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

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.