On Vacation

Hello all,

No cases this week as I'm snoozing on a beach in Hawaii. Perhaps I'll have some tropical medicine next Monday. Thanks for following along!

Craig

The Scream

Sitting on the bus, you overhear this conversation behind you. "Something weird happened to my neighbor last month. For about two weeks, she started having these hallucinations, seeing things, you know? And hearing things. And she kept thinking aliens had abducted her and she wasn't kidding. I couldn't convince her things were normal. She kept going on and on about things that weren't related and kept rambling too. She wasn't showering, wasn't wearing normal clothes, it was just so weird. I heard they brought her into the emergency department but everything in her body checked out okay, it was just her mind going crazy. I heard the drug screen was negative too. But then two weeks later, she was back to normal, back to her job, like nothing was wrong. It was just so weird. I guess she was pretty stressed when this all happened since she just moved here."

Challenge: What's your diagnosis?

Image of The Scream by Edvard Munch is in the public domain, from Wikipedia.

Let It Go

A warning - the images below aren't pretty. The first image is from when the patient came into your clinic 2-3 days after the injury.

Two weeks later, the toes looked like this:

Three weeks after the initial injury, they looked like this:

Challenge: What's your diagnosis?

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It Really is a Disease!

A volunteer who just returned from a mission to West Africa comes to your clinic. Two days upon returning, he develops abrupt high fever and malaise. His oral temperatures have been up to 40 degrees Celsius. The fever lasts about four days, and at that time, he starts developing arthralgias of the hands, wrists, and ankles. These joint pains are symmetric and seem to affect distal rather than proximal areas. There is some axial skeletal involvement. These arthralgias are intense and disabling.

The rash shown above started developing about three or four days into the illness. Other symptoms include headache, myalgias, and nausea. Physical exam demonstrates periarticular edema and cervical lymphadenopathy. Laboratory tests show lymphopenia and thrombocytopenia.

You aren't sure what this is so you advise symptomatic treatment and schedule follow-up in 2 weeks.

On his next visit, the patient complains of ongoing arthralgias, edematous polyarthritis of the fingers and toes, morning pain and stiffness, and tenosynovitis of the wrists, hand, and ankles. His exam is positive for carpal tunnel syndrome. He has joint and bony pain at sites of prior trauma.

Challenge: This case could also be called "that which bends up" or "stooped walk." What's the diagnosis?

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99 Luftballoons

Challenge: What do you see here in this CT scan taken during cardiac diastole?

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Indirect

You are a hospital administrator examining your patient census. Your nurse manager says that one of her patients can only be cared for by providers who are not pregnant. The patient needs a negative air pressure room with the door closed when she gets a treatment. Providers follow contact and droplet precautions and wear an N95 mask during treatment. The patient has had a bilateral lung transplant in the past for cystic fibrosis.

Next door, a patient admitted for jaundice is taking the same drug in a different formulation but does not need any of those precautions.

Challenge: What drug are we talking about?

Image is in the public domain.

Older Than Stated Age

A 12 year old boy is referred to your pediatric clinic for exercise intolerance. He had an unremarkable birth history, but as a young child, started developing abdominal pain, nausea, vomiting, and poor appetite. He was diagnosed with reflux, gastroenteritis, and failure to thrive, though none of the treatments he got worked. He later developed recurrent cough, shortness of breath, and wheezing but inhalers have not helped. After being frustrated with not getting answers, his parents brought him to you.

On exam, he has a heart rate 110 and regular. There is no murmur, but you note a heave. His extremities are cool and mottled, with decreased capillary refill and peripheral pulses. His blood pressures are low but similar on all extremities. He is slightly tachypneic and his pulmonary exam shows wheezing and rales. You palpate hepatomegaly and peripheral edema.

Here are your initial studies:

Challenge: What's your diagnosis?

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Cath Lab II

This is a continuation from Monday's case (scroll down to review).

The patient is taken emergently to the cath lab where a procedure is performed. The post-procedure chest X-ray is shown above. The patient is extubated after the procedure and brought to the PACU. The PACU nurse pages you because the patient is not moving his legs.

Challenge: What happened?

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