Not Good

Challenge: Well...that's not good (yes, it's an EKG). Assuming it is not artifact, what's the differential diagnosis (H's and T's)? What is your next step in management?

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Pelvic Pain

A 35 year old woman presents with sudden onset right-sided lower abdominal and pelvic pain. She said the pain started when she was "exercising," but upon further inquiry, it occurred when she was having sex. This was accompanied by light vaginal bleeding. Her past medical history is significant for appendectomy at age 20. The only medication she takes is aspirin for knee pain.

On exam, temperature is 38.1, heart rate is 75, blood pressure is 115/85, respiratory rate is 12, O2 sat is 99% on room air. On abdominal exam, right lower abdomen is moderately tender to deep palpation. On vaginal exam, an adnexal mass is barely palpable on bimanual examination. There is minimal cervical motion tenderness.

A serum hCG is undetectable. CBC is normal. Urinalysis is normal. Blood culture, urine culture, and cervical studies are negative for infection. Ultrasound shows an adnexal mass and fluid in the pelvis. A CT is shown below.

Challenge: Oral analgesia as an outpatient is the treatment for this condition if uncomplicated. What is it?

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Nine-Banded Armadillo

This gentleman presents with multiple skin lesions over his entire body. They are erythematous macules, plaques, and nodules. He has generalized nerve damage with decreased sensation throughout. He has a "claw hand," "foot drop," and "claw toes" as well. The treatment for this is a multidrug regimen including rifampin.

The alternate title for this case is "MMMBop."

Challenge: You have to check him for G6PD deficiency before starting which drug?

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Warsaw

Challenge: These two physical findings are seen in what syndrome or sequence? The abnormalities are on the same side of the body.

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Happy Memorial Day!

Hi everyone,

Thank you again for following along these cases. I am going to take a case of the day holiday today because I am out of town for a friend's wedding.

Thanks for understanding,
Craig

Dollars to Euros

A 26 year old woman presents with epilepsy from an unknown cause. She has already seen two neurologists who have been unable to make a diagnosis. For the last two years, she's had daily episodes of witnessed seizure-like activity. The episodes last around 5 minutes with variable motor activity; she thrusts her pelvis out, writhes and trashes, rolls from side to side, or arches her back. During an episode, these motor symptoms wax and wane. Her eyes are always squeezed tightly shut. She sometimes makes vocal noises. She has never had incontinence, cyanosis, or tachycardia with these episodes. She awakens rapidly and reorients quickly without a post-ictal headache. She sometimes recalls what happened during the seizure. No one has noticed any episodes while she is asleep. Antiepileptics have not worked to decrease the frequency of symptoms.

Physical exam is remarkable for profound weakness of the patient's left arm. She barely moves it antigravity and can't exert any force against resistance. When you ask about it, she just shrugs and says "whatever."

Challenge: What's going on?

Cut It Out

You are the pathologist receiving this specimen from the operating room. This patient had encephalopathy, GI bleed, weight loss, and early satiety. Labs show thrombocytopenia, hypoalbuminemia, hyperbilirubinemia, and prolonged PT and PTT. AST, ALT, alkaline phosphatase, and gammaglutamyl transpeptidase are all elevated. A chart biopsy shows that these abnormalities have been going on for years.

Challenge: What serum marker is often elevated in this disease?

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Whodunnit?

A patient is brought in from a skilled nursing facility. Four hours ago, she was given somebody else's pills but the nurse has run away! No one knows what she was given, except that it's probably a common nursing home medication. She was brought in because of a witnessed seizure about three hours ago. She has recovered from the seizure but has altered mental status with delirium. Her vitals show a heart rate of 40 and a blood pressure of 90/50. There are no focal neurologic deficits. Her labs show a glucose of 40 and potassium of 5.5; otherwise electrolytes, BUN, and creatinine are normal. Acetaminophen and salicylate levels are undetectable. Chest X-ray is clear. EKG is shown above.

You secure airway, breathing, and circulation. You give dextrose. You start atropine but the heart rate and blood pressure are minimally responsive.

Challenge: What's the antidote to this ingestion?

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Burn

Challenge: If all these patients were also deaf, what would be your diagnosis?

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Double Diagnosis

A 40 year old man with hepatitis C presents with a subacute onset of fever, nonproductive cough, and shortness of breath. These symptoms have been getting progressively worse over the last few weeks. Other than hepatitis C contracted from IV drug use, he doesn't know about a past medical history. He hasn't seen a physician in years. He takes no medications. He occasionally drinks, smokes, and does IV drugs. Review of systems is positive for fatigue, chills, chest pain, and weight loss.

Physical exam is notable for a temperature of 38.3 C and respiratory rate of 26. His heart rate and blood pressure are normal. The rest of his exam including cardiac, pulmonary, and abdominal exams are normal. A chest X-ray is shown below.

LDH is elevated. An induced sputum is done with inhalation of hypertonic saline. The slide is stained and shown below:

Challenge: Unfortunately, two separate diagnoses can be made here. What are they?

Related Questions:
1. What does the CXR show?
2. What does the second image show?

Both images are in the public domain.