Gratitude

Happy Thanksgiving! This blog revolves around obscure, fascinating, strange, and unusual diseases, but some days, we have to give thanks for the healthy.

You are a pediatrician evaluating a perfectly healthy baby. She can stand on one foot with some slight support, walk backward, and even go up stairs with one hand held. She scribbles spontaneously, picks up and drinks from a cup, fetches and carries objects, and finds a toy observed to be hidden under layers of covers. She periodically visually relocates her caregiver and has some self-consciousness, feeling embarrassed when she sees you observing her. She understands simple commands and uses 5-10 words.

Challenge: How old is she?

Image is from Wikipedia, shown under Creative Commons Share-Alike License.

The Coagulation Cascade

A 30 year old postpartum woman presents with bleeding after minor surgery. She is G1P1 and recently delivered a healthy baby boy at 39 weeks. Her pregnancy was complicated by gestational diabetes mellitus, but there were no problems with the delivery. Three months after delivery she had her wisdom teeth pulled and had prolonged bleeding. She also noted increased epistaxis and mucosal bleeding. She has no other surgical history. She takes iron, has no allergies, has a nonsignificant social history, and has an otherwise negative review of systems. Her labs show an prolonged aPTT with a normal PT. You then take her plasma and mix it with pooled normal plasma; the aPTT remains prolonged.

Challenge: What does this mean? What's the most likely diagnosis?

Image from Wikipedia, shown under Creative Commons Attribution Share-Alike License.

Catching Up with Life

Hi everyone,

Thank you for following along with all the cases. Each time I sit down to write a new blog, I wonder whether there are any more medical diseases I can find, but I always find something. It's been pretty time-consuming, however, and I need a break from Case of the Day this week. I've been falling behind with lots of competing priorities, and I just need to make a little more room. It's also why cases and solutions occasionally show up a little bit late. But thank you for understanding and I hope you're enjoying and learning. Come back next Monday for a new case.

Craig

Prognosis

A 60 year old man presents with headaches and seizures. A T1 weighted MRI is shown below.

Challenge: What's the most likely diagnosis?

Image shown under Fair Use.

April Showers

A 30 year old woman presents with an unprovoked pulmonary embolism. In searching for the cause, a contrast MRI is performed, shown above.

Challenge: What's the syndrome?

Image shown under Fair Use.

Goat's Rue

An 80 year old gentleman is brought in by ambulance to the emergency department for "problems breathing." His family found him at home with empty pill bottles, confused and tachypneic. It's not clear what he ingested, though all the pill bottles were his. His past medical history includes hypertension, hyperlipidemia, diabetes, osteoarthritis, and dementia. His family knows he takes one medication for each of those diseases. He also has chronic kidney disease and cirrhosis, though he does not take any medications for those comorbidities. His past surgical history is insignificant, he has no allergies, he does not smoke, he drinks 2 beers a night, and he does not do illicit drugs.

Currently, he is complaining of nausea and abdominal pain. He is tachycardic, hypotensive, and tachypneic. He is a little confused. A fingerstick glucose is 70. Acetaminophen and salicylate levels are negative. An EKG shows sinus tachycardia with no changes in QRS or QTc intervals. A chest X-ray and CT abdomen are normal. An arterial blood gas shows an anion gap metabolic acidosis with respiratory compensation. A chemistry panel shows a Cr of 1.8. His WBC is normal, he has no fever, blood cultures are obtained, and a urine sample is normal.

Challenge: There is no antidote for this culprit. What is it?

Image shown under Creative Commons Attribution license, from Wikipedia.

Check

A middle-aged man with an unknown past medical history is brought in after a motor vehicle accident. He was going 60mph when he hit the center divider of the highway and flipped his car. He was extricated after a prolonged period of time. On scene, he was confused but talking, moving all extremities, with a GCS of 12. On arrival to the emergency department, however, he becomes progressively more somnolent to a GCS of 7. He is hypotensive, tachycardic, and tachypneic. He is intubated for airway protection. A primary exam shows maxillofacial trauma, CSF rhinorrhea, absent breath sounds on the right, a positive FAST scan, and several extremity fractures. A chest tube is placed successfully. Multiple IVs are placed and blood transfusions are started. An attempt to start an arterial line is unsuccessful due to a weak pulse. A chest X-ray shows several rib fractures and a resolving pneumothorax. He is sent to the CT scanner.

In the CT scanner, he spikes a temperature and becomes more hypotensive. He is started on vancomycin and piperacillin-tazobactam. His blood pressures continue to plummet and the CT scan is aborted. He is taken emergently to the operating room for an exploratory laparotomy. The anesthesiologist continues to fluid resuscitate the patient, giving more blood products, fresh frozen plasma, and platelets. The patient is started on a dopamine drip. A fibrinogen panel comes back low and cryoglobulin is administered. At the end of the case, dark red-brown urine is noted in the Foley catheter. Initial placement of the Foley catheter showed concentrated yellow urine. At this time, the hematology lab calls and says that when they spun down the patient's blood, the plasma was light pink. A critical lab value of potassium 6.2 is also noted.

Challenge: What happened?

Bonus Question: What's shown in the picture above?

Image shown under GNU Free Documentation License, from Wikipedia.