(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 73 year-old African-American male with a history of hypertension, hypercholesterolemia, chronic renal failure with horseshoe kidney and coronary artery disease. He underwent 4-vessel coronary artery bypass graft 12 years ago and subsequently developed ischemic cardiomyopathy and recurrent ventricular tachycardia for which he had repeated ablation therapy and automatic implantable cardioverter defibrillator placement. His evaluation demonstrated B-natriuretic peptide of 1600 pg/ml and ejection fraction of 20% to 25% suggestive of congestive heart failure. The patient underwent orthotopic heart transplant with post-operative course complicated by respiratory failure, cardiac arrest and pseudomonas bacteremia but the patient eventually recovered and was discharged.

(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 73 year-old male presented with a 6 month history of progressive tetraparesis, during which he had deteriorated markedly from being mobile and performing in a steel band to completely bed-bound. Medical history included ischemic heart disease and type II diabetes mellitus. Neurological examination revealed symmetrical pyramidal weakness, pathologically increased deep tendon reflexes and increased tone in all 4 limbs. Plantar response was upgoing bilaterally. Pinprick-sensation was reduced below the neck. Cranial nerve examination was normal. An MRI scan showed a well-demarcated extra-axial mass on the dorsal surface of the lower medulla/upper cervical cord extending from the level of the clivus to the body of the axis inferiorly (figures 1, 2, 3 and 4). The mass exhibited heterogeneous hyper-intensity on T2W (figure 1), low-to-intermediate signal on T1W (figure 2), and florid enhancement with Gadolinium contrast-agent (figures 3 and 4). The spinal cord exhibited high T2-signal, consistent with edema, from the level of the tumour superiorly to the body of C5 inferiorly. There was no bony erosion or sclerosis, or enhancing dural 'tail'.

(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 74-year old woman was admitted to the ER and subsequently our department due to craniocerebral traumata following involvement in a road accident. Brain computed tomography showed right parieto-occipital fracture, left parietal and right occipital subdural hematomas, subarachnoid hemorrhage and diffuse cerebral oedema. Brain magnetic resonance T2 weighted imaging revealed a left parietal, space-occupying lesion (Fig. 1a) with contrast enhancement in T1 weighted imaging (Figs. 1b, 1c). Brain magnetic resonance angiography offered normal findings. In view of the radiologic findings with the identification of the space-occupying mass, the patient underwent excisional surgery to confirm the nature 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 74 year old man with a history of gait instability, bilateral hand numbness and hearing loss. An MRI showed a 4.4 x 2.5 x 3.4 centimeters (CC by AP by transverse) avidly enhancing heterogeneous T1 hypointense and T2 hyperintense mass with cystic components centered in the left cerebellopontine angle and widening extending through the left jugular foramen into the left carotid space. There was moderate to marked mass effect in the left middle cerebellar peduncle and the brainstem (Figs 1, 2 and 3). The patient was treated with radiation therapy and a course of dexamethasone. He returned 2 months after completing treatment with complaints of nausea, dizziness, gait imbalance and blurry vision. A repeat MRI was done showing fourth ventricle enlargement. The patient was admitted for VP shunt placement. This required multiple revisions. The patient was discharged to a rehabilitation facility. Shortly after discharge, the patient was found to be pale, diaphoretic and in respiratory distress. He progressed to asystole and expired.

(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 72 year-old right handed woman was referred to the Emergency Room of our Department with drug-resistant headache and unstable gait that had begun 7 days earlier. Neurological examination showed psychomotor slowing, wide-based ataxic gait, left homonymous hemianopsia, left-sided spatial neglect and ideomotor apraxia which emerged while putting on her shoes. In her medical history she mentioned hypothyroidism treated with levothyroxine 100mg, moderate hypertension, well-managed with antihypertensive medication, and a 5-year history of systemic lupus erythematosus (SLE), treated with prednisone 25mg. The complete blood count was normal. Lymphocyte count was 0.82×109/L

(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 74-year-old woman suffered from progressive weakness, paresis of the right hemisphere and occasional headache during the last three months. The patient denied having had nausea, vomiting, fever or weight loss. Nuclear magnetic resonance showed round lobular lesions involving the frontal lobe and corpus callosum, protruding into the lateral ventricle. Lesions were enhanced with the contrast medium exhibiting a ring-like appearance (Figs. 1a, 1b, 1c). A stereotactic brain biopsy was performed using VarioGuide system.

(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 74-year-old woman with no family history of breast cancer who presented for a screening mammogram. An asymmetric density was seen in the right breast, and she was recalled for diagnostic mammogram and ultrasound 2 weeks later. The mammogram confirmed the presence of an ill-defined density in the posterior right upper outer quadrant, with some evidence of spiculation. No suspicious calcifications were seen. Ultrasound showed 2 immediately adjacent, ill-defined, hypoechoic masses in the right upper outer quadrant, 8 x 11 mm and 5 x 4 mm, with irregular margins. No axillary lymphadenopathy was noted (Fig. 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.)

