A 42 Year Old Man With Neurological Weakness In His Legs

A 42-year-old man required ventilation for a prolonged period during an episode of septicaemia. Following this he developed difficulty with walking and required the aid of an assistant to mobilize. On neurological examination there was weakness on dorsiflexion of the toes, as well as
ankle eversion. The patient also had reduced sensation, affecting the anterior lateral aspects below the knee and the dorsum of the foot.

What is the Diagnosis?
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Common peroneal nerve palsy.

Case Discussion:
Weakness of dorsiflexion and eversion of the foot and reduced sensation over the antero-lateral aspects of the lower leg and dorsum of the foot are typical features of common peroneal nerve palsy. The common peronealnerve crosses over the fibula, where it may become damaged owing to acute or chronic compression.

A 50 Year Old Woman Presents With Long Standing Bone Pains.

A 50 year old woman who had a history of long standing body pains and aches , was found to have hypercalcemia on her blood reports. On further workup she also had high levels of parthyroid hormone. On further questioning she mentions that she frequently gets a stomach upset, with abdominal pain and constipation. She feels lethargic and has a feeling of lack of energy for a long time.

This patient was diagnosed to have Hypercalcemia secondary to Hyperparathroidism .

Case Discussion;

Hypercalcemia is a condition in which the calcium levels in the blood is above normal limits. By far the most common cause of hypercalcemia is hyperparthroidism, from the over activity or adenoma of parathroid glands.

A 61 Year Old Woman With Halitosis And Regurgitation Of Ingested Food.

A 61-year-old woman visits her doctor's office complaining of halitosis, regurgitation of undigested food 4 hours after eating, and heartburn. She also feels that the food is sticking in her throat. A Barium swallow done during the workup for her symptoms is shown below:

What is the most probable diagnosis?
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Zenker Diverticulum

Case Discussion:

A 47 Year Old man With A Blistering Rash On His Hands, Scalp And Face

A 47-year-old businessman was referred to the dermatology clinic with a rash over his hands, scalp and face. He had been generally well. He smoked 20 cigarettes per day and drank 8–10 units of alcohol on a daily basis. There was no other significant medical history of note. The patient had not taken any medication, with the exception of occasional chlorpheniramine to help relieve his
symptoms. On examination he had vesicular lesions affecting his face, forearms, hands and scalp. All other physical examination was essentially normal.

Blisters and fragility on the back of the hands.

What is the most probable diagnosis?
Porphyria cutanea tarda

Case Discussion:
Porphyria cutanea tarda (PCT) is a rare disorder of haem synthesis that is inherited as an autosomal dominant trait. Another acquired type is also described. 
Pathology: The primary cause of this disorder is a deficiency of uroporphyrinogen decarboxylase, a cytosolic enzyme that is the enzymatic pathway that leads to synthesis of heme. This enzyme catalyses the conversion of uroporphyrin to coproporphyrin. This leads to an excess of uroporphyrins in the blood and urine. The result is a
pruritic photosensitive blistering rash that affects areas exposed to sunlight, and cirrhosis of the liver. Blisters on
the skin lesion contain PAS-positive material. 

A 4 Year Old Girl Is Admitted In Pediatric Ward With The Chief Complaint Of Generalized Body Swelling

A 4 year old girl was admitted to the pediatric ward with the chief complains of generalized body swelling. He mother gives the history that she noticed the swelling first appearing on the face about 5 days ago which then gradually progressed to involve the entire body. The patient has decreased appetite and has lost interest in playing with her toys. Mother also mentions that the patient has only passed urine once yesterday and it was very small in quantity.Urine was dark colored but she did not see any blood in urine.  Before the onset of theses symptoms , the child was in good health except for a minor upper respiratory infection about a week ago. Before the illness the child was taking regular food cooked at home that included boiled eggs, vegetables and sometimes meat. She was immunized and her development was appropriate for her age.
On Examination she had a fever of 101 F. other vitals were within normal limits.

On general physical examination patient had a periorbital edema, puffy face, pedal edema and looked lethargic. There was no jaundice but she looked pale.
On abdominal examination she had ascites.
On auscultation of the chest there were some basal crepitations.

List the Differential Diagnosis of the above case:

A 2 Year Old Boy With Cafe au lait Spots

A 2 year old boy was seen by a general physician for symptoms of common cold. While doing the general physical

examination , he was seen to have a large pigmented flat patch on the right side of his abdomen. On questioning mother said it is present since birth and has increased in size with the growth of the child, it has never caused any problem and so she was not concerned.

Case Discussion:
Cafe au lait Spots: The name cafe au lait is French for "coffee with milk" and refers to their light-brown color. These are flat pigmented birth marks. The borders may be smooth or irregular. 
The size and number of cafe au lait spots differ widely and depends upon the underlying cause. Some may be insignificant while others may indicate some underlying medical condition. 

Café-au-lait spots are considered significant if:
 Prepubertal : > 5 mm in size and 5 in number
 Postpubertal : >15 mm in size and 6 in number
 Isolated Café-au-lait spot >15 cm in size
 Any Café-au-lait spot in the center of the body
 Café-au-lait spot associated with neurofibromatosis.

Causes: may include following:

A 40 Year Old Man Presents With Sudden Severe Back Pain.

A 40 year old man who is otherwise healthy with no past medical problems presents to the emergency department with the complains of sudden onset of severe back pain, along with gait disturbance and feeling of pins and needle sensation in the groin area and the inner thighs. While in the emergency room he felt losing control over his bladder and had urinary incontinence.
The doctor on call suspected Cauda equina syndrome and ordered urgent MRI and referral to neurosurgery to prevent long term complications.
The typical MRI from a patient with Cauda Equina syndrome is shown below:

The arrow shows a ruptures disc in the lumbar area.

Case Discussion:

Cauda Equina Syndrome:

Refers to a characteristic pattern of neuromuscular and urogenital symptoms resulting from the simultaneous compression of multiple lumbo sacral nerve roots below the level of conus medularis.

Causes:  Common causes include: