A 40 Year Old Woman presents With Unsteady Gait And Recurrent Falls.

A 40-year-old woman presented with a five-day history of recurrent falls and an unsteady gait. She had a past history of a stroke causing a right-sided hemiparesis, which resolved spontaneously after a few days. The patient underwent intensive investigation following presentation with the stroke including carotid Doppler studies, transoesophageal echocardiography and CT scan
of the brain, which were normal.
The Ct Scan is shown below which is normal:

On examination she had a broad-based gait. There was evidence of dysdiadochokinesia in both upper limbs and abnormal heel–shin testing. The lower limb reflexes were brisk and the plantar response was extensor. The heart rate was 80 beats/min and regular. The blood pressure was 130/90 mmHg. Both heart sounds were normal.

Question :
What is the most probable diagnosis? ( Chose the one best from the options below)
a. Systemic lupus erythematosus with cerebralinvolvement.
b. Multiple sclerosis.
c. Multiple paradoxical emboli.
d. Friedreich’s ataxia.
e. Multiple cerebral metastases.


Answer:
b. Multiple sclerosis.

Explanation:

A 32 Year Old Man Complains of Heel Pain

A 32 year old man visits his primary care physician with the complain of pain in the heel of his foot for the last few weeks. He describes the pain has stabbing in character and usually occurs when he wakes up and takes the first steps in the morning. the pain then gradually decreases as the day goes on. Patient says he is an active man and he has been training himself in the local gym for the last few months. On examination there was tenderness on palpation of the heel and the sole of the foot. An X ray of the foot is shown below:

The arrow shows a heel spur.

The patient is most likely suffering from plantar fasciitis.

Case Discussion:

PLANTAR FASCIITIS

Inflammation of plantar fascia on the planter aspect of foot.

Risk factor for developing plantar fasciitis:

-                     flat feet or high arch

-                     running long distances, up or downhill or on uneven surfaces

-                    Obesity

-                    Wearing shoes with poor arch support or soft soles

Clinical features: 

• -          Heel pain, usually unilateral, which is most severe during the first few steps after prolonged inactivity such as sleep or sitting

A 25 Year Old Female Presents With Chest Pain On Deep Breathing And Coughing

A 25 year old female comes to her primary care physician because she has been unwell for the past few days with fever, cough and difficulty breathing. She complains of having a sharp localized chest pain when she takes a deep breath or coughs. On Examination she had a fever of 102 F and had a fast breathing. On auscultation a pleural friction rub was heard.
Chest X ray shows few infiltrates but was otherwise normal:


                                                                                                                                                                                                                                                               What is the cause Of her Chest Pain?
..
.
The patient is most likely having pleuritc chest pain that is caused by inflammation of the pleura secondary to viral or bacterial lung infection.

Case Discussion:

 PLEURISY / PLEURITIC CHEST PAIN

Pleurisy is defined as an inflammation of the pleura (the lining that surrounds the lungs). This condition can cause sharp pain when breathing and is known as pleuritic chest pain.

Causes:

• ·         Viral infections (coxsackievirus, RSV, CMV, adenovirus, EBV, parainfluenza, influenza) is the most common cause of pleurisy.
• ·         Bacterial lung infection due to pneumonia or Tuberculosis.
• ·         Chest injuries
• ·         Autoimmune diseases like SLE, RA,
• ·         Malignancy
• ·         Pulmonary embolism
• ·         Drug reactions
• ·         Liver diseases.

Clinical Features: Depending upon the underlying cause of pleurisy patients may present with a variety of clinical signs and symptoms. These include:

A 35 Year Old Woman Has A High BP on Numerous Occasions

An apparently normal and healthy 35 year old woman is referred to a general physician by a local health nurse because she has noticed the patient having a high BP around 180/100 mmHg numerous occasions. The patient visited her nurse to get the prescription refill of her oral contraceptives.
On history taking patient gives no history of any medical problems and that she seems fine. She smokes about 10 cigarettes a day and does not drink. She has a strong family history of high blood pressure with her mother and elder sister on medications and her father died a few years ago due to stroke. On examination the patient is overweight with a BMI of 28.
Vitals: BP = 175/95 mmHg , H/R = 78/min, R/R = 14/min , Temp = 98.6 F
The patient brings with her  a chest x ray which was done a few weeks ago when she had some cough. the x ray is shown below:

The chest x ray is normal and apparently her cough was not due to lower respiratory infection. Also a normal heart size indicates her hypertension is not chronic or long standing. 

How will you approach this patient?

Hypertension is a common medical problem. The initial approach in managing this patient should be

A 79 Year Old Female Presents With Worsening Confusion Over The Last 2 Days.

A 79-year-old female nursing home resident with moderate dementia presents for worsening confusion over the last 2 days. She just finished antibiotics for a urinary tract infection. Her temperature is 38.1◦C, pulse 110, respiratory rate 18, and blood pressure 118/60 mm Hg. She is disoriented and lethargic.
Examination of the heart, lungs, and abdomen is unremarkable.
Laboratory studies are as follows:
Na 165 mEq/L,
K 4.6 mEq/L,
Cl 118 mEq/L,
HCO3 28 mEq/L,
BUN 31 mg/dL,
Cr 1.1 mg/dL.
Urine specific gravity is >1.030 and urine osmolality is 700 mmol/kg(elevated reflecting reabsorption of free water)
 Her CBC is normal.

