I Almost Couldn't Come In

"I almost couldn't come in to see you," your twenty year old female patient tells you. "I mean, since I was 14, I've been so shy. It's just part of my personality, I think, but I just get so afraid that someone will talk to me when I'm on the bus or something. I can't go out to a restaurant, I can't go to a party, I don't like being in small groups of people. What if someone I don't know talks to me? Or is looking at me? What if I do something stupid or embarrassing or humiliating? Even talking to you, doctor, makes me really nervous. Like, what if I have to use the bathroom? I can't use the bathroom here; it's a public bathroom. Or maybe you have one of those single-person bathrooms in your clinic, that would be good for me. I mean, I know it's silly, but I just get so anxious when I think about it. I haven't been on a date ever. I can't imagine talking to someone. I'd get so afraid. I don't think I have symptoms like palpitations or anything, I just feel terrified. So I avoid situations like that and if I have to be in one, I try to get out as soon as I can."

Challenge: Obviously, this falls within a spectrum of disorders, but pick a diagnosis.

Britney Spears' Toxic

Challenge: What is this rash, which occurs in 31-72% of full-term infants? (I know, what kind of statistics are those? But then again, what kind of case has this title?)

Both images are in the public domain.

Swimming

This man presented with the pruritic rash shown above. Actually, even though that's an arm, this infection is most commonly on the lower legs and feet. The only unusual exposure is that he went swimming yesterday when he felt tingling and itching of that arm. About 12 hours later, he got this intensely pruritic rash.

A CBC shows peripheral eosinophilia.

Challenge: Oh yes, in case you were wondering, he swam in a fresh water pond with snails. Does that help your diagnosis?

Image is in the public domain.

AC

Challenge: What's your diagnosis?

Image shown under fair use.

Got Milk?

A 25 year old woman with a new diagnosis of schizophrenia is started on risperidone. She then presents complaining of galactorrhea.

Challenge: What is the mechanism by which risperidone causes galactorrhea?

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An Agricultural Tool for Threshing

This is the CXR of an unidentified male patient, a passenger of a high speed motor vehicle accident. As you do your primary survey (ABC's!) you notice that his right chest moves in the opposite direction of his left chest with breathing. That is, a part of his chest retracts with inspiration and bulges with expiration. You look closer at that part of the X-ray.

Challenge: What's the diagnosis?

Both images shown under fair use.

Cough

A child presents to your clinic with chronic cough.

Challenge: What is your presumptive diagnosis for the following presentations?
1) A staccato cough in young infants?
2) A "seal barking" or "brassy" cough?
3) A chronic paroxysmal cough triggered by exercise, cold air, sleep, or allergens in a kid with a rash?
4) A "Canadian goose-like" honking cough that disappears at night?
5) An acute or subacute paroxysmal cough...with an inspiratory whoop?

Puff of Smoke

A 45 year old Japanese woman with atherosclerosis and Graves' disease presents with recurrent hemorrhagic stroke. She has no known risk factors: no hypertension, no alcohol, no dyslipidemia, and no trauma. CT shows dilatation of sulci and focal ventricular enlargement suggesting chronic disease. MRI shows dilated collateral vessels in the basal ganglia and thalamus. Angiography is shown above.

Challenge: This is a "double name." What is the cause of the hemorrhagic strokes?

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I Cannot

The next two cases have a "double" name theme, whatever that means, idea credited to Alex P.

This picture was taken in Southeast Asia at the beginning of the 20th century, now part of the U.S. National Library of Medicine. This gentleman probably suffered from a symmetric peripheral neuropathy of the distal extremities characterized by both sensory and motor impairments. He might even have cardiomegaly, cardiomyopathy, congestive heart failure, peripheral edema, and tachycardia.

Challenge: This disease has a "double" name. What is it?

Image is in the public domain.

Too Much Information

A 70 year old man presents with blood in his urine. He's noticed a few clots when he urinates and gets intermittent pain. His past medical history is significant for obesity, coronary artery disease, hypertension, COPD, and gout. He is on antihypertensives, aspirin, allopurinol, and a prn inhaler. His family history is notable for heart disease, obesity, and schizophrenia. He has a sixty pack year history of smoking and does occasional marijuana, but does not drink alcohol. He worked at a gas station for most of his life. Review of systems is positive for fever, night sweats, anorexia, weight loss, and fatigue.

On exam, he is an obese man and palpation of the abdomen is difficult, but you think you feel a firm, homogeneous, nontender abdominal mass. Testicular exam shows scrotal varices. You note mild lower extremity edema. Laboratory studies show hemoglobin of 9 g/dL, normocytic, normochromic, with low serum iron and transferrin but normal transferrin saturation. He also has an elevated serum alkaline phosphatase and hypercalcemia.

Challenge: What's the most likely diagnosis?

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Tricky

This is a Giemsa-stain from a woman complaining of pain on urination and frequency of urination. She also notes a purulent malodorous thin vaginal discharge and itching. She is sexually active but her male partner is asymptomatic. Physical exam shows erythema of the vulva and vaginal mucosa with green frothy discharge and punctate hemorrhages on the vagina and cervix.

Challenge: What's the organism?

Image is in the public domain.

Prospere

A 30 year old woman presents with episodic dizziness. She describes this as a rotary spinning or rocking sensation. She cannot identify the triggers, but they last from 20 minutes to 20 hours and involve nausea, vomiting, and aural fullness. This has been going on for months but she says that she's fine for long periods of time. She also complains of a low pitch buzzing, like "listening to a seashell" or "machinery." Ear exam is shown below:

An is the annulus fibrosis, Lpi is the long process of the incus, Um is the umbo, Lr is the light reflex, Lp is the lateral process of the malleus, At is the attic (pars flaccida), and Hm is the handle of the malleus. Pretty, isn't it?

You send her for audiometry which shows low frequency sensory loss with normal hearing in the mid frequencies. You rule out multiple sclerosis, TIA, and migraine.

Challenge: What's the diagnosis?

Related Question:
1. What's the "buzzing" called?
2. What does the ear exam show?

Image shown under fair use.

Verticillus

You take an elective in outpatient oncology. Your preceptor specializes in the treatment of squamous cell head and neck cancers, squamous cell cervical cancer, squamous cell esophageal cancer, germ cell tumors, and Hodgkin and non-Hodgkin lymphoma. This is an eclectic collection of cancers, but they can all be treated with the drug shown above. You note that some of the older patients, especially those who receive large doses, have renal impairment, or get radiation develop nonproductive cough, dyspnea, and pleuritic or substernal chest pain. This usually happens 1-6 months after starting chemotherapy. Other symptoms include fever, tachypnea, rales, lung restriction, and hypoxemia. A sputum analysis is negative for infection.

Unfortunately, I could not find a good image of this disease, but the "classic pattern" is bibasilar subpleural opacification with volume loss and blunting of the costophrenic angles. Eventually, there may be consolidation and honeycombing.

Challenge: What is the drug, and what is the diagnosis?

Image shown under GNU Free Documentation License.