A 2 Year Old Child With A Fever

A 2 year old female child is brought to the clinic by her mother with a complain of fever for 2 days. The mother reports that the child has been tired, and not playing with her toys or watching TV as she usually does. The fever was gradual in onset , intermittent in character and high grade. The child has no appetite and is refusing to eat anything. she has been pulling on her ears and has difficulty swallowing and sleeping for the past 2 days. Her past history is unremarkable and she is vaccinated up to date. Her developmental history is also appropriate for her age.
On physical Examination she had a temperature of 101 F and was very irritable. Her Respiratory rate was 42 breaths / minute and the lungs were clear on auscultation. She had no rash. On otoscopic examination following was seen:

The above picture shows a bulging , erythematous tympanic membrane, with indistinct landmarks and a displacement of the light reflex.

Diagnosis : Acute Otitis Media

Case Discussion:
Acute otitis media is a n infection of the middle ear that may be caused by bacteria or viruses and usually accompanies an upper respiratory tract infection. It can occur at any age but is most commonly seen in children 3 months to 3 years of age.
The signs and symptoms include:

A 56 Year Old Man, Chronic Smoker Complains Of Worsening Cough And Weight Loss

A 56 year old man who is a chronic smoker as well as have a past history of chronic bronchitis comes to the clinic with a complain of worsening cough over the last month. The cough is productive of 2 teaspoonfuls of  yellowish mucus, with streaks of blood. Patient has noticed dysnpnea on exertion as well as fatigue, decreased appetite and a weight loss of 12 pounds during the last 2 months. he has no history of recent travel or exposure to tuberculosis patient. .

The X Ray of his chest is shown below:

What is the diagnosis?
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Lung Cancer.

Case Discussion:

A 33 year Old female With Knee Pain For 2 Days

A 35 year old female presents to the clinic with a complain of pain in the right knee that started 2 days ago. The pain is associated with difficulty in walking but she denies any trauma to her knee. She has swelling ans redness in her right knee joint along with a mild fever. she denies having pain in any other joints of the body, any rash, or photo sensitivity.
Her past history is significant for an episode of acute left big toe arthritis 5 years back,

Physical Examination:

• Erythema, tenderness, pain and restricted range of motion on flexion and extension of the right knee joint.
• All other joints including the left knee are normal on examination.
• No abnormalities detected in any other organ system. 

The picture of her knee joints is shown below:

What is the Differential Diagnosis?

A 19 Year Old Woman With A Red Eye

A 19 year old woman presents to her school health officer after she woke up this morning with a red and a painful left eye. She says that she had some mild itching in her left eye when she went to bed the previous night. She also reports that she never had these symptoms previously. her eye feels mildly painful, itchy and teary. She has no visual difficulties and denies any problem in the right eye, fever, headache, neck pain sore throat or ear pain. She has no significant illnesses in the past but mentions working at a daycare 3 times in a week.

Physical Examination:

• Sclera and the conjunctiva of her left eye are inflamed. 
• No purulent discharge is notable.
• Left eye is watery.
• Her right eye has slight inflammation of the conjunctiva.
• Pupils are symmetrical and reactive to light.
•  Fundoscopic examination detects normal vascular markings in each eye.
• Slit lamp examination with fluorescein staining detects no corneal defects.
• Her periauricular lymph node is palpable on the left side.

The picture of her left eye is shown below:

Based on the history , physical examination and the picture shown what is the differential diagnosis?

Differential Diagnosis:

• Conjuctivitis
• Uveitis
• Closed angle glaucoma
• Corneal Abrasion

3 Year Old Boy Brought To Ophthalmologist For A White Eye

A 3 year old boy is brought to an ophthalmologist by his mother for evaluation of his right eye. The child's mother says that when she took a photo of her son 2 weeks ago she noticed that one of his eyes has a white spot in the center of the pupil. When she looked at his eyes afterwards she did not notice any abnormality but found that the white spot was reproduced when a light was shined in his eyes. She says her son has not been complaining of any pain in the eye or has not noticed and strange behavior recently. He has no fever, recent colds or trauma to his right eye. There is no family history of eye diseases.

