Economics

Here's a different way of looking at a disease. It is the most commonly diagnosed gastrointestinal condition, and direct and indirect costs of this disease can be up to $30 billion dollars a year. This is probably because it is the second highest cause of work absenteeism (behind the common cold). The prevalence in North America is approximately 10 to 15%, yet only 15% of patients seek medical attention. Young patients and women are more likely to have it; there is a 2:1 female to male predominance. This disease makes up 25-50% of referrals to gastroenterologists.

Challenge: What is it?

Are You Serious?

A family comes into urgent care, all complaining of abdominal cramps, nausea, and vomiting. One of them also has diarrhea. Earlier today, they ate fried rice.

Challenge: What's the diagnosis?

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Well, I Tried

Though not planned, I guess there are no cases this week. Oops! I'll have them over the holiday week next week. Sorry about that. I know I also have to get around to posting answers - it's all on the to-do list.

Craig

Not Seasickness

A 30 year old woman with depression presents with dizziness after being on a boat (or using a flight simulator or being on a water bed). When she's on a boat, she feels a sense of swaying or rocking, like she's walking on uneven ground. She doesn't feel like the room is spinning around her, but rather she just has disequilibrium. She does not feel nauseous. She's never had motion sickness or seasickness. Her physical examination is normal. Vestibular tests are normal. She is treated with benzodiazepines.

Challenge: What's the diagnosis?

Squiggles

Challenge: What category is this tracing?

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Phantom

Here's a great case! This blood smear is from a patient with massive hemolysis. In fact,the laboratory called because routine chemistries are not working correctly and they cannot cross-match the blood. The patient initially presented with multiple knife wounds in a fight over black tar heroin (he also does skin popping). He had severe pain at the site of the injuries and was admitted to the hospital for monitoring, but over the last 24 hours, has become quite ill. He was transferred to the intensive care unit with tachycardia, fever, and shock. He is developing renal failure. The skin over his injuries has developed a bronze appearance with some red and purple discoloration. The skin is tense and exquisitely tender. There are some bullae present.

Challenge: What's the diagnosis?

Interlude - QuantiaMD

Since readers of this blog might be interested in other websites with "case of the day" type presentations, I wanted to put a plug in for QuantiaMD. It is a community for health care practitioners (requiring an MD, DO, NP, or PA degree to sign up) with focused educational videos on many topics throughout medicine (from basic diagnosis and treatment of diseases to health care policy to physician well-being). Every field from radiology to surgery to oncology is covered. There are lots of "mystery" cases similar to the material I have here. Participating in it leads to rewards, which makes it fun and engaging. The material is pretty solid and it awards CME credits. If you're interested, check it out: QuantiaMD. It does require you to verify your clinician status. Full disclosure - I do get a referral if you sign up.

Thanks,
Craig

Spire

Challenge: What does this child have?

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Happy Thanksgiving!

I am thankful for you, reading this blog. I know there's a whole lot of other things out there to read and enjoy, and I really appreciate your time and attention. I'm going to take this week off for the holidays. I'll be back with new cases soon. Just a heads up - I have been pondering for a while how much longer to keep this blog going, and I think I might start wrapping it up within the next six months. It has been a real pleasure, lots of fun and lots of learning, but it may be time for me to move onto other projects. I wish you a lovely Thanksgiving.

Craig

Castaway

Challenge: What's the diagnosis?

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Broken

This frontal cervical radiograph is from a patient presenting with headache. She has a history of obesity, pre-diabetes, normal pressure hydrocephalus, and asthma. She's had several surgeries in the past.

Challenge: Look closely at the radiograph; what do you see here?

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Marathon

A 35 year old marathon runner comes to you because of foot pain. The pain is mostly in the medial arch of her foot. There is point tenderness over a bony prominence inferior and anterior to the medial malleolus. Imaging is shown above.

Challenge: What's your diagnosis?

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Post-Op Complications

A 72 year old man with obesity and COPD use on chronic steroids undergoes an open laparotomy, colon resection, and end-ileostomy for colon cancer. A year later, he develops a mild abdominal discomfort. CT is shown above.

Challenge: What do you see above?

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Drum

Challenge: What do you think?

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Scary

Too bad I missed Halloween. But here's a related case.

A preschool-aged child is brought in by his parents who worry about behaviors in his sleep. During the early part of the night, he often awakes abruptly with a loud scream. He is agitated, flushed, sweating, and tachycardic. Once, he even jumped out of bed. When his parents try to calm him, he apparently is unaware. He doesn't remember these episodes afterwards. His past medical history includes a work-up for obstructive sleep apnea; he is being evaluated by an otolaryngologist for potential tonsillectomy.

