Test your might!

[Depakote]

In the same vein as Allo's Name that Pathogen thread, let's get some good review going here. Anything on Step I is fair game.

A 37 year old male presents with a BP of 80/?. PT and PTT are elevated. Fibrinogen and Platelet count are decreased. D-Dimers are present. Peripheral blood smear reveals schistocytes as well as the following pathologic abnormality:

What is this patient's acute illness?
What is this patient's underlying illness?
Is there a specific abnormality associated with the underlying illness?
What must be done to treat this patient's underlying illness as not to aggravate the acute disease?

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[Depakote]

AUDIO VISUAL QUESTION!


A 38 year old male presents to your clinic complaining of horrible shaking whenever he attempts to perform tasks.

His presentation is below:

[YOUTUBE]http://www.youtube.com/watch?v=nsifBzm_Jw8[/YOUTUBE]
viewing this on the youtube site will give away the diagnosis

Note: The last 10 seconds are post-therapy.

What is the diagnosis? Is this a common condition?
If he told you that something improved his condition, what would that be?
What would you give to treat this?
If medical treatment failed, what would you do?
If this man's father had the disease, what are the chances that he'll pass it on to his children?

Edit. STUPID Youtube putting the names of their vids on the embed.

 

[werd]

Naegleria fowleri, yup. Amebic Meningoencephalitis was what I was thinking of... just found it on Access Medicine.

keep in mind that menigococcus, step pneumo, and h. flu are all much more likely, as are viral causes like HSV. he needs an LP following empiric treatment for meningitis.

 

[Aorta]

Essential tremor..
Autosomal dominant condition..50% of his children will be afected..
Alcohol will improve his condition..
Treatment is beta blocker
dont remember the surgery..
I had a doubt though..can it be wilson's disease.it kinda looks like wing beating tremor?????

 

[Depakote]

Essential tremor..
Autosomal dominant condition..50% of his children will be afected..
Alcohol will improve his condition..
Treatment is beta blocker
dont remember the surgery..
I had a doubt though..can it be wilson's disease.it kinda looks like wing beating tremor?????

Essential tremor. Autosomal Dom (if familial). You can also give anti-seizure meds like Topiramate. Deep brain stimulation is the surgical tx.

It is a very common condition (and frequently mis-diagnosed as parkinsons)

 

[Instatewaiter]

sounds like endometriosis, could be fibroids or bicornate uterus
confirm with US, but direct visualization is gold standard
pathophys is endometrial tissue outside the uterus, often around ovaries, cycles like regular endometrium during the month and the growth/degredation causes pain
treat with OCP's, consider surgical removal if it's causing infertility and want kids

Nice. Endometriosis it is. I was trying to steer you guys away from fibroids based on lack of AUB and pain that is 1-2 weeks before menses which is typical for endometriosis.

*possible* Pathophys= retrograde mestruation causing endometrial tissue outside of the uterus.

Direct visualization by laparoscopy is gold standard. I dont think u/s will show much unless there are some pretty significant lesions. I may be wrong though. Plus pain associated with endometriosis is not correlated with amt of ectopic endometrial tissue.

Tx- OCPs, progestins or depolupron. Or if surgically visualized, ablation.

Naegleria fowleri, yup. Amebic Meningoencephalitis was what I was thinking of... just found it on Access Medicine.

That's what i was looking for with the history of swiming in fresh water. True menigococcus and HSV are more common.

 

[Instatewaiter]

62 year old man who is brought in by his daughter who is concerned about him. She says he began having difficulty walking 2 years ago losing his balance frequently. He has significant trouble turning while walking. In the past year he began having a tremor in his hands but she thinks this may be due to old age. He seems a bit withdrawn she says because he doesnt have the same expressiveness in his face and wont look her in the eye. Physical exam is significant for a tremor that goes away with purposeful movement. Gait is slow and wide-based with marked trouble turning around. He does not make eye contact with you during the entire exam. When asked to look at the ceiling he cannot.

Diagnosis?