1. What will be the initial treatment for this patient?

A 15-Year Old Female With Right Upper Quadrant Abdominal Pain.

A 15-year-old Nigerian female was admitted with right upper quadrant abdominal pain. She had a history of sickle cell anemia, and had several admissions with hand and foot crises. During the last two admissions she complained of abdominal pain. She was born in England. She was the only child of a middle-class family.
On examination, she was distressed with pain. The temperature was 37.6°C (99.7°F). She was mildly jaundiced. The pulse was 105 beats/min, and blood pressure 100/75 mmHg. On examination of the respiratory system there was dullness to percussion on the anterior aspect of the right lung. Abdominal examination revealed tenderness in the right upper quadrant. The liver was palpable 3 cm below the costal margin.
Investigations are shown.

• Hb 6 g/dl
• WCC 12 109/l
• Platelets 200 109/l
• U&E Normal
• AST 50 iu/l
• Alkaline phosphatase 150 iu/l
• Albumin 34 g/l
• Urine osmolality 120 mOsm/kg
• Urinalysis Urobilinogen +++, Blood 0, Protein 0 ,Bilirubin 0
• Chest X-ray Opacification in the right upper zone

Practice Questions with Answers:

1. What is the cause of the abdominal pain?

A Baby Girl In The Nursery Has Hypertelorism

3rd year medical students during their posting in the new born nursery examined a 2 week old baby girl with following facies:

This baby has hypertelorism which is defined by a condition in which there is an increased interpupillary distance between the two eyes. It may have certain underlying causes to look for:

Differential Diagnosis Of Hypertelorism :

A New Born Is Observed To Have Low Set Ears

A new born male baby is examined in the nursery and is observed to have low set ears:

What are the possible underlying causes?

Imaginary line drawn between inner and outer canthi of the eyes should bisect the ears into upper one-third and lower two third portions. Normally 1/3rd of the ear comes above this line. When less than 20% comes above this line, it is low set ear.

Differential diagnosis include:

Bossing Of Skull In Children

Medical students during their posting in pediatrics ward are shown a patient with increased head circumference and a condition known as bossing of the skull is described in which the skull bones become prominent.
Picture of one such patient is shown below:

What is the differential diagnosis of Bossing of skull in children?

A 2 Month Old Baby With Irritability And Projectile Vomiting

A 2 month old baby boy is brought to the pediatrician because her mother has noticed that her baby has become excessively irritable, has a high pitched cry and refuses to feed for the last 2 days. when the mother attempted to spoon feed the child with expressed breast milk, the baby vomited it in a projectile manner.
On examination the baby had a temperature of 103 F, and was very irritable. The anterior fontanelle was bulging. The resp rate was 65/min and H/R was 102/min.

What are the causes of a bulging anterior fotanelle?

The fontanel should be examined in a quiet child held in an upright position. The fontanel is normally
flat and pulsatile. Bulging fontanel in infancy is a sign of raised intracranial tension.

Causes include:

A 62 Year Old Man Complains Of Worsening fatigue And Pain In His Back, Shoulders And Neck

A 62 year old man who has been a known case of hypertension for several years while on a followup with his general physician complains of worsening fatigue and aching in his back, shoulders and neck. He has been taking acetaminophen for about last 3 months with no improvement. On further asking the patient says he experiences neck and shoulder stiffness every morning for about 30 minutes. He occasionally has difficulty getting out of bed.
On examination Vital signs were normal. There is no evidence of synovitis of hands wrists and elbows. Active range of motion in the hands, neck and shoulder are slow but full, There was no tenderness on palpation of the neck, shoulder and back and there was no apparent muscle atrophy. The areas where the patient felt the pain is shown below:

Study Questions with Answers related to the above presented Case scenario:

A 3 Year Old Boy With Fever And Rash

A concerned mother brings in her 3 year old child with a history of fever for 1 week. She said initially she thought the fever would resolve but the child is getting sicker and she is now worried. The patient along with fever has developed a diffuse body rash, has decreased appetite and is lethargic. On examination , the child looked sick, has a temperature of 103 F and a diffuse, erythematous macular rash with peeling of skin on the finger tips. The tongue was bright red in color and cervical lymph nodes were enlarged and tender.

A few Picture taken in the clinic are shown below:

Bright red tongue with white papillae.

                    Skin Peeling at Finger tips.

What is the Differential Diagnosis?

• Rheumatic fever
• Kawasaki disease
• Scarlet fever
• Cervical lymphadenitis.
• Parvovirus B19 infection.
• Drug hypersensitivity reaction.

The Final Diagnosis in the above case was Kawasaki Syndrome.

Kawasaki syndrome is an acute vasculitis of unknown etiology