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Clinical Reasoning: An 87-year-old woman with left-sided numbness

Clinical Reasoning: An 87-year-old woman with left-sided numbness

An 87-year-old woman with a history of hyperten- sion, hyperlipidemia, and peripheral vascular disease presented with acute left paresthesias. On evaluation, blood pressure was 152/77 mm Hg and heart rate 78 and regular. Physical examination had normal results. On neurologic examination, she had normal mental status, decreased sensation on the left face, and normal strength, tone, and reflexes. Cerebellar examination and gait were normal. There was reduced light touch and pinprick sensation of the left arm and leg, with no extinction. Complete blood count and comprehensive metabolic panel were within normal limits, and ECG showed normal sinus rhythm. Head CT scan was

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Clinical Reasoning: A 64-year-old woman with progressive quadriparesis

Clinical Reasoning: A 64-year-old woman with progressive quadriparesis

A 64-year-old right-handed woman presented to an outside hospital with a 1-week history of weakness noted while walking. She reported bilateral weakness greater on the right, and several falls. She denied lower extremity numbness. Her medical history was signifi- cant for lower-back osteoarthritis and a 20 pack-year smoking history. She denied constitutional symptoms. Her examination on admission was notable for 4/5 right gastrocnemius strength and unsteady gait.

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A Fatal Twist: Volvulus of the Small Intestine in a 46-Year-Old Woman

A Fatal Twist: Volvulus of the Small Intestine in a 46-Year-Old Woman

Copyright © 2015 Jared Klein et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. A 46-year-old woman presented to two emergency departments within 12 hours because of acute abdominal pain. Physical exam demonstrated tenderness and epigastric guarding. An ultrasound was interpreted as negative; she was discharged home. Later that evening, she was found dead. Postmortem exam revealed acute hemorrhagic necrosis of a segment of jejunum secondary to volvulus. Clinical clues suggesting presentations of small bowel volvulus are usually nonspecific; the diagnosis is typically confirmed at surgery. Her unremitting abdominal pain, persistent vomiting, and absolute neutrophilia were consistent with an acute process. The etiology of this volvulus was caused by an elastic fibrous band at the root of the jejunal mesentery. While congenital fibrous bands are rare in adults, this interpretation is favored for two reasons. First, the band was located 20 cm superior to postsurgical adhesions in the lower abdomen and pelvis. Second, there was no history of trauma or previous surgery involving the site of volvulus.

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Clinical Reasoning: A 55-year-old obese woman with headache and rhinorrhea

Clinical Reasoning: A 55-year-old obese woman with headache and rhinorrhea

A 55-year-old obese woman with a history of migraine and tension-type headaches presented with headache for 5 days with acute worsening for 1 day. The headache was throbbing, holocephalic, and maximal at the left temple, and worsened with both standing and lying down and with exertion. The headache was initially mild for 4 days before acutely worsening in severity and waking her from sleep with associated nausea and photophobia. Unlike her typical headaches, it did not improve with over-the-counter analgesics and was more prolonged. There were no associated visual complaints, hearing changes or phonophobia, jaw claudication, weakness, numbness, or paresthesias.

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Clinical Reasoning: A 54-year-old woman with confusion and visual disturbances

Clinical Reasoning: A 54-year-old woman with confusion and visual disturbances

A 54-year-old woman presented to the emergency department with several days of visual disturbance. Her medical history included alcoholic liver cirrhosis with portosystemic en- cephalopathy (PSE), chronic hyponatremia, and chronic pain on opioids. She had a recent hospitalization for hepatic encephalopathy, but presented now with 5 days of new visual disturbance described mostly as an inability to see and impaired ability to focus. The patient’s husband corroborated that this episode was different from her past episodes of PSE and noted that she seemed unable to attend to him during their conversations and he wondered if she was looking at things that were not present. Typically her PSE episodes were characterized by lethargy, confusion, and disorientation, whereas now she was alert, oriented to herself and recognized familiar people, and was able to have a conversation despite her visual complaints. The patient also endorsed a holocephalic, dull headache. She had been abstinent from alcohol for 9 months and denied any substance abuse. She was compliant with her PSE regimen of lactulose and rifaximin, and reported 3–4 bowel movements daily. She requires weekly large- volume paracentesis procedures for ascites. Ophthalmology consultation was obtained and revealed no clear etiology for her visual complaints, but neurologic consultation was recommended.