62 year old man who is brought in by his daughter who is concerned about him. She says he began having difficulty walking 2 years ago losing his balance frequently. He has significant trouble turning while walking. In the past year he began having a tremor in his hands but she thinks this may be due to old age. He seems a bit withdrawn she says because he doesnt have the same expressiveness in his face. He has started to have visual hallucinations recently and his daughter want to put him in a nursing home. Physical exam is significant for a tremor that goes away with purposeful movement. Gait is slow and wide-based with marked trouble turning around.

Diagnosis?

 

[Aorta]

62 year old man who is brought in by his daughter who is concerned about him. She says he began having difficulty walking 2 years ago losing his balance frequently. He has significant trouble turning while walking. In the past year he began having a tremor in his hands but she thinks this may be due to old age...

diagnosis ..Parkinson's?

 

[Depakote]

the motor symptoms sound very much like parkinsons except the hallucinations have me a little hesitant to make the dx.

I know you can get dementia, but I though that was more of a disordered information processing issue.


You can get schizophrenic symptoms (hallucinations) when you over medicate them, due to over-activation of the dopaminergic system.

 

[LadyJubilee8_18]

Ok, a 58 year old previously homeless obese woman is being treated for stage 4 endometrial cancer. Her PMH includes diabetes and heart failure. Three weeks into treatment, she develops and cough and SOB. A pleural effusion is noted on chest X-ray. Thoracentesis is performed and the fluid protein to serum protein ratio is 0.7. Image of the path is shown below:

Is this a transudate or exudate? Why?
What is the most likely cause of the effusion?
What are the risk factors for this disorder?
In a hospitalized patient with this condition, what precautions should be taken?

Bonus: What is her risk factor for endometrial cancer?

 

[bluntdissector]

Bonus: What is her risk factor for endometrial cancer?

I know this is kinda cheating, answering this first, but:
She is fat = more peripheral conversion of androgens to estrogens

 

[LadyJubilee8_18]

I know this is kinda cheating, answering this first, but:
She is fat = more peripheral conversion of androgens to estrogens

Yay! Gold star for you:

Edit: Wow, that star is gigantic!

 

[Depakote]

Ok, a 58 year old previously homeless obese woman is being treated for stage 4 endometrial cancer. Her PMH includes diabetes and heart failure. Three weeks into treatment, she develops and cough and SOB. A pleural effusion is noted on chest X-ray. Thoracentesis is performed and the fluid protein to serum protein ratio is 0.7. Image of the path is shown below:

Is this a transudate or exudate? Why?
What is the most likely cause of the effusion?
What are the risk factors for this disorder?
In a hospitalized patient with this condition, what precautions should be taken?

Bonus: What is her risk factor for endometrial cancer?

Exudate. High protein ratio and lymphocytes.

I'd be concerned that, given the fact that she's homeless and being treated for cancer- probably immunosupressed, this could be a reactivation of Tuberculosis.

N95 masks for everyone and respiratory isolation precautions.

 

[Depakote]

Yay! Gold star for you:

Edit: Wow, that star is gigantic!

my eyes!

 

[bluntdissector]

That star is crazy!

N95 masks for everyone and respiratory isolation precautions.

It's so funny to see how the rest of the world treats TB...if you come to SA, especially to Tygerberg Hospital where I'm at, you'll see half the hospital has TB, the guy working is your garden has TB, all the little kids in the paeds wards have TB, TB is on every DDx (I've seen stacks of TB meningitis, TB of the GUT, pelvic TB, TB IRIS in a child, TB bone infections etc) etc etc...and yet, despite all of this, I had NO idea wtf N95 masks are! Lol...

Good answer tho!

 

[Depakote]

That star is crazy!




It's so funny to see how the rest of the world treats TB...if you come to SA, especially to Tygerberg Hospital where I'm at, you'll see half the hospital has TB, the guy working is your garden has TB, all the little kids in the paeds wards have TB, TB is on every DDx (I've seen stacks of TB meningitis, TB of the GUT, pelvic TB, TB IRIS in a child, TB bone infections etc) etc etc...and yet, despite all of this, I had NO idea wtf N95 masks are! Lol...

Good answer tho!

I'm not to the clinic yet and my ID lecture was a few months ago so I'll elaborate... but take this with a grain of salt.

If someone is PPD positive for the first time, but asymptomatic, they get treated for a latent infection but no contact precautions.

