Happy Pi Day!

Challenge: This finding is associated with which cancers?

Image shown under Fair Use.

Holes

This patient presented with vision loss, hearing loss, and a gradual confusion. The visual loss is monocular, restricted just to part of the visual field. Fundoscopic examination shows a sectoral pattern of retinal opacification. A T1 MRI is shown above.

Challenge: What's the rare diagnosis?

Image is in the public domain.

Puffy

Only 20-25 cases of this disease have been described in the literature in the post-antibiotic era. A 10 year old girl is involved in a car accident where she has some mild facial trauma. Her head CT at the time is only notable for some sinusitis; she is observed for 24 hours and then discharged home. She then presents again to the emergency department with forehead swelling, headache, fever, chills, and rhinorrhea. Exam shows a minimally tender area of doughy, puffy edema. Her cranial nerve exam is normal. She has an elevated WBC count, ESR, CRP, and the CT shown above.

Challenge: What's the diagnosis?

Image shown with permission from radswiki.net.

V

An adolescent presents to your pediatrics clinic with fatigue. Her parents think she just doesn't like gym class, but she truly has exercise intolerance, myalgias, and poor endurance. On exam, you note muscle swelling and weakness after brief periods of intense isometric exercise. However, after a short break, the patient can resume physical activity without significant symptoms. Over the next few visits, you check CKs and they are always elevated; she also has intermittent myoglobinuria.

Challenge: What's the autosomal recessive disease described here?

Image is in the public domain, from Wikipedia.

Nerve II

A 30 year old woman undergoes a prolonged pelvic surgery in lithotomy position. Post-operatively, she is noted to have acute foot drop. She cannot dorsiflex her foot against resistance; in order to walk, she has to flex her hip higher when walking. She also complains of loss of sensation over the top of her foot. Although she cannot evert her foot, inversion is preserved.

Challenge: Where's the lesion?

Image shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

Nerve I

This week, we're going to do some peripheral nerve palsies because I happen to be very weak (pun intended) on them.

A 30 year old man presents with wrist drop. On examination, he has weakness of his finger and wrist extensors. He also has loss of sensation over the dorsum of his hand. Triceps strength is normal. You give the patient some thiamine because of alcohol use, but that doesn't change anything.

Challenge: What's the lesion?

Image shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

No Cases This Week

Hi everyone,

Thanks for supporting this blog. As my yearly in-training exam looms nearer, I'm going to take a week off to study. Check in next Monday.

Thanks,
Craig

Nemo

I hope everyone is safe, warm, and healthy. The picture above is from the recent snowstorm in the Northeast, shown under GNU Free Documentation License, from Wikipedia.

Say a patient is pulled out of the vehicle above. She is brought to the emergency department, minimally responsive with a core temperature of 30 degrees. Her hematocrit is 36 (reference range 35.4-44.4). Her finger stick glucose is elevated to 200, and she is given insulin. From the extraction, she has some cuts and abrasions that continue to bleed. Despite a normal PT, PTT, and INR, you consider giving her clotting factors.

Challenge: Are you worried about the hematocrit? Tell me about the insulin. And would you give her some FFP?

Resistant

Two patients present with the same disease. A 60 year old man with three vessel coronary artery disease presents for a routine coronary artery bypass surgery. The surgery is uneventful until the team prepares to go onto bypass. Administration of a weight-based dose of heparin has very little effect on the patient's activated clotting time. His 25 year old daughter presents with her second episode of an unprovoked deep vein thrombosis.

Challenge: What's going on?

Image shown under GNU Free Documentation License, from Wikipedia.

Helium

Challenge: What is this?

Image shown under Fair Use.