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Clinical Reasoning: A 59-year-old woman with acute paraplegia

Clinical Reasoning: A 59-year-old woman with acute paraplegia

Case presentation. A 59-year-old woman with a history of hypertension developed acute bilateral flaccid leg weakness while watching television. She had shifted her weight while sitting on the couch and suddenly felt a sharp pain in her lower back and right leg. When she stood up to walk she noticed that her legs were numb; over the course of 1 hour she became unable to move her legs. She could not urinate voluntarily, and had dribbling incontinence. She was brought to the emergency department for evaluation.

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Clinical Reasoning: Headaches and double vision in a 68-year-old woman

Clinical Reasoning: Headaches and double vision in a 68-year-old woman

A 68-year-old woman presented with increased frequency of headaches accompanied by double vision. The patient had a history of migraines, which she typically experienced on a monthly basis. In the month prior to presentation, the frequency of her headaches gradually increased to daily and had become more common at night and upon waking from sleep. She also noted the recent development of double vision with vertical and horizontal gaze. Finally, she reported associated nausea, light, and noise sensitivity, which was typical of her usual migraines, as well as generalized fatigue and a feeling of being “off-kilter.” Her medical history was significant for right-sided breast cancer treated with radical mastectomy, since then in remission.

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Clinical Reasoning: A 52-year-old woman with subacute hemichorea

Clinical Reasoning: A 52-year-old woman with subacute hemichorea

A 52-year-old Korean woman with a history of poorly controlled Type 1 diabetes presented for eval- uation of abnormal movements of her right arm and leg. The movements began insidiously in her right hand and arm, progressing over several months to involve the right foot as well. She was unaware of the movements until her husband noticed them. Over time the movements became more violent, eventu- ally leading to severe flinging movements in the right arm. The movements interfered with activity. They were neither suppressible nor associated with any un- pleasant internal sensation. In retrospect, her hus- band felt that the onset had been heralded by several months of subtle personality change: he described her as more quiet, and no longer “the life of the party.”

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Clinical Reasoning: A 23-year-old woman with fever and vertical diplopia

Clinical Reasoning: A 23-year-old woman with fever and vertical diplopia

A 23-year-old woman with a history of uncomplicated migraine headaches presented with 2 days of headache. Her typical migraines were preceded by visual aura and usually resolved after taking a triptan. This headache was different in that there was no preceding aura, it did not respond to Imitrex, and it was accompanied by nausea/vomiting, dizziness, subjective fevers, and binocular vertical diplopia. She had had a mild upper respiratory tract infection 1 week prior to presentation. She had no sick contacts or recent travel history. Initial bedside examination showed hypertropia OD (figure 1) that did not change with direction of gaze. The degree of hypertropia improved with supine positioning. Her extraocular movements were otherwise not restricted, and her pupillary responses were normal. She had no other abnormalities on her neurologic examination.

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Clinical Reasoning:A 22-year-old woman with headache and diplopia

Clinical Reasoning:A 22-year-old woman with headache and diplopia

A 22-year-old woman without medical history pre- sented with sudden headache, blurred vision, and bin- ocular diplopia. Two weeks previously, she had developed headache after a neck massage in a public bath. The headache was initially severe and generalized including the posterior neck. The next day, the head- ache improved mildly but persisted without a specific pattern of positional modulation or diurnal fluctuation. One week later, she began to have binocular horizontal

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Clinical Reasoning: A 56-year-old woman with acute vertigo and diplopia

Clinical Reasoning: A 56-year-old woman with acute vertigo and diplopia

A 56-year-old woman with a recent diagnosis of primary light-chain (AL) (lambda type) amyloidosis complicated by mild infiltrative cardiomyopathy and autonomic neuropathy had sudden onset vertigo and diplopia. She also had a history of hyperlipidemia and hypothy- roidism. The diplopia was binocular and worsened on rightward gaze. The patient denied headache, fever, neck stiffness, photophobia, confusion, tinnitus, or impaired hearing. Prior to presentation, she had completed her third cycle of chemotherapy at an outside facility for AL amyloidosis with bortezomib, lenalidomide, and dexamethasone and had come to our facility for a second opinion regarding her amyloidosis when this event happened. Her other medi- cations included aspirin, atorvastatin, levothyroxine, spironolactone, torasemide, midodrine, calcium, and vitamin D. She did not smoke or use alcohol. Her vital signs included a temper- ature of 36.4°C, blood pressure 109/82 mm Hg, and heart rate 80. Her general examination revealed cachexia and bilateral pitting edema. Her neurologic examination revealed a right sixth cranial nerve palsy, direction-changing nystagmus, mild right-sided dysdiadochokinesis, and mild weakness (Medical Research Council grade 4 of 5) of the deltoids and iliopsoas bilaterally; head impulse test was negative and there was no skew deviation. Her mental status, gait, reflexes, and sensory examination were within normal limits. A skin examination revealed a scattered pustular right-sided rash in the peri-auricular region, neck, chest, and thigh, which the patient mentioned was of new onset. There was no periorbital purpura or macroglossia. Questions for consideration:

