(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 60 year-old male presented with progressive lower back pain of approximately two years duration. He reported ambulatory dysfunction and paresthesia in the feet, confirmed by clinical exam. Of note is that more than 15 years prior he had undergone back surgery for a lumbar lesion; however, pathologic material from the first surgery was not available for review. An MRI was performed, showing a homogeneously enhancing lobulated mass extending from the lower L4 through the mid S1 regions. The lesion was intradural, hypointense on T1, and moderately intense on T2 (Figure1), measuring 6.0 cm in greatest extent. The patient subsequently underwent an L4-5 laminectomy for resection and debulking of this spinal tumor, which yielded an approximate 4 mL aggregate of tan-pink tissue.

(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 60-year-old woman with a history of hypertension, hyperlipidemia, diabetes mellitus, and sickle cell trait. She initially presented in January 2013 with altered mental status, and was found to have multiple left middle cerebral artery (MCA) distribution subcortical strokes as well as left internal carotid artery stenosis and multifocal stenosis of the left MCA branches (Figs. 1A, 1B). The patient was readmitted in early October 2014 and early December 2014 with similar symptoms. An extensive laboratory work-up in October 2014 included multiple CSF analyses, skin and muscle biopsy, all of which were negative for malignancy. Similarly, an extensive work-up for infectious etiologies and a hepatitis panel were negative. A serum ANA was positive at 1:5120 (nucleolar), and there was a reported history of lupus in her mother. Following treatment with high-dose intravenous steroids, the patient showed marked improvement in her mental status. She was seen as an outpatient in late November 2014, and was started on CellCept in addition to 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.)

A 60-year-old man presented with a history of headaches. An MRI revealed a calcified enhancing partially cystic, partially solid right parieto-occipital mass (Figure 1). A craniotomy was performed and intra-operative consultation was requested.

(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 60-year old woman with past medical history of diabetes, systemic hypertension and diminished visual acuity since early infancy presented with progressive visual loss of the left eye occurring over 24 months prior to consultation. Physical examination revealed a blind left eye with atrophy of the optic papilla. No lymphadenopathies, fever, or weight loss were detected. On magnetic resonance imaging (MRI), an extra-axial mass, hypointense on T2-weighted scans, hyperintense on T1-weighted scans, with contrast enhancement along the posterior aspect of the left optic nerve cranial entrance, measuring 1.8 x 3 cm (Figures 1, 2, and 3) was visualized. A left frontotemporal craniotomy was performed and a pink-yellow soft mass was resected in its entirety. No evidence of brain invasion or involvement was found. Even though a preoperative MRI angiography (to rule out a potential aneurysm) was negative, the lesion bled during the procedure, and an intraoperative digital angiogram was done which was also negative for aneurysm.

(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 60 year-old woman who had inflammatory ductal carcinoma of the left breast diagnosed on a core biopsy in January 2005. An axillary lymph node was positive for metastatic disease on a concurrent FNA. The tumor was found to be ER-positive, PR-negative, and Her2-Neu weakly positive. Workup for further metastatic disease found multiple lesions in the liver and spine [images 1 and 2] as well as a 5 cm mass in the upper pole of the left kidney [image 3].

(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 60 year-old woman with a history of rheumatoid arthritis, 60 pack-year smoking, chronic obstructive pulmonary disease, and treated hypertension. She underwent a screening colonoscopy, then felt poorly for a week. Her creatinine and BUN 2 weeks after the screening were 4.6 and 46 mg/dl, respectively (baseline serum creatinine was 0.9 mg/dl). The bowel preparation for the colonoscopy procedure was Fleet' s Phospho-Soda and NuLytely.

