Clinical Challenge

Extreme weight loss in an elderly woman over a 24-month period

Extreme weight loss in an elderly woman over a 24-month period

A 65-year-old widow presented with a mass on her right breast and complaints of generally not feeling well.

Sudden neurologic symptom onset 
in an adolescent

Sudden neurologic symptom onset 
in an adolescent

Dizziness, photophobia, nausea and 
an unsteady gait develop following a 
routine annual check up.

Presyncope coupled with an enlarged spleen suggests infection

Presyncope coupled with an enlarged spleen suggests infection

A 69-year-old woman presents with night sweats, dizziness, fatigue and chronic pain in the upper abdomen.

Painful skin ulcer ­develops in older woman on dialysis

Painful skin ulcer ­develops in older woman on dialysis

Metastatic calcification of the left 
breast in a patient with renal failure 
raises suspicion.

A routine check-up 
reveals a significant 
genetic abnormality

A routine check-up 
reveals a significant 
genetic abnormality

A corrections officer came into the primary care office for a routine physical and left with an unexpected diagnosis.

Severe dizziness, nausea and vomiting prompt an ED visit

Severe dizziness, nausea and vomiting prompt an ED visit

The patient's gait was affected 48 hours after onset and any slight head movement intensified the feeling of imbalance.

Symptoms suggesting urolithiasis mask a 
life-threatening ailment

Symptoms suggesting urolithiasis mask a 
life-threatening ailment

Two days after symptom onset, a patient's skin is still mildly diaphoretic, he complains of fatigue and he cannot tolerate food.

A simple case of cellulitis on the third finger is a lot more

A simple case of cellulitis on the third finger is a lot more

A patient presents to the emergency department complaining of pain that originated over the distal tip of the digit.

When a patient falls, the pain 
indicates dislocation

When a patient falls, the pain 
indicates dislocation

Tenderness over the hypothenar eminence, swelling and limited flexion also suggest fracture.

Respiratory distress and pronounced muscular weakness signal trouble

Respiratory distress and pronounced muscular weakness signal trouble

A father is rushed to the emergency department after ingestion of a foreign, powderlike substance.

Acute onset of pain and a noncompressible area in the anterior forearm

Acute onset of pain and a noncompressible area in the anterior forearm

After a high-impact fall, a middle-aged 
firefighter presents with ecchymosis and fixed flexion in the right arm and hand.

A running accident leads to the discovery of a humeral lesion

A running accident leads to the discovery of a humeral lesion

A woman fractured her upper arm in a fall while exercising. A large osteolytic growth was discovered on x-ray.

Severe headache, fever and arm rash after vaccination

Severe headache, fever and arm rash after vaccination

The patient's symptoms indicated that lumbar puncture was required to rule out a meningitis diagnosis.

Kidney mass detected on ultrasound doubles in size over nine months

Kidney mass detected on ultrasound doubles in size over nine months

Imaging was ordered when the patient's clinician could not palpate her ovaries.

The effects of two boat trips linger even after coming ashore

The effects of two boat trips linger even after coming ashore

After vacationing on a houseboat, a woman could not stop feeling like she was rocking, especially when walking.

Burning rash spreads from the trunk to the rest of the body

Burning rash spreads from the trunk to the rest of the body

A Fite stain leads to the correct diagnosis of these lesions in a man originally from Micronesia.

Acute onset of recent memory loss

Acute onset of recent memory loss

Suddenly unable to remember the year or the president's name, an otherwise healthy man is admitted for observation.

Neck rash coupled with refractory neuropathic pain

Neck rash coupled with refractory neuropathic pain

After initial treatment, the rash left a hypopigmented patch.

Palpitations and dyspnea plus a family history of sudden cardiac death

Palpitations and dyspnea  plus a family history of sudden cardiac death

A specialist recommended placement of an implantable cardioverter-defibrillator, but the patient chose to wait and see.

Abdominal mass in a pregnant woman forces induction

Abdominal mass in a pregnant woman forces induction

After developing pancreatitis, the patient was admitted to the hospital and the tumor removed.

Shortness of breath and chest pain worsened by fruits and vegetables

Shortness of breath and chest pain worsened by fruits and vegetables

What first appeared to be infectious esophagitis ended up being a lifelong diagnosis for a young woman.

Silence surrounding a difficult birth adds insult to injury

Silence surrounding a difficult birth adds insult to injury

Respiratory problems lead to neurologic damage for the child and financial ruin for the family.

Mild fatigue follows progressively heavy monthly periods

Mild fatigue follows progressively heavy monthly periods

The patient's family practitioner advised a multivitamin with iron, but she did not comply.

Blisters on the hands and fingers of a woman with discolored urine

Blisters on the hands and fingers of a woman with discolored urine

Mild hypertrichosis and hyperpigmentation of the face were also noted, and plasma porphyrins were grossly elevated.

