(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 65-year-old gentleman, chronic smoker without any known co-morbidity presented with sudden onset right hemiplegia associated with headache and vomiting. He soon developed altered sensorium. However, there was no history of preceding trauma or hypertension. Contrast enhanced CT scan showed a left parietal hematoma with mass effect (Figs. 1A, 1B). In view of the expanding hematoma and deteriorating clinical condition, craniotomy was done to remove the hematoma and decompress the brain. A fleshy soft tissue with hematoma was excised. Postoperatively, his sensorium improved but the paresis persisted. Postoperative scans showed evacuation of the clot along with excision of lesion (Fig. 1C). A week later, he died and a whole-body scan could not be performed.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

The patient is a 65-year-old female who presented to her primary care physician for routine annual examination. At that time, a large pelvic mass was palpated. The patient reported that her pants were fitting tighter but she was otherwise asymptomatic. She denied nausea, vomiting, early satiety, bowel or bladder dysfunction and gynecological symptoms.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

The patient is a 65-year-old female with a history of exposure to tuberculosis who had an incidental lung mass - A CT chest showed a 5 cm heterogeneous solid-appearing mass along the medial margin of the right lower lobe of the lung. Radiology was unable to definitively state the origin of the mass, but suggested pleural or mediastinal origin. The mass was moderately PET avid, and the patient was scheduled for an FNA of the mass. The FNA with cell block preparation showed a reactive inflammatory process with chronic inflammation, fibrosis, and hemosiderin deposition. The patient was referred for surgery due to vague complaints of chest pain, and upon exploration, the mass was found to be intraparenchymal in the right lower lobe. It was well-encapsulated, but intimately associated with the inferior pulmonary vein. The mass was enucleated and sent for intraoperative consultation.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

The patient is a 65 year old man who presented for fine needle aspiration of the thyroid due to heterogeneous enlargement of both lobes of the gland.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 65-year-old man was diagnosed with esophageal adenocarcinoma with metastases to liver and lungs in July of 2001. Due to metastatic disease, he was not deemed to be a candidate for surgical resection but was given radiation and chemotherapy. Seven months later he presented with an 8x5x3.5 cm frontal, transcalvarial metastatic lesion. Past medical history includes cholecystectomy, appendectomy, osteoarthritis, left hemipelvectomy following a motor vehicle accident in 1970, and smoking with intermittent alcohol abuse since the age of 15. His clinical course continued to deteriorate and he eventually expired in December of 2002. An autopsy revealed widespread metastatic adenocarcinoma to the lungs, liver and calvarium with superficial extension into the dorsal surface of the frontal lobes, bilaterally. An acute, severe bronchopneumonia was also found.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

The patient is a 65-year-old woman with a history of diabetes mellitus and sarcoidosis who presented with a right breast mass detected on routine mammography.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 66-year-old Chinese woman presented with progressive cognitive decline, difficulty for calculating and dizziness for 2 years. She complained of bilateral limb weakness and gait disturbance which was characterized by small steps without falling for 1 month. No headache, nausea, vomiting, dysphagia, dysarthria, urinary incontinence, seizure attack, fever. Neurological examination showed an apathetic patient with severe cognitive decline (MMSE score was 14/30) and decreased muscle strength with limb spasm bilaterally. No hepatosplenomegaly and lymphadenopathy. Lumbar puncture showed normal pressure with mild lymphocytosis, glucose of 36 mg/dl, and protein of 60 mg/dl. PCR of CSF HSV and CMV returned negative. CSF was also negative for IgG oligoclonal bands. Serum EBV IgG was positive. EEG showed slowing of the normal background diffusely. Cranial MRI exhibited diffuse white matter changes, involving periventricular area, frontoparietal white matter, without mass effect (Figures 1A, 1B). Repeated MRI revealed progressive leukoencephalopathy involving brainstem and cerebellar peduncle (Figures 1C, 1D) with mild periventricular enhancement 5 months later (Figure 1E). Brain biopsy targeting periventricular deep white matter was therefore performed.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

