Wednesday, February 11, 2015

A 75 Year Old Hospitalized Patient Complains Of A Sudden Feeling That Her Heart Is Racing

A 75 year old woman is an inpatient at 2 days after a successful femoral-popliteal bypass. The surgery was performed because of a significant atheroscerotic peripheral vascular disease causing severely impeded blood flow to her right leg. The patient has been doing well since the completion of her surgery but on the 2nd post operative day she describes a sudden feeling that her heart is beating very fast , which seems like racing. She denies any chest pain, dizziness, or difficulty breathing. She says that she has never experienced a similar feeling before.
Past History: Peripheral vascular disease, Hypertension and mild Coronary artery disease.
Medication: Her medications include ASA, clopidogrel ( started post operatively), metoprolol, and enalapril. Prior to surgery she was taking pentoxifylline.
Patient was a heavy smoker for several years but quit 2 years ago.

On auscultation of her chest there was a rapid heart beat with significant irregularity.
Her H/R was 120 beats/min and BP was 145/83 mmHg.
As ECG was done and following was seen:

Irregular QRS rate with no discernible P waves

Diagnosis : Atrial Fibrillation

A 55 Year Old Diabetic Patient Presents With End Stage Renal Failure

A 55 year old man who is a known case of diabetes for almost 15 years presents with symptoms of end stage renal failure. His diabetes was mostly uncontrolled and his recent HbA1c level was 10. The patient has also been non compliant with his medicines. On examination the patient had bilateral lower extremity edema, and on laboratory workup he has a massive proteinuria. A biopsy of his kidney was done and following was seen on histopathology:

Glomeruli with Kimmelstiel-Wilson nodules. The smallest nodules can be more cellular and the greatest nodules tend to be acellular in the centre and surrounded by more cellular zones. Capillaries are seen around these nodules, sometimes adopting an aspect in garland (like in the three nodules indicated with arrows); in some cases we see microaneurisms around nodules. Notice the variability of size of the nodules (H&E, X.400).

The patient was diagnosed as a case of End stage Diabetic nephropathy.

Monday, February 9, 2015

A 54 Year Old Man Presents With A Chronic Heartburn

A 54 year old man presents to his primary care physician with the complains of a chronic heartburn that is not responding to medications. He says that he has intermittent symptoms of heartburn for several years but now over the past year the episodes have been more frequent and occasionally painful. He is taking omeprazole which was helping initially but now it seems that his problem is not getting any better. He describes his heartburn as a burning sensation behind the sternum and is worse after eating spicy food or bending over. He denies any episodes of dysphagia, vomiting, blood in stools etc. On examination the patient is an obese man with a normal findings on all the systems.
A Barium Swallow was done as a part of the workup and following was seen:

Air-contrast esophagram shows thick esophageal mucosal folds (arrows) and an ulcer (arrowhead) due to GERD.
Single contrast esophagram shows stricture (arrow) and sliding hiatus hernia

The patient was diagnosed as a case of Sliding Hiatal hernia with secondary GERD

Case Discussion:

Hiatal Hernia: is the herniation of a section of the stomach above the level of the diaphragm

  1. Sliding Type: Gastroesophageal junction and stomach are displaced above the diaphragm. (most common 95% cases)
  2. Paraesophageal Type: stomach protrudes through the diaphragm, but the gastroesophageal junction remains fixed in the correct location.

Sunday, February 8, 2015

A 4 Year Old Child Presents With Fever And Rash

A 4 year old female child is brought to a rural primary care clinic by her mother with the complains of a high grade fever for about a week followed by development of a rash that started on the head and face which has now spread to involve the entire body. Mother describes that the child has been very irritable, has no appetite and refusing to eat , has a runny nose and a hacking cough. The patient has been breathing faster than usual and shows no interest in playing with her toys.
Mother says that the child has never been vaccinated because of their cultural beliefs against vaccinations. The child has normal growth and development for her age.
On Examination Patient has a  fever of  102 F , a respiratory rate of 52 breaths per minute and a generalized maculopapular rash covering her entire body. The picture is shown as below;

What is the Diagnosis ?

35 Year Old Woman Complaining Of Pain In Her Right Calf

A 35 year old female presents to the hospital with the complains of pain in her right calf that started a few days ago and is now worsening. The pain is constant , 8/10 in intensity, and aggravated on walking and extending the knee. It is associated with swelling and redness of her calf region. The pain is slightly relieved by elevation of her foot and on taking ibuprofen. Patient gives a history of travelling a 15 hour flight 1 week ago. She is on oral contraceptive pills for last 2 years.
On examination the right calf appears red and swollen compared to the left side but there is no ulceration or abnormal pigmentation. On palpation the right calf is warmer compared to the left and there is a positive pitting pedal edema on the right side. The pulses are palpable and felt equal on both sides. Mobility is normal on both sides in the ankle, knee and hip joints. There is a positive Homan's sign on the right side.
The picture of her legs is shown below:

What is the differential diagnosis?