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Clinical Reasoning: A 28-year-old pregnant woman with encephalopathy

Clinical Reasoning: A 28-year-old pregnant woman with encephalopathy

A 28-year-old woman at 37 weeks’ gestation be- came increasingly confused and forgetful. She slept 12 hours daily, mistook her apartment for previous residences, and forgot her children’s names. Her husband helped her eat and walk. She presented to the obstetrical service fully dilated af- ter 2 days of leaking vaginal fluid, and delivered a healthy baby girl. A few hours later, she did not remember giving birth. She was transferred to the neurology service for evaluation.

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Clinical Reasoning: A 45-year-old woman with immobility and incontinence

Clinical Reasoning: A 45-year-old woman with immobility and incontinence

A 45-year-old woman presented with immobility and incontinence in July 2016. Her symptoms started 6 months prior to presentation, when she had multiple falls (without major injuries) at home because of weak- ness in the lower extremities. She experienced urinary incontinence 1 month later. An indwelling catheter was placed and clamped every 2 – 3 hours in the day- time and kept open during the night. Later, she pre- ferred not to walk for fear of falling. The patient started to feel stiffness and tightness in her lower extremities 3 months later. The condition worsened gradually to the extent that she could barely move her lower extremities in bed and reported it affected her sleep recently. Along with motor dysfunctions, she also experienced numb- ness in her lower extremities, but denied pain. She was able to sit in a wheelchair for 7 hours per day. A pressure ulcer was noticed in the sacral region 4 months later. She denied other discomfort. Her appe- tite has been good. She had no significant weight changes during the last half year.

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Fatal Urosepsis: A 41 Year Old Pregnant Woman—Case Report

Fatal Urosepsis: A 41 Year Old Pregnant Woman—Case Report

Introduction: Urinary tract infections are one of the most frequent infectious complications during pregnancy [1], while acute pyelonephritis is the main non-obstetric reason for hospitalisation [2] [3] and septic shock in pregnant women. Objectives and methods: The aim of our study is to ana- lyse the diagnostics and treatment of a 41-year-old pregnant woman with the most severe form of urinary tract infection—urosepsis. Case report: A 41-year old woman in the 12th week of preg- nancy hospitalised at Intensive Care Unit (ICU) after urological intervention (JJ stent). On the first day after the intervention, the patient was diagnosed as having urosepsis. Scores: SOFA 14 pts, APACHE II 26 pts, SAPS II SCORE 61 pts. Second day in ICU: spontaneous abortion. Microbiological investigation: Escherichia coli—extended-spectrum beta-lactamase (ESBL+). Conclusions: A preg- nant patient with a complicated infection of the urinary system ought to be treated in a multi-pro- file hospital, offering a possibility to consult doctors of various specialisations (urologist, gynaecol- ogist, anaesthesiologist, nephrologist) as well as full access to a radiology laboratory, which will ensure the choice of appropriate and safe treatment for both the mother and the developing foetus.

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Clinical Reasoning: A 65-year-old woman with subacute hemiballism

Clinical Reasoning: A 65-year-old woman with subacute hemiballism

A 65-year-old, right-hand-dominant woman with a history of hypertension, hyperlipidemia, poorly controlled diabetes, and remote breast cancer presented with 1 week of progressive, involuntary left hemibody movements. One month prior, she was a restrained driver in a head- on motor vehicle collision with possible brief loss of consciousness. The patient was evaluated at an emergency department and was noted to have musculoskeletal injuries not requiring intervention. No imaging was performed. Since the accident, she described feeling a “mental fog” with slurred speech that has progressively worsened and persistent left shoulder pain.

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Intestinal tuberculosis in a 55-year-old woman with a 30-year history of rheumatoid arthritis

Intestinal tuberculosis in a 55-year-old woman with a 30-year history of rheumatoid arthritis

Case report: A 55-year-old woman with a 30-year history of RA using prednisolone and hydroxychloroquine presented with a nonpositional hypogastric pain and a weight loss of 20 kg over 7 months. No history of biological therapy was recorded. Colonoscopy revealed an ulcerated mass that was suspicious for malignancy. The pathobiological assessments confirmed ulceration and granulation tissue formation, foci of necrotizing granulomatous inflammation in lamina propria with adjacent mild crypt regenerative changes. Also, Ziehl–Neelsen staining for acid-fast bacilli in the granulomas was positive though the polymerase chain reaction assay did not detect the Mycobacterium tuberculosis. Anti-TB medication for 2 weeks eliminated the symptoms.

