No Man is an Island

Challenge: What are we looking at?

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Echo (echo) II

The echo and aortic root angiography shown above are taken in a patient with Williams syndrome.

Challenge: What do you see?

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Echo (echo) I

Although this is the most common congenital heart defect at birth, it accounts for only 10% of defects in adults. Although most patients are asymptomatic, some are at risk for aortic regurgitation, endocarditis, or heart failure.

Challenge: What's shown here?

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The Apple and the Tree

A 25 year old G4P0 woman who has not had any prenatal care comes to the hospital with sudden vaginal bleeding, abdominal and back pain, and uterine contractions. Her obstetric history is notable for stillbirths and a fetal demise in the past. She appears to be at term. Because of nonreassuring fetal heart tones, she goes to a stat C-section. She is hypertensive in the operating room prior to anesthesia. After delivery, there is significant blood loss, and baby is delivered to the pediatric team.

When the baby is two to three days old, he is noted to have tremors, a high pitched cry, irritability, excess suck, hyperalertness, and episodes of apnea.

Challenge: What's going on?

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Where's the Pain? II

A 50 year old woman presents with right leg pain. She complains of back pain radiating down the posterior aspect of her leg into the foot. Examination shows weakness of plantar flexion, leg extension, and toe flexion. There is no ankle reflect. Sensation is diminished on the posterior aspect of the leg and lateral foot.

Challenge: Where's the pain coming from?

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Where's the Pain? I

A 40 year old woman with depression, PTSD, and PCOS presents with continued abdominal pain. She localizes the pain to a highly discrete region of her lower right abdomen 2cm in diameter near the lateral aspect of the rectus abdominus sheath. The character of the pain is difficult to describe, and it's worse with standing, walking, stretching, laughing, coughing, and sneezing. While supine, you ask her to raise both legs off the table, and touching the area produces greater pain. Her past surgical history includes a cholecystectomy, appendectomy, and lysis of adhesions. She takes several hydrocodone-acetaminophen pills a day, an oral contraceptive, and sertraline. The rest of her review of systems is negative.

Challenge: What's your diagnosis?

Happy July!

Happy July! For medical residents, this signifies a new year as graduates start their first jobs, finishing medical students attach an "MD" to their name, and each resident adds a "+1" to their level of training. I'm going to take a week off from writing cases, so I'll be back next Monday. Thanks for following along!

Craig