school sports physical. Note the long and narrow face with a prominent forehead, chin, and large ears. Perhaps his eyes are slightly sunken. He has developmental and language delay as well as intellectual and learning disabilities. He has a diagnosis of ADHD. He has testicular enlargement but normal function. His father is unknown, and in fact, does not matter in this disease state. The mother's genetics may be sufficient to tell the tale.

Challenge: What's the diagnosis?

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Algae

A 50 year old patient with hepatitis C presents with the rash shown above. It also affects the wrists, elbows, nails, and oral mucosa. Note that the rash is somewhat shiny and flat. The lesions are itchy.

A biopsy is shown below:

Challenge: What's your diagnosis?

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Pulsating

A 30 year old man who had a recent motor vehicle accident where he sustained a basilar skull fracture, a humerus fracture, and multiple rib fractures, now presents with weird symptoms of "pulsating" over his right eye. In fact, you auscultate a bruit over his eye. He also has blurred and double vision, headache, and ocular pain. Examination shows some proptosis and chemosis of the eye. Extraocular movements are limited and there is some facial sensory loss.

Challenge: What's the diagnosis?

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Always Sick

You see two patients who have the same diagnosis: a 3 year old child and a 23 year old adult who present because they are "always sick." They have recurrent infections including pneumonia, bronchitis, sinusitis, otitis, and conjunctivitis. Cultures have grown out Pneumococcus, Hemophilius, and Mycoplasma. For one of the patients, rhinovirus has been a persistent infection. For the other, a septic arthritis from Streptococci has caused problems.

Both patients suffer from chronic lung disease with bronchiectasis. Gastrointestinal manifestations in the older patient includes inflammatory bowel disease and nodular lymphoid hyperplasia, shown above. His alkaline phosphatase is elevated. The other patient suffers from diarrhea, weight loss, and nonspecific malabsorption. The older patient has autoimmune hemolytic anemia and thrombocytopenia. The younger patient has lymphadenopathy and splenomegaly; a biopsy might show noncaseating granulomas. The younger patient also has allergic rhinitis and asthma.

These patients have an increased risk of malignancies, especially for non-Hodgkin's lymphoma, almost always extra-nodal, well differentiated, and of B cell origin. Neither of these patients responds to vaccinations. Routine blood counts, serum chemistries, electrolytes, and urinalysis are normal.

Challenge: These variable manifestations describe what disease?

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Ethnicity

An Armenian patient comes to you in desperation because "no doctors have been able to figure out what is wrong with me." He says his first attack began in childhood, before adolescence. He had severe belly pain and fever for 2-3 days which got better on its own. Since then, he's had recurrent attacks of abdominal pain and fever with an abrupt onset, lasting 1-3 days, resolving spontaneously. In between attacks he feels perfectly well. He has not been able to identify any triggers.

The abdominal pain usually starts with focal pain and tenderness that then generalizes with guarding, rebound tenderness, rigidity, and ileus. In fact, he's had an exploratory laparotomy in the past, but the surgeons found nothing remarkable and took out a perfectly normal appendix. Once, he had unilateral pleuritic chest pain and a pleural effusion that resolved after several days. During these attacks, laboratory tests show leukocytosis with neutrophillia and elevated acute phase reactants like ESR and CRP.

Challenge: Although these short term attacks cause a great deal of morbidity, the major source of mortality is progressive secondary amyloidosis. What is this?

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Phoenix

Challenge: The title Phoenix is because of the third image. What do these pictures show?

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Pharmacology II

A 30 year old G1P0 at 38 weeks is undergoing active labor. Her blood pressure is 145/92 and she has 4+ protein in her urine. She is 5 cm dilated. Fetal heart tones are reassuring. The resident writes her for magnesium 6g IV load followed by an infusion. However, just as the nurse is about to give it, you stop her and ask the patient: do you ever have fluctuating muscle fatigue, especially after exercise or later in the day? You ask: do you ever see double or get jaw tiredness when eating a steak?

Challenge: What are you asking about and why?

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