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03 January Blurred vision &.Fungal sinusitis
A 26-year-old man was seen in the Neuro-Ophthalmology Clinic because of blurred vision and discomfort in the right eye. Approximately 8 days earlier, vision in the right eye became hazy, and periorbital pain developed. Six days earlier, he was evaluated in the emergency department. He had recently had an upper respiratory infection and nasal congestion.During the next 5 days, visual acuity in the right eye gradually decreased, and the patient felt mild discomfort with movement of the eye. Nasal congestion and headache persisted.
On examination, there was decreased visual acuity, loss of color vision, a swollen right optic nerve, and visual-field abnormalities. Computed tomography of the orbits and sinuses revealed sinusitis with erosion of the optic canals.
When a patient such as this one presents with blurred vision, the first and most important task is to determine whether the vision loss is (1) refractive (2)related to an ophthalmic disorder (3)neurologic disorder. In this case, pinhole testing raised the possibility that the vision loss was of retinal or neurologic origin. The next step is to localize the defect within the visual pathway. 19 December Myxomatous &.Cerebral Infarctions
A 25-year-old woman with a history of depression, mitral-valve prolapse, and migraine presented with a 3-day history of fever, arthralgia, and a severe generalized headache that was not characteristic of her previous migraines. On examination, the patient was afebrile, with a pulse rate of 120 beats per minute and a blood pressure of 98/41 mm Hg. She was somnolent but easily arousable, with normal mentation, and the neurologic examination was normal. Laboratory studies showed a normocytic anemia and severe thrombocytopenia. A peripheral-blood smear revealed few platelets and some schistocytes. Thrombotic thrombocytopenic purpura(血栓性血小板减少性紫癜)was suspected, plasma exchange and corticosteroid therapy were initiated with improvement of her symptoms and hematologic abnormalities. However, five days after discharge, the patient returned because of a recurrent headache and emesis, and falling platelet count to 23,000 per cubic millimeter. Blood cultures now showed β-hemolytic group C streptococcus. A trans-esophageal echocardiogram revealed ruptured chordae tendineae of the mitral valve leaflet(二尖瓣腱索断裂), possible leaflet perforation, and severe regurgitation. This suggested infective endocarditis, not thrombotic thrombocytopenic purpura, as the unifying diagnosis. This case discussed “How a clinical presentation prompted an incorrect diagnosis”, and asks clinicians to re-sweep the case and the correct diagnosis of Myxoma" should’ve been made earlier. 05 December lymphoma with myocardial infiltration
A 20-year-old man presented to the emergency department after a syncopal episode. During the previous 2 weeks, he had had persistent low-grade fever, anorexia, rhinorrhea, and headache. On the morning of admission, he felt weak and then collapsed while walking into a room; he had no other antece’dent symptoms. Once he regained consciousness, he reported having dyspnea. In the emergency department, the patient remained hypotensive and dyspneic. Electrocardiography (ECG) showed a right bundle-branch block with right-axis deviation, a finding that had not been present 8 months earlier. Two years earlier, the patient had received the diagnosis of stage IV pre–T-cell lymphoblastic lymphoma at the age of 18 years. Despite a complete remission after induction and consolidation chemotherapy, he had had a recurrence within the year. After the patient’s initial presentation with hypotension, syncope, and ECG evidence of right heart strain, the treating physicians pursued the diagnosis of pulmonary embolism. The patient’s long-term use of corticosteroids also prompted consideration of sepsis and adrenal insufficiency. In the process of the evaluation, he was found to have cardiomyopathy. A comparison with previous imaging revealed that there had been rapid progression of ventricular-wall thickening; this was immediately recognized to be pathologic and to point to an infiltrative process. 02 November Wegener’s granulomatosis
mp3 : http://www.zshare.net/audio/5079534053f04fc4/ A 39-year-old man was admitted to the hospital because of chest pain, arthralgias, and a mediastinal mass. Two months before admission, pain in the middle and right chest developed, which radiated intermittently to the right arm, increased in intensity with deep inspiration or changes in position, and was accompanied by fatigue and mild shortness of breath; He had had pericarditis 1 year earlier and optic neuritis 5 years earlier. On examination, the first heart sound was absent, the second was loud with a prominent split, and there was a new systolic ejection murmur at the left upper sternal border. Imaging showed an infiltrative mediastinal mass surrounding the aorta and narrowing the lumen of the main and right pulmonary arteries. The key elements of this case are the subacute appearance and progressive growth of a middle mediastinal mass affecting the pulmonary arteries and cardiac conduction system, the recent onset of arthritis, other extrathoracic organ system disease, previous and current glucocorticoid use, and a positive test for antineutrophil cytoplasmic autoantibodies (ANCA). The discussants review each of these as a way of arriving at a diagnosis. 31 October Cervical spinal osteomyelitis MP3 http://www.zshare.net/audio/50781514556c8c01/ A 58-year-old woman was transferred to this hospital because of severe neck pain, fever, and a spinal epidural mass extending from the level of the fourth to the seventh cervical vertebrae, with evidence of mild cord compression seen on imaging studies. 2 to 3 weeks before admission, she noted swelling in the right anterior portion of the neck, which she thought was an enlarged lymph node; the swelling was associated with pain in her neck. Twelve days before admission, the patient went to the urgent care clinic at another hospital. She reported that intermittent right-sided neck pain and mild headaches had occurred for the past 3 months 3 days before admission, a 5-day course of azithromycin was prescribed. The next day, the temperature rose to 39.4°C; Specimens of blood were sent for cultures. The patient was a technologist in a microbiology laboratory. She reported occupational exposed to a clinical specimen of B melitensis Seven months earlier, she had been monitored in the occupational health clinic for 4 months after the exposure. Serum samples obtained both 2 weeks and 4 months after exposure were tested for brucella antibodies, but the results were normal. 30 October Medical Mystery 2---The puffing intrahepatic bile ductDiagnosis： obstructive jaundice, combined with intrahepatic bile duct infection Medical Mystery 1---What is the mass?