Physical Examination:

• Well appearing child, appropriate development for his age.
• When light is shined in his eyes, the left eye has a normal red reflex, but the right eye has a central white appearance. 
• His pupils react normally, and he is able to tract objects well.
• His conjunctiva are pink and sclera are not injected.
• Fundoscopic slit lamp examination detects a whitish growth involving the posterior wall of the retina.
• No corneal or lens defects. 

The picture taken of the child is shown below:

And the fundoscopic examination showed the following picture;

Diagnosis: Retinoblastoma

A 72 Year Old Man With Complaints Of Chronic Right Knee Pain

A 72 year old man presents to his primary care physician with a complaint of chronic right knee pain that has gradually worsened over the past few years. the patient denies any significant trauma to his knee. he says that he feels minimal pain in the morning , but the pain gets worse as the day passes. The pain particularly occurs when he stands or walks for a long time. He says that his knee feels stiff but he does not have any episodes of the joint locking or giving way. Sometimes he has felt his knee making grinding sounds when he walks. he has been talking ibuprofen for the pain which does reduce the symptoms to some extent. He denies similar symptoms in other joints.

Physical Examination:

• A well appearing man in no distress.
• The right knee does not appear swollen or erythematous and there is no effusion.
• He has a dull pain along the tibial-femoral joint line.
• He has mild deep pain with range of motion that worsens at the extremes of flexion and extension.
• There is a palpable crepitus during movement. 
• Neurological examination is normal.

The X ray of his knee joint is shown below:

Based on the above history, examination and the x ray findings what is your diagnosis?

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A 5 Day Old Baby Brought By A Concerned Mother Because The Child Has Yellow Skin And Eyes

Mother of a 5 day old baby boy comes to the doctor's office because she has noticed her baby having yellow discoloration of the eyes and skin for 2 days. The condition has not worsened and the baby is awake, responsive, playful and active. He is breast fed and has 2 -3 bowel movements daily. The color of the stool is brown. He is wetting 7-8 diapers per day every 3-4 hours. Mother denies the baby having any history of fever, vomiting, seizure or breathlessness. Mother had a healthy pregnancy and the baby was delivered vaginally at full term.
The picture of the neonate is shown below:

On the basis of the history given above and the appearance of the baby in the photo what could be the differential diagnosis?
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A 20 year Old Man With Chronic Back Pain Thinks He Is too Young For This Pain

A 20 year old man who is a college student presents to an orthopedic spine specialist with the complaint of chronic back pain that has lasted for the past few years. He denies any history of back trauma and says that the pain began insidiously about 3 years ago. He says that the pain is in located in the mid and lower back and is more upon waking and he feels stiff. The pain and stiffness improve after he is out of bed for a few hours. The pain worsens after prolonged sitting while he is taking his classes. He is physically active and runs three times per week and he feels hi back pain gets better after the exercise. He denies any numbness, weakness or incontinence.

Physical Examination:

• Well appearing young man in no acute distress.
• Palpation of back reveals mild tenderness only at his sacroilliac joints..
• he has difficult bending forward and laterally because of stiffness in his lower back.
• There is no asymmetry or lateral curvature of the spine.
• Neurological examination is normal
• All other organ systems are unremarkable.

On workup he has an ESR of 55 which is increased and the X ray of the spine is shown below:

 

This patient was diagnosed to have Ankylosing Spondylitis. 

Case Discussion:

Ankylosing spondylitis

Ankylosing spondylitis is a chronic inflammatory disease of the spine and pelvis that results in the eventual fusion of adjacent vertebrae, It is more common in males and patients present with complains of hip and low back pain that is worse in the morning and following periods of inactivity. The pain improves over the course of the day and with exercise. On examination there is limited range of motion in the spine and chest wall. Some patients may have associated peripheral arthritis, anterior uveitis and /or cardiac arrhythmias.

Radiographic features

Features predominantly affect the axial skeleton although can involve the peripheral joints in ≈20% of cases.

