Monday, May 25, 2015

A 40 Year Old Known Diabetic Patient Presents With Double Vision

A 50 year old man who is a known case of diabetes presents to the clinic with symptoms of double vision that started a few days ago and has not improved. His wife observed that his right eye is directed outwards and does not seem normal.
On neurological examination the patient was diagnosed to have an oculomotor nerve palsy most probably secondary to diabetic neuropathy. Rest of the examination was normal.
The picture is shown below:

The right eye is directed downwards and outwards. pupil is slightly dilated compared to the normal left side. In this case there is no ptosis (which is possible in 3rd cranial nerve palsy)

Case Discussion:

Oculomotor (3rd Cranial Nerve) Palsy:

Oculomotor nerve palsy is an eye condition resulting from damage to the third cranial nerve or any of its branch.

Thursday, May 21, 2015

A 25 Year Old Man Presents With 3 Day History Of Chest Pain And Increasing Breathlessness.

A 25-year-old male presented to the Accident and Emergency Department with a three-day history of
pleuritic, lright-sided chest pain and increasing breathlessness. The symptoms started suddenly while he was playing football. He denied any chest trauma. Until then he had been fit and well, and there was no past medical history of note. His father died suddenly at the age of 32 years.
On examination he was thin and tall and distressed with pain. There was no pallor or cyanosis. He had a wide arm span. The heart rate was 100 beats/min and blood pressure 150/80 mmHg. The respiratory rate was 32/min. The trachea was deviated to the left. Percussion appeared to be reduced on the left side and was loud on the right side. The right lung base was dull to percussion. On auscultation of the lung fields breath sounds were absent on the right side and normal on the left side. Auscultation of the precordium demonstrated
quiet heart sounds and a soft mid-systolic murmur. The femoral pulses were easily palpable. The left calf was bruised and slightly tender. He attributed this to an injury sustained during the football match. The ECG revealed normal sinus rhythm.

1. Which test would you perform to reach a diagnosis?
Answer: Chest X ray.

The chest X ray is shown below:
The X ray Shows a large pneumothorax on the right side with a collapsed lung (arrows).

A 2 Month Old Baby Is Hospitalized With Hydrocephalus Since Birth

A 2 month old baby who was diagnosed as a case of hydrocephalus on a prenatal ultrasound is hospitalized since birth and is under the care of pediatricians and neurosurgeons. The baby has an enlarged head circumference above 95 percentile and has difficulty feeding and has had 3 episodes of seizures. There is no active infection and there is plan for surgically inserting a shunt system.
The picture of the patient is shown below;

The eyes show the sun-set sign characteristic of hydrocephalus in babies.

Case Discussion:
Hydrocephalus is derived for the Greek words: Hydro means water and cephalus means head. It is a condition that is characterized by excessive accumulation of fluid in the brain. Since in young babies the skull sutures ares till open, the excess fluid leads to rapid enlargement of the head.

Physiology:  Cerebrospinal fluid (CSF)is an essential component of the nervous system that circulates through a system of passageways known as ventricles in the brain and exists through a reservoir known as cistern. CSF provides nutrients to the brain and takes away the waste products. If there is a blockage at any of these passages the fluid starts to accumulate leading to hydrocephalus. Sometimes there is no blockage but there is excess production of fluid and inadequate absorption leading to accumulation.

Tuesday, May 19, 2015

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A 32 Year Old Man Presents With Hair Loss

A 32 year old man who is otherwise healthy presents with patchy hair loss from the scalp that he observed a few months ago. He denies any recent change in his shampoo or use of any chemicals. He denies any recent illness or use of drugs. He is concerned about the hair loss and the patches of hair loss are progressively increasing to involve more areas of his scalp.
The picture of the patient is shown below:

What is the Diagnosis?
 Alopecia Areata.

Case Discussion:
Alopecia means hair loss and Alopecia areata is a medical condition in which hair loss occurs in some or all areas of the body in patches. It is an autoimmune disorder and it is most commoly seen on the scalp but may involve the whole body.

Patients are otherwise healthy, the condition is not contagious and there is no nerve involvement.
Since it causes bald spots on the scalp usually in the early stages it is also sometimes called as spot baldness.

Types: It has different types depending on the type and extent of hair loss.

Sunday, May 17, 2015

A 43 Year Old Lady Presents With Dysphagia And Feelings Of Skin Tightening.

