Separation

(Click to enlarge)

Challenge: What is your diagnosis?

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Hugs and Kisses

This girl is short for her age. She was also diagnosed with a horseshoe kidney.

Challenge: What is the most common cardiovascular anomaly in patients with this disease?

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Where's the Lesion?

A 20 year old presents with a seizure. He says he felt a rising roller-coaster sensation in his stomach, a feeling of deja vu along with intense fear, and a weird smell. Then his roommate noticed he had a behavioral arrest with staring that lasted 30-120 seconds. The patient was unaware and unresponsive during this time, but he did have stereotyped purposeless fidgeting of his hands. At this time, the roommate called 911. The patient does not remember anything.

Challenge: If you were to guess where the lesion is, what would you say?

The Answer is Cancer III

A 35 year old woman presents to her gynecologist and is incidentally found to have a cystic ovarian mass. She is asymptomatic, but ovarian cystectomy is recommended to prevent torsion, rupture, and a 0.2-2% chance of malignant transformation, usually into a squamous cell carcinoma.

Challenge: What's the diagnosis?

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The Answer is Cancer II

In the third image, those black spots all appeared within the time span of weeks. The base of some of those lesions is erythematous. They are itchy.

Challenge: What's the most likely cancer causing these skin manifestations?

Related Questions:
1. What does the first image show? What's the differential diagnosis of this finding?
2. What does the second image show?
3. What is the third image called? What are those spots?

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The Answer is Cancer

These are two separate patients with the same disease. The other finding is hepatomegaly. When scanned, a liver mass is found. The patient, unfortunately, has dementia. His estranged daughter says, "Well, he had some sort of minor surgery years ago, but he never told me what it was for."

Challenge: One unifying diagnosis connects the reason for the prior surgery, the current presentation now, and the liver mass. The median survival for this patient is 4.4 months; the five-year survival is 3%.

Note: I got this case idea from a morning report during a preliminary medicine interview.

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Backwards

Yes, this week was indeed cardiac week. Here's an easy one. Next week I'll find some good challenging cases!

Challenge: What happened to this patient?

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Car Insurance

You are the surgeon on call at midnight and you're getting antsy because there aren't any good cases going on. You troll through the emergency department looking for appendices to remove and wander into the CT scan just as this image comes onto the screen. You're in business! You glance at the CT requisition and it says "65 year old man, back pain, hypotension."

Challenge: You call the OR immediately and tell them a patient is coming up with what?

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Sports Physical

A 16 year old boy comes to you for a routine sports physical. He has no symptoms and is feeling pretty well. An adolescent HEADSS interview reveals that his parents are divorced but he gets along with both, he is a B+ student, he enjoys running and playing video games, he has tried alcohol but no other drugs, he is sexually active with one partner, and he has no suicidal thoughts. He has no past medical history and takes no medications. His family history reveals that a paternal grandfather died of heart failure at age 50, an uncle died of sudden death at age 25, and his father has unexplained dyspnea on exertion and chest pain though a recent coronary arteriogram was normal.

On exam, the patient's vitals are normal and he is in no acute distress. On cardiac exam, you feel a prominent left ventricular lift with a diffuse apical impulse. You hear an S4 along with a harsh crescendo-decrescendo systolic murmur best heard at the apex and left lower sternal border. The murmur radiates to the axilla and base. When you have the patient Valsalva, the murmur gets louder. When you elevate the patient's legs, the murmur gets softer. The carotid pulses are normal. The lungs are clear to auscultation bilaterally. The abdomen is benign. There is no cyanosis, clubbing, or edema. An EKG is taken in the office and shown below.

Challenge: What's the most likely diagnosis?

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Tired

A 45 year old man presents with fatigue, your favorite chief complaint. The fatigue has been getting worse over the last few months. He's just been so sleepy during the daytime, especially when doing boring, passive, or monotonous activities. He even admits to dozing off while reading, watching television, and driving. Last week, he fell asleep and began snoring at church which embarrassed him. When you delve deeper, it's not that he doesn't have energy, he just falls asleep. Sometimes at night, he wakes up with a sensation of choking, gasping, or smothering. He also complains of a dry mouth while asleep and often has restless, fitful sleep. He has a past medical history of obesity, hypertension, coronary artery disease, chronic renal insufficiency, type 2 diabetes mellitus, and GERD. Review of systems is positive for decreased sex drive, headaches in the morning, and poor concentration. He denies feeling depressed.

Challenge: With just the history, what's your diagnosis?

Hard

This patient also has fatigue, stiff joints, weakness, pain, sleeping difficulties, and skin discoloration.

Challenge: What's your diagnosis?

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Say Ahhh

The tongue shown here belongs to a 25 year old woman presenting to a primary care doctor. She recently got health insurance because of the new healthcare reform bill. Yay! She has no complaints. She is otherwise healthy, but had a lot of spontaneous recurrent nosebleeds in childhood. She takes no medications. She has a family history of embolic strokes (including one from a deep vein thrombosis in someone without a heart defect), recurrent GI bleeds, and cerebral abscess in every generation of her father's side. She does not smoke or do drugs, and she only drinks occasionally. She lives with her cat and works at the supermarket.

Her physical exam is normal except for the finding shown above and a rectal exam that is positive for occult blood in the stool. Because of that, you send some basic labs which show a microcytic anemia. Wow! This was totally unexpected. You just made an important diagnosis because more people have health insurance and can see a doctor due to the healthcare reform bill.

Challenge: This syndrome has two names, each of which has three words. What is it?

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Because I Could Not Stop for Death

A 35 year old woman presents with pelvic discomfort. She hasn't had a menstrual period in six weeks but yesterday began to have some vaginal spotting with mild suprapubic pain. She is sexually active with two partners. She has smoked one pack of cigarettes a day for 5 years and is a moderate to heavy drinker.

On exam, you note a closed cervical os. A urine pregnancy test is positive. An ultrasound shows a long, closed cervix with uterine size appropriate for gestational age.

Challenge: What "kind" of abortion is this?