Saturday, September 26, 2015

A 55 Year Old Diabetic Woman Presents With Malignant Otitis Externa

A 55 year-old woman with type 2 diabetes presents to her family  physician with a 2-day history of bilateral ear pain and discharge as well as some hearing loss. Symptoms started in the right ear and then rapidly spread to the left ear. She had a low-grade fever and felt ill.
On examination the external ear was swollen with honey-crusts. The external auditory canal (EAC) was narrowed and contained purulent discharge Ear, nose, and throat (ENT) was consulted and she was admitted to the hospital for the presumptive diagnosis of malignant otitis externa. She was started on IV ciprofloxacin and the ear culture grew out Pseudomonas aeruginosa sensitive to ciprofloxacin. The patient responded well to treatment and was able to go home on oral ciprofloxacin 5 days later.

Case Discussion:

Otitis Externa:
Otitis externa (OE) is a common condition and is defined as inflammation, often with infection, of the external auditary canal.
It occurs more commonly in adults than in children.

Friday, September 25, 2015

Head Lice Infestation In Children

A mother brings her two children, ages 7 and 4, who have been complaining of itchy scalps. So far, they have not tried any treatments.
On examination of both children, you find erythematous papules on the occiput and small white
eggs firmly attached to the hair shaft about 1 cm from the scalp.

What is the most likely cause and how to manage it?
 Head Lice Infestation ( Pediculosis Capitis)

Case Discussion:

Head Lice (Pediculosis Capitis) is a common and highly contagioug infection most commonly seen in school going children , at day care and people living under crowded and low socioeconomic conditions.

Etiology: It is caused by infestation with the human head louse : Pediculus humanus capitis. .

Pathogenesis: Lice are very small insects that feed on human blood. The female louse attaches her eggs (nits) to the base of the hair near the scalp, and the nits hatch in 7 to 10 days. lice are spread from child to child by close head to head contact and by sharing hair brushes and other infested belongings.

Clinical features: It causes discomfort and itching but typically does not constitute a serious condition. A child may be irritable from itching or may not sleep properly. Excessive itching may cause scratches and secondary skin infections.

1. Using fine toothed comb to remove the lice and the nits.
2. Good hygiene and regular hair washing.
3. Treatment with topical agents such as permethrin cream for two applications is also effective.
4. It is important to disinfect the bedding and treat all close contacts at the same time
5.Children need regular and frequent inspection of the hair as they may get re infected.

A Young Male Presents With Multiple Moles On His Body

A young while male is seen by the dermatologist for multiple moles on his body that are progressively increasing in number , some one them have uneven color pigmentation and notched borders. The patient is concerned as few years ago his elder sister who has similar presentation was diagnosed with malignancy.

What is the most likely Diagnosis?
Dysplastic Nevi Syndrome.

Saturday, September 19, 2015

A 43 Year Old Woman With Varicose Veins

A 43-year-old woman presents to her physician’s office with complaints of heaviness and fatigue in her legs.  She does not experience the symptoms in the morning but they become more noticeable as the day progresses and with prolonged standing. When she stands for many hours, she develops swelling in both of her legs. The symptoms are concentrated over her medial calf where she has
prominent tortuous veins. She first noted the veins approximately 15 years ago when she was pregnant. Initially, they did not cause her any discomfort but have progressively enlarged now and over the past 10 years have become increasingly painful. She recalls that her mother had similar veins in her legs.

This patient was diagnosed with varicose veins or Venous insufficiency.

Case Discussion
Varicose veins: Also known as Venous insufficiency is a condition that is caused by improperly functioning valves in the venous system and is most commonly seen in the legs causing abnormally thick, enlarged and twisted, engorged veins. This may lead to skin changes and even ulceration in advanced cases.

Friday, September 18, 2015

A 70 year Old Man With Hyperkalemia Secondary To Medication Side Effect

A 70 year old man with congestive cardiac failure and taking angiotensin converting enzyme inhibitor, spironolactone , digoxin and furosemide comes to the emergency department complaining of nausea and palpitations. He also mentions having not passed urine for last 24 hours. On admission an ECG was done which is shown below:

Note the tall peaked T waves.

What investigation should be performed next?

Answer: Serum potassium

Tall tented T-waves is an ECG feature of hyperkalaemia. In this case, the cause of hyperkalaemia is a combination of potassium-sparing drugs and obstructive uropathy.

Case Discussion:

Thursday, September 17, 2015

A 5 Year Old Child With Anal Itching

A mother brings in her 5 year-old boy who has been suffering with anal itching.
On examination the physician finds several excoriations around the anus and suspects pin worms. The physician then applies scotch tape to the perianal area and places the tape on a glass slide. Review of the slide demonstrates adult worms and ova of Enterobius vermicularis (pinworms)

A magnified view of enterobius vermicularis worm (Pin worm)

The boy is treated with a single dose of chewable mebendazole and his symptoms resolove. His mother is advised to give the child mebendazole dose again in 2 weeks to increase the long-term
cure rate.
If the scotch tape test were negative, the physician could choose to treat empirically as mebendazole is a very safe medication. Another option is to test again having the parent apply the scotch tape to the boy’s perianal area first thing in the morning and bring that back to the office (the yield is higher in the morning).