A 43 year old woman is seen by a General physician where she complains of difficulty swallowing and associated chest pain that started a few years ago and has gradually progressed. It mostly occurs with solid foods and drinking a lot of liquid and taking very small bites helps in swallowing. She denies any regurgitation of food or any history of weight loss. The patient reports that she often feels her skin of the fingers and face getting tight as well episodes of bluish discoloration of finger tips on exposure to cold.
During the Physical Examination the picture of her hands was taken that is shown below:

What is the most probable Diagnosis?
CREST Syndrome.

Case Discussion:
CREST syndrome is also known as Limited scleroderma which is an autoimmune disorder and it is characterized by:

Saturday, May 16, 2015

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A 25 Year Old Female With A History Of Depression Presents With An Overdose

A 25 year old female who was diagnosed with depression attempted suicide by taking an over doses of her prescription medicines clonazepam and nortriptyline. When seen in the emergency department, patient is unresponsive and is having difficulty in breathing. After the initial steps of incubating the patient and protection her airway an ECG was performed and the following was obtained:

The ECG shown above is showing torse de pointes.

Torsade de Pointes (TdP) is a form of polymorphic ventricular tachycardia associated with a long QT interval on the resting ECG. Torsade de Pointes is typically initiated by a short-long-short interval. A ventricle extrasystole (first beat: short) is followed by a compensatory pause. The following beat (second beat: long) has a longer QT interval. If the next beat follows shortly thereafter, there is a good chance that this third beat falls within the QT interval, resulting in the R on T phenomenon and subsequent Torsades de Pointes. During Torsades de Pointes the ventricles depolarize in a circular fashion resulting in QRS complexes with a continuously turning heart axis around the baseline (hence the name Torsade de Pointes).


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A New Born After A Difficult Delivery Is Seen To Have Asymmetrical Moro's Reflex.

A new born is examined in the nursery after a difficult delivery and a prolonged second stage of labor that involved some pulling on the shoulders. The baby looks healthy and weighs 8.5 lbs.
On attempting a Moro's reflex it was asymmetrical with the right arm having little or no movement at all. While the baby was lying flat it was noticed that his right shoulder was adducted and internally rotated , the elbow was extended and pronated while the wrist was flexed. Brachial plexus damage and Erb's Palsy was suspected. The picture of the new born is shown below:

Case Discussion:
Erb's Palsy also know as Erb- Duchenne palsy is the paralysis of the arm caused by injury to the upper group of the arm's main nerves.
The brachial plexus is a network of nerves near the neck from which arises all the major nerves to the upper arm. Most commonly during a difficult labor and delivery the upper part of these nerves are damaged leading to paralysis of the arm.

Friday, May 15, 2015

A 2 Year Old Child Is Seen By A Pediatrician For Bowing Of Legs

A 2 year old child is brought to a pediatrician for the evaluation of delayed growth, muscle weakness and bowing of the legs. The mother gives the history that the child was weaned early as she was expecting again and since the child frequently suffered from diarrhea he was given almost little or no milk. They live in a close apartment with almost no sunlight exposure. The child's diet mainly consists of vegetables and rice. His mental development seems to be normal for his age but he has delayed walking and still falls while playing.
On examination, the child was quiet and cooperative. He looks malnourished with signs of growth delays. On standing he had bowing of the legs, the picture is shown below:

His wrists were widened and there was frontal bossing of the skull.
His vitals were normal. There were some coarse crackles on auscultation of the lung fields. The rest of the examination was within normal limits.

What is the Diagnosis?

A 30 Year Old Man Presents With Headaches And Symptoms Of Transient Visual Loss

A 30 year old man come to his physician complaining of chronic headaches that has started about 6 months ago. He describes the headache as a diffuse pain, worse in the mornings and sometimes associated with nausea. The pain extends into the neck and the back. He was not much concerned about his headaches but for the last few weeks he is having episodes of transient visual loss in one or both eyes that lasts for up to 30 seconds. The visual loss is sometimes related to changing posture. .

On examination patient is a well appearing obese man with normal vitals.
The fundoscopic findings are shown below:

The features of Papilledema (optic disc swelling ) is seen.

Definition Of Papilledema: Is the swelling of the optic disc caused by a raised intracranial pressure. It is usually bilateral.

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Thursday, May 14, 2015

A 45 year Old Man Taking Immunosuppressant Drugs presents With Jaundice And Fever

A 45 year old man with a 7 year history of rheumatoid arthritis presents with cough, high fever and a painless jaundice. Over the past 16 months his symptoms of joint pain were not controlled by NSAIDs alone and so he was switched to immunosuppressant drugs which helped in controlling his symptoms. Patient is a non smoker and consumes less than 2 units of alcohol per week.
On examination;

  •  patient looks unwell and deeply jaundiced.