74 yo female with inflamed "seborrheic keratosis" on dorsum of right ankle. Her only other pertinent history is that of a seborrheic keratosis removed in eight years ago. We received a pale-tan fragment of cutis and subcutis that corresponded to a shave biopsy, which was 1.3 x 1.0 x 0.2 cm.

(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 74-year-old Caucasian male, who had intermittent skin rash for seven years. Rash usually goes away with medicated creams, but recurs every year. A skin biopsy was obtained at a local hospital four years ago and was suggestive of mycosis fungoides (cutaneous T-cell lymphoma). He was treated with oral and topical steroids. The topical therapy included prednisone (with a taper), triamcinolone and fluocinonide. In the past 2 years, the patient was found to have anemia (hemoglobin was 10.3 g/dl) with a normal white cell count and thrombocytopenia (96 x 109/L) of unknown etiology. Laboratory studies indicated normal values for reticulocyte count, serum levels of B12, folate, ferritin, and total iron binding capacity. He did have a history of heme-positive stool, but refused colonoscopy. The patient underwent a bone marrow biopsy one and half years ago. The results included a hypercellular marrow with trilineage hematopoiesis, focally increased and dysplastic megakaryocytes, suggestive of myelodysplastic syndrome (MDS) and no increase in blasts. Flow cytometry immunophenotyping did not identify an aberrant T or B cell immunophenotype. Cytogenetic studies were normal. He had been treated with Procrit.

(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 74-year-old African-American male veteran, with a past medical history of hypertension and DJD, presented to his primary care physician with a self-report of a 20-pound weight loss and fatigue over a 6-month period. His review of symptoms was significant for alcohol abuse, previous history of multiple sexual partners, and nonspecific joint pain. He had no complaints of fever or night sweats and had previously tested negative for HIV, on multiple occasions. Medications include furosemide, hydrochlorothiazide, metoprolol, lisinopril, oxybutynin, and aspirin. Physical exam showed a blood pressure of 142/52, pulse of 72, but no focal exam findings. Initial laboratory studies revealed a normocytic, normochromic anemia (Hb/Hct: 10.2 g/dL/29.2%, MCV 89.3 fl) and a mild leukopenia (WBC 3.8 x 109/L with a normal differential), and normal platelet count of 213,000. Electrolytes included an elevated creatinine of 1.4 (baseline 1.2) with normal BUN 12, calcium 9.0 mg/dL, albumin 3.8 g/dL, and alkaline phosphatase 43 IU/L. Further studies were all within normal limits: B12, folate, iron studies (Fe 65 µg/dL, TIBC 285 µg/dL, and percent saturation 23%), haptoglobin, erythropoietin, ESR, RF, and PSA. Testing for anti-nuclear antibodies and hepatitis C antibody testing were both negative. Computed tomography (CT) imaging of the chest, abdomen, and pelvis showed no evidence of lymphoma or primary/metastatic neoplasm, with a mildly enlarged prostate, small bilateral renal cysts, and old granulomatous disease of the left upper lung lobe. Colonoscopy had a single 2 mm tubular adenoma that was removed.

(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.)

75 year-old male with past medical history significant for prostate cancer status-post radical prostatectomy 15 years ago, who presented with complaints of approximately diarrhea, dark urine, light stools, pruritus and 15 lb weight loss over the last month. He also admits to fevers and chills. He had a few episodes of abdominal cramps over the last couple weeks but denied persistent abdominal pain, nausea or vomiting. Laboratory tests demonstrated the following values: total bilirubin 10.3 mg/dl, direct bilirubin 6.9 mg/dl, ALT 121 IU/L, AST 64 IU/L, alkaline phosphatase 435 IU/L, amylase 57 IU/L and lipase 238 U/L. A CT scan of the abdomen and pelvis with contrast revealed a vague area of architectural distortion and perhaps diminished enhancement within the pancreatic head that measured between 1.5 to 2.0 cm. In addition, multiple clustered, slightly enlarged celiac-gastrohepatic ligament lymph nodes were identified together with a conglomerate peripancreatic nodal mass measures approximately 3.0 x 2.4 cm. Biliary dilatation with possible distal common bile duct stricture and dilatation of the gallbladder were also identified.

(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 75 year-old man presented with a four week history of back pain that acutely worsened. The pain was associated with leg weakness and intermittent numbness of his feet which interfered with his ambulation and prompted him to go to seek medical attention. He denied trauma to his back and any recent falls. He had no constitutional symptoms or loss of bowel and bladder control.

(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 76 year-old lady presented to the emergency department with a one-week history of progressively worsening generalized edema, fatigue, intermittent chest tightness, mild nausea and decreased exercise tolerance along with 22-lbs unintentional weight gain over the prior four weeks. Significant background history included hypertension, gastro-esophageal reflux disease, hypothyroidism, Crohn's disease and bilateral lumpectomies and radiotherapy for ductal carcinoma in situ (DCIS). Relevant medications included levothyroxine, losartan, adalimumab, omeprazole, ergocalciferol, calcium carbonate, folic acid and cyanocobalamin.

