Back to the Drawing Board

A 30 year old woman with anxiety and longstanding migraines comes in with severe head pain despite "trying everything." Her headache history starts as a teenager when she had classic migraine symptoms of unilateral head pain lasting 24 hours triggered by poor sleep, stress, or poor eating habits, associated with nausea, vomiting, photophobia, and phonophobia. These were treated with NSAIDs and acetaminophen.

However, in her late 20s, her migraines started happening more and more frequently. She started taking compounds containing acetaminophen, hydrocodone, oxycodone, butalbital, caffeine, aspirin, and ibuprofen with some relief. She now takes multiple medications a day including a daily triptan. Despite trying everything, she currently suffers a constant debilitating headache present when she wakes up in the morning. She gets some relief from her medications but never enough. She also has nausea, difficulty concentrating, and irritability. Her vital signs and neurologic exam are normal.

Challenge: She asks if she has a brain tumor or if you have another medication or why her migraines have gotten so bad. What do you say?

Image of Fioricet is in the public domain, from Wikipedia.

Bound

 A 70 year old man with a history of smoking, COPD, and lung cancer undergoes a pneumonectomy for non small cell lung cancer. His post-operative course is complicated by hemothorax requiring chest tube placement. He eventually is discharged to home. On his routine post-operative visit, he continues to complain of shortness of breath. There is no pleuritic chest pain, cough, or fever. CXR shows an effusion and thoracentesis is performed which has LDH and pleural fluid protein that are borderline between transudate and exudate. WBC is low and predominantly mononuclear. Weeks later, the pleural effusion is back.

A CT is obtained and shown above.

Challenge: What's your diagnosis?

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Tonic Water

Challenge: What antiarrhythmic causes this arrhythmia? Side effects include nausea, diarrhea, abdominal pain, tinnitus, hearing loss, confusion, delirium, vision changes, and psychosis.

Beware the Internet

A 50 year old man presents to your family practice clinic with a multitude of complaints. He says he bought some Internet supplements for "sexual function." Since taking them, however, he's noticed increased acne, gynecomastia, urinary frequency at night, snoring, and daytime sleepiness. Lab tests show that his hematocrit has increased compared to a year ago.

This scientist in Zurich shared the Nobel Prize for synthesizing the drug from a cholesterol base.

Challenge: What supplement is he taking?

X Files

A 5 year old boy comes to your clinic because of bleeding propensity. Even at birth, he had petechiae and prolonged bleeding from the umbilical stump and after circumcision. Through his childhood, he has had purpura, epistaxis, hematuria, and even one episode of GI bleeding. His past medical history is significant for eczema, for which he is followed by a dermatologist, and recurrent Streptococcal and Haemophilus infections. He's had otitis media, sinusitis, and pneumonia, especially in the last two years.

Exam shows some lymphadenopathy and hepatosplenomegaly. He has eczema and some Molluscum. Labs show a decreased platelet count.

Challenge: This patient is at risk for lymphoma, autoimmune disorders, and other malignancies. What does he have?

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Cottonmouth

You're working in an emergency department in the geographical area shown above. A patient comes in with marked swelling of a hand. He fell into a river and felt pain in the affected hand. He also has nausea, vomiting, diarrhea, light-headedness, diaphoresis, and chills.

Challenge: What's your diagnosis?

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Dolor

A 35 year old G4P4 woman presents with chronic pelvic pain, your favorite chief complaint. This has been going on for years. It began with her second pregnancy and worsened with each subsequent pregnancy. It's a dull ache or heaviness that increases premenstrually. It is exacerbated by prolonged standing, postural changes, walking, coughing, and after intercourse. It is mostly on the left side. A bimanual examination shows marked ovarian tenderness, cervical motion tenderness, and uterine tenderness with direct palpation.

She's seen multiple physicians. Pelvic sonograms have only shown dilated pelvic veins in the adnexa and outer myometrium. CT scans have only showed tortuous and dilated ovarian veins. A left ovarian venogram is shown above. She's even had a diagnostic laparoscopy that was normal. She's been treated with opiates, antibiotics, steroids, and other medications. The only thing that has benefited has been medroxyprogesterone acetate.

Challenge: What's your diagnosis?

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Spiro

You see three patients in thoracic surgery pre-operative clinic, all with a 100 pack-year smoking history, COPD, and lung cancer.

Patient 1 has an FEV1 of 1.4L and will undergo a lobectomy. Based on a CT scan, you predict his postoperative FEV1 to be 900mL.

Patient 2 has an FEV1 of 1.9L and will undergo a lobectomy. He also has interstitial lung disease and his DLCO is 55%.

Patient 3 has an FEV1 of 2.2L and will undergo a pneumonectomy. He does not have any further studies.

Challenge: All three patients are scheduled for surgery tomorrow. Do you need to cancel or delay any surgeries for further studies?

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