Case Discussion:

Wednesday, September 16, 2015

A 55 Year Old Man With Diabetes Was Found To Have Diabetic Retinopathy On Fundoscopy.

A 55 year old man with non insulin dependent diabetes mellitus for almost 15 years came for a followup with his family physician. His blood pressure was 148/94 mmHg. The investigations done are shown below:

  • Hb 13.1 g/dl 
  • WCC 5 109/l 
  • Platelets 290 109/l 
  • Sodium 138 mmol/l , Potassium 4.1 mmol/l 
  • Urea 9 mmol/l , Creatinine 138 ╬╝mol/l 
  • Glucose 8 mmol/l 
  • Cholesterol 5.8 mmol/l , Triglycerides 3.2 mmol/l 
  • 12-lead ECG Normal 
  • 24-hour urine protein 1g
On Fundoscopy there  was background retinopathy and the picture is shown below:

Case Discussion:

Diabetic Retinopathy: 
Diabetic retinopathy, which is also known as diabetic eye disease is a condition in which the small blood vessels in the retina are affected as a complication of diabetes. The blood vessels in the retina may become leaked , get blocked and eventually affect the sight and may even lead to blindness.

Tuesday, September 15, 2015

A 63 Year Old Man Presents With Symptoms Of Stroke

A 63 year-old hypertensive man is brought to the emergency department with onset of right face, arm, and hand paralysis, as well as difficulty in communication. Rapid diagnostic testing using MRI revealed an ischemic infarct in the left middle cerebral artery.

The patient was diagnosed as a case of stroke. He was immediately given tissue plasminogen activator (TPA). After the stroke, he was treated with aspirin, antihypertensives, and cholesterol-lowering medication. He recovered 80% of his neurologic deficit over the next 3 months.

Case Discussion:
Stroke Or Cerebral Vascular Accidents: 
Cerebral vascular accidents or strokes are common, especially in older populations. Most strokes are ischemic (66%)  or hemorrhagic(10%).

Risk factors include :

  • hypertension, 
  • smoking, 
  • diabetes mellitus, 
  • atrial fibrillation.
  • Obesity
  • Black ethnicity.
  • Older age 
1. Ischemic stroke occur when atherosclerosis progresses to a plaque,which ruptures acutely. Each step of this process is mediated by inflammation. 

Wednesday, September 9, 2015

A 65 Year Old Man Presents With Cough And Hemoptysis

A 65 year old man presents with a severe dry cough accompanied by rusty blood streaked sputum, that started 2 days ago. He had a past history of tuberculosis and he is a chronic smoker. He denies having any fever. His chest X ray is shown below;

The x ray shows a classic finding of a fungus ball ( upper right ) in an old tuberculosis cavity. This finding is typical of an Aspergilloma.

Case Discussion:
Aspergilloma is due to colonization by the species Aspergillus fumigatus rather than direct tissue invasion, and is usually not an indicator of an immuno - compromised state. It arises most commonly in old tuberculous cavities but may occur in cavities created by neoplasms, sarcoidosis and other fungal infections such as histoplasmosis.
The aspergilloma comprises fungal hyphae, inflammatory cells and fibrin.
Clinically, patients may be asymptomatic but the vast majority experience haemoptysis. Some patients complain of chest pain, wheeze and a fever.
The diagnosis is made with radiological tests. The chest X-ray is usually diagnostic but confirmation of the aspergilloma may require a CT scan or MRI scan of the thorax. The identification of Aspergillus in the sputum in such patients is highly suggestive of the diagnosis.
Treatment: Patients with recurrent haemoptysis are treated with surgical resection of the cavity and removal of the aspergilloma.

List the causes for Cavitating Lung lesions:

Tuesday, September 8, 2015

A Pregnant Woman Presents With Persistent Itching At 31 Weeks Of Gestation

A 32-year-old G3P2 woman presents with persistent itching in her 31st week of pregnancy. The itching is constant and worse at night. Her pregnancy had been uncomplicated and she has no past history of medical problems. Many excoriations are noted and there are no blister.

She has no jaundice or scleral icterus.  On laboratory workup her transaminases were greater than 300 and her total bilirubin was elevated at 2.1. Her bile salts were elevated and her hepatitis panel was negative. The ultrasound showed gallstones but no obstruction was seen.
A diagnosis of “intrahepatic cholestasis of pregnancy” was made and the patient was treated with oral ursodiol (a bile salt binding agent) and topical 1% hydrocortisone cream. The bile salts and transaminases were decreased and the patient’s pruritus improved but did not resolve until after delivery.

