Delay

A 50 year old smoker comes in with severe headache, altered mentation, and this CT scan. He goes to interventional radiology for a procedure. Over the next several days, he slowly improves. A week later, though, he suddenly gets worse. He becomes more confused and somnolent. CT and EEG do not explain his neurologic exam. Ultrasound confirms the diagnosis.

Challenge: What do you suspect?

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Sign Here

Challenge: What does the arrow indicate?

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Ventilators III

This unresponsive patient was intubated for airway protection.

Challenge: What is your goal with the ventilator?

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Test

You are a medical student rotating on ICU, and on your first day, you witness a test. An intubated patient is put onto 100% oxygen for 10 minutes. An ABG and electrolytes are checked and normal. His vital signs, including temperature, are normal. He is then taken off the ventilator and observed for ten minutes. A repeat ABG is sent.

Challenge: What test did you just witness?

Food

A 23 year old woman with a history of diabetes, hypertension, chronic pain, phobias, major depressive disorder, and alcohol dependence is brought in by her sister who is worried about an eating disorder. Her sister says the patient will eat unusually large amounts of food from time to time. The patient says she "just can't help it" and will eat rapidly until uncomfortably full, even when she is not hungry. The sister says the patient often eats alone because she feels ashamed and guilty. This has been happening once or twice a week for many months. Nevertheless, the patient denies purging, fasting, or excessive exercise.

Challenge: What is the most accurate diagnosis?

The Greatest

The top brain is a normal brain. The bottom brain shows the gross pathology of a professional athlete who developed cognitive impairment, behavior and personality changes, depression, speech and gait abnormalities, and Parkinsonism at the end of his life. Note the severe dilation of the second and third ventricles, marked atrophy of the medial temporal lobes, and shrinkage of the mammillary bodies.

Challenge: What kind of sports did he likely participate in?

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Frozen

A 35 year old woman with a history of type 1 diabetes mellitus and anxiety is referred to you because of a "Frankenstein gait." When she enters your office, you note an awkward wide-based unsteady gait with a tendency to fall in a fashion like a log tumbling down. She also has pronounced lumbar lordosis. On exam, she has extreme truncal stiffness and generalized rigidity. When you palpate her lumbar, trunk, and proximal limb muscles, you find sustained muscular contractions of both agonist and antagonist muscles. She says the symptoms initially started in the low back and came on gradually, eventually involving the proximal limbs. When her walk started changing, she developed a lot of anxiety about going outside and being in public. Now, activities of daily living are becoming challenging.

In addition, she gets muscle spasms that seem triggered by sudden movement, noise, or emotional upset. These spasms begin in the truncal muscles and spread to the extremities. She has one in your office and you note the muscles becoming tight and rock-hard. Palpating it is like palpating a board. The rest of your motor and sensory exam is normal.

Challenge: What's your diagnosis?

Refresher II

I'm not sure if this counts as a refresher type case, but it's an important one nonetheless.

The top two panels of the MRI were taken two days after admission. The lower two panels were taken two weeks after admission.

This patient presents with acute onset focal neurologic deficits. He is altered with hemiparesis, dysphagia, aphasia, ataxia, and seizures. He also has been running a high fever.

Challenge: When you perform the lumbar puncture, what diagnostic test should you order?

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Chemo I

A patient starts developing numbness and tingling in the fingertips and feet. There isn't much pain, but you do note some mild distal weakness. On exam, you can't really get deep tendon reflexes, not even an ankle jerk. Vibration perception is quite poor. On review of systems, the patient complains of colicky abdominal pain and constipation. You send the patient to nerve conduction studies and electromyography and find that there is a symmetric axonal neuropathy.

Challenge: What chemotherapeutic agent caused this?

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Balloon

Challenge: This CT is from a patient who suffered trauma to the torso but not to the head. What do you see?

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Counting

A 10 year old boy is brought in by his parents because of behavioral problems leading to poor grades at school. He says he has uncontrollable persistent thoughts about how his possessions at school are out of order or messy. He constantly counts and checks them and refuses to interact with anyone else while he does so. He also hoards candies, action figurines, and erasers. Attempts to convince him not to do these activities don't work; he says there are "rules he must follow." His parents both have anxiety. One sister has ADHD. A brother has autism.

