No Cases this Week

Hi Everyone,

Thank you for following Case of the Day. I'm going to take a quick break this week as I am feeling fairly exhausted and behind in coming up with cases. As always, suggestions and ideas are welcomed. New cases will be posted next Monday.

Craig

Plosive

This child is referred to you for a routine tonsillectomy and adenoidectomy. His cleft lip and palate have not been repaired. His pediatrician, however, feels that the tonsils and adenoids are more of a problem because the child has severe OSA and recurrent tonsillitis. When you examine the child, he is able to repeat nasal consonants ("m" "n"). However, with plosives ("Bobby" "puppy"), you hear air escape. You also note air escape with sibilant fricatives ("s" "z" "sh").

Challenge: Would you do the tonsillectomy, adenoidectomy, both, or neither?

Image shown under Creative Commons Attribution Share-Alike License.

Mask

You meet this child. He does not smile. He does not frown. In fact, his face doesn't move at all. You notice that as he looks around, his eyes never move laterally from side to side. 

Challenge: What's the diagnosis?

Image shown under Creative Commons Attribution Share-Alike License.

Sangre

A 65 year old man presents with debilitating fatigue and some weight loss. On exam, you note hepatomegaly and splenomegaly. The spleen is pretty remarkable; you feel the inferior border at the pelvic brim and the right border past midline. His past medical history includes a DVT when he had a knee replacement. Otherwise, he's pretty healthy. However, labs are surprising. Hemoglobin is 9g/dL, WBC is 26,000/microL, platelets are 90,000/microL.

Peripheral blood smears are shown below:

You attempt to do a bone marrow aspiration but get a "dry tap." A bone marrow biopsy is shown below; the trichrome stain colors collagen blue.

Challenge: What's your diagnosis?

Images shown under Fair Use.

Artemis

This patient has a rare disease with an estimated incidence of one case per million per year. Symptoms started two weeks ago with a steady gnawing or boring pain behind the left eye. This was followed by double vision. Your extraocular movement exam is shown above (the center picture is neutral, the patient looks in the direction of the image relative to the center picture).

Labs including CBC, electrolytes, glucose, hemoglobin A1c, liver function tests, ACE, ANA, Anti-dsDNA, Anti-Sm, ANCA, FTA/ABS, lyme serologies, SPEP, ESR, and CRP are normal. A lumbar puncture is performed and all CSF studies are normal.

Contrast-enhanced coronal T1 MRI shown below:

Since you don't know what's going on, you give a trial of steroids, and within 48 hours, the patient's pain has resolved. Within a month, all the eye findings have resolved as well.

Challenge: Now you suspect the diagnosis is...what?

First image shown under Creative Commons Share-Alike License. Second image shown under Fair Use.

Wall

Challenge: This patient has an old MI in which wall?

Image shown under Fair Use.

Labor Day

This is a fetus with massive hydrocephalus in a patient with premature labor at 34 weeks. On digital examination, you palpate the orbital ridge, saddle of the nose, mouth, and chin.

Challenge: What is happening here?

Image shown under Fair Use.