A 42-year-old man presented to Respiratory Disease Department with cough and hemoptysis for 30 years. Tuberculosis have been diagnosed 30 years ago. CT of the chest are shown. What is the mass?
welcome to submit your answers to the blog. 24 October Interstitial lung disease(ILD)-1
mp3: http://www.zshare.net/audio/506425339585b346/ A 63-year-old woman was admitted to the hospital because of a 3-week history of dyspnea on exertion, associated left subscapular burning pain, and a mild dry cough. The patient had had Ulcerative Colitis for more than 10 years, with recurrent episodes of cramps, diarrhea, tenesmus, urgency of defecation, and mucus which was most recently treated with azathioprine and infliximab. The most recent dose of infliximab had been administered 15 days before admission.
On examination, there were inspiratory wheezes and rales, without expiratory wheezes. Chest imaging showed ground-glass opacities in both lower lobes.
Two questions help to frame the differential diagnosis in this patient: “Why is this patient ill?” and “Why is she ill at this time?” The answers to these questions will come from analyzing her current illness in the context of several factors:
(1) Her immunocompromised state (since she is receiving a potent immunosuppressive medication), (2) Her underlying ulcerative colitis, (3) The medications that she is receiving to treat the underlying disease (4) An independent process that is unrelated to her ulcerative colitis or her medications.
20 October Zinc deficiency & skin Lesions
A 10.8-year-old girl was seen in the pediatric dermatology clinic because of recurrent oral ulcers and cutaneous bullae since 2 years of age. White lesions in the mouth and vesicles and bullae on the dorsal and plantar surfaces of the feet, the knees, and the hands that ulcerated and became painful occurred at intervals of 3 to 4 months, lasted 4 days to 2 weeks, and resolved without scarring. Biopsy of a lesion 2 years earlier was reported to show features of epidermolysis bullosa.
Treatment with antibiotics was given on several occasions without improvement in the lesions. Ten days after the current visit, vesicular lesions developed on both feet after the patient wore new shoes. The patient carried a diagnosis of epidermolysis bullosa with laminin-5 deficiency. However, the author and the discussant considered that diagnosis to be unlikely, since the patient appeared well and had no scarring. Two punch biopsies of affected skin were performed. The sections of affected skin processed for routine histologic examination showed confluent intraepidermal vesicles with a dense inflammatory infiltrate within intraepidermal spaces.