  • Deep vein thrombosis
  • Cellulitis
  • Myositis
  • Rupture of Baker's cyst
  • Hematoma
  • Spasm due to injury or sprain
What workup is advised in the above described case?
  • Doppler Ultrasound
  • D-dimer
  • Hypercoagulability testing
  • CBC with differential
  • CPK and myoglobin level
  • CT venography

Saturday, February 7, 2015

A 63 Year Old Man Presents With The complains Of Burning Epigastric pain

A 63 year old man presents to his primary care physician with the complaint of burning epigastric pain that occurs soon after eating. He says the pain begins within an hour after taking the meals and also describes having mild nausea associated with the pain. He says that these symptoms have begin about 2 months back and in the last week he had an episode of vomiting and he noticed some brown discoloration in his vomitus. He denies having any blood in the stool or any history of weight loss.
He gets some pain releif by over the counter antacids and ranitidine.
Past History: His past history is significant for osteoarthritis in both his knees and he has been taking naproxen and asprin for the pain relief.
On examination there was mild tenderness on palpation in the epigastric area otherwise no other abnormality was detected.

What is the Differential Diagnosis on the basis of above given history and examination?

Differential Diagnosis:

  • Gastritis
  • Peptic ulcer disease
  • Zollinger Ellison syndrome
  • Pancreatitis
  • Gastro esophageal reflux disease
  • Gastric cancer
The patient was referred for an esophago-gastro-dudenoscopy and has following picture seen:

An ulcer was seen on the lesser curvature of the stomach. 

Diagnosis: Gastric ulcer (peptic ulcer disease) secondary to NSAID overuse.

A 37 Year Old Woman Comes For An Evaluation Of Frequent Bouts of Loose Stools For The Past 5 Years

A 37 year old woman presents to a gastroenterologist on referral from her primary care physician for the workup of chronic diarrhea and multiple other GI symptoms. The patient gives a history of frequent bouts of loose stools or watery diarrhea for the past 5 years. She is getting increasing frustrated with her symptoms and has tried to change her diet but has no significant improvement in her symptoms. The patient also describes having frequent abdominal cramping, flatulence, bloating, fatigue and an itchy rash on her trunk. She denies any blood in her stools, or any symptoms of vomiting, or joint pains.

Physical Examination:

  • A thin appearing woman in no acute distress.
  • Abdomen is mildly distended and hypertympanic, on auscultation bowel sounds are hyper active. no masses or organomegaly. 
  • She has a faint papular rash on her back and anterior legs. 
The close view of her rash on her back is shown in the picture below:

Among the workup done for the diagnosis following were of note:
  • no abnormal masses or defects in the colon on barium enema.
  • Stool sudan stain: positive for high fecal fat content.
  • positive antigliadin and antiendomysial antibodies. 
  • A biopsy was done of the jejunum and following histopathology was seen:

The patient was diagnosed as a case of Celiac Sprue. and the rash as Dermatitis herpetiformis. 

Friday, February 6, 2015

A 20 Year Old Man Referred To Gastroenterologist To Evaluate For Bloody Diarrhea

A 20 year old man is refereed to a gastroenterologist by his college internist for a workup of bloody diarrhea. The patient gives a history of recurrent bouts of bloody diarrhea, abdominal pain and painful bowel movements over the past 8 months. He describes the abdominal pain to be crampy in nature and he has normal formed stools and bowel movements in between the episodes. He denies any symptoms of vomiting, constipation or urinary problems. He has no significant illnesses in the past. On Examination the patient appears to be a thin white male in no acute distress. he has diffuse mild abdominal tenderness and no organomegaly. His bowel sounds are normal. The patient is noticed to have multiple painful nodules on his anterior lower legs. Other systems are normal on examination. Rectal examination detects occult blood.

On the basis of the above history and examination what is the Differential Diagnosis:

Differential Diagnosis:

  • Inflammatory bowel disease ( ulcerative colitis or crohn's disease)
  • Bacterial or parasitic gastroenteritis
  • Celiac sprue
  • Lactose intolerance
  • Whipple disease
  • Irritable bowel disease
  • Carcinoid tumor
X ray barium enema done in this case is shown below:

On colonoscopy highly friable colonic mucosa was seen involving the full length of the colon without interruption. 

