1000

Wow! This is actually the last Case of the Day. I made it to 1000 cases over 9 years! I'll write a post after this just to tie things up, but this will be the last medical mystery. I never meant for Case of the Day to last forever, and it's been an incredible amount of work to get here. I'm pretty happy to say there are more cases here than most textbooks and all of them are backed by reasonable references.

This last case I actually wrote at the very beginning, nine years ago. It was sort of a prototype which I never published. There is some poetry in having it bookend this project. I will write more in a closing post, but thank you all for reading, responding, learning, and teaching me.

With respect, love, and passion,
Craig

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A 30 year old man with a history of "allergies" presents for an infertility workup because he and his wife have been unsuccessful in getting pregnant for over a year. Her workup is apparently normal. When you ask the husband, he notes that he has a chronic cough and mild shortness of breath. You wonder about cystic fibrosis and order a chest X-ray:

Challenge: What syndrome does he have?

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Last Few Cases

Sorry, I was on call yesterday, and Case of the Day totally slipped my mind. Here's a pretty good one on a disease that was on critical care boards. This week is busy for me but I'll put up answers for the last few cases soon.

A patient with leukemia undergoes an autologous hematopoietic stem cell transplant. Two weeks later, she develops a temperature of 38.5C and a maculopapular rash initially concerning for graft-versus-host disease. She feels short of breath, and her room air saturation is only 84%. Review of systems is positive for diarrhea, but stool infectious workup is negative. Chest X ray shows bilateral air-space opacities. Her blood cultures, urinalysis, and sputum are negative; a procalcitonin is normal. A bronchioalveolar lavage is performed which is unremarkable. Her echo does not show heart failure though she does have some edema, weight gain, and ascites. Labs show hypoalbuminemia.

Challenge: What is your diagnosis?

Well?

ECG Wave Maven has been my go-to resource for great EKG's. Created by Beth Israel Deaconness Medical Center in 2001, it has an incredible number of fascinating cardiograms, cases, and explanations. It's an unsurpassed repository for learning and education, and I hope you check it out.

This EKG comes from a middle aged man with vague chest pain. Initial troponins are negative.

Challenge: What does the EKG show? (Click for full image)

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Exit Here

This CT scan is from a young woman with a pulsatile supraclavicular mass on the left side. She also gets pain with exertion in that arm. Sometimes, she gets pallor, paresthesias, and coldness in her left hand, and she was initially diagnosed with Raynaud's but wants a second opinion. There is no history of trauma. She has no other medical problems. Her pulses on that arm are diminished. There is no musculoskeletal tenderness.

Challenge: This is the least common version of what syndrome?

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Sphygmomanometer

I can't believe I've written 9 years of cases, almost a thousand of them, and didn't get to this one. This is the the kind of medical trivia I like.

You pump this blood pressure cuff on the arm of a patient to 200mmHg. The phone rings and you go and answer it. The BP cuff is left inflated for three minutes, and the patient begins having adduction of the thumb, flexion of the MCP joints, extension of the IP joints, and flexion of the wrist.

In addition, when you tap the patient just anterior of the ear, she gets contraction of the ipsilateral facial muscles.

Challenge: What's going on? What two signs are described above?

Image is in the public domain.

My Fair Lady

My goal for the last handful of cases on this blog is to actually post a case a day; it always bothered me a little to have a blog titled "Case of the Day" that was only running twice or thrice weekly posts. This may not actually happen, but I'm trying to go out with a bang.

These CT images are from an older Caucasian woman infected with a nontuberculous mycobacterium. She has a chronic cough but no known chronic lung disease. She tries to hide her cough.

Challenge: What syndrome is this?

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Africa

This disease is common in rural Africans, but can also be seen with travelers returning from Africa or the east Caribbean. It presents as a mild illness with headache, fever, and myalgias. Solitary or multiple eschars as shown above are common, along with regional lymphadenopathy. There may be a scant generalized rash, and uncommonly, subacute neuropathy or myocarditis.

Challenge: What is your diagnosis?

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Whoops

A 70 year old patient comes in with septic shock. She is febrile, tachycardic, hypotensive, tachypneic, and hypoxemic. Her labs show a leukocytosis, elevated lactate, and elevated procalcitonin. Chest X-ray shows a right lower lung focal opacity. She is fluid resuscitated with 5 liters of crystalloid but still has refractory hypotension. The emergency medicine intern puts in a right internal jugular central venous catheter to start norepinephrine. Later, a KUB is taken which is shown above.

Challenge: What complication happened here?

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No Biopsy Needed

This patient also has bilateral parotid gland enlargement and facial nerve palsies. His review of systems is notable for fever and arthritis. He was seen by an ENT recently who ruled out parotid tumor. Apparently pathology showed granulomas.

Challenge: What's your diagnosis?