Challenge: What's the most likely diagnosis?

The Early Bird

Challenge: This is sometimes associated with osteogenesis imperfecta. What do you see here?

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Not Seasickness

A 30 year old woman with depression presents with dizziness after being on a boat (or using a flight simulator or being on a water bed). When she's on a boat, she feels a sense of swaying or rocking, like she's walking on uneven ground. She doesn't feel like the room is spinning around her, but rather she just has disequilibrium. She does not feel nauseous. She's never had motion sickness or seasickness. Her physical examination is normal. Vestibular tests are normal. She is treated with benzodiazepines.

Challenge: What's the diagnosis?

Broken

This frontal cervical radiograph is from a patient presenting with headache. She has a history of obesity, pre-diabetes, normal pressure hydrocephalus, and asthma. She's had several surgeries in the past.

Challenge: Look closely at the radiograph; what do you see here?

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Hang Ten

A young otherwise-healthy man is learning to surf for the first time. After his first lesson, he begins to develop progressively worsening low back pain, followed by lower extremity paresthesias. On arrival to urgent care, he has normal vital signs, normal cardiopulmonary exam, no spinal deformity, and a neurologic exam significant for decreased sensation and strength in the lower extremities. Two hours later, he lost complete sensation and motor function of his legs as well as rectal tone. Labs and CSF are unremarkable. Lumbar spine films are unremarkable. CT of the lumbar spine showed no evidence of spondylolysis, spondylisthesis, fracture, or soft tissue abnormalities. Brain MRI is normal. A non-contrast spine MRI (T1w sagittal image) four weeks later shows this:

Challenge: What happened?

Matchmaker

Challenge: What are we looking at here?

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Airlines

This gentleman is getting a sleep study. One of the waves noted on the EEG looked like this:

Challenge: What's the significance of this wave?

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Use the Labels

Challenge: Why is this case of the day labeled with "psychiatry" (as well as internal medicine)?

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They Need a Better Name

A 75 year old man comes to you with gradual onset cognitive decline. A few years ago, he was encouraged to ramp his career down because of poor job performance. A year later, he started having driving difficulty, getting lost, misjudging distances, and failing to see other cars and stop signs. He had a cognitive evaluation which noted impairments in attention and executive and visuospatial function. His memory isn't impaired.

When you talk to his wife and children, they say that his cognitive impairment seems to have fluctuations. In fact, one time he "blanked out" so badly, he was brought to the emergency department. They ruled out stroke and seizure, and sent him home. He occasionally acts in a bizarre manner, has speech or motor arrest, or becomes really somnolent. The episodes have variable durations, and in between, he has pretty normal function. For a while, they thought he was just tired in the daytime, requiring long naps, but once he started having prolonged staring spells and speech disturbances, they became more concerned. In addition, the wife wonders if he's having visual hallucinations from time to time.

He has a family history of Parkinson's disease. He is a retired college professor. He reports no bad habits: no drinking, smoking, drugs, or even caffeine.

You perform a brief neuro exam and find that he has trouble copying overlapping pentagons, drawing a clock, subtracting serial sevens, and spelling WORLD backwards. On the rest of your exam, you note bradykinesia, limb rigidity, and an unusual gait. He has no tremor. His deficits are subtle and symmetric.

His MRI is the one on the left. The MRI on the right is a patient with a similar presentation but a different diagnosis.

Challenge: What do you think this is?

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Essential Oils

A 4 year old who broke into the medicine cabinet is brought to the emergency department with seizures. He has a strong medicinal smell on his breath. On the ambulance ride over, he had nausea, vomiting, and abdominal pain. The parents say the medicine cabinet only had over-the-counter cold remedies. Labs and neuroimaging are unremarkable. His seizures are treated with benzodiazepines. Decontamination of the skin is performed with soap and lukewarm water. The poison control center says activated charcoal is not indicated because the substance is so quickly absorbed. Gastric emptying with syrup of ipecac is contraindicated.

Challenge: About 11,000 exposures are reported to United States poison control centers annually. What is this ingestion?

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