A 40 Year Old Alcoholic Man With fatigue, Anorexia And Jaundice

A 40 year old man presents to the clinic with the complains of feeling tired with aches in his arms and legs for the past 2 months. He says he feels nauseous and has vomited multiple times in the last one month. He feels anorexic and has lost his appetite. He has also noticed having an intermittent right upper quadrant abdominal pain. He drinks approximately 20 alcoholic beverages per week. He denies any chest pain, cough, difficulty breathing, or any problems with urination or bowel habits. He did notice his skin to be mildly jaundiced. On examination he has mild abdominal tenderness in the right upper quadrant and has a palpable mild hepatosplenomegaly.

What is the Differential Diagnosis?

Differential Diagnosis:

• Hepatitis
• Alcohol related liver disease
• Cirrhosis
• Acute pancreatitis.
• Hepatocellular carcinoma. 

A biopsy from his liver shows following pathologic features:

The main pathologic features of alcoholic steatohepatitis include macrovesicular steatosis, hepatocellular damage, inflammation, and pericellular fibrosis.


The patient was diagnosed with Alcohol related liver disease.

A 65 Year Old Man With Pancytopenia

A 65 year old man is referred to a hematology-oncology center for evaluation of his pancytopenia. The patient has a history of constant fatigue over the last 1 month, he feels short of breath on mild exertion and had a persistent upper respiratory infection for the past 2 months with chest congestion and a non productive cough. He has also noticed that he has developed multiple bruises from minor trauma on his legs or arms. He denies any similar symptoms in the past and has not used any new medicines recently.

Physical Examination:

• Patient looks pale.
• petechiae around his mucosal surfaces
• No lymphadenopathy
• Mild ronchi on auscultation of the lungs
• soft systolic murmur on auscultation of heart.
• Abdomen is soft and non tender with a palpable spleen
• Normal neurological examination.

The routine blood test done by his general physcian shows a pancytopenia and the valuse are shown below:

Hb = 11.5gm/dl, WBC = 3100/mm3, Platelet = 128,000/mm3

What is the Differential Diagnosis?

• Aplastic anemia
• Acute myelogenous leukemia
• Acute lymphocytic leukemia
• Lymphoma
• HIV
• Hairy cell leukemia
• Chronic myelogenous/ lymphocytic leukemia

On further work up the blood smear had the following picture;

several large myeloblastic leukocytes , some with Auer rods and notched(bilobed) nuclei

HIV Elisa was negative 

Bone marrow biopsy shows high proportion of blast staining with myeloperoxidase.

What is the Final Diagnosis?

A 27 Year Old Woman Involved In A Car Crash

A 27 year old woman is brought to an emergency department by an ambulance after being involved in a single car collision , when her car slipped off on a wet road and hit a telephone pole. The patient is conscious now but says she thinks she lost consciousness for sometime after the accident. She complains of some mild neck and upper back soreness but denies any pain elsewhere in her body. She has no numbness or weakness of her extremities , no history of nausea or vomiting or loss of bladder or bowel control. She had a laceration about 4 cm length on her scalp that was covered with a bandage in the emergency department.
On her initial examination she is found to be alert and conscious with no neurological abnormalities. On her second survey she seems to be disoriented not knowing her name and location and is also complaining of a severe headache.
A CT scan Is done and shows the following findings:

This is a sagittal head CT scan without contrast demonstrating a large epidural hematoma with right to left shift and ventricular narrowing.

The patient was diagnosed as a case of

33 Year Old Man With Watery Diarrhea, Abdominal Pain And Weight Loss

A 33 year old man presents to the clinic with the complains of watery diarrhea, diffuse abdominal pain and gradual weight loss over the past 3 weeks. He has been given antibiotics but his diarrhea is not responding. He mentions having a similar problem 6 months back. His appetite has decreased and he describes having painful ulcers in his mouth that makes eating difficult and painful.
On examination he looks pale and in mild discomfort. He has a fever of 101 F.  His abdomen in mildly tender on palpation but there is no visceromegaly.
Based on the above history and examination what is the differential diagnosis?

Differential Diagnosis:

• Gastroenteritis.
• Inflammatory bowel disease
• Pseudomembranous colitis
• Small bowel lymphoma
• HIV induced Infection
• Carcinoid

What Lab test and workup will you advice for this patient?

Workup:

• Complete blood count
• Serum electrolytes
• Stool exam and culture
• Colonoscopy
• CT abdomen
• Urinary 5- HIAA
• Small bowel series.

This patient was scheduled for a colonoscopy and the following was observed:

Colonoscopic image showing erythematous and friable mucosa with numerous pseudopolyps .

21 Year Old female With Complaint Of Severe Right Lower Abdominal Pain

A 21 year old female presents to the emergency department with the complain of severe right lower abdominal pain that started this morning. The pain is 7/10 in intensity and constant in nature. It is exacerbated by movement and does not radiate. It is accompanied by fever, nausea and one episode of vomiting. Her LMP was 4 weeks back and she is sexually active. She has a history of regular periods every 4 weeks lasting for 6 days. She did notice some brownish spotting this morning which she thought was her periods because she was due. She is on birth control pills nowadays. She had a normal vaginal delivery 18 months back. Her past history is not significant for any illnesses or any major surgery.  On examination, she looked pale and was in pain. Her abdomen was tender on palpation more on the right side. On pelvic examination she had severe pain and the cervix and the uterus seemed to be pushed on one side.

 What will be the differential diagnosis on the basis of History and examination?

Differential Diagnosis:

• Pelvic inflammatory disease.
• Torsion of an ovary
• Torsion of the ovarian cyst
• Adnexal torsion
• Acute appendicitis
• Ruptured ectopic pregnancy
• Abortion

 Urine hCG was negative and pregnancy was almost ruled out. She was taken for a transvaginal ultrasound and it shows the following picture;

Sonographic Whirlpool Sign in Ovarian Torsion

A 70 year Old Man Comes In With Complaints Of Hand Tremors And Shakiness.

A 70 year old man presents to a neurologist accompanied by his wife. His wife says that she first noticed the tremors in her husband's hands 6 months ago., but it has gradually worsened since that time. The tremor seem to be present both at rest and during activity.The tremor nearly resolves while he is asleep. The patient has been unstable on his feet and has fallen on a couple of occasions. The patient tend to forget things easily and does not participate in activities he previously enjoyed.

Physical Examination:

• An old man with no acute distress.
• he shows little or no emotion during the history and physical examination.
• His face appears symmetric.
• he has a resting tremor in both the hands that consists of a regular beat of writ and finger flexion.
• He has an increased tone throughout his body , and it is difficult to passively range his extremities. 
• Sensation is grossly intact.
• When his gait is observed, he has difficulty initiating his first steps, walks in a shuffling pattern, and takes several extra steps when he tries to come to a stop. 

His photo taken in the office is shown below:

he was asked to write on a paper and he wrote like the pattern shown below;