We present a 66-year-old woman with a previous medical history of probable polyarteritis nodosa (PAN) diagnosed by our medical team six months ago, performing a complete laboratory workout including hematological, neurophysiological, biochemical (checking blood and cerebrospinal fluid), microbiological and radiological tests. A subacute demyelinating polyneuropathy was noticed at that time. Eventually, she received cyclophosphamide in combination with high dose corticosteroid therapy with a significant clinical improvement. Almost six months thereafter, she was admitted to Internal Medicine Department because of a casual midnight fall suffering cranial contusion and transient fever. Physical examination pointed out mild confusion, one facial bruising over her right malar region and remarkable proximal weaknesses to grade 3/5 in the upper limbs and 2/5 in the lower limbs, leaving her unable to walk but preserving sensory responses. According to clinical evolution and her medical history, steroid myopathy was considered as a potential cause of her muscle weakness. However, during her hospitalization she developed acute respiratory failure, treated with corticosteroid bolus and intravenous immunoglobulins, recovering from her respiratory failure and her muscular weakness. CK levels were always within normal limits. In this light, a possible vasculitic myopathy versus amyopathic myositis was considered. MRI performed in both thighs showed a significant muscular edema with perifascial, muscle and subcutaneous hyperintensities (Figures 1a and 1b). Then, the leading diagnostic consideration was inflammatory myopathy. Autoimmune antibodies were tested such as anti-Mi2, KU, Pm-Scl100, Jo-1, SRP, PL-7, PL12, EJ, OJ, Ro, NMDA, Mus-ck and acetylcholine and did not show abnormal results. Then, a muscle biopsy was considered and it was performed on the left thigh.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 66-year-old man with a medical history of metastatic prostate cancer (Stage IV) had undergone systemic chemotherapy until June and received hormone therapy since then. Regular follow-up examinations showed stable disease. A bone scintigraphy two weeks prior to presentation showed known diffuse metastases throughout the skeleton, excluding the cranium. In August the patient presented to the emergency room with a 10 day history of progressive right-sided facial pain, diplopia and drooping of his right upper eyelid. On physical examination he was alert and complained about right deep orbital pain, numbness down the right side of his face and horizontal diplopia.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

This 66-year-old female presented with an enlarging right middle lobe mass that had been incidentally found on a prior tuberculosis screen 6 years ago. The patient had been a lifelong nonsmoker. She had no pulmonary complaints. On physical exam, her neck was supple with no masses, no cervical or supraclavicular adenopathy was identified, her chest was clear to auscultation and percussion bilaterally, and heart rhythm was regular.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 66-year-old female with metastatic colon cancer presents to the emergency department with the complaint of weakness, which was so bad that she had to be carried to the car before being driven to the ED. She underwent debulking surgery one month prior to presentation and has since followed up for problems including fecal impaction and diarrhea. She has poor oral intake and is losing weight. She reports compliance with her bowel regimen of docusate sodium, senna, polyethylene glycol, and milk of magnesia. Initial laboratory findings are listed in the table.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 66 year old female with excessive fatigue. On examination, patient was found to have splenomegaly measuring 7-8 cm below the costal margin. CT scan was negative for lymphadenopathy.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

The patient is a 66-year-old male with a history of precursor B-cell acute-lymphoblastic-leukemia diagnosed in July. Classical cytogenetic analysis of the bone marrow aspirate demonstrated Trisomy 11 and corresponding 3 signals for the MLL locus on FISH, with no translocation or rearrangement of the MLL gene locus using a break-apart probe. FISH studies were also negative for the BCR/ABL1 gene rearrangement. The patient achieved complete remission after induction chemotherapy in August. He remained in complete remission through maintenance chemotherapy until his presentation in December, with an upper lip mass that was biopsied. Subsequently, a 2 cm lip mass was excised in February, 2008. No evidence of precursor B-cell leukemia was concurrently evident on blood or bone marrow review.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 66 year old married, Caucasian male with a history of HIV/AIDS presents to the emergency department with a chief complaint of back pain for the past 3 weeks and hemoptysis for the past few days. The pain is sharp, in the left side of his lower back, and does not radiate or cause weakness or numbness. The pain is exacerbated with movement and minimally relieved with pain medication. The patient denies fevers, night sweats, and weight loss. His HIV is managed with Atripla. His HIV RNA levels are undetectable. His family history is significant for his mother having pancreatic cancer, his father having prostate cancer, and his brother acquiring tuberculosis at the age of 14. The patient is a retired maintenance man and lives at home. He has a 15 pack year smoking history. He denies alcohol and intravenous drug use. The physical exam is significant for tachycardia and tenderness over the left rib cage and flank. A straight leg test is positive at 30 degrees, reproducing the patient's flank pain.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