Final Diagnosis:

Thursday, February 5, 2015

A 35 Year Old Woman With Weight Loss And Protruding Eyes

A 35 year old woman comes to the clinic with the complains of 15 lb weight loss over the past 2 months, despite a good appetite, as well as difficulty sleeping, palpitations and feeling anxious all the time. She says she feels hot although it is cold weather nowadays. On examination her pulse was 112 beats per minute and she was noticed to have protruding eyes. The photo taken in the clinic is shown below:

Her palms were sweaty and she had a fine tremor in her hands.

What workup will you advice for the suspected diagnosis?

  • TSH
  • Serum free T4
  • Serum electrolytes
  • Complete blood count
  • Urine toxicology
What is the Diagnosis?

Tuesday, February 3, 2015

A 46 Year Old Woman With Acute Severe Right Upper Abdominal Pain

A 46 year old woman presents to the emergency department with the complaint of significant right upper quadrant abdominal pain that started about 10 hours ago. She says the pain has been fairly continuous during this time and the pain radiates to her back. She remembers experiencing a much milder form of this pain previously that typically occurred following heavy fatty meals and would last for an hour or so. The current episode is very severe, associated with vomiting and mild fever. She denies any chest pain, heart burn or any history of recent weight loss.

Physical Examination:

  • An obese woman in discomfort due to pain. 
  • Abdominal tenderness with voluntary guarding to palpation of the right upper quadrant and is unable to breathe inwards during palpation. 
  • she has fullness in her right upper quadrant but it is difficult to detect any organomegaly because of her obese body. 
  • She is not jaundiced.
  • Bowel sounds are mildly hypoactive.
  • All other systems are normal on examination.
  • She had a mild temperature of 100.1 F
The Patient was taken in for an ultrasound of her abdomen and it shows the following findings:

Ultrasound findings above show gallstone shadows, gall bladder wall thickening and a pericholecystic fluid . These findings as well as the history and examination are pointing to the diagnosis of.........

Monday, February 2, 2015

A 40 Year Old Alcoholic Man With fatigue, Anorexia And Jaundice

A 40 year old man presents to the clinic with the complains of feeling tired with aches in his arms and legs for the past 2 months. He says he feels nauseous and has vomited multiple times in the last one month. He feels anorexic and has lost his appetite. He has also noticed having an intermittent right upper quadrant abdominal pain. He drinks approximately 20 alcoholic beverages per week. He denies any chest pain, cough, difficulty breathing, or any problems with urination or bowel habits. He did notice his skin to be mildly jaundiced. On examination he has mild abdominal tenderness in the right upper quadrant and has a palpable mild hepatosplenomegaly.

What is the Differential Diagnosis?

Differential Diagnosis:

  • Hepatitis
  • Alcohol related liver disease
  • Cirrhosis
  • Acute pancreatitis.
  • Hepatocellular carcinoma. 
A biopsy from his liver shows following pathologic features:

The main pathologic features of alcoholic steatohepatitis include macrovesicular steatosis, hepatocellular damage, inflammation, and pericellular fibrosis.

The patient was diagnosed with Alcohol related liver disease.

A 65 Year Old Man With Pancytopenia

A 65 year old man is referred to a hematology-oncology center for evaluation of his pancytopenia. The patient has a history of constant fatigue over the last 1 month, he feels short of breath on mild exertion and had a persistent upper respiratory infection for the past 2 months with chest congestion and a non productive cough. He has also noticed that he has developed multiple bruises from minor trauma on his legs or arms. He denies any similar symptoms in the past and has not used any new medicines recently.

Physical Examination:

  • Patient looks pale.
  • petechiae around his mucosal surfaces
  • No lymphadenopathy
  • Mild ronchi on auscultation of the lungs
  • soft systolic murmur on auscultation of heart.
  • Abdomen is soft and non tender with a palpable spleen
  • Normal neurological examination.
The routine blood test done by his general physcian shows a pancytopenia and the valuse are shown below:
Hb = 11.5gm/dl, WBC = 3100/mm3, Platelet = 128,000/mm3

What is the Differential Diagnosis?
  • Aplastic anemia
  • Acute myelogenous leukemia
  • Acute lymphocytic leukemia
  • Lymphoma
  • HIV
  • Hairy cell leukemia
  • Chronic myelogenous/ lymphocytic leukemia
On further work up the blood smear had the following picture;

several large myeloblastic leukocytes , some with Auer rods and notched(bilobed) nuclei

HIV Elisa was negative 
Bone marrow biopsy shows high proportion of blast staining with myeloperoxidase.

