(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.)

CASE 1:

(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 male in his 60s presented with a slowly growing, progressively enlarging expansile lytic mass in the petrous area of his left temporal bone present for several years on radiologic imaging (Figure 1).

The patient's past medical history is significant for resection of a left parapharyngeal space mass diagnosed as acinic cell carcinoma more than a decade ago which was also treated with radiation therapy. He subsequently had locoregional disease recurrence about five years after the initial resection treated with surgery and radiation therapy. He is otherwise in good health with no other history of malignancy.

(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 male in his early 60s, presenting with worsening fatigue, found to have diffuse lymphadenopathy and pleural effusions diagnosed as stage IV follicular lymphoma grade 1-2 of 3 with pleural effusions and bone marrow involvement. He was treated with six cycles of bendamustine and rituximab with complete response followed by observation. 20 months post completion of therapy the patient presented with an enlarged right groin lymph node with CT scans showing extensive lymphadenopathy consistent with relapsed lymphoma. The patient was lost to follow up presenting 5 months later with significant B symptoms and repeat CT scans showing worsening lymphadenopathy, splenomegaly and pleural effusion, treated with six cycles of R-CHOP. Post therapy imaging showed complete response. Patient refused maintenance rituximab. 3 and a half years later presented to the ER with 10 pound weight loss, fatigue, and 2 new neck masses of 2-3 weeks duration. CT scan showed extensive lymphadenopathy, clinically suspicious for recurrent lymphoma. Right cervical lymph node excisional biopsy was performed and sent for histopathologic evaluation.

(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 female fetus was the product of elective delivery at 23 weeks of gestational age after a prenatal ultrasound disclosed bilateral multicystic kidneys. A full autopsy was performed. Anthropometric values were adequate for the gestational age. On external examination, no gross malformations were identified; significant abdominal distention was noted. Internal examination revealed massively enlarged kidneys, with poor demarcation between the renal cortex and medulla and numerous cysts throughout the parenchyma, ranging from 0.1 to 0.7 cm in diameter, some of them filled by clear yellow fluid (Figure 1). No other urinary system abnormalities were identified, and both ureters and the urethra were patent. The other organs were grossly normal.

(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 multigravida African-American female in her 30s presented with a 4 month history of bleeding during intercourse. She also complained of external irritation secondary to an enlarging left labial mass. She had recently removed an intra-uterine device due to malposition secondary to the presence of submucosal fibroid detected on ultrasonography (US). She also had a slowly enlarging cervical polyp.

(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 female in her 20s with no significant past medical history that presented with presumed anorexia nervosa. She was admitted to the hospital and subsequently required total parenteral nutrition. Physical examination was significant for retinitis pigmentosa on ophthalmoscopic exam as well as shortening of the fourth toe. Her hospital stay was complicated by progressive impairment of vision and hearing loss. Her lab values showed elevated levels of phytanic acid.

(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 is a female in her 20s with past medical history significant for bipolar disorder and asthma. In August, the patient was admitted to a psychiatric hospital for treatment of bipolar disorder. She was on several different psychiatric medications including lithium. In October, the patient began to feel fatigued and noticed some weight gain. Thyroid function tests were performed which showed that the patient was hypothyroid with a TSH= 110.2, free thyroxine index= 0.9, and total T3= 0.41. The patient also had a palpable mass in the right lobe of the thyroid. A thyroid ultrasound was performed which showed diffuse enlargement of the entire gland as well as multiple microcalcifications. Both thyroid lobes were biopsied. Based on those results, the patient was scheduled for a lobectomy/ possible total thyroidectomy.

(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.)

26 year old female presented with a 3-4 week history of pharyngitis, odynophagia and dysphagia. She had initially been treated with two courses of Augmentin (amox/clav) and one course of Avelox (moxifloxacin), and her symptoms seemed to improve, but then came back to the point where she was having trouble swallowing and had airway problems, with a fever as high as 104.7F.

(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 35-year-old woman, who presented with a large right iliac mass and anemia. Physical examination showed no enlarged lymph nodes, and lungs are free of lesions on chest X-ray. The pelvic CT scan showed a destructive supra-acetabular mass involving the right iliac bone (Figure 1). An internal hemipelvectomy was performed following a 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.)

The patient is a white female in her 40s with no significant past medical history who presented initially in late June of 2003 after experiencing a severe syncope-like episode. This was associated with a sudden onset of facial flushing, headache, weakness, lightheadness, tachycardia, shortness of breath, a sensation of the impending loss of consciousness. She was playing the piano at the time of the episode. Paramedics at the scene found her pulse to be in the 140-150 range with a blood pressure of 60/palp, with fecal incontinent. She was taken to the emergency Department and was given intravenous fluid. Her blood pressure responded appropriately and symptoms resolved after about half an hour. The patient had a second episode of flushing hypotension a week later, without any apparent triggering factor. She showed similar symptoms to the previous attack and experienced nausea and vomiting. She was taken to an emergency Department, and EKG changes were noted. The patient underwent a coronary angiogram which did not reveal any lesions. Two weeks later, the patient had a third episode and was brought to the UPMC emergency Department. This was associated with headache, facial flushing and lightheadness. She took an aspirin, but continued to have worsening symptoms, including nausea, vomiting, tachycardia and fecal incontinence. She was found to be hypotensive in the ambulance and had several similar episodes after admission to the hospital. Each time, the patient responded to fluid challenge. Her family history is unremarkable. Her past medical is essential negative except for psoriasis. She denies any foreign travel or sick contact. Physical examination: the patient is afebrile. Her heart rate is 100, blood pressure 92/palp. She dose not have lymphadenopathy and hepatsplenomegaly. EKG and echocardiogram rule out cardiac abnormality. Chest X-ray is negative. An MRI of the brain was unremarkable. Her electrolytes and liver and kidney function tests are within the normal range.

