Happy Holidays

Whoops! I forgot to note that I'm taking another Case-of-the-Day break for the holidays. See you next Monday!

Craig

Early Bird

A 33 year old G1P0 woman at 33 weeks, 5 days gestation presents with painful regular contractions. Her pregnancy has otherwise been uneventful. Her fetal heart tracing is reassuring. You start her on some betamethasone and give her an oral medication that can cause nausea, flushing, headache, dizziness and palpitations.

Challenge: What medication is it?

Image is in the public domain.

Hemisphere

This CT scan is from an 8-year-old girl who presented with seizures and progressive hemiparesis. The seizures are unilateral and intractable, frequently evolving into focal motor status epilepticus or epilepsia partialis continua. She has been treated unsuccessfully with immunosuppressants. Brain biopsy only shows nonspecific inflammation.

Challenge: What's your diagnosis?

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Nuff SAID

You are seeing a new patient for the first time in your family practice clinic. This is a young gentleman with a history of asthma with occasional albuterol use. His surgical history is notable for resection of nasal polyps and functional endoscopic sinus surgery for chronic rhinosinusitis. He is allergic to aspirin, getting wheezing, chest tightness, facial flushing, and conjunctival injection between 30 minutes and 3 hours after taking it. His family history is significant for diabetes, hypertension, and dementia. He drinks occasionally, quit smoking after his diagnosis of asthma, and denies drug use. He is a lawyer and lives with his wife.

Challenge: What triad stands out from his history and what does it signify?

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Many Faces

Challenge: Here are many faces of what disease?

First image is in the public domain; last three are shown under Creative Common Attribution Share-Alike License.

The Difficult Patient

A 30 year old man who recently got out of jail for the fourth time sees you for mandatory follow-up. He has been in trouble with the law since his late teenage years. But when you look farther back, he's had problems since age 10 with fights with peers, conflicts with authority figures, stealing, vandalism, fire setting, and running away from home. He's never been able to hold a consistent job. His social support is poor; he has been divorced, and his ex-wife says he never showed any empathy. He doesn't have any strong interpersonal relationships. He is estranged from his family for stealing and lying. When you talk to him, he doesn't show any remorse for his past transgressions.

He has past diagnoses of substance misuse, major depressive disorder, and attention deficit hyperactivity disorder. He continues to smoke, drink, and use marijuana, but has avoided other drugs.

Challenge: What personality disorder do you recognize here?

Airway

A morbidly obese middle aged man with unknown past medical and surgical history has a motorcycle crash. All his injuries are above the neck. He has multiple facial fractures, orbital fractures, mandibular fractures, tongue lacerations, CSF rhinorrhea, and scalp hematomas. On arrival, he is obtunded. Bag-mask-ventilation is impossible with the jaw fractures. An attempt is made to intubate him but nothing can be visualized. An attempt to place a laryngeal mask (LMA) also fails. The patient begins to desaturate.

You come to the rescue. After identifying the appropriate landmark and scrubbing with povidone-iodine, you place a needle with a syringe half-filled with saline into the airway at 30-45 degrees directed caudally. When you see air bubbles in the syringe, you advance a catheter, remove the needle, and confirm placement again. Then you connect the catheter to a bag-valve-mask, confirm CO2, and call a surgeon for a definitive procedure.

An X-ray is shown below.

Challenge: What procedure did you perform and what complication do you see above?

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Gratitude

Happy Thanksgiving! This blog revolves around obscure, fascinating, strange, and unusual diseases, but some days, we have to give thanks for the healthy.

You are a pediatrician evaluating a perfectly healthy baby. She can stand on one foot with some slight support, walk backward, and even go up stairs with one hand held. She scribbles spontaneously, picks up and drinks from a cup, fetches and carries objects, and finds a toy observed to be hidden under layers of covers. She periodically visually relocates her caregiver and has some self-consciousness, feeling embarrassed when she sees you observing her. She understands simple commands and uses 5-10 words.

Challenge: How old is she?

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The Coagulation Cascade

A 30 year old postpartum woman presents with bleeding after minor surgery. She is G1P1 and recently delivered a healthy baby boy at 39 weeks. Her pregnancy was complicated by gestational diabetes mellitus, but there were no problems with the delivery. Three months after delivery she had her wisdom teeth pulled and had prolonged bleeding. She also noted increased epistaxis and mucosal bleeding. She has no other surgical history. She takes iron, has no allergies, has a nonsignificant social history, and has an otherwise negative review of systems. Her labs show an prolonged aPTT with a normal PT. You then take her plasma and mix it with pooled normal plasma; the aPTT remains prolonged.

Challenge: What does this mean? What's the most likely diagnosis?

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Catching Up with Life

Hi everyone,

Thank you for following along with all the cases. Each time I sit down to write a new blog, I wonder whether there are any more medical diseases I can find, but I always find something. It's been pretty time-consuming, however, and I need a break from Case of the Day this week. I've been falling behind with lots of competing priorities, and I just need to make a little more room. It's also why cases and solutions occasionally show up a little bit late. But thank you for understanding and I hope you're enjoying and learning. Come back next Monday for a new case.

Craig