Plain film

Sacroiliac joints

• Sacroillitis is usually the first manifestation and is symmetrical and bilateral
• joints widen before they narrow
• subchondral erosions, sclerosis and proliferation on the iliac side of SI joints
• at endstage, the SI joint may be a thin line or not visible 

Spine

• early spondylitis is characterized by small erosions at the corners of vertebral bodies with reactive sclerosis (Romanus lesions of the spine: shiny corner sign)
• vertebral body squaring
• diffuse syndesmophyitic ankylosis can give a "bamboo spine" appearance
• interspinous ligament calcification can give a "dagger spine" appearance
• ossification of spinal ligaments, joints and discs (with fatty marrow within ossified disc, best seen on MRI)
• pseudoarthroses may form at fracture sites
• enthesophyte formation from enthesopathy
• non-infectious spondylodiscitis: Andersson lesion

Hips

Hip involvement is generally bilateral and symmetric, with uniform joint space narrowing, axial migration of the femoral head, and a collar of osteophytes at the femoral head-neck junction.

MRI

• may have a role in early diagnosis of sacroiliitis
• synovial enhancement on MR correlates with disease activity measured by inflammatory mediators
• enhancement of the interspinuous ligamants is indicative of an enthesitis
• increased T2 signal correlates with edema or vascularized fibrous tissue
• superior to CT in detection of cartilage, bone erosions, and subchondral bone changes
• useful in following treatment results in patients with active ankylosing spondylitis.

A 4 Year Old Boy Presented With Trouble Walking

A 4 year old boy is brought to a pediatrician because his mother has noticed that he has been limping for several days. She says she cannot recall any trauma or fall sustained by the child in the past week. During this time the child has been hesitant to walk much and has asked to be carried by his parents. He has started to complain that his left hip hurts. There is no history of fever or any sick contacts. The child has not complained of pain in any other joint. There is no significant past history or any history of inflammatory arthropathies in the family.

Physical Examination:

• The child appears to be a healthy boy in no acute distress. 
• He is mildly uncomfortable with range of motion of his left hip 
• No abnormal sounds are elicited with motion of the left hip
• Range of motion is normal and painless in all other joints.
• When asked to walk , the child is notable for a Trendelenburg limp on left side. 
• All the other organ systems are normal on examination.

His Vitals Are:

Temp : 98.7 F

HR: 90 b/min

RR: 18 b/min

BP: 110/70 mmHg

What is The Differential Diagnosis:

• Septic Arthritis
• Developmental dysplasia of hip joint
• Juvenile rheumatoid arthritis
• Legg-Calve Perthes disease
• Slipped capital femoral epiphysis
• fracture

X Ray of the Pelvis and the Hip Joints is shown below:

The x ray above shows asymmetry of the hips with the right hip appearing normal, while the left hip is notable for a small and incomplete femoral head and a widened joint space. There are no fractures or dislocation seen.

5 year Old Child Presents With Blistering Around The Mouth

A 5 year old child is brought to his pediatrician by his mother with a 2 day history of blistering around the mouth. The mother says that she noticed a single tiny blister near his lips 2 days ago , but now there are multiple small blisters around his mouth and nostrils. Several of the blisters have broken and have become crusted. She has not noticed any other lesions else where on the body. She says that he has never has these lesions previously. The child has been complaining of his mouth hurting and itching and has been rubbing his lips. There are no symptoms of congestion, ear or throat pain or cough. The child has not consumed any new food recently or used any new personal hygiene products. Mother mentions that the child is is kinder garden , and one of the student also has suffered from similar findings.
The Photo of the child's lesions is shown below:

 What Is The Diagnosis?

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Impetigo

Case Discussion:
Impetigo is a highly contagious skin infection caused by Staphylococcus aureus or Group A Streptococci. It is most commonly seen in infants and school age children.

Concerned Parents Brings 5 Month Old Baby Boy Because He Is Not Growing

A 5 month old infant boy is brought to a rural health clinic because his parents are concerned and say he has grown very little since birth. They say the child is a good baby because he is quiet and sleeps most of the day. The family lives in a rural, mountainous region and has little access to health care. The child's mother received no antenatal care and was delivered at home by a local midwife. Mother says that the baby does not demand feeding much and he has a bowel movement after every few days. He has three elder siblings who are all normal.

Physical Examination reveals:

• A small boy who is relatively lethargic.
• Yellow discoloration of skin 
• Dry skin
• Open fontanelles
• Large protruding tongue
• Small umbilical hernia
• Normal anus and normal appearing genitalia. 
• Decreased muscle tone
• Little or no resistance to examination

The photo of the child is shown below:

What Is the Diagnosis?