(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 is a female in her 50s who presented to the Emergency Department with severe right upper abdominal and flank pain, nausea, vomiting, fever, and chills. Past medical history was significant only for hypertension. Evaluation by CT-scan revealed a right ureteral stone with associated hydronephrosis. Urinalysis was positive for both blood and nitrites. She was hydrated, discharged home with both antibiotics and analgesics, and instructed to follow up with her primary care physician.

(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 female in her 60s general practitioner first noticed muscular atrophy of both arms 10 years ago. She also experienced difficulties standing in an upright position because of weakness of her paraspinal muscles, and difficulties walking downhill. She uses walking canes and is exhausted after walking more than 500 m. Creatine kinase was slightly elevated (95 U/l). There is no family history of muscular diseases. On physical examination she showed facial weakness and reduced muscular strength of the shoulder and upper arm muscles, with scapular winging. There was also weakness of limb girdle muscles with Gowers' maneuver, atrophy of upper leg muscles, and hyperlordosis. The EMG of her right medial vastus muscle revealed a myopathic pattern whereas nerve conduction velocities were normal. A tentative diagnosis of facioscapulohumeral dystrophy (FSHD) was made. A biopsy was taken from the left deltoid muscle. Vaccination against hepatitis A and B into the left deltoid muscle had been performed 4 weeks prior to biopsy.

(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 female in her 70s with pelvic masses and ascites. Her preoperative CA-125 increased to 130 units/ml, but CA19-9 and CEA were normal. She underwent total abdominal hysterectomy, bilateral salphingo-oophorectomy, omentectomy as well as cul-de-sac excisional biopsy.

(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 forty-six year old female patient presented with a five month history of numbness in the toes of the right foot accompanied by numbness in the right arm since two months. She developed a paresis of the right leg and focal seizures. The MRI revealed a contrast enhancing lesion in the left occipital and parietal lobe. Three years ago a multiple myeloma (MM) (IgG, stage IIIA) was diagnosed and treated with autologous stem cell transplantation. One year later a relapse with fracture of the fourth lumbar vertebral body occurred, treated by radiation. A stereotactic biopsy of the CNS lesion 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 fifty year old male with a history of metastatic prostate cancer was admitted with chief complaints of generalized weakness and headache.

(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 five-day old female presented to the Emergency Department, without symptoms, following parental notification of an abnormal newborn screen. No abnormal findings were noted on the patient's physical exam.

(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 is a 54-year-old female with a medical history of emphysema secondary to alpha-1 antitrypsin deficiency, status-post double lung transplant in January 2004. Her post-operative course was complicated by acute cellular rejection (grade 3), severe hemodynamic instability, pneumonia, and a sternal wound infection, requiring multiple, prolonged hospital admissions. During that time she was treated with a variety of immunosuppressants including azathioprine, cyclosporine, tacrolimus, and prednisone.

(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 an African-American male in his 20s with a history of HIV infection, who presented with diarrhea, weight loss, and abdominal pain. On colonoscopy, multiple serpiginous ulcers with overlying exudate were found throughout the colon, but predominantly in the left and transverse colon. Serial biopsies from the colonic mucosa and from the margins of several of the ulcers were taken and sent to pathology. These biopsies were obtained in the left, transverse and right colon. The terminal ileum was also intubated and the ileal mucosa was normal in appearance. Biopsies of the ileal mucosa were taken and sent to pathology.

(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 otherwise healthy male in his 20s presented with a 0.95 cm shiny unequally pigmented erythematous papule in the left supraclavicular area to a private dermatology clinic. The clinical suspicion was that of pigmented basal cell carcinoma. The lesion was completely excised and submitted for histopathologic examination (see specimen #1). The lesion has been sent to our dermatopathology practice for a consultation. Several months later, in our hospital, the patient underwent excision of two clinically "atypical nevi" (specimen #2: midline lower back; specimen #3: left lower back). After about 2 months yet another pigmented lesion clinically suspicious for malignancy was excised from this patient's lower back (specimen #4)

(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 male in his 30s with history of severe hemophilia A and end-stage liver disease secondary to hepatitis C. The course of his disease was complicated by progressive hepatic encephalopathy. The patient was scheduled for Liver transplant. Blood bank was contacted for the dosing of factor VIII perioperatively. The patient did not produce inhibitors to factor VIII.