If someone is symptomatic and there is clear evidence that they have TB (positive culture, sputum stain, etc), then we do what we can to keep it from spreading. This includes some stiff precautions. Given that this lady was symptomatic, she'd fall into this category. (n95 masks are a tight enough fit that they'll effectively prevent airborne transmission of TB)

 

[LadyJubilee8_18]

Exudate. High protein ratio and lymphocytes.

I'd be concerned that, given the fact that she's homeless and being treated for cancer- probably immunosupressed, this could be a reactivation of Tuberculosis.

N95 masks for everyone and respiratory isolation precautions.

OMG you're so smart I can't stand it!! Less obnoxious gold star for you:

 

[bluntdissector]

I'm not to the clinic yet and my ID lecture was a few months ago so I'll elaborate... but take this with a grain of salt.

If someone is PPD positive for the first time, but asymptomatic, they get treated for a latent infection but no contact precautions.

If someone is symptomatic and there is clear evidence that they have TB (positive culture, sputum stain, etc), then we do what we can to keep it from spreading. This includes some stiff precautions. Given that this lady was symptomatic, she'd fall into this category. (n95 masks are a tight enough fit that they'll effectively prevent airborne transmission of TB)

Just so you know, over here we TRY and convince the patients to AT LEAST cough into a handkerchief (can't afford masks, there's just no way) and we try even harder to get them to take their Rifafour tablets for 6 months. Mostly the people are SO symptomatic that it's a spot Dx and the sputum is simply protocol. And then every now and then you see a kid with Stage 3 TBM and it kinda p1sses you off that their parents didn't take their meds:

(Sorry, I didn't have place to host!)

 

[PeepshowJohnny]

Wilson's Ds.
Low ceruloplasmin, high serum copper--> deposits in basal ganglia
Kayser Fleischer rings
Serum copper levels/ceruloplasmin
Can result from alcohol abuse and resultant cirrhosis- alcohol counseling
Penicillamine

Good job, what I was going for in number 4 was genetic testing/counseling for the other kids, but it's kind of a "read my mind" question

 

[Captopril]

That star is crazy!




It's so funny to see how the rest of the world treats TB...if you come to SA, especially to Tygerberg Hospital where I'm at, you'll see half the hospital has TB, the guy working is your garden has TB, all the little kids in the paeds wards have TB, TB is on every DDx (I've seen stacks of TB meningitis, TB of the GUT, pelvic TB, TB IRIS in a child, TB bone infections etc) etc etc...and yet, despite all of this, I had NO idea wtf N95 masks are! Lol...

Good answer tho!

Ya I've been in open contact with so many TB patients that I'm pretty sure I have the little buggers chillin out having cocktails in my system.

 

[Depakote]

A 75 year old female is admitted for knee replacement surgery. 24 hours post-op the patient appears agitated and you notice an irregular tremor of variable severity. She complains about spiders crawling up the wall (there aren't any).

You review the anesthesiologist's note to confirm your suspicion and the patient required higher than normal doses (for a patient of her age and body weight) of thiopental to achieve anesthesia induction.

What is this patient suffering from?
What is the proper treatment?
Why did the patient require higher than normal doses of thiopental for anesthesia induction? What does this tell you?

 

[Aorta]

A 75 year old female is admitted for knee replacement surgery. 24 hours post-op the patient appears agitated and you notice an irregular tremor of variable severity. She complains about spiders crawling up the wall.You review the anesthesiologist's note to confirm your suspicion and the patient required higher than normal doses (for a patient of her age and body weight) of thiopental to achieve anesthesia induction.
What is this patient suffering from?
What is the proper treatment?
Why did the patient require higher than normal doses of thiopental for anesthesia induction? What does this tell you?

hmm..dx..Opiod withdrawal..(as an analgesic for knee pain)
methadone for maintenance
pt required higher dose of thiopental cos they develop tolerance

 

[Depakote]

hmm..dx..Opiod withdrawal..(as an analgesic for knee pain)
methadone for maintenance
pt required higher dose of thiopental cos they develop tolerance

you're on the right track, but everything ties together. Opioids aren't a bad thought, but if they were on them before, they're probably going to still be on them post-surgery for a total-knee.

