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)?

Image shown under Fair Use.

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?

Both images shown under Fair Use.

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?

Image shown under Creative Commons Attribution Share-Alike License.

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?)

Image shown under Fair Use.

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?

Images shown under Fair Use.

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?

Image shown under Creative Commons Attribution Share-Alike License.