What is the Final Diagnosis?

A 27 Year Old Woman Involved In A Car Crash

A 27 year old woman is brought to an emergency department by an ambulance after being involved in a single car collision , when her car slipped off on a wet road and hit a telephone pole. The patient is conscious now but says she thinks she lost consciousness for sometime after the accident. She complains of some mild neck and upper back soreness but denies any pain elsewhere in her body. She has no numbness or weakness of her extremities , no history of nausea or vomiting or loss of bladder or bowel control. She had a laceration about 4 cm length on her scalp that was covered with a bandage in the emergency department.
On her initial examination she is found to be alert and conscious with no neurological abnormalities. On her second survey she seems to be disoriented not knowing her name and location and is also complaining of a severe headache.
A CT scan Is done and shows the following findings:

This is a sagittal head CT scan without contrast demonstrating a large epidural hematoma with right to left shift and ventricular narrowing.

The patient was diagnosed as a case of

33 Year Old Man With Watery Diarrhea, Abdominal Pain And Weight Loss

A 33 year old man presents to the clinic with the complains of watery diarrhea, diffuse abdominal pain and gradual weight loss over the past 3 weeks. He has been given antibiotics but his diarrhea is not responding. He mentions having a similar problem 6 months back. His appetite has decreased and he describes having painful ulcers in his mouth that makes eating difficult and painful.
On examination he looks pale and in mild discomfort. He has a fever of 101 F.  His abdomen in mildly tender on palpation but there is no visceromegaly.
Based on the above history and examination what is the differential diagnosis?

Differential Diagnosis:

  • Gastroenteritis.
  • Inflammatory bowel disease
  • Pseudomembranous colitis
  • Small bowel lymphoma
  • HIV induced Infection
  • Carcinoid
What Lab test and workup will you advice for this patient?

  • Complete blood count
  • Serum electrolytes
  • Stool exam and culture
  • Colonoscopy
  • CT abdomen
  • Urinary 5- HIAA
  • Small bowel series.
This patient was scheduled for a colonoscopy and the following was observed:

Colonoscopic image showing erythematous and friable mucosa with numerous pseudopolyps .

Sunday, February 1, 2015

21 Year Old female With Complaint Of Severe Right Lower Abdominal Pain

A 21 year old female presents to the emergency department with the complain of severe right lower abdominal pain that started this morning. The pain is 7/10 in intensity and constant in nature. It is exacerbated by movement and does not radiate. It is accompanied by fever, nausea and one episode of vomiting. Her LMP was 4 weeks back and she is sexually active. She has a history of regular periods every 4 weeks lasting for 6 days. She did notice some brownish spotting this morning which she thought was her periods because she was due. She is on birth control pills nowadays. She had a normal vaginal delivery 18 months back. Her past history is not significant for any illnesses or any major surgery.  On examination, she looked pale and was in pain. Her abdomen was tender on palpation more on the right side. On pelvic examination she had severe pain and the cervix and the uterus seemed to be pushed on one side.

 What will be the differential diagnosis on the basis of History and examination?

Differential Diagnosis:

  • Pelvic inflammatory disease.
  • Torsion of an ovary
  • Torsion of the ovarian cyst
  • Adnexal torsion
  • Acute appendicitis
  • Ruptured ectopic pregnancy
  • Abortion
 Urine hCG was negative and pregnancy was almost ruled out. She was taken for a transvaginal ultrasound and it shows the following picture;

Sonographic Whirlpool Sign in Ovarian Torsion

A 70 year Old Man Comes In With Complaints Of Hand Tremors And Shakiness.

A 70 year old man presents to a neurologist accompanied by his wife. His wife says that she first noticed the tremors in her husband's hands 6 months ago., but it has gradually worsened since that time. The tremor seem to be present both at rest and during activity.The tremor nearly resolves while he is asleep. The patient has been unstable on his feet and has fallen on a couple of occasions. The patient tend to forget things easily and does not participate in activities he previously enjoyed.

Physical Examination:

  • An old man with no acute distress.
  • he shows little or no emotion during the history and physical examination.
  • His face appears symmetric.
  • he has a resting tremor in both the hands that consists of a regular beat of writ and finger flexion.
  • He has an increased tone throughout his body , and it is difficult to passively range his extremities. 
  • Sensation is grossly intact.
  • When his gait is observed, he has difficulty initiating his first steps, walks in a shuffling pattern, and takes several extra steps when he tries to come to a stop. 
His photo taken in the office is shown below:

he was asked to write on a paper and he wrote like the pattern shown below;