Challenge: What is going on here?

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Busy

Hi,

I usually try to plan ahead, but I haven't been so great about it. I'm attending in the ICU this week, and looking at the census - including someone who survived 65 minutes of compressions and 20 defibrillations - I don't think I'll get around to writing cases of the day. I'll try but if not, I'll be back next week.

Craig

Echo

You are passing by the critical care unit when you see the intensivist performing an ultrasound at the bedside of a patient. The ultrasound appears to be positioned in the midline, upper abdomen. The patient is an older patient with congestive heart failure who presented with septic shock from urinary tract infection.

Challenge: What is the intensivist doing?

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Avogadro

This 40 year old woman presented with severe nausea and vomiting. She also notes pelvic discomfort and vaginal bleeding the color of "prune juice." Her heart rate is 104, blood pressure is 152/91. She has a mild tremor. Her urine dipstick shows 1+ protein. Her hCG is quite elevated. Her TSH is low.

Challenge: What is this disease, first described by Hippocrates in 400BC?

Teenagers (Sigh)

A high school football player gets in trouble for tackling players head-on. On lateral view of the neck in neutral alignment, you note developmental narrowing of the cervical spine canal as well as straightening of the normal cervical lordotic curve.

Challenge: What is this injury, first described in 1993?

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

Board Exam this Week

The next in a never-ending series of tests happens this week for me. I'm going to be out of town taking my oral board exams, so next case will be a week for now. Thanks for reading.

Craig

Glow in the Dark

You are in a emergency exploratory laparotomy for a patient who developed peritonitis. Half way through running the bowel, the surgeon asks the anesthesiologist to give fluorescein. He then asks the circulator to pull this device out of the closet.

Challenge: What is it and what's he looking for?

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Hang Ten

A young otherwise-healthy man is learning to surf for the first time. After his first lesson, he begins to develop progressively worsening low back pain, followed by lower extremity paresthesias. On arrival to urgent care, he has normal vital signs, normal cardiopulmonary exam, no spinal deformity, and a neurologic exam significant for decreased sensation and strength in the lower extremities. Two hours later, he lost complete sensation and motor function of his legs as well as rectal tone. Labs and CSF are unremarkable. Lumbar spine films are unremarkable. CT of the lumbar spine showed no evidence of spondylolysis, spondylisthesis, fracture, or soft tissue abnormalities. Brain MRI is normal. A non-contrast spine MRI (T1w sagittal image) four weeks later shows this:

Challenge: What happened?

Axis of Awesome

Challenge: What does the echo show?

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Burrito

Challenge: What's being shown here?

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Everything but the Kitchen Sink

This is a poor child in a developing country. He gets recurrent infections because of a depressed immune system. He has impaired taste and smell as well as diarrhea. He has a bullous pustular rash. If untreated, he may develop night blindness, alopecia, and decreased spermatogenesis. The treatment, though, is fairly easy.

Challenge: What's he missing?

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Taking a Break

Hi everyone,

Thanks for following along Case of the Day. I'm going to take a break this week. I have my oral board exams coming up in a month so things are looking quite busy; I'll probably take a breather then as well. I feel a little like a hamster running on a wheel, always playing catch-up so hopefully this will give me a chance to get on top of things.

Craig

Names

This rash begins in the second or third trimester. The erythematous excoriated nodules or papules are seen on the extensor surfaces of limbs and the trunk. It should resolve in the immediate postpartum period. Labs are unrevealing.

Challenge: What is one of the many names for this disease?

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Remember 1897?

You are on a cruise ship well-known for its crazy seafood buffets. When passengers start getting sick, a call for, "Is there a doctor on board?" rouses you. Alas, you seem to be working every vacation. At first, you think this is just a viral GI bug because the passengers complain of diarrhea and abdominal cramps. But what's more remarkable is that this is followed by headache, memory loss, and disorientation. In severe cases, you note diminished reflexes, ophthalmoplegia, coma. One person is sent to shore because he needs an intensive care unit.

Challenge: What's the cause of this?

Image is in the public domain.

Slides

Back to basics! I pulled out Robbins ad Cotran for this one.

Challenge: This is the buzzword for which diseases?

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Misleading

Challenge: What's the problem here?

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Big Cat

This adolescent girl started developing these spots during infancy and early childhood. They mostly involve the face, upper trunk, and neck. These were expected since she has some characteristic facial features of a particular syndrome, with abnormally wide set eyes, deafness, and growth retardation. Her astute pediatrician checked an EKG and found conduction abnormalities. A subsequent echocardiogram showed pulmonic stenosis.

