Crystal Clear

You are examining specimens in the lab and come across this one. The clinical correlation says, "Patient with Burkitt's lymphoma, undergoing first round chemotherapy, now with acute kidney injury."

Challenge: You don't have much information to go on, but what do you think this is?

Tick Tock

This rash occurred in an 8 year old child who was traveling around the United States with his family. He presented with fever, headache, malaise, myalgias, and arthralgias. He also complained of abdominal pain, but ultrasound ruled out appendicitis. This rash developed about three days after the onset of the other symptoms. The rash is blanchable and began at the wrists and ankles. You also note some pedal edema. There is no meningismus. The CBC shows a normal white blood cell count, but thrombocytopenia. Sodium is on the low side. Blood cultures are negative.

Challenge: Time's running out...What's your diagnosis?

Atropine

You are an emergency physician attending in a busy ER. A resident comes up to you with this EKG and says it's from a person who was "found down." She administered atropine but there was no increase in heart rate.

Challenge: Why not?

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No Cases This Week

Sorry! I don't have my things together this week so no cases. I will try to get back on track next weekend.

Craig

What's the Surgery?

A middle aged patient presents with acute onset persistent severe epigastric abdominal pain. The pain radiates to the back and is relieved by sitting up or bending forward. It is accompanied by nausea, vomiting, and dyspnea. Exam shows diffuse tenderness, abdominal distension, and hypoactive bowel sounds. He is admitted to the hospital for supportive management.

Unfortunately, overnight, he develops fever, tachypnea, tachycardia, and hypotension. He is transferred to the critical care unit and started on norepinephrine and vasopressin for septic shock after adequate fluid resuscitation. A CT is shown below:

He has acute kidney injury and acute respiratory distress syndrome requiring intubation, but over the next few weeks, he is stabilized and eventually extubated. Four weeks after the initial presentation, he still has chronic low grade fever, nausea, lethargy, and inability to eat.

He then undergoes surgery even though the mortality rate is somewhere between 4-25% and complications include intra-abdominal fluid collections, bleeding, fistulas, incisional hernias, poor glucose control, and need for enzyme therapies.

Challenge: What was the operation?

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Frozen

A 35 year old woman with a history of type 1 diabetes mellitus and anxiety is referred to you because of a "Frankenstein gait." When she enters your office, you note an awkward wide-based unsteady gait with a tendency to fall in a fashion like a log tumbling down. She also has pronounced lumbar lordosis. On exam, she has extreme truncal stiffness and generalized rigidity. When you palpate her lumbar, trunk, and proximal limb muscles, you find sustained muscular contractions of both agonist and antagonist muscles. She says the symptoms initially started in the low back and came on gradually, eventually involving the proximal limbs. When her walk started changing, she developed a lot of anxiety about going outside and being in public. Now, activities of daily living are becoming challenging.

In addition, she gets muscle spasms that seem triggered by sudden movement, noise, or emotional upset. These spasms begin in the truncal muscles and spread to the extremities. She has one in your office and you note the muscles becoming tight and rock-hard. Palpating it is like palpating a board. The rest of your motor and sensory exam is normal.

Challenge: What's your diagnosis?

Name That Object II

Challenge: What do you see here?

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Name That Object I

I prefer ones made out of glass; the plastic versions just don't feel as slippery. This syringe is normally filled with air or sterile saline.

Challenge: What is this particular type of syringe used for?

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