(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 the case of a 61-year-old male with a longstanding history of pituitary macro-prolactinoma medically treated with high dose cabergoline without significant reduction in tumor size. The pituitary lesion was first discovered more than 11 years prior to presentation and had been routinely monitored since that time with serial magnetic resonance imaging (MRI) scans and hormone profile testing. Pre-operative MRI in July 2014 revealed an enlarged, remodeled sella and a pituitary macroadenoma measuring approximately 2 cm in greatest dimension (Figure 1). Pre-operative laboratory values from March 2015 showed no evidence for an active neuroendocrine tumor. Detailed serology included a prolactin level of 7.6 ng/mL (reference range, 2.1 - 17.7 ng/mL) and a growth hormone level of 0.07 ng/mL (reference range, 0.01 - 0.97 ng/mL). Cortisol, adrenocorticotropic, luteinizing, and follicle stimulating hormones were also within normal serologic range. The patient underwent endoscopic endonasal resection of the pituitary mass, and a gross total resection was achieved. Intraoperatively, the lesion was described as extremely gritty and nodular. Post-operatively, the patient remained asymptomatic for several months despite a slight increase in his prolactin level to 8.9 ng/mL and remains asymptomatic to date almost one year post surgery. His postoperative endocrinologic pituitary hormonal profile is unchanged from his preoperative levels.

(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 61-year-old female with bipolar disease and hypertension presented with a one month history of an enlarged mass in the right supraclavicular area. She did not report having fevers and/or chills, but she stated that she lost five pounds over the past few months.

(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 61-year-old female patient presented to UPMC Presbyterian Hospital with right upper quadrant pain and jaundice. She had non-specific complaints of feeling tired, and having dull pain in her shoulders for years. Recently, one of her co-workers noted that she was "yellow". The patient's medical history was significant for fibromyalgia, treated hypothyroidism and treated depression. Physical examination revealed a mildly enlarged, tender liver with a firm liver edge palpable 2 cm below the thoracic arch. Liver function tests showed AST of 360 U/mL, ALT 519 U/mL, ALP 94 U/mL GGT 327 U/mL and bilirubin 9.4 mg/mL. Alpha-1-antitrypsin, ceruloplasmin, and ferritin were within normal limits. No peripheral blood eosinophilia was present, but the patient had slight leukocytosis with a white blood cell count of 10,000/ml. There was no clinical sign suggestive of pancreatitis or cholecystitis. The patient's medications contained Synthroid, Celexa, Vitamin B12, Vitamin D, and Tramadol-hydrochloride tablets. A contrast enhanced abdominal CT scan was performed. It showed normal liver morphology with no focal lesions, no enhancement abnormalities, and no bile duct dilatation. The gallbladder and the pancreas were unremarkable.

(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.)

What benefit is there to perform additional MTHFR 1298A>C variant analysis as requested by clinician?

(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 61 year old female who presents with a right-sided 1.9 cm submandibular gland mass.

(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 61-year old male with a past medical history of chronic obstructive pulmonary disorder (COPD) was recently admitted for left-sided pneumothorax. He underwent chest tube placement and pleurodesis and was discharged home. Three days later, he returned to the Emergency Room with shortness of breath, cough, and left-sided pleuritic chest pain. A CT scan of the chest showed left upper lobe lung consolidation consistent with pneumonia, a moderate left pleural effusion, and giant bullous emphysema.

(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 61-year old male presented with dizziness, nausea, vomiting, hyponatremia of 128 mmol/l, and a reduced serum osmolality of 271 mosm/kg (normal range 280-300 mosm/kg). A CT scan of the head showed an intra- and suprasellar mass. Endocrinologically, low levels of ADH, 1.2 ng/l (2-6ng/l), morning cortisol, 90 µg/l (100-250µg/l), and testosterone, 1.6 µg/l (2.8-8µg/l). Low-normal values for ACTH, LH, and FSH were also found. Basal hormone levels were normal for PRL, STH, TSH, and IGF-1. After adequate cortisol substitution, the hyponatremia resolved with a complete clinical relief of symptoms. A MRI scan of the sellar region was performed. The scan confirmed an adenoma-like appearance of an intra- and suprasellar tumor of 2.8 x 2.8 x 2.3 cm in diameter without obvious infiltration of the cavernous sinus (Figure 1A and 1B). The optic chiasm was elevated, but an ophthalmological exam showed no signs of chiasm syndrome. No involvement of other cranial nerves was observed. The patient underwent transsphenoidal microsurgery without complications under adapted perioperative hydrocortisone substitution. The post-operative course was uneventful, further anterior lobe insufficiencies or Diabetes insipidus did not occur. A MRI scan 5 months after surgery showed gross total removal of the lesion, however, a suspected remnant of the lesion is currently under observation. (Figure 1C and 1D)

(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 60 year-old man, without relevant medical history, noted a slight and progressive instability of gait for one month, and right hand clumsiness two weeks before admission.