Vision and balance disturbances initially blamed on aging

Vision and balance disturbances initially blamed on aging

Over a period of three years, the patient's writing worsened, and she had trouble seeing some colors.

Painless bump on the leg for two years' duration

Painless bump on the leg for two years' duration

The boy had no history of pain, rapid growth, or trauma-associated local or systemic abnormalities.

Intermittent ringing in the ear turns constant

Intermittent ringing in the ear turns constant

The patient first suspected wax was the culprit and underwent an MRI to rule out a benign tumor.

A schizophrenic with poorly controlled diabetes

A schizophrenic with poorly controlled diabetes

Dietary supervision may have driven the patient out of his facility

Acute onset of pain, numbness in the face, and slurred speech

Acute onset of pain, numbness in the face, and slurred speech

Spontaneous hemiparesis, headache, and involuntary eye movements in a healthy young man raise diagnostic questions.

Intensely itchy rash erupts soon after hemodialysis begins

Intensely itchy rash erupts soon after hemodialysis begins

The man's widespread lesions did not respond to several therapies, including topical corticosteroids.

Unexplained low-back pain in an adolescent with scoliosis

Unexplained low-back pain in an adolescent with scoliosis

Nothing offered more than temporary relief for the aching, constant pain, which was unaccompanied by other symptoms.

Red breast is a red flag in a case of new-onset pain and swelling

Red breast is a red flag in a case of new-onset pain and swelling

Despite a normal exam three months earlier, skin changes and palpable lumps in the axilla were noted.

Akathisia and visual hallucintions in an elderly woman

Akathisia and visual hallucintions in an elderly woman

First diagnosed with Alzheimer's and Parkinson's, the patient could not tolerate antipsychotic meds.

Fever, arthralgias and leg pain after trip to Costa Rica

Fever, arthralgias and leg pain after trip to Costa Rica

Rocky Mountain spotted fever was suspected, but that disease is not endemic to Central America.

Abdominal pain in a posthysterectomy patient

Ms. L, 34 years old and para 1 gravida 2, presented to the emergency room one evening following a four-day battle with "the flu." She became concerned after experiencing increasing pain in her left flank and pelvic area. On questioning, she recounted being constipated and very nauseated.

Throat pain causes a patient to divulge his lifelong secret

Throat pain causes a patient to divulge his lifelong secret

The man's heretofore unknown neurologic condition calls the original diagnosis into question.

An unexpected foreign object

An unexpected foreign object

After taking all her pills at once, the patient developed dysphagia. But the meds weren't to blame.

Pain, tingling, and limited range of motion after a cat bite to the finger

Pain, tingling, and limited range of motion after  a cat bite to the finger

Originally diagnosed with cellulitis, the pain, swelling, and redness worsened considerably over the next three days.

Botched cryotherapy procedure leads to painful bullous lesion

Botched cryotherapy procedure leads to painful bullous lesion

Used correctly, liquid nitrogen is safe, but defective equipment and inadequate monitoring can cause complications.

Slip and fall ends in more than a simple muscle strain

Slip and fall ends in more than a simple muscle strain

Four weeks after the accident, the patient was still in severe pain and reported urinary frequency.

Pain and hardening of the skin constricts shoulder movement

Pain and hardening of the skin constricts shoulder movement

Had the patient agreed to a biopsy, the diagnosis may have been made sooner.

Blood-collection device leads to low platelet count

Blood-collection device leads to low platelet count

A misdiagnosis would have led to unnecessary tests and treatment.

An antipsychotic's side effects derail a patient's symptom management

An antipsychotic's side effects derail a patient's symptom management

After five years of treatment without side effects, his glucose level took off.

Bacterial meningitis complicated by seizures and confusion

Bacterial meningitis complicated by seizures and confusion

The seizures began following surgery to repair a cerebrospinal fluid leak.

Prescription and OTC creams ineffective against itchy lesions

Prescription and OTC creams ineffective against itchy lesions

The patient's physical and psychological discomfort upset every aspect of his life.

Drastic weight loss and bone deformities in a breastfed infant

Drastic weight loss and bone deformities in a breastfed infant

Could the mother's religious custom of wearing a full veil at all times have played a role in the child's illness?

Severe muscle spasms and jaw stiffness after stepping on a nail

Severe muscle spasms and jaw stiffness after stepping on a nail

The symptoms began 10 days after the accident. Steroids provided no relief, and diagnostic tests were inconclusive.

New onset of lower extremity weakness after a viral illness

New onset of lower extremity weakness after a viral illness

Upper respiratory infection triggers complications in a healthy college student.

An infrequent cause of chronic cough

An infrequent cause of chronic cough

A number of diagnostic possibilities are raised, including allergy, asthma, postnasal drip, and reflux.

Cutaneous symptoms uncover unintentionally obscured disease

Cutaneous symptoms uncover unintentionally obscured disease

As a nurse, the patient had access to many informal opinions. Would a proper evaluation have led to a quicker diagnosis?

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