Challenge: What's this autosomal dominant disease?

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Matchmaker

Challenge: What are we looking at here?

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Kaleidoscope

Sorry I missed Monday's case of the day! It's been really busy!

Here's a procedure I've never heard about!

It is performed several weeks after a traumatic injury to the eye to look for angle recession or a cyclodialysis cleft.

Challenge: What are we doing here?

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Encapsulated

This woman worries because she feels a painless discrete lump in her left breast. The mammogram is shown above.

Challenge: Luckily, the disease is benign. What is the most likely etiology?

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Challenge

The rash shown in the first image disappears after a few months. The third leg of the triad is a polyarthritis that can last for a couple years. This disease is usually self-limiting.

Challenge: What's the syndrome and what's the underlying disease?

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Complications

A 60 year old man undergoes a coronary catheterization for unstable angina. He is found to have three vessel disease; there is no intervention and the plan is to refer him to cardiothoracic surgery. His other medical problems are hypertension, hyperlipidemia, and diabetes. However, after cardiac catheterization, the finding above was noted. His pulses are all normal. The toes are cool and painful but the rest of the foot is warm.

Challenge: What happened?

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Airlines

This gentleman is getting a sleep study. One of the waves noted on the EEG looked like this:

Challenge: What's the significance of this wave?

First image is in the public domain. Second image is shown under Creative Commons Attribution Share-Alike License.

Systems

You are the technician trying to set up the system shown above. Here is the operating room schedule:
OR 1: Laparoscopic cholecystectomy
OR 2: Open partial nephrectomy
OR 3: Explantation of infected hip joint, irrigation with antibiotic solution
OR 4: Total knee replacement, use of methylmethacrylate
OR 5: CABG, Jehovah's witness

Challenge: Which room(s) might need the system shown above?

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Dasher, Prancer, Vixen

Sorry about the disorganized cases; I've been traveling in Europe, and internet hasn't been as quick as easy as I hoped.

A basketball player comes in complaining of foot pain that occurred when he landed awkwardly after a jump. A runner has the same complaint when she inverts her ankle running on an uneven surface. Both are worried they sprained their ankle. Their pain is on the lateral edge of their foot. There is focal tenderness, bruising, and swelling at the base of the fifth toe. Both can walk but it's quite painful to do so.

Here is a radiograph:

Challenge: What's the diagnosis?

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The Only Word Kids Dread More Than "Shots"

Visiting friends in Germany, I was asked to consult on the case of a two year old toddler who fell while trying to climb stairs too fast.

Child 1 has this image:

Child 2 has this image:

Challenge: Which, if any (or both) child needs to see a dentist?

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Access II

Similar case as the last one. An adult comes in as a major trauma alert. He was involved in a high speed car accident with a prolonged extrication. Unfortunately, all four extremities are mangled, and there is no place to put intravenous access. In addition, all sites for intraosseous access are contraindicated as well; he has tibial plate fractures, sternal fractures, and humeral head fractures.

In your emergency department, he goes into a ventricular fibrillation arrest, potentially from cardiac contusions sustained in the accident. As you start advanced cardiac life support, you wonder how you can give the epinephrine.

Challenge: Any ideas?

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Access I

A child in a motor vehicle accident with prolonged extraction is confused, crying, agitated, and hypotensive. Multiple attempts at placing an intravenous line are unsuccessful. A nurse asks you if you can place an internal jugular central line. The child needs fluid resuscitation, antibiotics for open fractures, and analgesia.

Challenge: What's the most appropriate intervention here?

Last Week of Fellowship

Dear all,

July 1st is a major calendar turn for most hospitals; newly minted interns write their first orders, residents take up that cloak of supervision, and fellows begin narrowing their area of expertise. For me, this July 1st is a big transition; I will finally be done with four years of medical school and five years of training. That's nine years of case-of-the-day! As I do so, I'm rethinking of what this blog is and could be; I have many ideas, but haven't yet decided. Meanwhile, I will take this week off as a break from cases. I envision that I will continue having projects like this, but the form and content are still up in the air. Even if this doesn't continue forever, I will try to keep all the archived cases available for education and study. Hopefully I'll be back in a week.

Thanks,
Craig

Too Young

A newborn infant is brought to your attention within 24 hours post delivery because of failure to thrive. The mother notes excessive sweating, sneezing, fever, nasal stuffiness, and yawning. He has a high pitched cry, irritability, sleep and wake disturbances, hyperactive primitive reflexes, hypertonicity, and tremors. His feeding is poor. He has some vomiting and loose stools.