What wouldn't she be getting after being admitted to the hospital? (Something she had enough of that she'd be experiencing withdrawl) Why would she need a higher dose of thiopental?

 

[LadyJubilee8_18]

hmm..dx..Opiod withdrawal..(as an analgesic for knee pain)
methadone for maintenance
pt required higher dose of thiopental cos they develop tolerance

Oh thank God, for a minute I thought granny was hittin the junk

 

[LadyJubilee8_18]

you're on the right track, but everything ties together. Opioids aren't a bad thought, but if they were on them before, they're probably going to still be on them post-surgery for a total-knee.

What wouldn't she be getting after being admitted to the hospital? (Something she had enough of that she'd be experiencing withdrawl) Why would she need a higher dose of thiopental?

DTs?

 

[Instatewaiter]

62 year old man who is brought in by his daughter who is concerned about him. She says he began having difficulty walking 2 years ago losing his balance frequently. He has significant trouble turning while walking. In the past year he began having a tremor in his hands but she thinks this may be due to old age. He seems a bit withdrawn she says because he doesnt have the same expressiveness in his face and wont look her in the eye. Physical exam is significant for a tremor that goes away with purposeful movement. Gait is slow and wide-based with marked trouble turning around. He does not make eye contact with you during the entire exam. When asked to look at the ceiling he cannot.

Diagnosis?

62 year old man who is brought in by his daughter who is concerned about him. She says he began having difficulty walking 2 years ago losing his balance frequently. He has significant trouble turning while walking. In the past year he began having a tremor in his hands but she thinks this may be due to old age. He seems a bit withdrawn she says because he doesnt have the same expressiveness in his face. He has started to have visual hallucinations recently and his daughter want to put him in a nursing home. Physical exam is significant for a tremor that goes away with purposeful movement. Gait is slow and wide-based with marked trouble turning around.

Diagnosis?

These were just a few things in the differential for a resting tremor.

Diagnosis 1: progressive supranuclear palsy essentially is parkinsons + inability to look up

Diagnosis 2: Diffuse lewy body dementia= parkinsons + visual hallucinations. Lewy bodies are spread diffusely througout the brain esp in the frontal cortex.

 

[Aorta]

you're on the right track, but everything ties together. Opioids aren't a bad thought, but if they were on them before, they're probably going to still be on them post-surgery for a total-knee...

I guess u r right..think will go with ladyjubille's answer...delirium tremens..

 

[Aorta]

A 55 yr old female comes with the compliant of pricking and burning sensation in the feet since 2-3 months.Symptoms increase after walking.She complains of weakness of both upper limbs.
Previous medical history include subtotal thyroidectomy.She is on thyroxine and calcium supplements.Attained menopause 3 years back.
Hb-12,random blood sugar-123mg/dl..


What is the diagnosis?
What investigation is done to confirm the diagnosis?
What could be the cause of the disease?
Rx?

 

[SomeDoc]

A 75 year old female is admitted for knee replacement surgery. 24 hours post-op the patient appears agitated and you notice an irregular tremor of variable severity. She complains about spiders crawling up the wall (there aren't any).

You review the anesthesiologist's note to confirm your suspicion and the patient required higher than normal doses (for a patient of her age and body weight) of thiopental to achieve anesthesia induction.

What is this patient suffering from?
What is the proper treatment?
Why did the patient require higher than normal doses of thiopental for anesthesia induction? What does this tell you?

-ETOH withdrawal (DT)
-Benzo's
-(educated guess)Alcohol=depressant via GABA receptors. Chronic ETOH use=potential downregulation of GABA receptors=more thiopental needed for depressant effect.

 

[SomeDoc]

A 55 yr old female comes with the compliant of pricking and burning sensation in the feet since 2-3 months.Symptoms increase after walking.She complains of weakness of both upper limbs.
Previous medical history include subtotal thyroidectomy.She is on thyroxine and calcium supplements.Attained menopause 3 years back.
Hb-12,random blood sugar-123mg/dl..


What is the diagnosis?
What investigation is done to confirm the diagnosis?
What could be the cause of the disease?
Rx?

Hypocalcemic tetany
Serum Ca2+/PTH
Low Ca2+=less presynaptic ACh release, especially evident after muscle use.

