Your Favorite Patient

A 35 year old woman with fibromyalgia and irritable bowel syndrome presents with 2 months of gradually worsening bladder pain, especially with a full bladder, relieved with voiding. The sensation varies from pressure and discomfort to painful spasms to severe debilitating pain. The pain is suprapubic and accompanied by urgency and frequency. There was no identifiable triggering event. This symptoms are worse with some foods, stress, and the menstrual cycle. There is no incontinence but she urinates up to 50 times a day to avoid pain. This has greatly affected her quality of life and ability to work. Examination shows tenderness of the abdominal wall, hip girdle, pelvic floor, bladder base, and urethra. The pelvic floor muscles are tight. Urinalysis is unremarkable and urine culture is negative. A post-void residual volume is normal. A cystoscopy shows reddened lesions on the bladder mucosa with attached fibrin deposits.

Challenge: What is your most likely diagnosis?

Limewater

I apologize for the missed case Monday - personal emergency. However, this is a good, rare case of the day which I had never heard of (or seen).

This chest X-ray is from a 30 year old man presenting with shortness of breath. He was treated with antibiotics without any improvement. Although sputum AFBs are negative, you take a social history to get an idea of his tuberculosis risk factors. He works in a Portuguese vineyard spraying plants with a fungicidal solution. The rest of his history is noncontributory; he is a nonsmoker. Pulmonary function tests suggest the lesion is interstitial. A thoracotomy was performed (this case is modeled after a case report from 1969) and the visceral pleura had areas that were blue.

Challenge: What's your diagnosis?

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Clinical Correlation Recommended

A 70 year old woman with a history of mastectomy presents to the emergency department with back pain for a month. A gadolinium-enhanced MRI is shown below.

Challenge: What's the concern?

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Organelle

These infants all have the same syndrome. Note the high forehead, epicanthal folds, and hypopolasia of supraorbital ridges and midface. This autosomal recessive disorder is noted early in infancy. Patients have hepatomegaly, cirrhosis, and biliary dysgenesis. They also have calcific stipping of the patellae, hips, and other epiphyses. Some have glomerulocystic kidney disease, cataracts, and pigmentary retinopathy. They all have profound hypotonia and weakness with absent reflexes, severe hearing and vision impairment, and neonatal seizures. Developmental delay is profound. Life expectancy is less than six months.

Challenge: What's the unfortunate diagnosis?

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Nerves?

Your neurology practice gets two referrals from a rheumatologist. The first is a 30 year old woman with Churg-Strauss syndrome who presents with the following physical exam finding:

Note the wrist drop in the left hand and dorsiflexion weakness in the right hand. You also notice as she enters the exam room that she has an unusual gait. She lifts one knee higher than the other as she walks, a sort of "foot-slapping" step.

Another patient, a 50 year old woman with microscopic polyangiitis has this finding on exam:

She also has a foot drop.

Challenge: What's this constellation of neurologic symptoms called?

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A Single Drop

A 35 year old G5P1 woman currently pregnant with a 32 week fetus through IVF presents for a routine obstetric visit. Her obstetric history is only significant for a second-trimester low-lying placenta. A transvaginal ultrasound is shown below:

Note the posterior placenta with a linear sonolucent area with color flow Doppler. You admit the patient, give betamethasone and perform frequent fetal heart monitoring. You make a plan to deliver the fetus by emergency C-section if the patient goes into labor, premature rupture of membranes, repetitive variable decelerations refractory to tocolysis, or vaginal bleeding accompanied by fetal heart rate changes. You schedule a C-section at 36 weeks.

Challenge: What's the diagnosis?

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The Goose

A 55 year old Caucasian man with obesity and GERD gets an endoscopy for erosive esophagitis.

Challenge: Images shown above confirm the diagnosis of what?

The first image is in the public domain. The second image is shown under Creative Commons Attribution Share-Alike License.

Wrong Consult

You are a surgeon moonlighting as a consultant in a hospital in the southwestern U.S during the early fall. The emergency department calls you to see a patient with acute abdomen. He was in his usual state of health, even working in his garage and storage shed 6 hours ago. Since then, he has developed severe abdominal pain with abdominal muscle rigidity. He also has muscle pain in his extremities and back, tremor, weakness, headache, nausea, and vomiting. Vital signs are normal though the patient is quite diaphoretic. Abdominal exam shows muscle rigidity and tenderness. Bowel sounds are normal. Labs are non-specific and include hematuria, leukocytosis, and elevations in CPK, glucose, and liver enzymes. A CT scan was negative for acute cholecystitis or acute appendicitis. EKG and troponins are negative.

On exam, you note this rash on the patient's leg:

Challenge: What's the diagnosis?

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Cheesesteak

This FISH analysis comes from a 50 year old radiology technician who presented to his primary care physician with fatigue, weight loss, and abdominal pain. He has splenomegaly on exam but no lymphadenopathy. Laboratory tests show a remarkable leukocytosis with myelocytes and segmented neutrophils. There is also an absolute basophilia and absolute eosinophilia. He also has thrombocytosis and a normochromic, normocytic anemia.

Challenge: What's your diagnosis?

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Paganini and Rachmaninoff

Panel A is normal; panel B represents the patient; panel C is a variant.

These are images from a tall young adult with scoliosis and history of pneumothorax.

Challenge: What an awesome collection of pictures demonstrating this autosomal dominant disease - what is it?

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