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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Advanced Circulatory Support I

This may be an unfair case as it's quite complicated, but I figure I've spent some of the last week taking care of these patients and its good to review mechanical circulatory support devices.

A patient with end stage nonischemic cardiomyopathy undergoes placement of a permanent left ventricular assist device as a bridge to cardiac transplantation. It is a continuous flow device. His surgery is uncomplicated, he is started on coumadin, and then discharged to home. Several weeks later, he calls your office because over the last few days, his device has been reporting changing numbers. The pump speed, revolutions per minute, is the same as it was when he was discharged. The cardiac output is similar to his discharge value at 3.5 L/min. However, the pump power, has been markedly rising. It is now five times what it was at discharge (2W versus 10W). The patient has been doing his usual activities, does not feel thirsty or dehydrated, and feels otherwise well.

Challenge: What is your main concern?

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Lab Rat

Sorry there was no case on Monday - I got pulled to cover the cardiothoracic ICU and it got really busy.

You are processing samples in the lab when you get the following tests: CRP 160 mg/L, WBC 30/mm3, hemoglobin 10 g/dL, sodium 132, creatinine 2.0 mg/dL, glucose 200 mg/dL. You briefly look up the clinical "one-liner" and it says: "Young man, otherwise healthy, complaining of pain."

Challenge: What do you think it is?

I own the rights to the picture.