(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 77-year-old man presented with a three-year history of asymmetric rest tremor in the upper limbs associated with bradykinesia, early gait instability with frequent falls, dysphagia and cognitive impairment. He had both short and long-term memory loss associated with marked personality changes, with fluctuating cognition. There were no seizures or other parkinsonism-related symptoms, such as hyposmia, constipation and sleep disturbances. Past medical history was significant for depression, anxiety and hypertension, for which he took imipramine, clonazepam and hydrochlorothiazide. On examination he presented facial hypomimia, limitation on upward gaze, hypophonia and asymmetrical rigid-akinetic parkinsonism. He scored 26 out of 30 points in the Mini-Mental State Examination. There was no evidence of orthostatic hypotension or pyramidal tract dysfunction. Motor abnormalities were worse on left side and did not respond to levodopa therapy. Because of medical history and physical examination, we suspected atypical parkinsonism and requested a brain MRI, which showed a diffuse lesion with focal ring-enhancing nodule (Figs. 1a, 1b, 1c and 1d). An open brain biopsy was performed due to clinical and radiological findings.

(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 77-year old woman presented with progressive dizziness over several months. She also reported bilateral tinnitus, but denied headache. Physical exam revealed an unsteady, wide based gait, slow finger to nose test bilaterally, and inability to walk toes to heel. The patient had been diagnosed with mantle cell lymphoma (MCL) three years ago and she has completed six cycles of bendamustine and rituximab, followed by 2 years of rituximab maintenance therapy that was completed two months prior to onset of her symptoms. A recent bone marrow biopsy showed no evidence of residual lymphoma. MRI of the brain (Fig. 1) showed a right cerebellar lesion with central high T2 signal and peripheral rim enhancement.

(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 77 year-old male with a history of atrial fibrillation, hypertension, hyperlipidemia, and gastroesophageal reflux presented to the Emergency Department with complaints of two days of copious watery diarrhea. He admitted to anorexia, but denied abdominal pain or cramping, nausea, fever, and blood or mucus in the stool. He had not recently taken any antibiotics and his maintenance medications included warfarin, metoprolol, hydrochlorothiazide, atorvastatin, and pantoprazole.

(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 77-year-old white male had insulin-dependent diabetes mellitus, hyperlipidemia, peripheral vascular disease, hypothyroidism, peptic ulcer disease attributed to non-steroidal anti-inflammatory drug use, and a remote smoking history.

(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 77-year-old female presented with three months of headache, impulsivity, irritability and aggressive behavior. Neurological exam revealed a flattened affect, poor short-term memory and urinary incontinence.

(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 78-year-old male patient developed gait disturbances, increasing left hemianopsia and left visual impairment for several weeks. The patient did not present clinical or anamnestic evidence of systemic disease. The MRI examination revealed a 3 cm contrast enhancing, right parieto-occipital lesion with marked edema and involvement of the posterior horn of the lateral right ventricle as well as infiltration of the splenium of the corpus callosum (Figs. 1, 2 and 3). The neuroradiological features were suspicious of a high grade glioma. The patient underwent surgical operation through an occipital craniotomy. The lesion was completely resected.

(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 78 year old right handed male presented with dysphagia particularly for liquids and dysarthria for the last four months. He was recently under evaluation for his fairly new onset anemia and renal failure in a private clinic. He denied any headaches, visual problems, fainting or any word finding difficulty. His past medical history was significant for ischemic heart disease, hypertension, bronchitis and kidney stones. The most prominent findings on physical exam were left sided lower (VIII-XII) cranial nerve palsies. Laboratory tests revealed an anemia with hemoglobin of 7.8 g/dl and a serum creatinine of 8.1 mg/dl. The Brain MRI demonstrated a left posterior fossa hyper-intense extra-axial mass extending into the left jugular foramen. (Figure 1). The differential based on the location was paraganglioma, schwannoma and meningioma. The patient underwent a sub-occipital biopsy of the 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 79-year-old woman was admitted with sporadic headache for over 5 years and slow growth of feet. On physical examination, coarse facial features, prognathism and enlargement of hands were also noted. There were no visual complaints. Blood tests indicated increased levels of growth hormone (GH; 9.36 ng/mL; normal values: 0.06 - 5.00 ng/mL) and somatomedin C (insulin-like growth factor 1 (IGF-1); 420.00 ng/mL; normal values (> 65 years): 55.00 - 200.00 ng/mL). Peripheral concentrations of other pituitary hormones were normal. CT and MRI scans showed an expansive lesion occupying the sella and measuring 12.2 x 5.7 x 7.65 mm with neither suprasellar extension nor invasion of the sphenoidal sinus (Figs. 1a and 1b). On MRI, the lesion was iso- or slightly hyperintense on T1-weighted images and no contrast enhancement was detected. The presumably remaining pituitary gland was noticed as an enhancing tissue displaced to the left. Comparisons of exams over 5 years indicated stable lesion volume. A transsphenoidal resection was performed. The specimen was submitted in totum to histological analysis.

(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.)

Serial hemolyzed samples of 79 year-old female with a complicated history of chronic disease including hemodialysis-dependent end-stage renal disease, status post recent ureteral stenting procedure for uretropelvic junction obstruction, atrial fibrillation, coronary artery disease, diabetes mellitus II, hypertension and hypothyroidism. At the end of the dialysis session she developed abdominal pain and passed bloody urine. She confirmed that this has been going on for a couple of weeks and the symptoms have been progressively worsening. She also had altered mental status. The clinician noted, "There have also been questions surrounding the validity of her blood draws from the emergency department where her labs appear to be hemolyzing serially, but the values are remaining essentially identical."