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19 Year Old Female With Sore Throat

A 19 year old female presents to the clinic with the complains of sore throat for 1 week. She has felt feverish and sluggish for the past 3 weeks. She denies any cough, or shortness of breath. She says she has lost her appetite and it hurts when she swallows.
On examination she has a temperature of 100.4 F and pharynx is red and inflamed. Tonsils are enlarged and she has a diffuse adenopathy , most prominent in the posterior cervical lymph nodes. Lungs are clear to auscultation. Her abdomen is tender on palpation just below the left costal margin.

What tests will you advice to help in diagnosis?

• Complete blood count with peripheral smear
• Throat culture
• Monospot test
• Liver function tests

The peripheral blood film is shown below:

Infectious mononucleosis, peripheral smear, high power showing reactive lymphocytes

The final diagnosis is Infectious Mononucleosis

A 43 year Old Woman With Progressive Difficulty With Swallowing

A 43 year old woman presents to a gastroenterologist on referral for progressive difficulty with swallowing. She says over the past several years she has difficulty swallowing both solid foods and liquids. More recently she has had episodes of coughing during eating and she feels she is aspirating small amounts of food during these episodes. She occasionally gets heart burn and she feels she is losing weight because of difficulty eating food.
A barium swallow was done as a part of workup and is shown below:

What is the Diagnosis?
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Achlasia

Case discussion:
Achlasia is a neuromuscular disorder of the esophagus characterized by impaired peristalsis and decreased relaxation of lower esophageal sphincter resulting in dysphagia.

• Most commonly is is an idiopathic condition affecting patients 20 to 60 years of age.
• Patients present with difficulty in swallowing due to impaired transport of food through the esophagus.
• Patients have difficulty in swallowing both solids as well as liquids.
• Barium swallow demonstrates a dilated esophagus with a 'bird's beak' taper at the site of lower esophageal sphincter. 

60 Year Old Man With Sudden Onset Heavy Chest Pain

A 60 year old male presents to the emergency room with sudden onset of substernal hest pain that has lasted for 30 minutes and radiates to the left arm. the pain is accompanied by dyspnea, diaphoresis and nausea. He has a history of hypertension, hyperlipedemia and smoking.

What is the differential diagnosis on the basis of above given history?

• Myocardial infarction
• Angina
• Pericarditis
• Aortic dissection
• Pulmonary embolism
• Gastroesophageal reflux disease
• Pneumothorax.

What workup will you advice to help in diagnosis?

• ECG
• Cardiac enzymes; CPK-MB, troponin
• Cest X ray
• Complete blood count
• Serum electrolytes
• Echocardiography

ECG done is shown below:

65 year Old Female Present With Right Temporal Headache

A 65 year old female presents with sever, intermittent, right temporal headache, fever, blurred vision in her right eye and pain in her jaw when chewing. She was suspected to have Temporal arteritis (giant cell arteritis ) and the biopsy of the temporal artery was done. The pathology picture is shown below:

H & E staining of a medium-sized artery with giant cell arteritis. Note thickening of the media and intima with inflammatory cells ( appearing as blue dots)


Case Discussion:

GIANT CELL ARTERITIS :

Giant cell arteritis is the inflammation of the arteries specially affecting the arteries of the temple. This is the reason it is also known as temporal arteritis.

• Giant cell arteritis frequently causes headache, jaw pain and blurred or double vision. 
• Blindness and less often stroke are serious complications of this disease,
• Prompt treatment of giant cell arteritis is necessary to prevent tissue damage and loss of vision.
• Corticosteroids mostly help in control of symptoms and preventing complications and loss of vision. 

Pathophysiology:

• Giant cell arteritis is primarily a disease of cell mediated immunity, which is thought to arise as a maladaptive response to endothelial injury. 
• The primary inflammatory response involves the internal elastic lamina within the media of the arterial wall.

21 Year Old Female With Ankle Pain

A 21 Year old comes to the clinic with ankle pain. Her vitals taken are:
Temp: 101 F
BP : 120/80 mmHg
HR: 80/min
R/R: 20/min
The patient tells that she twisted her right ankle one week ago. She scraped off a little skin and has a sudden popping sensation on the outside part of her right ankle. The pain is severe and sharp and moves into her right foot. The pain gets better when she elevates her leg and puts ice on the ankle. She has noticed increasing redness and swelling with some oozing over the last 3 days.

