A nursing home patient is brought by ambulance with a cough. Nursing home staff believe the patient may have aspirated lunch 30 minutes ago. The patient’s workup is normal except for his EKG which is shown below (you can click on it for a much larger/printable version).

What’s the diagnosis? What needs to be done with the patient? Does it make any difference whether this was a new finding or an old finding?

I’ll provide the answer in the comments section in a couple of days.

An elderly patient presents with leg weakness over the prior two days. The day of presentation he also notices pain in his upper back which seems to be fairly persistent. His medical history includes diabetes and renal failure. He was dialyzed the afternoon prior to his presentation and his glucose was 264. The patient’s daughter stated that he “wasn’t acting himself.”
The patient’s physical exam was fairly normal. Perhaps a little weakness in his legs, but he still moved all extremities.
His current EKG (dark background) and another EKG faxed from a different hospital done six months earlier (light background) are shown below. You can click on them for larger images. What’s the diagnosis and what’s the next step?
I’ll post the answer underneath the EKGs in a couple of days.

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A patient in her late 60′s comes in with vomiting and some vague abdominal pain over the previous 24 hours. Her husband states that her stomach looks swollen. It does. X-rays below can be clicked upon to give you a higher resolution image if you want one.

What is wrong with the patient? What’s the treatment?

I’ll post the answer in the comments section in a couple of days.

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A breast cancer patient presents with painful rash to her hands and feet for the past 24 hours. The palms and soles were warm and she had a horrible “burning” sensation that didn’t improve with pain medications. Putting ice on her hands and feet seemed to provide her with temporary relief.

She started several new medications recently including an an ACE inhibitor, prednisone, pyridoxine, and Vicodin. She had finished one round of chemotherapy and did not have a satisfactory response. Her oncologist had therefore started her on a different regimen several days prior to her emergency department visit.

Vital signs were stable. The rash stopped at the wrist creases and the ankles and was nowhere else on her body. CBC and basic chemistries were normal. She had mild relief with IV morphine. The dermatologist on call said that it sounded like contact dermatitis and that he would see the patient in his office the following day.

What’s the diagnosis?
Why does the rash occur?
What is the treatment?

I will post the answer in the comments section in a couple of days.

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A 15 year old girl goes to a pharmacy chain’s walk in clinic with a nonproductive cough and nasal congestion. She is diagnosed with “bronchitis” and is of course given antibiotics.

Two days later, she presents with joint pains and the rash below.

What’s the diagnosis?
What is/are the likely cause(s)?
What is the treatment?
What two clinical findings are most likely to predict an increased risk of death from this disease?

Answers in the comments section in a couple of days.

A 26 year old female comes in complaining of chronic neck pain for the past 6-8 months. She was seen in the emergency department 4-5 months ago for the same pain and was diagnosed with a neck strain. Since that time, she has had intermittent pain.
She states that the pain is worse when she tilts her head forward or backward and also worse when she coughs.
There is no history of trauma. She has had no fevers or difficulty swallowing. Her vital signs are normal. Her teeth are in good shape with no signs of abscess. Oropharynx is also normal. No meningeal signs are present. She can move her head about fairly easily, but does notice some pain when flexing her head forward. Neurological examination is normal.
She came to the emergency department this time because when she woke up, the pain was worse and she had tingling down her back and into her fingertips when she was bending over to tie her shoes.
Xrays of her cervical spine are below (the AP view was unremarkable).
What is the abnormality on the x-rays? What is the name of the clinical sign that she was demonstrating? Given these two pieces of information, what was her diagnosis?

I’ll post the answers under the x-rays in a couple of days.

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Final Answer:

The patient was indeed exhibiting Lhermitte’s Sign. More common in multiple sclerosis, it can also be caused by other etiologies, including trauma. The presence of this sign and her pain with coughing were what prompted me to order a c-spine x-ray.

Scanman hit the x-ray results right on the nose. Atlantoaxial instability with posterior fusion of C2 and C3. The predental space (between the posterior arch of the atlas and the anterior surface of the dens) should be no more than 3mm. See more about interpreting C-spine x-rays in this AAFP article. In this patient, the predental space was 7 mm. The instability and the patient’s symptoms resulted in a sphinchter tightening moment while we scurried around to find a cervical collar.