(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 79 year old female presenting with a complaint of severe low back pain with radiation into the sacral area.

An MRI of the spine was performed and it showed an intradural extramedullary contrast enhancing mass with a small central area of hemorrhage, located at the level of the L2, within the central thecal sac and circumferentially displacing the cauda equina nerve roots.

A multilevel lumbar laminectomy for resection of tumor was 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.)

A 79-year-old male is status post distal pancreatectomy for low-grade multilocular intraductal papillary mucinous tumor (Image 1), and post splenectomy for incidental B cell chronic lymphocytic leukemia (Image 2) in 2002.

A follow-up abdominal CT scan in 2005 showed 2.9 x 2.5 cm lesion in the head of the pancreas. Serum CA19-9 was 2.9 U/ml.

The patient underwent endoscopic ultrasound guided FNA which revealed a hypoechoic and heterogenous area 2.0 x 1.5 cm. The cytology slide was read as "suspicious for low-grade mucinous neoplasm". A Whipple procedure was 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.)

A 79-year-old man presented with a two month history of worsening back pain, urinary dysfunction and bilateral leg weakness. His past medical history included a childhood diagnosis of a metabolic disorder, which over the course of his life had manifested with hepatosplenomegaly, bone pain and osteoporosis. Seven years ago he was also diagnosed with prostatic carcinoma that had been managed conservatively. More recently he developed cognitive dysfunction and Parkinsonism and was awaiting neurocognitive assessment.

(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 7-month-old male with a 4.5 cm deep left inner thigh lesion for four months. The lesion was initially swollen, tender and erythematous. It gradually improved, changed to a darker color, and then stabilized. No fluctuance or drainage was noted. The area showed deep induration and was not warm to touch. Range of motion was somewhat limited. He had some fevers during the past few months and was treated with multiple antibiotics. X-rays were taken by the PCP and were negative.

(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 seven month old male with a history of ambiguous genitalia and Hirschprung disease presented for follow up evaluation. He was born via normal spontaneous vaginal delivery at 39 weeks to a grava 4 para 3 mother with one previous miscarriage. The pregnancy was uneventful. The physical exam was remarkable for ambiguous genitalia, mildly low set posteriorly rotated ears, and syndactyly of the second and third toes bilaterally. He initially experienced bilious emesis and feeding intolerance and improved secondary to a leveling colostomy and partial colon 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 7-year-old Chinese boy with a history of bronchial asthma had upper respiratory tract infection for the preceding two weeks treated by a pediatrician. He then presented with confusion and incoherent speech on the day of admission. He was afebrile, with the Glasgow coma scale (GCS) of 14/15 (E4V4M6) and normal physical findings. Investigations showed normal complete blood counts, blood glucose, renal and liver function tests except for mildly elevated ALT at 34 IU/L (5-25 IU/L). His blood ammonia, lactate and pyruvate levels were normal. The CT brain showed no space occupying lesion or cerebral edema. Lumbar puncture showed an opening pressure of 12cm water, CSF glucose 3.1mmol/L, protein 1.25 gm/L (0.15-0.45 gm/L), RBC 2/mm3 and WBC 2/mm3. The gram stain showed no organisms. The nasopharyngeal aspirate for rapid antigen test for both influenza A and B were negative. About 12 hr after admission, he developed generalized tonic convulsions progressing to decorticate posturing, GCS 3/15 (E1V1M1) and pupils 2.5mm, equal and reacting sluggishly to light. Seizures were controlled with anticonvulsants. He was intubated and put on mechanical ventilation. Despite treatment with acyclovir, cefotaxime, anti-tuberculous medications, dexamethasone, hyperventilation and mannitol infusion, the child remained comatose. MRI of brain was done (see below). His condition continued to deteriorate and the pupils became fixed and dilated 34 hours after hospitalization. He finally succumbed on the fourth day of hospitalization.

(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 7 year old boy of Turkish descent who was diagnosed in Russia with splenomegaly and anemia at the age of 8 months. He began having seizures, usually associated with fever, at the age of 6 months. These continued every two to four months until the age of five. He has not had any seizures for two years, and his medications have been discontinued. He was hospitalized at an outside hospital in the fall of 2005 due to severe anemia.

(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 seven year old boy presented in 2006 with multiple skin lesions. A biopsy of one of the lesions was diagnosed as cutaneous anaplastic large cell lymphoma by another institution. He was treated with topical Aldara. He did not receive any systemic therapy. All of the lesions regressed with the exception of a lesion on his left chest wall. The lesion continued to enlarge and became ulcerated. Serial imaging studies did not demonstrate any evidence of systemic disease. The peripheral blood differential was normal. The lesion was surgically excised in early 2007.

(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 7-year-old Caucasian male with polyuria, polydipsia, and enuresis for two months. He also has occasional headaches and blurred vision recently, but he has good energy level and good appetite with no heat or cold intolerance.

(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.)

An 82-year old male presented with a 3 month long progressive cognitive deterioration, particularly regarding temporo-spatial orientation and short term memory. Previous medical history included colorectal carcinoma with liver metastases, prostatic carcinoma, type 2 DM and arterial hypertension. No focal neurological signs were elicited, and a MRI scan (Fig. 1a) showed an extra-axial fronto-basal tumor, with heterogenous contrast enhancement and dural tail sign (not seen in the image). A large cyst between the lesion and the cortex could also be seen. A frontal craniotomy with total excision of a non-infiltrative, dural-adherent mass was performed. MICROSCOPIC EXAMINATION

(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 94 year old male who on a recent CT scan for evaluation for renal stones was discovered to have a bladder mass. No other significant past medical history is present.