Paganini and Rachmaninoff

Panel A is normal; panel B represents the patient; panel C is a variant.

These are images from a tall young adult with scoliosis and history of pneumothorax.

Challenge: What an awesome collection of pictures demonstrating this autosomal dominant disease - what is it?

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Happy Holidays

Whoops! I forgot to note that I'm taking another Case-of-the-Day break for the holidays. See you next Monday!

Craig

Early Bird

A 33 year old G1P0 woman at 33 weeks, 5 days gestation presents with painful regular contractions. Her pregnancy has otherwise been uneventful. Her fetal heart tracing is reassuring. You start her on some betamethasone and give her an oral medication that can cause nausea, flushing, headache, dizziness and palpitations.

Challenge: What medication is it?

Image is in the public domain.

Hemisphere

This CT scan is from an 8-year-old girl who presented with seizures and progressive hemiparesis. The seizures are unilateral and intractable, frequently evolving into focal motor status epilepticus or epilepsia partialis continua. She has been treated unsuccessfully with immunosuppressants. Brain biopsy only shows nonspecific inflammation.

Challenge: What's your diagnosis?

Image shown under Creative Commons Attribution Share-Alike License.

Nuff SAID

You are seeing a new patient for the first time in your family practice clinic. This is a young gentleman with a history of asthma with occasional albuterol use. His surgical history is notable for resection of nasal polyps and functional endoscopic sinus surgery for chronic rhinosinusitis. He is allergic to aspirin, getting wheezing, chest tightness, facial flushing, and conjunctival injection between 30 minutes and 3 hours after taking it. His family history is significant for diabetes, hypertension, and dementia. He drinks occasionally, quit smoking after his diagnosis of asthma, and denies drug use. He is a lawyer and lives with his wife.

Challenge: What triad stands out from his history and what does it signify?

Image shown under GNU Free Documentation License.

Many Faces

Challenge: Here are many faces of what disease?

First image is in the public domain; last three are shown under Creative Common Attribution Share-Alike License.

The Difficult Patient

A 30 year old man who recently got out of jail for the fourth time sees you for mandatory follow-up. He has been in trouble with the law since his late teenage years. But when you look farther back, he's had problems since age 10 with fights with peers, conflicts with authority figures, stealing, vandalism, fire setting, and running away from home. He's never been able to hold a consistent job. His social support is poor; he has been divorced, and his ex-wife says he never showed any empathy. He doesn't have any strong interpersonal relationships. He is estranged from his family for stealing and lying. When you talk to him, he doesn't show any remorse for his past transgressions.

He has past diagnoses of substance misuse, major depressive disorder, and attention deficit hyperactivity disorder. He continues to smoke, drink, and use marijuana, but has avoided other drugs.

Challenge: What personality disorder do you recognize here?

Airway

A morbidly obese middle aged man with unknown past medical and surgical history has a motorcycle crash. All his injuries are above the neck. He has multiple facial fractures, orbital fractures, mandibular fractures, tongue lacerations, CSF rhinorrhea, and scalp hematomas. On arrival, he is obtunded. Bag-mask-ventilation is impossible with the jaw fractures. An attempt is made to intubate him but nothing can be visualized. An attempt to place a laryngeal mask (LMA) also fails. The patient begins to desaturate.

You come to the rescue. After identifying the appropriate landmark and scrubbing with povidone-iodine, you place a needle with a syringe half-filled with saline into the airway at 30-45 degrees directed caudally. When you see air bubbles in the syringe, you advance a catheter, remove the needle, and confirm placement again. Then you connect the catheter to a bag-valve-mask, confirm CO2, and call a surgeon for a definitive procedure.

An X-ray is shown below.

Challenge: What procedure did you perform and what complication do you see above?

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