Multisystem Disorder

This man with a positive family history of this disease presents with leg pain, exacerbated by deep palpation of the muscles. He also complains of colicky abdominal pain, constipation, diarrhea, and dysphagia. Recently, his cardiologist told him he had atrial flutter, his primary care doctor noted primary hypogonadism and testicular atrophy, and his ophthalmologist found cataracts. Review of systems picks up excessive daytime sleepiness. When he first comes in to shake your hand, you notice he has trouble letting go; when he leaves, he also has difficulty letting go of the doorknob. You note weakness in the facial muscles, intrinsic hand muscles, and bilateral foot drop.

Challenge: What's the diagnosis?

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Obstruction 3

A 3 year old boy living in Asia presents with intermittent colicky abdominal pain, vomiting, and constipation. On exam, you feel an abdominal mass near the ileocecal valve area. In the past, he has had longstanding abdominal discomfort, anorexia, nausea, and diarrhea. About a month ago, he had an irritating nonproductive cough, pleuritic chest pain, rales, and wheezing. Laboratory tests at the time showed eosinophilia. Luckily, you recognize the cause:

Challenge: What is the disease?

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Obstruction 2

A 70 year old man with multiple medical conditions including a recent pneumonia, a recent MI, and Parkinson's disease presents with nausea, vomiting, constipation, and diarrhea. On exam, his abdomen is so distended that it causes labored breathing. The abdomen is tympanic and bowel sounds are present. Labs show hypokalemia, hypocalcemia, and hypomagnesemia. Further workup excludes toxic megacolon and mechanical obstruction. The treatment is neostigmine.

Challenge: What is this eponymous disease?

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Obstruction

This week is obstruction week! Here's the first case:

A 70 year old woman presents with intermittent abdominal pain and vomiting over the last few days. Past medical history is significant for coronary artery disease, COPD, and diabetes mellitus. There is no history of abdominal surgery. On exam, the patient is febrile, appears dehydrated, has increased bowel sounds, and has abdominal distension. Here's a CT with contrast:

The red and blue arrows note air, the yellow arrow notes the pathological finding, and the green arrow notes dilated and fluid-filled small bowel.

Challenge: This is small bowel obstruction but what specifically is the etiology?

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First Described in 1849

A 35 year old African American woman who gave birth to twins 2 months ago presents with marked dyspnea and cough, sometimes bringing up blood. She says that she requires several pillows to sleep and will wake up short of breath several times in the night. Although she had pre-eclampsia in pregnancy, her cardiac function before that was normal. There was postpartum hypertension.

You do a cardiac work-up and find LV ejection fraction of 35%; EKG with sinus tachycardia, nonspecific ST wave abnormalities, and voltage abnormalities; echo showing global reduction in contractility and LV enlargement; and CXR confirming enlargement of the cardiac silhouette with pulmonary venous congestion. You rule out PE, amniotic fluid embolus, anxiety, infection, and asthma.

Challenge: What's the diagnosis here?

The Nose Knows

A 15 year old male presents with severe epistaxis from the back of his nose. There is nasal obstruction, nasal drainage, serous otitis media, and diminished hearing on exam. A gadolinium enhanced T1 weighted fat saturated MRI is shown above. Although locally aggressive, histology shows this mass to be benign.

Challenge: What is it?

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Very Important

A 40 year old woman presents with months of diarrhea. Even when fasting, the stool volume is >700 mL/day; it averages 3 L/day. You hate to ask, but you learn the stool is tea-colored and odorless. There is no abdominal pain, but she gets some flushing, lethargy, nausea, vomiting, muscle weakness, and muscle cramps. Labs show a low potassium. A stool analysis shows an osmotic gap of 30 mOsm/kg (normal 50-125).

Challenge: What's the diagnosis?

Thief

A middle age man with known atherosclerotic disease presents with left arm claudication, fatigue, coolness, and tingling. He gets dizzy when he exercises the arm. On examination, you note the left arm has a 15mmHg lower systolic pressure than the right arm. Palpation of both radial pulses shows a decreased amplitude and delayed arrival on the left side.

Challenge: If blood is flowing in the wrong direction, what syndrome is this?

Out of Crime

This smear is seen from a woman who had an uncomplicated UTI treated with an oral agent 100 mg twice daily for 7 days. This agent is only used for E coli UTI.

Challenge: What caused the finding shown in the blood smear?

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Emergency Ultrasound

*Note: I originally put up a different case for today but decided to change it to a pregnancy-related case since, of course, it's labor day.

A 33 year old woman is BIBA (brought in by ambulance) for hypovolemic shock. You note a significant ascites, hyponatremia, hyperkalemia, and pleural effusion. She says, "I've been trying to get pregnant." You get an ultrasound:

It might look like PCOS (polycystic ovarian syndrome) but your attending suggests it is something more serious.

Challenge: What does your attending think?

Related Question:
1. How does wanting to get pregnant fit into this picture?

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