The patient was a 67-year-old male with a 39-year history of relapsing multiple sclerosis (MS). He had been treated with 54 doses of Natalizumab (Tysabri) during the past 5 years. Due to new onset of neurological symptoms including bilateral upper extremity dysmetria, slurred speech and choking, MRI of the brain was performed. FLAIR/T2 showed longstanding lesions in the cerebral periventricular regions bilaterally (Fig. 1) and new hyperintense foci in bilateral cerebellar white matter extending into the middle cerebellar peduncles (Fig. 2). The larger left-sided cerebellar lesion measured 2.7 x 2.4 cm. The cerebral and cerebellar lesions had well-defined borders with no significant mass effect and minimal peripheral contrast enhancement. CSF analysis showed an opening pressure of 12 mm H2O, a normal differential count and glucose level with an elevated protein level, elevated IgG index and oligoclonal bands. HHV6, HSV1, HSV2, and cytology studies were negative. The patient was admitted. Natalizumab was discontinued, and plasmapheresis and IV Dexamethasone initiated. Despite the treatment, his neurological condition continued to deteriorate. He was discharged to hospice and expired 8 days afterward.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 67-year-old man presented with a two-year history of dyspnea on exertion and lower limb weakness. He had undergone endoscopic early gastric cancer treatment twice, at ages 64 and 67. He had no family history of neuromuscular diseases. Hyper-creatine kinase-emia (300 to 1000 IU/L) was noted during annual medical check-ups since age 62. Dyspnea on exertion occurred at age 65, and lower proximal limb weakness occurred at age 66, for which he used a cane at age 67. Neurological examination at age 67 revealed proximal lower limb weakness (Medical Research Council grade 2) with decreased deep tendon reflexes, and constipation/diarrhea with marked intestinal gas accumulation. Blood tests showed hypoproteinemia [total protein (g/dL)/albumin (g/dL) = 5.9/3.8 (1.5)] and hypogammaglobulinemia [IgG 357 mg/dL (870-1700), IgA 17 mg/dL (110-410), and IgM 7 mg/dL (33-190)]. Electrocardiography revealed complete right bundle-branch block, not detected during routine screening until age 64. Echocardiography revealed hypertrophic cardiomyopathy with moderate mitral valve regurgitation. His respiratory function was normal. No dysphagia was observed on video fluoroscopic examination. Results of nerve conduction study were normal. EMG indicated a myogenic pattern with abundant fibrillation potentials and positive sharp waves in the affected/weak muscles. CT revealed bilaterally positioned mass-like lesions in the adductor magnus. 18F-FDG PET demonstrated low diffuse uptake throughout the skeletal muscles and subcutaneous tissues.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

The patient is a 67-year-old man with a history of hypertension and coronary artery disease who presented with progressively worsening low back pain for 1 year. He underwent a laminectomy for lumbar spinal stenosis 17 years prior and had done very well after the procedure. Review of systems was negative for weakness as well as bowel or bladder dysfunction. Physical exam revealed normal strength in the upper and lower extremities. Spine films showed lumbar levoscoliosis, multilevel degenerative lumbar disease, and lumbar lordosis with normal pelvic tilt. MRI of the spine showed multilevel degenerative disc disease and an incidental intradural, intramedullary mass at L1-L2 (Figures 1 and 2). The radiologic diagnosis was schwannoma, and the differential included ependymoma and neurofibroma. The patient presented to this institution for a second opinion. He chose to undergo surgery for tumor resection.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 67 year old female presented with left upper quadrant abdominal pain. She had a strong family history of non-insulin dependent diabetes mellitus. Amylase, lipase, CA19-9, total bilirubin, direct bilirubin, and liver enzymes were within normal limits. Abdominal computed tomography (CT) imaging showed a hypodense, hypoenhancing 3.2 x 2.6 cm lesion in the body/tail of the pancreas. The mass encased the splenic artery but did not involve any other major vessels. There was no abdominal lymphadenopathy. She underwent an endoscopic ultrasound (EUS) with fine-needle aspiration (FNA) of the lesion. EUS demonstrated a focal mass encasing the splenic artery. Cytology was suspicious for malignancy. Given the presence of a mass, pain, and suspicious cytology, she underwent surgical exploration and removal of this lesion.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 67 year old male, who had no significant past medical history, presented with a four year history of progressive paraparesis, lower extremity sensory loss, and dysesthesias. He was initially diagnosed and treated for peripheral neuropathy, but his symptoms progressed. Further work-up revealed degenerative changes in his lumbar spine and he underwent a laminectomy at L4-5 for significant stenosis. Unfortunately this surgical procedure also did not alleviate his symptoms. He eventually progressed to complete paraplegia with an associated sensory level at T11 and loss of sphincter control. Other findings on physical examination included significant muscular atrophy and spasticity, with positive clonus and Babinski sign in his lower extremities but sparing of his upper extremities. He otherwise had no other neurological or constitutional symptoms or signs.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

This 67-year old man, with a past medical history significant for basal cell carcinoma, presented with prominent constitutional symptoms including high spiking fever, generalized pruritus, fatigue and 18 pound weight loss over 2 months. The patient underwent an upper gastrointestinal endoscopy and the possibility of gastric tumor was ruled out. Whole body computed tomography revealed generalized lymphadenopathy involving bilateral axillary, mediastinal, hilar, abdominal, retroperitoneal, bilateral iliac and inguinal regions. Bilateral pleural effusions were also noted. All intra-abdominal organs including liver and spleen were unremarkable. Initial laboratory tests revealed mild thrombocytopenia and raised alkaline phosphatase levels. Multiple blood cultures and urine culture were negative.