The Lost Art

Welcome back! You have a first year medical student tagging along and send her to listen to a murmur. She describes a mid to late diastolic rumble heard at the apex. S1 sounds normal and there is no opening snap. You are an old school pharmacologist so you administer inhaled amyl nitrate. The murmur decreases in intensity and duration. As you teach the medical student, you pull out an old pathology slide:

Challenge: What's the murmur? What's the valve defect? What does the slide show?

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Happy Holidays!

I'm taking a break from Case of the Day this week. It's been a pretty busy year, but I thank you all for following along, posting answers and comments, and learning with me. Surprisingly, this blog hit 80,000 hits! Wishing you and your family a warm, safe, and happy holiday season. I'll see you next week. 

-Craig.

1 in 2200

Prenatal ultrasound showed a "heterogenous mass" in the chest concerning for "cystic adenomatoid malformation." After delivery, this X-ray was obtained due to a barrel chest and scaphoid abdomen.

Challenge: What do you think of the prenatal ultrasound interpretation?

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The Sound Must Seem an Echo to the Sense

A 51 year old man with hypothyroidism presents with a confusing constellation of symptoms. He's seen multiple physicians without an answer. Five years ago, he began having tingling, paresthesias, and the feeling of coldness in his feet. Over time, he developed weakness in his lower extremities. All these symptoms started distally and had gradual, proximal, symmetric spread. He has no history of diabetes or alcoholism; his B12 and methylmalonic acid are normal. His primary care physician was baffled. A few years later, he could not even climb stairs, arise from a chair, or grip things strongly in either hand. On exam, muscle weakness is more marked than sensory loss, though he has both; his touch, pressure, vibratory, and joint discrimination are more affected than temperature and nociception. There are no cranial nerve abnormalities, though you do note papilledema. A lumbar puncture shows an elevated CSF protein > 100mg/dL with a normal cell count.

Review of systems is remarkable for erectile dysfunction and unintentional weight loss. The rest of the exam is surprising for hyperpigmented skin, telangiectasias, mild hepatosplenomegaly, and lymphadenopathy. Labs show low testosterone and a serum monoclonal protein. An X-ray is shown below.

(Just focus on the arrow; I know this X-ray is a female, not a male)

Challenge: What's your diagnosis?

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Lumps and Bumps

A 30 year old woman palpates a soft mass in her breast. Ultrasound is shown above. Aspiration yields a milky substance.

Challenge: What's your diagnosis?

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Chips

A man in his 20s is brought in as a trauma victim. He is an unrestrained passenger in a high speed motor vehicle accident. His GCS is 7 and he is intubated in the trauma bay. The patient is hemodynamically unstable with tachycardia and hypotension. An abdominal wall contusion is noted and there are several rib fractures. An exploratory laparotomy for shock is undertaken.

Blood is found in the abdomen. The hemoperitoneum is drained and laparotomy pads are placed in all four quadrants, along the peri-colic gutters, and into the pelvis. A large liver laceration is noted and manual compression of the liver is started. Because of ongoing bleeding, the following procedure is performed with a vascular clamp:

Challenge: What's this procedure called?

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Greece

A 34 year old man presents with ankle pain. The pain is worst when he tries to push off from the ground; it is minimal when his foot touches down. The pain and stiffness is about 2-6 cm above the posterior calcaneus. It is burning, worse with activity, relieved by rest. Since his last visit, he has started to run because you counseled him to get more exercise for weight loss; his BMI is 32. You palpate crepitus when the patient dorsi and plantarflexes the foot.

Challenge: What's the diagnosis?

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Japan

The map above shows the geographic distribution of an important cause of childhood neurologic infection and disability. Mosquitoes are the main vectors, and the primary hosts are pigs and wading birds. In the most common presentation, after a 5 to 15 day incubation period, patients develop fever, rigor, and diarrhea. This is followed by headache, vomiting, and generalized weakness. Finally, there are mental status changes, focal neurologic deficits (paresis, plegia, cranial nerve palsies), and movement disorders. Many patients go into a coma and have respiratory failure. In children, seizures are very common and can be subtle - twitching of a digit, eye movement, or irregular breathing. Labs reflect a mild leukocytosis and hyponatremia. CSF studies show an elevated opening pressure, and thalamic lesions are seen on imaging.

Challenge: What's the disease?

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