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Clinical Reasoning: A 60-year-old woman with ataxia

Clinical Reasoning: A 60-year-old woman with ataxia

A 60-year-old woman presented to the hospital 4 days after onset of difficulty speaking. Her tongue was not moving as usual and speech was slurred. In the hospital, she had difficulty with walking, tending to fall to the left. Her medical history included irritable bowel syndrome. Stroke was suspected. MRI brain was negative except for a basilar artery tip aneurysm mea- suring 8 mm in the largest dimension. She was thought to have a small stroke not revealed on MRI and discharged home on aspirin and statin. She was brought back to the hospital 2 weeks later to treat her aneurysm but reported further decline in functional status. Her examination was inconsistent, with astasia-abasia diagnosed on gait evaluation. She was thought to have psychiatric overlay in her symptoms, her procedure was postponed, and she was sent home to follow-up with her primary medical doctor to address her symptoms with possible psychiatry referral. She had no prior psychiatric disease.

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Mystery Case: A case of fulminant encephalopathy in a 69-year-old woman

Mystery Case: A case of fulminant encephalopathy in a 69-year-old woman

One hundred ninety-two people provided answers to this mystery case that discussed a 69- year-old woman with a history of sickle cell disease presenting to the hospital acutely encephalopathic. The most striking imaging finding was the one most reported with 87.5% of respondents correctly observing multiple petechial foci in the white matter and deep gray matter on susceptibility-weighted imaging. A majority, 56%, also found corpus callos- um and middle cerebral peduncle FLAIR hyperin- tensities, while less, 37.5%, picked up on diffusion restriction in the corpus callosum and white matter. Only 18.5% of respondents, however, indicated that there were diffuse cervical and thoracic vertebral body hyperintensities. These latter findings, though subtle, suggest that bone marrow necrosis and infarc- tion and were an important clue to the ultimate diagnosis. Given the patient’s acute presentation, medical history, examination, laboratory test results, nonictal EEG, and vessel imaging, the leading dif- ferential diagnoses included sickle cell crisis, acute

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Clinical Reasoning: A 54-year-old woman with dementia, myoclonus, and ataxia

Clinical Reasoning: A 54-year-old woman with dementia, myoclonus, and ataxia

A 54-year-old woman was referred for a second opin- ion regarding a 3-month history of subacute onset progressive cognitive decline. She complained of memory difficulties particularly with short term recall. Decision-making and organizational skills were increasingly difficult. She also developed sudden brief jerking movements of her body and progressive gait imbalance and incoordination leading to falls. Three months after onset, she could not work, drive, cook, or perform activities of daily living. She had not had episodes suggestive of seizures. Her medical history was remarkable for celiac disease diagnosed 9 years previously, which resolved with a gluten-free diet, col- lagenous colitis, Raynaud syndrome, osteopenia, anx- iety, and prior episodes of hyponatremia related to polydipsia. Current medications included amitripty- line, venlafaxine, and Pepto-Bismol. She worked as a financial analyst, had never consumed tobacco

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Marked hyperandrogenicity in a 60-year-old woman

Marked hyperandrogenicity in a 60-year-old woman

Markedly elevated androgen levels can lead to clinical virilization in females. Clinical features of virilization in a female patient, in association with biochemical hyperandrogenism, should prompt a search for an androgen-producing tumor, especially of ovarian or adrenal origin. We herein report the case of a 60-year-old woman of Pakistani origin who presented with the incidental finding of male pattern baldness and hirsutism. Her serum testosterone level was markedly elevated at 21 nmol/L (normal range: 0.4–1.7 nmol/L), while her DHEAS level was normal, indicating a likely ovarian source of her elevated testosterone. Subsequently, a CT abdomen-pelvis was performed, which revealed a bulky right ovary, confirmed on MRI of the pelvis as an enlarged right ovary, measuring 2.9 × 2.2 cm transaxially. A laparoscopic bilateral salpingo-oophorectomy was performed, and histopathological examination and immunohistochemistry confirmed the diagnosis of a Leydig cell tumor, a rare tumor accounting for 0.1% of ovarian tumors. Surgical resection led to normalization of testosterone levels.

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