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Ventilators II

A patient with severe COPD presents with an acute exacerbation. He is intubated for hypercapneic respiratory failure and has the waveform seen above. Over the next hour, he develops significant hemodynamic instability. Suddenly, he has a cardiac arrest, and you immediately start CPR and follow ACLS.

Challenge: What is your next intervention (with the ventilator)?

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Ventilators I

By request, some ICU topics. This mode of ventilation is occasionally used in medical, surgical, or trauma patients with acute respiratory distress syndrome. The advantage is that it allows the patient to be awake or lightly sedated, spontaneously ventilating. Its high mean airway pressures aid alveolar recruitment.

Challenge: What kind of mode is this?

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Harlequin

An adult patient develops severe hypoxemia from a pneumonia and goes into cardiac arrest. He is successfully resuscitated with the machine shown above. The following day, it is noted that a sat probe on his right forefinger and a sat probe on his ear reads 75% whereas a sat probe on the toe reads 98%. He does have a right femoral arterial cannula and an ABG drawn there reads a PaO2 of 150mmHg. However, when you do a fresh ABG stick from the right radial artery, the PaO2 is 40mmHg.

Challenge: What machine is he on?

Image is in the public domain.

Scandinavia II

A 77 year old woman of Scandinavian descent presents with subacute fever, fatigue, and weight loss. She has been undergoing a workup for fever of unknown origin. She is finally referred to a neurologist because of a new headache. The characteristics of the headache, though, are nonspecific. She also has some jaw claudication with a rapid onset of pain once she starts chewing. Still, no diagnosis is made until she presents to the emergency room with transient monocular visual loss. There was a temporary partial field cut that returned when she was in the ER. The ophthalmologic exam was unremarkable.

Challenge: You better make the diagnosis before she has permanent visual loss; what is this?

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Scandinavia I

A 75 year old woman presents with "aches and pains." She complains of soreness and stiffness in her shoulders and hips in the morning. This can last from half an hour to an hour. Her neck and torso are also affected. The symptoms are symmetric. This all started pretty abruptly. The symptoms are so bad she has trouble dressing herself; once, she couldn't even get out of bed. She can't abduct her shoulders past 90 degrees. Nevertheless, she has normal muscle strength. During the rest of the day, the stiffness and ache occurs if she has been sedentary and tries to do something. She also has the findings in the image above. Social history is significant for being of Scandinavian descent. Review of systems is notable for malaise, fatigue, depression, anorexia, weight loss, and low-grade fever.

Challenge: What is your diagnosis?

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Pace Yourself

This EKG is from a patient with a dual chamber pacemaker that presents to the emergency room with presyncope. The resident says, "It's a paced rhythm, we can't interpret it."

Challenge: But you reply, "The patient's presyncope is from...what?"

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Dough

"so went Satan forth from the presence of the Lord and smote Job with sore boils from the sole of his foot unto his crown"

Ever since this patient was a child, he's had skin problems. In his first few weeks of life, he had a papulopustular crusted rash on his face, scalp, upper trunk, and buttocks. He was diagnosed with atopic dermatitis. He didn't have any wheezing, food allergies, or hayfever, though, and there's no family history of atopic dermatitis. He's also had lots of skin infections, including abscesses, furuncles, cellulitis, and lymphadenitis. Oddly enough, sometimes he has infections that lack classic signs of inflammation; they don't always manifest with erythema, warmth, or tenderness.

His other medical problems include recurrent sinus and middle ear infections. He's had pneumonia once requiring hospitalization. He's had weird teeth; he kept his primary teeth leading to two rows of teeth. This was later corrected by a dentist. He has scoliosis. He's had a few orthopedic surgeries for fractures from minor trauma.

Challenge: What's your diagnosis?

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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?

2 4 6 0 1

In multiple studies including a recent JAMA article, I have been shown to reduce the duration of mechanical ventilation and ICU stay compared to my more traditional counterparts. I'm sometimes used in procedural sedation (even as anesthesia for awake craniotomies!). Other times, you might find me hanging with benzos for that drunk patient sobering up. Sometimes, I am given as a loading dose, and I can cause either hypertension or hypotension, to the confusion of many medical students. Avoid me if the patient has heart block or bradycardia, though.

Challenge: Who am I?

Image is in the public domain.

Refresher I

I got a request for a few more basic cases. I'll see what I can do.

Challenge: In a patient with Raynaud phenomenon, thromboembolic disease, and renal insufficiency, what does the rash above signify?

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Chemo II

Three months after finishing this ruby red chemotherapy regimen, a patient develops shortness of breath. He gets tired even after climbing a flight of stairs. He's noticed some swelling of his legs. At night, he props himself up with pillows to avoid waking up gasping for air.

Challenge; What chemotherapeutic agent caused this?

Image is in the public domain.