(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 76-year-old man presented to an outside hospital with nausea and vomiting. Further questioning disclosed a two month history of worsening gait instability, dizziness, and frequent falls. His limited past medical history included melanoma of the interscapular region diagnosed six year prior to presentation at an outside hospital.

(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 76-year-old man presented with progressively worsening vertigo, memory and concentration impairment, spatial disorientation and mild expressive dysphasia for 6 months. His medical history included hypertension and a surgically treated abdominal aortic aneurysm. A few weeks before admission, headache, fatigue, weakness of the lower limbs and left arm, a tendency to fall to the left, incontinence, and episodes of confusion occurred. Upon admission the patient showed marked fatigue, confusion and apathy, and a contrast-enhancing round lesion, 1 cm in diameter, was seen in the left temporal lobe on magnetic resonance imaging (MRI). Repeated cognitive testing demonstrated fluctuating deficits in language, working and episodic memory, visuospatial ability, attention and psychomotor speed. A second MRI, performed one month after the first, showed attenuation of the previous lesion, with general signal enhancement in the leptomeninges, a heterogeneous contrast-enhancing lesion measuring 1x2 cm in the left frontal lobe, and a smaller lesion near the left sylvian fissure (Figure 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.)

The patient is a 76 year old gentleman with recent (~6 mos prior to admission) left lung transplantation, with a non-cytomegalovirus (CMV)- matched organ, for idiopathic pulmonary fibrosis. Following transplantation he was maintained on prednisone, pantoprazole, valganciclovir, voriconazole (for pulmonary "colonization" with Aspergillus), tacrolimus, metoprolol, and dapsone. The patient presented to the emergency room on the advice of his pulmonologist after calling the latter with complaints of nausea with a few bouts of "biliary" emesis and fevers to 100-101 degrees Farenheit over the previous week. In the emergency room, that patient denied cough, shortness of breath, and tobacco use, and confessed to an increased gag reflex thought to be secondary to medications he was taking with reduced oral intake. He has lost about 15 pounds over the past several weeks. The patient's respiratory rate was 17 breaths per minute and his oxygen saturation was 95% on room air. A computed tomography scan of the chest was significant for focal left lower lobe pneumonia with reactive mediastinal lymph nodes. Because of the patient's difficulties in swallowing from gag reflex abnormality, he was started on broad spectrum antibiotic coverage reflecting his known allergies to trimethoprim/sulfamethoxazole and penicillins. Multiple blood cultures and quantitative PCR for CMV were negative over the next 10 days. On day 10 of treatment, the patient had a repeat computed tomography scan of the chest that showed a mild to moderate left pleural effusion and left basilar consolidation, with persistent reactive mediastinal lymph nodes. The patient at this point was deemed stable enough for bronchoscopy with biopsy, to rule out possible acute cellular rejection and try to find a cause for fever. The biopsy was significant for marked necrotizing granulomas in the left lung, with Grocott silver staining showing thin, filamentous, non-septate organisms with acute angle branching and no yeast forms among the granulomas (Figure 1). These organisms were weakly Gram positive in a beaded pattern.

(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 76 year-old female who is status post partial nephrectomy for renal cell carcinoma, chromophobe subtype, four years prior to presentation. She has had no subsequent recurrence, but now presents with a mass in the anterior medial aspect of her left thigh that had been progressively enlarging over the past nine months. A few weeks before her presentation, the lesion began to grow more rapidly and became painful.

(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 76-year-old woman operated on bladder cancer two months ago, presented with dysarthria and brachiofacial hypesthesia of the left side. Magnetic resonance imaging (MRI) revealed a T2-hyperintensity in the right gyrus precentralis with only minimal space-occupying effect (Figure 1). Application of Gadolinium revealed an inhomogeneous enhancement of this lesion (Figure 2). Magnetic resonance spectroscopy (MRS) suggested a metastasis, presumably, derived from to the bladder cancer. The patient underwent stereotactic 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 76 year old woman was admitted to a spinal trauma hospital after a collapse at home with paraplegia and total loss of deep tendon reflexes of unknown duration. Upon admission she was responsive but not well orientated. A spinal MRI showed T2 signal enhancement from Th4 to L2, without revealing evidence of the etiology. Over the course of the next 3 days her mental status decreased to where she could only be woken up with strong pain stimuli. Leukocytosis (30.3 G/l) and fever (39°C) were noted. In a cerebral computed tomography, several hypodense white matter lesions were visible. The cerebrospinal fluid (CSF) contained 61 cells/µl with 3.33g/l protein and 1.8mmol/l glucose (serum: 6.0 mmol/l) and treatment with broad spectrum antibiotics and glucocorticosteroids was started.

(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.