  • He had a temperature of 102 F. 
  • Examination of the oral cavity shows yeast infection.

  • On auscultation of the lung fields there were coarse crackles at the right lung base. 
  • On abdominal examination spleen was palpable 3 cm below the left costal margin.
Investigations done are shown below:

Wednesday, May 13, 2015

A 35 year Old Man Presents With A Long History Of Backpain

A 35 year Old man is seen in The Physician office for a prolonged history of back pain. The patient says the back pain started about 12 years back and is progressively getting worse. The pain is disabling him and he cannot participate in any kind of sports which he is very interested to take part. He takes ibuprofen for the pain which he now feels is not helping. For the past two years he has also noticed intermittent pain and swelling in both of his knee joints.
On examination of the locomotor system there was pain and loss of lumbar lordosis. His knee joints were swollen, with bilateral effusion.
On general Physical examination, he was noticed to have bluish discoloration of his ear cartilage. The picture is shown below:

He was advised some lab work to be done that also included a routine urine analysis. The lab technician forgot his specimen on the table for a few hours and when returned observed a color change shown below.

The physician was noticed about the color change of the urine and he ordered to test urine homogentisic acid levels which came out elevated.

What is the Diagnosis?

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Tuesday, May 12, 2015

A 48 Year Old Lady Presents With Difficulty Swallowing And Fatigue

A 48 year old woman who has a long history of weakness and fatigue come to see her physician because she has been feeling difficulty in swallowing for the last few weeks. This dysphagia was intermittent and is limited to solids. She denies any history of weight loss. The patient was previously prescribed iron supplements to correct her anemia and resulting fatigue but she never took the supplement
On Examination the patient is a middle aged lady looking pale and a bit anxious. On general physical the following features were seen in the nails and the tongue.

Spoon shaped nails known as Koilonychia seen in chronic long standing Iron deficiency anemia.

Smooth, red tongue with loss of lingual papillae (Atrophic glossitis)

On lab work There was microcytic hypochromic anemia and a barium swallow revealed esophageal webs on the anterior esophageal wall.

What is the most probable diagnosis?

Friday, May 8, 2015

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A 38 Year Old Woman Presents With A 2 Day History Of Severe Headache And Neck Stiffness.

A 38 year old woman is seen in the emergency department with the complains of severe headache and neck stiffness for the last 2 days. On examination she had a temperature of 101 F and BP of 120/70 mmHg. There was no rash seen on the skin. On neurological examination there was mild nuchal rigidity.
CSF analysis was done and the report is given below:

  • Appearance = clear
  • WCC = 20/ cubic mm (60% lymphocytes)
  • Protein = 0.48 gm/l
  • Glucose = 2.3 mmol/l ( simultaneous blood glucose = 4.5 mmol/l)
  • Gram stain = No organism identified. 
A CT scan Of the brain was done and the image is shown below:

Normal CT scan of the brain.

What is the Differential Diagnosis?
  • Aspectic Meningitis
  • Viral Meningitis
  • Partially treated Bacterial Meningitis
  • Tuberculous Meningitis.
  • Listeria infection
  • Lymes Disease
  • Herpes Simplex Encephalitis.
The Final Diagnosis was

Thursday, May 7, 2015

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1 Year Old Child With A Dry Itchy Rash On The Face

A 1 year old boy was brought to  a general physician by his mother with the complains of irritability, trouble sleeping and a dry, scaly and itchy rash on his face. Mother says that the child has been scratching his face and is getting irritable most probably because the rash is itchy which is also disturbing his sleep. The problem has began since the changing season last month.
Two of his older siblings also have had similar skin problems and are also diagnosed with asthma.
The picture of the child is shown below:

What is the Differential Diagnosis?

  • Atopic Dermatitis/Eczema.
  • Scabies
  • Contact Dermatitis
  • Fungal Infection 
  • Impetigo.

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Tuesday, May 5, 2015

9 year Old Boy With A Chronic History Of Cough And Diarrhea Is In The Clinic For A Routine Followup

A 9 year old male child is having a routine followup with his primary care physician when a voluntary medical student approaches this patient for clinical history and examination. The child's mother gives the history of the patient being always sick since the time when he was an infant. He suffers from repeated respiratory infections needing antibiotic for treatment. The patient also has repeated episodes of diarrhea and he looks young for his age with some degree of growth retardation.
On physical examination, the medical student found a very striking sign in the hands. The picture is shown below:

What is the sign seen in the above picture?
Clubbing of the fingers.

