A Patient With End- Stage Renal Disease Is Evaluated For Shortness Of Breath

A patient with end-stage renal disease complains his doctor about shortness of breath on slight exertion and even sometimes at rest. After dialysis , he is found to have a hematocrit of 28 (normal 37-42) and a MCV of 68 (normal 80 -100). His peripheral blood smear is shown below:

Hypochromic, microcytic cells.

Iron studies are performed which shows normal Iron, normal Total iron binding capacity and normal Ferritin. What is the most likely Diagnosis?
.
.
Anemia Of Chronic Disease.

Case Discussion: 
Anemia of chronic disease is an anemia that is found in patients suffering from certain long term medical conditions like Rheumatoid arthritis, end stage renal disease, chronic, infectious or inflammatory connective tissue disease.

Clinical features: Early during the disease anemia may be mild with almost no symptoms. Later on patients may complain of shortness of breath, fatigue. headache and pallor.

Diagnosis: Along with a history of a chronic medical condition, anemia of chronic disease can be distinguished from iron deficiency anemia by performing iron studies.

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.

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.

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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.