Careful evaluation revealed that the mechanism of vesicle formation involve the degeneration of individual keratinocytes with ballooning degeneration, dyskeratosis, loss of intercellular connections, cell necrosis, and a secondary inflammatory response. 10 October Pulmonary - Renal Syndrome
The patient’s medical history included hypertension, type 2 diabetes mellitus, hyperlipidemia, and gastroesophageal reflux with Barrett’s esophagus; He was a heavy smoker and He had worked with paint solvents approximately 2 weeks before coming to the hospital but reported no previous exposure to hydrocarbons. On admission, the patient has tachypnea, and his oxygen saturation was mildly depressed; there was conjunctival pallor and dried blood in the oropharynx. Crackles were heard at both lung bases. The cardiac examination revealed an early systolic murmur, grade 1 out of 6, A rectal examination revealed external hemorrhoids. The seemingly unrelated array of symptoms cannot be readily explained by a single diagnosis, but their simultaneous development tempts the clinician to find a unifying cause. this case of multiorgan disease has classic themes with interesting variations. A good clinical history with rigorous analysis enabled the discussant to deduce combined diagnoses. 02 August 26-year-old lung cancer man
mp3: http://www.zshare.net/audio/50657735867014b1/ A 26-year-old man experienced the sudden onset of back pain. 17 days before admission, he bent down to lift something and felt a sudden snap in his back, followed by pain that was associated with profuse diaphoresis and muscle spasms that extended from the left shoulder to the buttocks but did not radiate to the legs. Approximately 8 months before admission, dyspnea on exertion developed; it was attributed to exertional asthma and was treated with metered-dose inhalers. He had had chronic, intermittent lower back pain after a fracture of the L1 vertebra in a sports-related injury 9 years earlier
MRI disclosed a pathologic fracture of the T9 vertebral body. A chest X-ray and CT of the chest showed a mass in the upper lobe of the left lung, with involvement of the hilar and mediastinal structures. The differential diagnosis of a pulmonary nodule is broad, however, signal abnormalities of the bone marrow noted on MRI of the spine, the constellation of pulmonary findings on CT, and the very high levels of protein and lactate dehydrogenase in the pleural fluid, even in the absence of malignant cells — were most consistent with a neoplastic process. 08 June Acute leukemia
A 59-year-old woman presented with newly-onset oligoarthritis非对称性寡关节炎and extreme fatigue. 6 weeks earlier, she noted a gradual onset of pain and swelling in her right knee. 2 weeks before presenting for care, she began to experience pain in her left knee, followed by an onset of pain and swelling in her left ankle and left wrist. The pain in her joints worsened with movement. In the previous 2 weeks, she had noted fatigue and progressive dyspnea on exertion. On physical examination, the patient appeared fatigued. The left wrist joint was swollen, with a limited range of motion. Both knees were swollen, warm, erythematous, and painful on palpation. There was periarticular swelling, a reduced range of motion, and pain in her left ankle. The erythrocyte sedimentation rate(ESR) and serum ferritin level was strikingly high accompany with severe anemia. A bone marrow biopsy is warranted. A few days after admission, the patient’s body temperature rose to 39.1°C, and a rash appeared bilaterally on her anterior shins. Final Diagnosis: Acute leukemia 05 June Metastatic lung cancer
Welcome to Medical Insight , today is June 5, 2008. I’m Dr. Alex Roy. A 63-year-old man was admitted to the hospital because of a mass in the left kidney and pulmonary nodules. 5 months before admission, when mild nausea, loss of appetite, abdominal pain, and constipation developed, followed by fatigue, weight loss of 3.2 kg, and a nonproductive cough. Examination revealed scrotal varicoceles. CT revealed a mass in the left kidney, another mass in the left adrenal gland, and multiple pulmonary lesions. The imaging studies in this case were virtually diagnostic of renal-cell carcinoma with metastases. The first question in such a case is whether to perform a radical nephrectomy for both diagnosis and treatment or simply to obtain tissue through a biopsy procedure. the patient was healthy, he exercised daily, and his functional status was excellent. he was an excellent candidate for nephrectomy. The left kidney and left adrenal gland were submitted for pathological evaluation. And the diagnosis in this case is renal-cell carcinoma of the clear-cell type, Fuhrman grade 4, with sarcomatoid areas showing microscopical extension into perinephric fat, vascular invasion, and metastasis to the adrenal gland and lungs. Despite radical nephrectomy, additional treatment was required. 29 May Hyperparathyroidism Secondary to Bone tumorMedical Insight Self-made Audio Programme 51 download Roy audio material at
Welcome to Medical Insight , today is May 11, 2008. I’m Dr. Alex Roy. A 46-year-old woman was evaluated because of pain in the right hip and leg. Several months earlier, pain had developed in her right upper medial thigh and had gradually increased in intensity despite treatment with Ibuprofen, Pantoprazole泮托拉唑质子泵抑制剂, and Acetaminophen–codeine对乙酰氨基酚. A diagnosis of Celiac disease乳糜泻had been made 25 years earlier. At the time of presentation, the patient had hypocalcemia, hypophosphatemia, and a dramatic increase in parathyroid hormone, accompanied by Vitamin D deficiency. Laboratory tests showed low serum calcium and elevated alkaline phosphatase levels. The radiographic images showed lytic but enhancing lesions and a salt-and-pepper appearance in the skull, and there was a nodule in the neck that suggested an enlarged parathyroid gland.Are the skeletal lesions a consequence of metabolic bone disease or of a malignant tumor? Osteoporosis does not cause lytic lesions, but other metabolic bone diseases to be considered include Paget’s disease, osteomalacia, and osteitis fibrosa cystica. Imaging studies will be helpful in this differential diagnosis. |
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