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?

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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?

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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?

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Helium

Challenge: What is this?

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Congo

A 50 year old African American presents with an embolic stroke. During the stroke workup, he is found to have intraatrial thrombi but is in normal sinus rhythm. The echocardiogram shows LV thickening and atrial thrombi.

Over the next year, he develops lower extremity edema, decreased exercise tolerance, and elevated liver enzymes. He has some chest pain, but an angiogram is negative for coronary artery disease. EKG shows low voltage in the limb leads. A repeat echo shows diastolic dysfunction, a small LV cavity, biatrial enlargement, and RV dilatation. The myocardium is easily seen and described as "granular and sparkling."

A year later, he develops exertional syncope. Two months later, he has sudden cardiac death. On autopsy, the heart is large and rubbery. The histopathology is shown below. The left slide is stained with H&E. The right slide is stained with alcian blue.

A slide of normal myocardium is shown below for comparison:

Challenge: What's your diagnosis?

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Truth Serum

A patient is referred to your interventional neurology practice for pre-operative assessment prior to temporal lobe resection. Other than a longstanding history of refractory seizures, the patient is healthy. You place a percutaneous transfemoral catheter under local anesthesia into the femoral artery. You guide the catheter into the left carotid artery. You inject 100mg of truth serum, shown above. Then, you ask the patient to speak, repeat sentences, answer questions, and memorize a series of pictures. Afterwards, you repeat the procedure with the right carotid artery.

Challenge: What procedure did you just perform?

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Pescatarian

A 3 year old is brought in for dry, scaling skin. Interestingly, the father has this skin problem too, though it has been undiagnosed. "I always thought it was just atopic dermatitis," he says. The father says that his got significantly worse at puberty. It becomes worse with dry weather and is especially pronounced in winter. Most of the lesions are on the shins, back, and heels. They do not occur in flexural areas.

Challenge: What do father and son have?

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Ring

A 70 year old gentleman is struck by a car while walking across the street. Upon arrival to the trauma bay, he is tachycardic, tachypneic, hypotensive, and altered. He is in a great amount of pain around his hips, back, and lower abdomen. On examination, you note blood at the penile meatus. You obtain a plain AP X-ray:

Challenge: What's your diagnosis?

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