On the basis of history what is the Differential Diagnosis?

  • Cystic Fibrosis
  • Congenital heart disease.
  • Celiac disease.
  • Malabsorption disorder.
The above mentioned patient has cystic fibrosis.

Monday, May 4, 2015

A 22 Year Old Lady Presents With Skin Depigmentation

A 22 year old lady is seen by a dermatologist for the complains of skin depigmentation and appearance of white patches on her hands, face and arms. She first noticed around 6 months ago as a spot in her face but now the depigmentation is spreading through tout her body gradually. She has also noticed her scalp hair turn white. The white patches are mostly symmetrical in distribution and there is no itching or any signs of infection in the involved areas.
The picture of her hands is shown below:

What is the most probable diagnosis?


Case Discussion:
Vitiligo is a skin disease that causes loss of skin color and is characterized by portions of skin depigmentation seen as white patches. The disease is not contagious or life threatening but it leads to severe mental stress and cosmetic issues.
The disease can affect all types of skin but it is more prominent in people with dark skin.

Sunday, May 3, 2015

A 50 Year Old Woman Presents With Yellow Bumps All Over Her Body

A 50 Year old Woman who is a known case of Diabetes presents with yellow small bumps all over her body including her eye lids, back and behind the elbows. The lesions are painless but she is concerned. The picture of the lesions on her eyelids and the back of the elbow her shown below:

Her diabetes is not well controlled and on investigations her lipid profile was also abnormal with high cholesterol and triglycerides.

What is the Diagnosis:

Saturday, May 2, 2015

A 30 year Old Man Presents With Joint Pain And Nail Deformities

A 30 year old male patient is seen by a Rheumatologist for pain in his small joints of the hand and feet as well as lower back pain. He has a past history of some skin problem which is nowadays under control but he has observed that his finger nails has become dry and cracked with pitting and looks deformed. He remembers having had such nail problems previously and was treated along with his skin lesions. This time he complains of pain in his small joints of the hand and stiffness.
On examination he has warm and tender distal interphalangeal joints symmetrically in both the hands with severe nail deformities.
The picture of his hands is shown below

There is some stiffness in his neck and the vertebral column as well.

A skin lesion on his elbow is shown below:

What investigations will you order in this case?

  • Rheumatoid Factor.
  • ESR
  • Joint fluid aspiration and analysis.
  • Joint X ray.

A 70 Year Old Man Presents With Bone pains And Fatigue

A 70 year old man is brought to a primary care physician by his son because the patient has been complaining of fatigue and bone pains over the past 5 months. Although he lives alone, for the past few days he has been feeling very sick and had to call his son for help. His appetite has reduced and he feels nauseous all the time. His son feels that the patient has lost a lot of his weight during the last few months. He says due to weakness he has not been out of bed for the last 4 days.
On examination the patient appears to be slightly confused. he looks pale and malnourished.
Temperature = 102 F
Heart rate = 110 beats/ minute
B.P = 110/60 mmHg
Resp rate = 17 breaths /min

On abdominal examination liver was palpable 3 cm below the right costal margin.
All the bones including the upper and the lower limbs as well as the ribs were tender on palpation.

What Investigations will you order?

  • Complete Blood count
  • Urinalysis 
  • Serum and urine assessment for monoclonal protein
  • Bone marrow aspiration and/or biopsy
  • Skeletal survey ( that includes a series of X rays of the skull, axial skeleton and proximal long bones).
The results shows:
  • Hb = 8 g/dl. 
  • Peripheral blood smear shows the following picture:
Plasma cells seen along with rouleau formation of blood red blood cells

Friday, May 1, 2015

A 40 Year Old Woman Presents With A Painless Swelling In Her Neck

A 40 year old woman was brought to the doctor's office by her cousin for a swelling in her neck. The patient lives in a mountainous region of the country and has little or no medical facilities. She was in the city visiting her cousin when she was insisted to get a checkup for the swelling. The patient describes the swelling to appear gradually over the last few years and it is painless and is not causing any symptoms.
On further questioning she says that her diet mostly consists of vegetables and she never knows about iodized salt. She mentions many people in her village has similar swellings in the neck.
The swelling on her neck is shown in the picture below:

A diagnosis of goiter secondary to iodine deficiency was made.

Case Discussion:
Goiter is defined as a swelling in the neck due to enlargement of the thyroid gland.