The picture of her ankle is shown below:

On palpation the right ankle and lateral malleolus is very tender with limited range of motion because of pain.

What is the differential diagnosis and how will you support your diagnosis on the basis of history and physical findings?

7 year Old African American Boy Presents With Fever And Chest Pain.

A 7 Year old African American boy presents with high grade fever for 2 days and chest pain for 2 hours. He looks pale and lethargic.

The picture of his blood film is shown below:

What is the Diagnosis:

Sickle Cell Anemia

Case Discussion:

Sickle cell anemia is an autosomal recessive disease resulting from the substitution of valine for glutamic acid at sixth position in the globin chain. 

Clinical signs And Symptoms:

Sickle cell patients often have a positive family history. they may also have a history of gall stones and poorly healing ulcers. On examination they may have significant jaundice, splenomegaly (in childhood) or even congestive heart failure when anemia is severe. 

3 year Old Boy With A Cough

A mother brings her 3 year old boy to the pediatrician because he has had a barking cough for 2 days. She says that he goes to day care 5 days a week and that some of the other children there are suffering from similar symptoms. Mother tells that the child has no trouble breathing but his cough is loud, he has a runny nose and temperatures up to 101 F during the past 2 days. His voice is a little horse and his mother says that he has had colds in the past but none were associated with this type of cough.
Examination shows:

• Red nose with sniffing often.
• Minimal pharyngeal erythema.
• No pharyngeal exudates.
• Mild cervical lympadenopathy.
• Mild coarse breath sounds on auscultation of the lungs but no wheezing. 

Vitals: 

Temperature: 100 F

Heart rate : 100 bmp

BP : 95/45 mm Hg

Respiratory rate: 20 breaths/min

X ray of the chest is shown blow:

and the X- ray of the neck

 What is the Differential Diagnosis?

X-Ray Of A Patient With Cleidocranial Dystosis

The X-Ray shown below is taken from a 50 year old female. Look for what is missing ??

Case Discussion:

Cleidocranial dysostosis

Cleidocranial dysostosis (CCD) is a skeletal dysplasia with predominant membranous bone involvement. It carries an autosomal dominant inheritance.

Pathology

It is characterized by incomplete ossification of skeletal structures inclusive of the clavicle as well as defective development of the pubic bones, vertebral column, and long bones.

Clinical features

• large head, with large fontenelles with delayed closure
• broad mandible
• supernumerary teeth
• high arched palate
• neonatal distress due to thorax being narrowed and bell shaped
• excessively mobile shoulders
• may have genu valgum and short fingers

Radiographic features

Plain film

Skull

• wormian bones
• widened sutures / fontanelles
• premature fusion of the coronal suture (brachycephaly)
• frontal / parietal bossing
• basilar invagination (atlanto axial impaction)
• persistant metopic suture

Chest

• hypoplasia / aplasia of lateral clavicle (absent clavicles): may have two separate hypoplastic segments 5
• supernumerary ribs
• hemivertebrae with spondylosis
• small and high scapulae

Pelvis

• hypoplasia of illiac bones
• absent / delayed ossification of the pubic bone (pseudo widening of the symphysis pubis)

Limbs

• short / absent fibula
• short / absent radius
• coxa vera
• hypoplastic terminal phalanges

A 19 Year old Male With Sore Throat And Unable To Eat

A 19 year old man presents to the emergency department with a 5 day history of a worsening sore throat. HE describes an increasing difficulty with eating because of throat pain and having a lump in the throat.He feels the pain becomes worse when trying to open his mouth. He says that he has had chills intermittently over the past few days and the temperature when he took at home was 102 F. He denies any nasal congestion, nausea, vomiting or diarrhea.

Physical Examination: reveals

• a moderately sick appearing individual
• mildly hoarse voice
• Oropharynx:  significant erythema with some streaky whitish material in posterior pharynx. Asymmetrical with uvular deviation to the right side and a focal area of swelling near the left palatine tonsil.
• Palpable lymphadenopathy in cervical nodes.
• Lung fields are clear on auscultation. 

The picture of the pharynx is shown below:

What is the Diagnosis?

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A 23 Year Old Female With Oligomenorrhea

A 23 year old female presents to the clinic with presenting symptoms of  irregular menstrual periods ( every 3-4 months) and excessive facial hair. She is sexually active and never used birth control but has never been pregnant. On General appearance she looks obese and has acne.

