9 year Old Boy With A Chronic History Of Cough And Diarrhea Is In The Clinic For A Routine Followup

A 9 year old male child is having a routine followup with his primary care physician when a voluntary medical student approaches this patient for clinical history and examination. The child's mother gives the history of the patient being always sick since the time when he was an infant. He suffers from repeated respiratory infections needing antibiotic for treatment. The patient also has repeated episodes of diarrhea and he looks young for his age with some degree of growth retardation.
On physical examination, the medical student found a very striking sign in the hands. The picture is shown below:

What is the sign seen in the above picture?
.
.
Clubbing of the fingers.

On the basis of history what is the Differential Diagnosis?

• Cystic Fibrosis
• Congenital heart disease.
• Celiac disease.
• Malabsorption disorder.

The above mentioned patient has cystic fibrosis.

A 22 Year Old Lady Presents With Skin Depigmentation

A 22 year old lady is seen by a dermatologist for the complains of skin depigmentation and appearance of white patches on her hands, face and arms. She first noticed around 6 months ago as a spot in her face but now the depigmentation is spreading through tout her body gradually. She has also noticed her scalp hair turn white. The white patches are mostly symmetrical in distribution and there is no itching or any signs of infection in the involved areas.
The picture of her hands is shown below:

What is the most probable diagnosis?

Vitiligo.

Case Discussion:
Vitiligo is a skin disease that causes loss of skin color and is characterized by portions of skin depigmentation seen as white patches. The disease is not contagious or life threatening but it leads to severe mental stress and cosmetic issues.
The disease can affect all types of skin but it is more prominent in people with dark skin.

A 50 Year Old Woman Presents With Yellow Bumps All Over Her Body

A 50 Year old Woman who is a known case of Diabetes presents with yellow small bumps all over her body including her eye lids, back and behind the elbows. The lesions are painless but she is concerned. The picture of the lesions on her eyelids and the back of the elbow her shown below:

Her diabetes is not well controlled and on investigations her lipid profile was also abnormal with high cholesterol and triglycerides.

What is the Diagnosis:
Xanthomata

A 30 year Old Man Presents With Joint Pain And Nail Deformities

A 30 year old male patient is seen by a Rheumatologist for pain in his small joints of the hand and feet as well as lower back pain. He has a past history of some skin problem which is nowadays under control but he has observed that his finger nails has become dry and cracked with pitting and looks deformed. He remembers having had such nail problems previously and was treated along with his skin lesions. This time he complains of pain in his small joints of the hand and stiffness.
On examination he has warm and tender distal interphalangeal joints symmetrically in both the hands with severe nail deformities.
The picture of his hands is shown below

There is some stiffness in his neck and the vertebral column as well.

A skin lesion on his elbow is shown below:

What investigations will you order in this case?
.

• Rheumatoid Factor.
• ESR
• Joint fluid aspiration and analysis.
• Joint X ray.

A 70 Year Old Man Presents With Bone pains And Fatigue

A 70 year old man is brought to a primary care physician by his son because the patient has been complaining of fatigue and bone pains over the past 5 months. Although he lives alone, for the past few days he has been feeling very sick and had to call his son for help. His appetite has reduced and he feels nauseous all the time. His son feels that the patient has lost a lot of his weight during the last few months. He says due to weakness he has not been out of bed for the last 4 days.
On examination the patient appears to be slightly confused. he looks pale and malnourished.
Vitals:
Temperature = 102 F
Heart rate = 110 beats/ minute
B.P = 110/60 mmHg
Resp rate = 17 breaths /min

On abdominal examination liver was palpable 3 cm below the right costal margin.
All the bones including the upper and the lower limbs as well as the ribs were tender on palpation.

What Investigations will you order?

• Complete Blood count
• Urinalysis 
• Serum and urine assessment for monoclonal protein
• Bone marrow aspiration and/or biopsy
• Skeletal survey ( that includes a series of X rays of the skull, axial skeleton and proximal long bones).

The results shows:

• Hb = 8 g/dl. 
• Peripheral blood smear shows the following picture:

Plasma cells seen along with rouleau formation of blood red blood cells

A 40 Year Old Woman Presents With A Painless Swelling In Her Neck

A 40 year old woman was brought to the doctor's office by her cousin for a swelling in her neck. The patient lives in a mountainous region of the country and has little or no medical facilities. She was in the city visiting her cousin when she was insisted to get a checkup for the swelling. The patient describes the swelling to appear gradually over the last few years and it is painless and is not causing any symptoms.
On further questioning she says that her diet mostly consists of vegetables and she never knows about iodized salt. She mentions many people in her village has similar swellings in the neck.
The swelling on her neck is shown in the picture below:

A diagnosis of goiter secondary to iodine deficiency was made.

Case Discussion:
Goiter is defined as a swelling in the neck due to enlargement of the thyroid gland.