Case Discussion
Common Skin Findings In Pregnancy: 
Maternal skin and skin structures undergo numerous changes during pregnancy. There are two general categories of pregnancy-associated skin conditions:
(a) benign skin conditions associated with normal hormonal changes of pregnancy

  • Striae gravidarum, Or Stretch Marks
  • hyperpigmentation,
  • hair and vascular changes
(b) pregnancy-specific dermatoses

Monday, September 7, 2015

A 30 Year Old Woman Presents With Increasing Shortness Of Breath

A 30-year-old woman presented to her family physician with increasing shortness of breath over the past 2 weeks. Prior to this, she had a flu-like illness and felt like she never recovered. She denied chest pain and edema, did not take any medications, and had not had any recent trauma or surgery. She had a normal examination. Her chest radiograph showed a classic globular heart as demonstrated in the picture above.  She had nonspecific ST changes on her ECG. An echocardiogram
confirmed pericardial effusion. The underlying etiology was not elucidated and she recovered spontaneously over the next several months.

Case Discussion
Pericardial Effusion:
Pericardial effusions are commonly found in the general population and the incidence increases with age.
Causes: It can be caused by :

  • cardiac disease or surgery, 
  • connective tissue disorders, 
  • neoplasms, 
  • infections,
  • renal disease, 
  • hypothyroidism, or 
  • medications; 
The cause is however identified only 50% of the time. 

Saturday, September 5, 2015

A 50 Year Old Man Presents With A Growth In His Eye

A 50 year old man presents to his general physician as he is concerned about something growing in his eye and wonders if it is something serious and needed to be removed. He denies any problem with his vision but he has noticed his eyes often to be dry and irritated. He has spent most of his life working outdoors, with exposure to environmental pollutants. .
The picture and the lesion in his eye is shown below:

What is the diagnosis:?

Case Discussion:

A pterygium is a generally benign growth of fibroblastic tissue on the eye of an adult with chronic UV exposure. Pterygia can be unilateral or bilateral, are usually located on the nasal side, and extend to the cornea. Pterygia often require no treatment, but can be removed surgically if they interfere with vision. Patients with dry eyes are prone to the development and progression of pterygia.

Thursday, September 3, 2015

A Neonate With A Skin Rash

A 2 day old baby boy is brought for evaluation of a skin rash.
The baby was born at full term to a mother with no antenatal care. While giving the history she mentions having infected with syphillis but is not certain about the treatment and never had a followup for her disease. The baby was suspected to be infected with congenital syphillis and VDRL titers were done which were high, and exceeding those of the mother. This confirmed the diagnosis.

Case Discussion:
Congenital Syphillis:
Congenital syphillis is a serious and often life threatening or life disabling condition that occurs when a child is born to a mother infected with syphilis.

Etiology: The causative bacteria treponema pallidium is transmitted from the mother to the baby during pregnancy or at child birth.

Wednesday, September 2, 2015

A Middle Aged Man Presents With Flaccid Blisters Containing Serous Fluid

A middle aged man is seen in the dermatology clinic for blisters appearing on his skin and mucus membranes all over his body. He says he first noticed the blister to appear in his mouth, later it spread out to involve the skin and all the body. Some of these blister have ruptured with oozing of clear fluid, and leaving red erosions which are very painful
A picture of his lesions is shown below:


The clinical history suggested a diagnosis of Pemphigus Vulgaris which was confirmed by histological examination (skin biopsy) 

Tuesday, September 1, 2015

A Case Of Purpura

A patient is seen with a rash of purplish spots caused by internal bleeding from small blood vessels.
The condition is known as purpura which can be caused by a number of different cause.

Approach to A Patient With Purpura:
Purpura is defined as purple colored spots and patches that may occur on the skin and the mucous membranes and caused by blood leaking from the small blood vessels under the skin.

When the purpura spots are less than 3 mm in diameter , they are called petechiae.
When these spots are larger than 1 cm in diameter it is called ecchymoses 

A 60 Year Old Man With Numbness And Tingling In His Lower Extremities

A 60-year-old man comes in with a complaint of numbness and tingling in his lower extremities for about 10 months. He notes no weakness. He has had type 2 diabetes mellitus for 6 years and has a 30-pack-year smoking history.
Examination reveals decreased sensation to light touch, pin prick, and vibratory sensation in the feet extending to 7 cm below the knees symmetrically. You also notice lack of hair on his leg to the same level. Chest, abdomen, and upper extremities have normal sensation. His reflexes are 1+ in the upper extremities and quadriceps with absent Achilles bilaterally. The remainder of his neurological and general medical examination is unremarkable.

What is the most probable diagnosis?

Peripheral Neuropathy secondary to diabetes.

Case Discussion:

A 45 Year Old Diabetic Man Presents With Leg Swelling

A 45 year-old obese male with poorly controlled diabetes mellitus and hyperlipidemia presents to clinic complaining that his left leg is red. He denies constitutional symptoms or pain. His vital signs are within normal limits. He has a warm leg with circumferential erythema extending from the ankle to the mid-calf. He has 2+ pitting edema bilaterally  There are no open sores.

His complete blood count with differential is within normal limits. Doppler studies fail to reveal venous thromboses. Patient was prescribed 7 days of oral antibiotics and sent home. The patient returns after 3 days with no improvement in his symptoms.

What is the diagnosis and why did he not respond to antibiotic treatment?