The pelvic ultrasound is shown below:

The ultrasound shows multiple ovarian cysts. The patient is suffering from Polycystic ovarian Syndrome.

Case Discussion
Poly Cystic Ovarian Syndrome:

• It is the most common cause of female hirsutism (male-pattern hair growth).
• Patients may have mild or no symptoms or present with oligomenorrhea, infertilty and virilization.
• The cause is umknown but hyperinsulinemia with insulin resistance is usually seen. 
• Typically affects women in the teenage age years who are obese .

A 67 Year Old Post menopausal Woman For Routine Checkup

A 67 year old post menopausal woman comes to the clinic for a routine checkup. She denies any serious symptoms but complains of backache and admits that she has been inactive for last few years after retirement.
The X- rays taken are shown here

What bony abnormality is seen in these X- rays?
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Case Discussion:
Osteoporosis:
Osteoporosis is a common metabolic bone disease characterized by osteopenia with normal bone mineralization. Most commonly seen in in active, postmenopausal women.

Clinical Features:
This condition is commonly asymptomatic. Some patients may present with hip fractures, vertebral compression fractures (resulting in loss of height and progressive thoracic kyphosis) , and / or distal radius fracture after minimal trauma.

Differential Diagnosis:

• Osteomalacia (inadequate bone mineralization)
• Hyperparathyroidism
• Multiple myeloma
• Metastatic cancer

38 Year Old Male (Known Case Of COPD) Presents With Weight Gain

This 38 years old man presents with unintentional weight gain over the past few months. He is a known case of COPD and is on steroid medicines.

Case Discussion:
Cushing Syndrome:

A condition that results from hypercortisolism and the most common cause is exogenous steroid use.

Clinical features:
Patients has typical features of truncal obesity with moon facies and a buffalo hump. Other signs and symptoms include hypertension, psychiatric disturbances, impotence, hirsutism, easy brusibility and purple striae.

Diagnosis:
1. Elevated 24 hour urine cortisol is diagnostic for cushing 's syndrome.
2. Low DHEA is seen only with exogenous steroids.
3. Morning serum ACTH levels are < 5 pg/ml in exogenous steroids or adrenal adenoma.

A 32 Year Old Male Presents In ER With Sharp Chest Pain

A 32 years old man is brought to the emergency department with a complaint of sharp chest pain that began suddenly an hour ago. He says he was moving some furniture when this pain started. The pain is sharp and tearing in nature. It is located just behind the sternum and radiated to the back. He also complains of mild dizziness since the pain started. His past history includes a mirtal valve prolapse and he takes a low dose aspirin for this condition.

Physical Examination reveals:

• A tall, thin man looking very anxious and diaphoretic.
• On auscultation, lung fields are clear but a blowing late systolic murmur can be heard that radiates from the apex to the axilla. 
• Pulses are palpable and strong. 
• He has long arms and legs and long thin digits. 
• Neurological examination is normal. 

X-Ray Chest shows following appearance:

What is the Diagnosis?

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3 Year Old Child With Protein Calorie Malnutrition

An X-ray of chest taken of a child with protein- calorie malnutrition and delayed developmental milestones is shown below.

What bony abnormality is seen in the x-ray from this child ?
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Rachitic rosary.

Discussion:

Rachitic rosary refers to expansion of the anterior rib ends at the costochondral junctions and is most frequently seen in rickets.

Causes of this appearance include: 

• Rickets: nodularity at costochondral junction (rachitic rosary)
• Scury 
  • the costochondral junction is more angular and has a sharper step-off (scorbutic rosary). 
  • the sternum is usually found to be depressed.

22 Years Old Female With Rash And Joint Pain

A 22 years old female presents to the clinic with a history of fatigue, on and off fever and pain in  her joints. On examination she has a characteristic butterfly rash over the cheeks and nose.

Case Discussion:

Systemic Lupus Erythematosus (SLE) :
A multisystem chronic inflammatory disease that is secondary to ANA complex formation and deposition. Patients may experience acute flare ups of their symptoms. SLE is generally primary, but sometimes occur secondary to drug use.

Drugs That Can Cause SLE:

• Hydralazine
• Procainamide
• Penicillamine

The drug induced SLE is reversible. 