(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 61-year-old female with a past medical history of chronic lymphocytic leukemia (CLL) for 10 years, presented to the emergency room (ER) with left upper quadrant pain and multiple ecchymoses. Her past medical history included treatment with Fludarabine (last dose more than one year ago), Rituximab and Cytoxan. Of note, she presented to the ER with a seizure 6 months previously. Studies revealed a left fronto-temporal lesion, which was resected and diagnosed as a meningioma. To prevent seizures, she was started on Dilantin. At a follow up visit in neurosurgery, CBC values indicated pancytopenia. Because this was thought to be related to Dilantin treatment, it was suspended and Levetiracetam was initiated, but there were no improvements in her counts.

(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 55-year-old woman presented with bilateral hip and rib pain. A chest radiograph revealed multiple bilateral rib fractures with callus formation. Insufficiency fractures of the right superior and inferior pubic rami and ischium and possibly of the sacrum were noted on hip and pelvic radiographs, and a subsequent MRI showed avascular necrosis of the left femoral head. Laboratory studies demonstrating hypophosphatemia, in combination with the patient's clinical presentation of osteomalacia, prompted further investigation for the underlying cause.

(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 62-year-old male presented with a one-month history of progressive weakness of his right limbs, accompanied with pain of occipitocervical region. Physical examination revealed a severe right hemiplegic paralysis and mild urinary incontinence. MRI sagittal T2 images showed a slightly high signal of occupancy within the spinal cord at C2/C3 level, which was covered with an arc-shaped low signal at the superior and inferior margins (Figure 1a). Contrast-enhanced MRI images showed a markedly inhomogeneous enhancement at C2/C3 level (Figure 1b, 1c). Moreover, during the period of routine preoperative examination, thoracic CT unexpectedly discovered a huge mass in right lower lobe and perihilar without any cancer-related clinical symptoms were noted (Figure 1d). Then, the patient was examined by whole-body positron emission tomography (PET-CT) which showed an enormous tumor in lung and an isolated intramedullary spinal cord neoplasm, no additional systemic metastasis were found. A intramedullary tumor resection 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.)

The patient was a 62-year-old woman who presented at the hospital with a one-month history of muscle pain and skin rash. Before this visit, she had experienced fever for 2 months. She had no other underlying medical condition except for rheumatoid arthritis which had been treated for over 20 years. Physical examination revealed mild symmetrical proximal muscle weakness of both upper and lower extremities (Medical Research Council grade 4). Erythema was observed in lower legs. Serum creatine kinase (CK) was 2048 U/L (normal range 32 - 180 U/L). Muscle biopsy was performed in the left tibialis anterior muscle.

(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 62 year-old male with no significant past medical history who presented with flank pain, chills, and hematuria. He was found to be in acute renal failure with a creatinine of 7.6 mg/dl. The patient's baseline creatinine level was 0.9 mg/dl five months earlier. He has no history of hypertension, diabetes mellitus, polyuria, or renal masses. There was no clinical evidence of nephrotic syndrome. His creatinine continued to rise to a level of 12.2 mg/dl. Urine dipstick showed 3+ protein. Urinalysis revealed many crenated red blood cell casts, many white blood cells, and few granular casts. Renal biopsy 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 62-year old female patient presented with constricted nasal breathing on the right side, disorder of smell and anosmia for the past six months. She had no epistaxis, rhinorrhea or loss of sensitivity in the face. Three months before presentation she suffered from a cold with swelling of the right eyelid that improved under conservative therapy. Physical examination revealed a glazed, bleeding tumor occupying the complete right nasal cavity and right nasopharynx and extending to the opposite site (Figure 1).