Today's case is not a diagnostic dilemma, but rather a patient education question. A 25 year old woman comes to your clinic because she is interested in starting combined oral contraceptives.
A 30 year old previously healthy man presents with high fever, tachycardia, hypotension, and severe localized pain of his left lower extremity. The leg has tense edema, red-purple erythema, crepitus, blisters, and bullae, but the pain seems to be greater than he should feel with these findings. The pain has been rapidly increasing over the last day or two. C-reactive protein is 180 mg/L, WBC is 30,000/uL, Hgb is 10 g/dL, sodium is 132 meq/L, Cr is 1.6 mg/dL, glucose is 190 mg/dL. Gram stain is shown above.
A 7 year old child presents with "weird" movements and utterances. Throughout the day, he will have involuntary facial grimacing and shoulder shrugging. The symptoms wax and wane. When he concentrates really hard, he can suppress them, but otherwise, he feels an irresistible urge before the movement and great relief afterward. He says he can tell when they're coming on. His teacher has sent him home from school multiple times for saying "bad words." Review of systems is positive for restlessness, insomnia, enuresis, somnambulism, nightmares, and bruxism. His parents have observed his weird movements in his sleep. A head MRI is negative.
You are a pediatrics intern on your first day of clinic. Now you get third year medical students running around for you! You send a medical student to see a 2 year old who is "fussy." The medical student comes back about an hour and a half later, fumbling through pages of notes. He says this is a 2 year old with no significant past medical history and a normal birth history who presents with irritation that started about an hour ago. He was in his crib, unmonitored, when he began to cry. The parents don't know what was wrong and brought him into urgent care. The child has had a nonproductive cough.
The CXR and CT shown above are from a patient referred to you because she has asthma that just won't go away. She is 30, but she had asthma since she was a child. Every year, she gets a few exacerbations with bronchial obstruction, fever, malaise, cough productive of brown mucous plugs, and occasional hemoptysis. Her blood counts always show peripheral eosinophilia. Wheezing is present. These episodes are only minimally responsive to bronchodilators such as albuterol and ipratropium, but they respond well to systemic steroids. Pulmonary function tests show airflow obstruction, air trapping with a reduced FEV1, and increased residual volume. Improvement is minimal with a bronchodilator. A skin test shows reactivity to Aspergillus antigens, serum antibodies against Aspergillus are positive, and serum total IgE is elevated >1000 ng/mL.
This girl is short for her age. She was also diagnosed with a horseshoe kidney.
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