His labs including glucose are normal. His sepsis workup is negative. Thyroid studies are unremarkable.

Challenge: What can you tell me abut the mother's social history?

Use the Labels

Challenge: Why is this case of the day labeled with "psychiatry" (as well as internal medicine)?

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Lodestone

"Supine and upright views of the abdomen show an elongated rod shaped radioopaque structure measuring maximally 12cm in length and about a centimeter in width which lies obliquely within the stomach. It has 8 dense radioopaque elements. The bowel gas pattern is normal. The osseous structures are intact."

If only one of these were ingested, it wouldn't be so bad. But this child needed endoscopic intervention to remove these things.

Challenge: What are they?

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AAA

This chest X-ray comes from a patient who has never cried. Ever since she was a child, she's never had tears. As a child, she was also diagnosed with adrenal insufficiency and has required chronic steroids. Some patients with a disease variant have mental retardation, deafness, peripheral neuropathy, cerebellar ataxia, and autonomic impairment. She has the hallmark finding of dysphagia of solids and liquids along with regurgitation of undigested food or saliva. She also has difficulty belching, occasional chest pain, and heartburn.

Challenge: What is this rare autosomal recessive disorder?

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Airway II

Challenge: What's that? (Or how does it work?)

Airway I

What can I say? I'm an anesthesiologist.

Challenge: What is this? (Or how does it work?)

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Comes in Yellow and Black

A few days post-op from a laparoscopic cholecystectomy, a patient continues to have pain, fever, abdominal distension, ileus, and jaundice. Unfortunately, the drain placed after the lap chole was pulled out when the patient was agitated. The patient gets further imaging and a procedure shown below.

Challenge: What's shown in the images above?

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Rhapsody, Rhetoric, Rhythm

A 35 year old G4P1 woman at 32 weeks gestation is referred to your obstetric practice because of an unusual ultrasound. She has not had prenatal care because she immigrated from Mexico just several weeks ago. She established care with an obstetrician who obtained an ultrasound showing ascites, pericardial effusions, and pleural effusions. She then referred the patient to you for further workup and management.

The patient does not regularly see a doctor and doesn't know about any medical problems. Her family history includes diabetes, cataracts, and dementia. Her husband is healthy but has a family history of hypertension, kidney disease, and alcoholism. The patient's other children are healthy. Her past surgical history only includes several orthopedic surgeries and exploratory laparotomies when she had a severe car accident in her early twenties. She spent time in an ICU but does not recall the details. Although she has used IV drugs in the past, she has been clean for five years. She does not drink or smoke.

Challenge: You perform the test shown above. What are you looking for?

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Child Genu

Challenge: The first image is normal. What does the second image show?

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Away for the Weekend

Sorry there was no case of the day yesterday. I am out of town for Memorial Day weekend. Depending on how much free time and internet access I have, Monday's case is up in the air. I will definitely be back next Thursday. Thanks!

Craig

They Need a Better Name

A 75 year old man comes to you with gradual onset cognitive decline. A few years ago, he was encouraged to ramp his career down because of poor job performance. A year later, he started having driving difficulty, getting lost, misjudging distances, and failing to see other cars and stop signs. He had a cognitive evaluation which noted impairments in attention and executive and visuospatial function. His memory isn't impaired.

When you talk to his wife and children, they say that his cognitive impairment seems to have fluctuations. In fact, one time he "blanked out" so badly, he was brought to the emergency department. They ruled out stroke and seizure, and sent him home. He occasionally acts in a bizarre manner, has speech or motor arrest, or becomes really somnolent. The episodes have variable durations, and in between, he has pretty normal function. For a while, they thought he was just tired in the daytime, requiring long naps, but once he started having prolonged staring spells and speech disturbances, they became more concerned. In addition, the wife wonders if he's having visual hallucinations from time to time.

He has a family history of Parkinson's disease. He is a retired college professor. He reports no bad habits: no drinking, smoking, drugs, or even caffeine.

You perform a brief neuro exam and find that he has trouble copying overlapping pentagons, drawing a clock, subtracting serial sevens, and spelling WORLD backwards. On the rest of your exam, you note bradykinesia, limb rigidity, and an unusual gait. He has no tremor. His deficits are subtle and symmetric.

His MRI is the one on the left. The MRI on the right is a patient with a similar presentation but a different diagnosis.

Challenge: What do you think this is?

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Advanced Circulatory Support II

Challenge: If the native lungs are not contributing at all, what is the arterial oxygen saturation?

Additional Questions:
1. What is shown here?

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