Clinical features:

Patients are generally young female. Finding include:

1. Constitutional symptoms like fatigue, fever and weight loss.

2. Arthritis: usually migratory and asymmetric, involving mostly small joints of the hands.

3. Skin Involvement: It includes;

• Malar rash ( butterfly rash over the cheeks and nose). 
• Discoid rash (scaling papules that can leave residual scaring), 
• Alopecia, 
• Painless oral ulcers,
• Raynaud's phenomenon,
• Photosensitive rash. 

A 40 Year Old Female With Problem In Toe Nails

A 40 years old female with known case of diabetes presents to the clinic with a chronic history of repeated infection in the toe nails, with occasional pain and sometimes a foul odor from the infection. Her toe nails has become distorted in shape and have lost the normal shine.

What is the Diagnosis?
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Toe Nail Fungus Also Known as Onychomycosis or Tinea Unguium


Discussion:

The fungal infections in the toes usually cause discoloration, thickening and often softening of the nails. Nail fungus is a difficult condition to treat and may often cause permanent damage and possibly nail loss.

45 Years Old Male With Abdominal Pain And Diarrhea For 3 Weeks

A 45 years old male with a past history of inflammatory arthritis presents with abdominal pain and diarrhea. the X- rays that were taken are shown :

Modality X-Ray

Featureless transverse colon and distal descending colon / proximal sigmoid consistent with the lead pipe sign of chronic ulcerative colitis. Additional chronic sacroillitis with ankylosis on the left and partial ankylosis on the right. Asymmetric left hip joint arthropathy.   

X- Ray Modality : Annotated Image

Lead pipe appearance of the colon (red arrows). Ankylosis of the left sacroiliac joint and partial ankylosis on the right (yellow arrow). 

Case Discussion:

A nice example of the lead pipe sign of chronic ulcerative colitis and of enteropathy associated arthritis with chronic bilateral sacroillitis and left hip joint arthropathy.

13 years Old Male With Cough And Episodes Of Difficult Breathing

X Ray 1:

X- Ray 2

Lungs are well expanded. No collapse or consolidation. No pneumothorax. Incidental bifid ribs.

Discussion:

A Female Presenting With Exertion Dyspnoea (Known Case Of Pulmonary Hypertension)

X-Ray Chest Frontal.

CT Axial C+ CTPA

CT Coronal C + CTPA

Case Discussion:

A 5 year Old Child Presents With Delayed Growth And Mental Retardation

This 5 years old child was brought to a pediatrician with symptoms of delayed growth and mental retardation. Parents were concerned about him since his birth. His developmental milestones were delayed and his IQ is below average.

Physical Appearance:
 This child has following features notable on Physical examination:

• Flat facial appearance with a flat nose and a flat occiput.
• Upward slanting palpebral fissures
• Protruding tongue
• Small ears
• Single transverse palmar crease.
• Short broad hands
• A heart murmur

Diagnosis:

40 years old Female Presents with Hand pain

X- Ray hand DP

X-Ray Hand Medial Oblique

There is well-defined lytic destruction of the first proximal phalanx and 2nd metacarpal, with a preserved honeycomb trabecular pattern in these areas. These lesions extend throughout the entire length and diameter of the involved bones. The 2nd metacarpal is mildly expanded overall, with irregular areas of calcification along the ventral and radial aspect of the diaphysis likely representing callus formation from a healing pathological fracture. 

The exostotic area along the ulnar aspect of the 5th metacarpal is likely from previous fracture, given the anterior angulation at this site. Multiple traction enthesophytes are noted along the medial and lateral aspects of the phalanges (e.g. 4th proximal). 

Case Discussion:

15 Years old Female With known Case of Kartagener Syndrome For A Checkup

Chest X- Ray PA view. 

Case Discussion:

This case demonstrates a situs inversus totalis. Here you see dextrocardia with right descending aorta and a right-sided gastric bubble.

Study Questions:

Q: What is the underlying pathology in Kartagener syndrome? 

52 Years old HIV positive male with Chest Pain

Modality: X-ray

CXR at presentation, 2 weeks, 3 weeks and 4 weeks. Large right opacity showing rapid progression over 4 weeks.

PET/CT at the time of presentation.

Modality: Nuclear medicine

Large right pleurally based mass, with partial necrosis, and a number of smaller satellite pleurally based nodules.