Prognosis

A 60 year old man presents with headaches and seizures. A T1 weighted MRI is shown below.

Challenge: What's the most likely diagnosis?

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April Showers

A 30 year old woman presents with an unprovoked pulmonary embolism. In searching for the cause, a contrast MRI is performed, shown above.

Challenge: What's the syndrome?

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Goat's Rue

An 80 year old gentleman is brought in by ambulance to the emergency department for "problems breathing." His family found him at home with empty pill bottles, confused and tachypneic. It's not clear what he ingested, though all the pill bottles were his. His past medical history includes hypertension, hyperlipidemia, diabetes, osteoarthritis, and dementia. His family knows he takes one medication for each of those diseases. He also has chronic kidney disease and cirrhosis, though he does not take any medications for those comorbidities. His past surgical history is insignificant, he has no allergies, he does not smoke, he drinks 2 beers a night, and he does not do illicit drugs.

Currently, he is complaining of nausea and abdominal pain. He is tachycardic, hypotensive, and tachypneic. He is a little confused. A fingerstick glucose is 70. Acetaminophen and salicylate levels are negative. An EKG shows sinus tachycardia with no changes in QRS or QTc intervals. A chest X-ray and CT abdomen are normal. An arterial blood gas shows an anion gap metabolic acidosis with respiratory compensation. A chemistry panel shows a Cr of 1.8. His WBC is normal, he has no fever, blood cultures are obtained, and a urine sample is normal.

Challenge: There is no antidote for this culprit. What is it?

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Check

A middle-aged man with an unknown past medical history is brought in after a motor vehicle accident. He was going 60mph when he hit the center divider of the highway and flipped his car. He was extricated after a prolonged period of time. On scene, he was confused but talking, moving all extremities, with a GCS of 12. On arrival to the emergency department, however, he becomes progressively more somnolent to a GCS of 7. He is hypotensive, tachycardic, and tachypneic. He is intubated for airway protection. A primary exam shows maxillofacial trauma, CSF rhinorrhea, absent breath sounds on the right, a positive FAST scan, and several extremity fractures. A chest tube is placed successfully. Multiple IVs are placed and blood transfusions are started. An attempt to start an arterial line is unsuccessful due to a weak pulse. A chest X-ray shows several rib fractures and a resolving pneumothorax. He is sent to the CT scanner.

In the CT scanner, he spikes a temperature and becomes more hypotensive. He is started on vancomycin and piperacillin-tazobactam. His blood pressures continue to plummet and the CT scan is aborted. He is taken emergently to the operating room for an exploratory laparotomy. The anesthesiologist continues to fluid resuscitate the patient, giving more blood products, fresh frozen plasma, and platelets. The patient is started on a dopamine drip. A fibrinogen panel comes back low and cryoglobulin is administered. At the end of the case, dark red-brown urine is noted in the Foley catheter. Initial placement of the Foley catheter showed concentrated yellow urine. At this time, the hematology lab calls and says that when they spun down the patient's blood, the plasma was light pink. A critical lab value of potassium 6.2 is also noted.

Challenge: What happened?

Bonus Question: What's shown in the picture above?

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Zombie

You live in Papua New Guinea. You meet a patient who was normal up to a year ago when he developed tremors, ataxia, and postural instability. You remember him well; he was shaking so hard that he looked like he was shivering. Because of worsening tremors and ataxia, he became nonambulatory six months ago. At that time, he was noted to have myoclonus, choreoathetosis, and fasciculations. Unfortunately, you are unable to diagnose the disease, and he progresses to dementia. Exam shows frontal release signs and dysarthria. He ultimately succumbs to pneumonia.

Challenge: What's the diagnosis? Happy Halloween!

Cat and Mouse

A 30 year old G1P0 pregnant woman brings in her pet rat. "He's acting so weirdly," she says. Apparently, the rat "Ralph S Mouse" is normally terrified of cat urine. The woman owns a cat as well. However, lately, the mouse has been attracted to cat urine. His other fears of loud sounds, snakes, and strangers are not abolished.

Challenge: You tell the pregnant woman that she must not do what?

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Vanished

Challenge: What's the diagnosis? (Click to zoom)

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Hot Cross Buns

A 55 year old man is initially diagnosed with Parkinson's disease. He has bradykinesia, rigidity, postural instability, and an irregular jerky action tremor of the arms. Parkinson's was initially diagnosed by his primary care physician when he had multiple falls at home. Since then, however, he's developed extensor plantar responses, severe anterior flexion of the spine (camptocormia), anterocollis, and dysphagia. With these progressive changes, he is sent to you.

When you begin talking to the patient, you note hypophonic monotony. His wife says his voice has also undergone an increase in pitch and gained a quivering, strained element. She's also noticed a weird change in his sleep; he talks, shouts, and occasionally even strikes out into the air. When he awakes, he says he had a vivid, frightening dream. He also has a high-pitched inspiratory noise during his sleep; he is being worked up for obstructive sleep apnea. On review of systems, you find that he has symptomatic orthostatic hypotension, erectile dysfunction, and urinary dysfunction. He does not seem to exhibit any cognitive changes.

Here is a T2 weighted MRI:

Challenge: What's your diagnosis?

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Curving of Joints

This drawing from 1841 depicts an infant with contractures of multiple joints. This heterogeneous group of disorders is characterized by degeneration of motor neurons. Most cases are neurogenic (disorders of the CNS, genetic syndromes, and chromosomal aberrations), but a small fraction result from primary muscle disease. Severity is variable.

Challenge: What is this?

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Tired, Heavy Legs

This 60 year old obese smoker complains of aching and swelling of his legs, especially when standing or seated for a prolonged time. The pain is not relieved with rest. His past surgical history is significant for bilateral knee replacements for osteoarthritis.

Challenge: What's your diagnosis?

Image is in the public domain.