Include trosseaus sign (migratory thrombophlebitis) in the differential.

 

[Depakote]

DTs?

you're on the right track, but everything ties together. Opioids aren't a bad thought, but if they were on them before, they're probably going to still be on them post-surgery for a total-knee...

I guess u r right..think will go with ladyjubille's answer...delirium tremens..

-ETOH withdrawal (DT)
-Benzo's
-(educated guess)Alcohol=depressant via GABA receptors. Chronic ETOH use=potential downregulation of GABA receptors=more thiopental needed for depressant effect.

yup. you're all right.

 

[SomeDoc]

Hypocalcemic tetany
Serum Ca2+/PTH
Low Ca2+=less presynaptic ACh release, especially evident after muscle use.

Include trosseaus sign (migratory thrombophlebitis) in the differential.

Wait... just had a thought- PT could have had autoimmune thyroiditis--> treatment was Sx resection. Given her Hx, she's at risk for lambert eatons- autoantibodies to presynaptic Ca2+ channels, which produce her symptoms.
-Test w/ elisa- antibodies to presyn Ca2+ receptor autoantibodies.

 

[Aorta]

hi somedoc..
It is autoimmune related..but it isnt eaton lambort syn as it is part of paraneoplastic syn -related to small cell ca of lung..

The symtoms point to peripheral neuropathy..I think now the diagnosis should be easy

 

[SomeDoc]

hi somedoc..
It is autoimmune related..but it isnt eaton lambort syn as it is part of paraneoplastic syn -related to small cell ca of lung..

The symtoms point to peripheral neuropathy..I think now the diagnosis should be easy

You bet, Myasthenia Gravis.

 

[bluntdissector]

How would MG explain the paraesthesia?
I thought I remembered something about CIDP being found with some cancers, but that would probably be ruled out by Aorta's 'its not paraneoplatic'...

 

[SomeDoc]

Good point. With paresthesias and peripheral neuropathy, we could also be looking at any one of the lysosomal storage diseases. But none of those are autoimmune. I guess we'll just have to see what it is when Aorta gets back to the thread.

 

[SomeDoc]

In the meantime, here's a quickie.

PT's fetus presents with clear cell adenocarcinoma of the vagina. What agent was the mother most probably exposed to?

 

[Teee]

DES

diethyl something

 

[SomeDoc]

DES=diethylstilbestrol

 

[Teee]

a male patient presents with acute gastrointestinal symtpoms including diarrhea with blood and mucus. he is is dehydrated and fatigued. he is admitted pending blood tests, blood culture results.

what is the first course of treatment?

blood tests show increased bilirubin, blood smear shows schistocytes (helmet cells). blood cultures/ gram stain is positive for a motile gram negative lactose fermenting organism.

what organism (strain) is this? what is the name of the syndrome? what is the name of the disease?

 

[FutureInternist]

a male patient presents with acute gastrointestinal symtpoms including diarrhea with blood and mucus. he is is dehydrated and fatigued. he is admitted pending blood tests, blood culture results.

what is the first course of treatment?

blood tests show increased bilirubin, blood smear shows schistocytes (helmet cells). blood cultures/ gram stain is positive for a motile gram negative lactose fermenting organism.

what organism (strain) is this? what is the name of the syndrome? what is the name of the disease?

GUESSES: -
Start IV fluids & Abx
EHEC
HUS

 

[Aorta]

You bet, Myasthenia Gravis.

It aint MG..cant be hypocalcemia bcos she is taking calcium supplements.

This pt had vit B 12 def.Myelin formation in peripheral nerves and CNS will be effected..
She had undergone subtotal thyroidectomy 3 yr back-for adenoma..
Hypothyroid pts can develop B12 def..

Reflexes were diminished in lower limbs indicating peripheral neuropathy.

Blood sugar was normal-rules out diabetic cause.(also u need a long history of DM to develop neuropathy)

She had weakness of upper limbs-explained by abnormal myelination of corticospinal tracts.(pts develop spastic paresis)

Also dorsal column and spinocerebellar tracts will be involved if not treated soon..

Investigation-
Peripheral smear will show megaloblastic anaemia
MCV>100
Vit B12 <211pg/ml

Rx-Intamuscular Vit B12

Guess this one was lil difficult.Anyways nice try somedoc and bluntdissector..