Final diagnosis from our ED was shown on CT scan below – odontoid fracture. Probably subacute, but a fracture nonetheless. This occurred in the rural ED where I moonlight, so she was shipped to a tertiary care center.

By the way – I remember from my trauma training that coughing exacerbates the pain of a c-spine fracture, but was unable to find a name to go along with this sign. Anyone know of it? This is the third time I have caught an occult c-spine fracture because the patient complained of pain in the neck with coughing.

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A patient presents with an itchy rash to the elbow that started a week prior to presentation. After initially becoming red, the rash developed small blisters then the blisters ruptured, leaving small sores. There is no warmth or fluctuance to the area.  The patient saw his primary care physician 5 days ago and was prescribed topical steroids which had no effect on the rash. He also notes that he has been having diarrhea and stomach cramping lately. WBC count and sed rate are normal.

What is the diagnosis, how is it treated, and what other disease is it associated with?

I’ll post the answer below the picture on Friday.

Answer: Dermatitis Herpetiformis
Kudos to anon for the perfect answer.
Dermatitis herpetiformis is associated with celiac disease. In fact, some clinicians assert that a diagnosis of dermatitis herpetiformis can be used as a “backdoor diagnosis” to celiac disease.
DH occurs most commonly in the extensor surfaces of the joints, on the buttocks, and on the back of the neck, but can occur anywhere on the body. It is often misdiagnosed, being confused with drug eruptions, contact dermatitis, dishydrotic eczema, and even scabies.
DH is diagnosed by skin biopsy, but multiple biopsies must be taken from diseased and healthy skin as at least one biopsy must show IgA deposits in the dermal layers under immunofluorescence in order to confirm the diagnosis.
Long-term treatment is a gluten-free diet, but dapsone (a drug used to treat leprosy – more in-depth information here) may be used to treat the rash in resistant cases or in flares.

Read more about dermatitis herpetiformis at the Celiac Sprue Association, eMedicine.com and Medline Plus.

A 3 year old child is carried into the emergency department because of pain in her left hip. Her mother stated that she woke up with the pain and has refused to walk all day because of the pain. The patient has been running a low grade fever and “just wasn’t acting right.”

The mother brought the child to the pediatrician earlier in the day. The pediatrician diagnosed the patient with “double ear infections” and prescribed the child that powerful pink healing elixir otherwise known as amoxicillin. When the mother asked the pediatrician why the child’s hip was hurting, the pediatrician stated that the child “probably slept on it wrong.” The mother stated that the pediatrician never even examined the child’s leg.

The child didn’t seem like she was getting better, so the mother brought her to the emergency department for another exam.

When I examined the leg, the child held her hip in flexion and cried with any movement of the hip joint. Distal sensory, motor, and circulatory exams were intact to the extent that the patient would allow an exam to be done. There was no appreciable swelling over the joints. She wouldn’t even try to walk. Oh, and her otoscopic exam was within normal limits.

I decided to do a few labs. Her WBC was 13,000 with 91% segs. The sedimentation rate was 120.

What’s the diagnosis, how is the diagnosis made, and what’s the treatment?

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UPDATE MARCH 25, 2010
Final Diagnosis: Septic arthritis of the hip.
Culture showed staph aureus, which is the responsible organism in about half of all cases.
Nice summary of septic hip in pediatric patients is at Wheeless’ Online Orthopaedics
Kocher criteria include non-weight bearing on the affected side, sedimentation rate > 40, fever, and WBC count > 12,000. When all four criteria are present, septic arthritis has a 99% likelihood. When three criteria are present, the likelihood of septic arthritis is still 93%.
Diagnosis requires joint aspiration under either ultrasound or fluoroscopy.
Treatment requires surgical drainage and antibiotics. Preliminary treatment is usually a third generation cephalosporin – pending culture results.  Keep in mind that MRSA is a growing problem (no pun intended) and that IV vancomycin may be necessary. Also keep in mind that sickle cell patients are prone to salmonella infections in bone and joints.
Unfortunately, septic arthritis may lead to many long-term hip problems such as dysplasia, deformities in hip development, and postinfectious arthritis – even with appropriate care.

As an aside, I was completely blown away by the number of thoughtful responses and differential diagnoses for this case. I intended it to be just a relatively straightforward case to jog the memories of the attendings and to teach the young grasshoppers. You guys came up with several things that even I hadn’t considered.
I’ll have to post these cases more often.
Thanks for the education!