 

[bluntdissector]

This pt had vit B 12 def.Myelin formation in peripheral nerves and CNS will be effected..
She had undergone subtotal thyroidectomy 3 yr back-for adenoma..
Hypothyroid pts can develop B12 def..

Was a fun case!

The only mechanism I know of that links hypothyroidism and b12 deficiency is auto-immune (AI diseases 'hunt in packs' as they say) but she didn't have auto-immune hypothyroidism, she had iatrogenic hypothyroidism. So how does that cause B12 deficiency? I can't seem to remember anythin like that!

 

[mlw47]

Hypothyroid pts can develop B12 def..

Could someone explain this to me please?

 

[Aorta]

Was a fun case!

The only mechanism I know of that links hypothyroidism and b12 deficiency is auto-immune (AI diseases 'hunt in packs' as they say) but she didn't have auto-immune hypothyroidism, she had iatrogenic hypothyroidism. So how does that cause B12 deficiency? I can't seem to remember anythin like that!

Even I dint get it when professor said hypothyroidism could be the cause

After the treatment her B12 levels have increased to 683pg/ml..

Did my bit of research..
http://www.lef.org/protocols/abstracts/abstr-txt/t-abstr-104.html

I am sure u will find this useful..

 

[bluntdissector]

Even I dint get it when professor said hypothyroidism could be the cause

After the treatment her B12 levels have increased to 683pg/ml..

Did my bit of research..
http://www.lef.org/protocols/abstracts/abstr-txt/t-abstr-104.html

I am sure u will find this useful..

I can't find an article at that link that explains it, they just advocate screening for thyroid dysfunction and b12 deficiency, but not as occuring from the same disorder, simply because they are both cheap!

I could find some articles from the 50s and 60s that explore protein and B12 deficiency in rats...

I think that the most important cause (@mlw47) of hypothyroidism and b12 deficience would be if the patient has auto-immune disease, since these often occur together (vitiligo, pernicious anemia, etc). Thats the only mechanism I am aware of...

So I'm still not convinced that a patient that had a thyroidectomy for, say cancer (i.e. no auto immune disease) will develop b12 deficiency UNLESS there is a drug side-effect/reaction OR she develops auto-immune reaction in response to surgery (Dunno how)...and I assume she is euthyroid on treatment anyway? I'm not accusing you of lying (nor am I critical of the proff) I just need some more evidence that hypothyroidism in and of itself can cause low B12...

Sorry, one mechanism I found - you can have a bad surgeon who takes out the parathyroid hormones too, and then not treat the hypoparathyroidism, which can have an increased risk for pernicious anemia, which causes b12 deficiency (Seems like a long shot!)

http://www.nlm.nih.gov/medlineplus/ency/article/000385.htm#Complications

 

[THE armada]

We just covered all things thyroid and never discussed a link b/w hypothyroid and vit B12 deficiency other than the increase risk of other autoimmune diseases w/ one autoimmune disease.

 

[bluntdissector]

I think that there arr some ways the two can be linked, but not anything we should be worried about for step 1!

Think we've gone deep enough into this case, ha ha...Thanks Aorta, always fun to try and figure the 'harder' ones out...

Keep 'em coming!

 

[Teee]

GUESSES: -
Start IV fluids & Abx
EHEC
HUS

yep, the disease is microangiopathic anemia


why does vitamin b12 deficiency and not folate deficiency cause peripheral neuropathy?

 

[LadyJubilee8_18]

yep, the disease is microangiopathic anemia


why does vitamin b12 deficiency and not folate deficiency cause peripheral neuropathy?

B12 is a cofactor for methlymalonyl-coA mutase in beta oxidation of odd chain fatty acids. Without B12, the enzyme doesn't work and the D form of methylmalonyl-coA builds up and is deposited in myelin causing faulty insulation of nerve fibers. This creates the peripheral neuropathy

 

[Instatewaiter]

The only thing about the B12 deficiency case is that I would expect there to be more severe anemia. i would guess that a hemoglobin of 12 is kinda high to see neurological sequellae but i couldnt find anything online that said the level of anemia where cord degeneration occurs. Anyone know for sure?