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A 16-year-old male is brought to the emergency department by his father following a generalized tonic-clonic seizure. He has had these seizures regularly since early childhood, though their frequency has increased over the past two months. As an infant, he had regular episodes of apnea, which resolved at the age of six months. He has a history of developmental delay and ataxia. On examination, the patient is alert and mildly disoriented. Mild generalized hypotonia and strabismus are present, and polydactyly is noted bilaterally. An MRI of the brain is performed, revealing the findings seen here.

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Answer: End-stage renal disease

This patient has Joubert syndrome, a rare autosomal recessive condition characterized by hypoplasia of the cerebellar vermis. MR imaging of the brain reveals the pathognomonic “molar tooth sign,” resulting from the presence of prominent superior cerebellar peduncles. Clinical features associated with Joubert syndrome include neonatal respiratory dysfunction, developmental delay, ataxia, hypotonia, and abnormal eye movements, commonly oculomotor apraxia, strabismus, and nystagmus. The disorder is associated with nephronophthisis (NPHP), an autosomal recessive cystic kidney disease which is present in up to 30% of patients, and leads to end-stage renal disease.

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A 58-year-old male presents to the emergency department with dyspnea, and severe chest pain that radiates to his shoulder. He has a history of alcoholism and has just finished a 4-day drinking binge. On examination, crepitus is heard on palpation of the chest wall, and his pain worsens as he swallows. A diagnosis of Boerhaave syndrome is suspected and thoracentesis drains 800 ml of brown liquid.

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Answer: Left posterolateral aspect of distal intrathoracic esophagus

This patient has Boerhaave syndrome, a perforation of the esophagus. It is caused by a combination of increased intraesophageal pressure and negative intrathoracic pressure associated with vomiting. The most common site of perforation is the left posterolateral aspect of the distal intrathoracic esophagus. Rupture of this area contaminates the mediastinal cavity with gastric contents, usually resulting in a left-sided hydropneumothorax. Perforation of the midesophagus typically produces a pleural reaction in the right hemithorax.

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An 11-month-old male with a two-day history of irritability and lethargy is brought to the emergency department by his mother. She reports that he has vomited four times today and has had fewer wet diapers than usual. He is up to date with his vaccinations. On examination, he is febrile, and a slight bulging of his anterior fontanel and neck stiffness are noted. Laboratory tests demonstrate a serum glucose of 75 mg/dL, and blood cultures and a lumbar puncture are performed. Analysis of the cerebrospinal fluid (CSF) reveals a predominance of neutrophils.

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Answer: Glucose of 18 mg/dL

This patient’s findings are consistent with a diagnosis of meningitis, an inflammatory disease of the tissues surrounding the brain and spinal cord. The cloudiness of his CSF and the predominance of neutrophils present are suggestive of bacterial meningitis. Although there is some overlap in CSF findings for the different causes of meningitis, the CSF in bacterial meningitis typically has a low glucose concentration and a serum to glucose ratio less than 0.6.

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A 40-year-old male presents to the emergency department with sharp chest pain and palpitations. He says the pain is worse when he lies down and is exacerbated by coughing, but improves when he moves to a seated position. He was recently diagnosed with systemic lupus erythematosus (SLE) after investigation for recurrent cyanotic discoloration and numbness of his fingers following exposure to the cold, as well as small-joint polyarticular arthritis.��

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Answer: Pericardial friction rub

This patient’s presentation is suggestive of pericarditis, secondary to SLE. Pericarditis, an inflammation of the pericardial sac, is the most common cardiac manifestation of the condition occurring in approximately 25% of SLE patients. The major clinical manifestations of pericarditis include pleuritic chest pain, diffuse ST elevation and PR depression on ECG, and a pericardial friction rub. This specific finding—described as having a scratching, grating, or squeaky quality—is highly specific for the condition and should alert clinicians to investigate for the diagnosis.

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A 38-year-old man presents with itchy, scaly lesions on his elbows and small, erythematous papules in the web spaces of his fingers.

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Answer: Scabies

Scabies is caused by the tick Sarcoptes scabiei, that burrows into human skin where it lays its eggs. The inflammation is caused by a type IV hypersensitivity reaction which produces erythema and intense pruritus that is often worse at night. Scabies can be treated with topical or systemic therapy.

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A 28-year-old male presents with a three-month history of a chronic cough and weight loss. Upon further discussion, he mentions a painless lump in his left testicle. A firm mass is felt in the left testis on examination. A chest X-ray reveals the pulmonary lesions seen here and a scrotal ultrasound confirms the presence of a heterogenous tumor. Blood tests demonstrate highly elevated beta-hCG, slightly elevated lactate dehydrogenase (LDH), and normal alpha-fetoprotein (AFP) levels.

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Answer: Choriocarcinoma

This patient’s clinical presentation and imaging findings suggest a diagnosis of testicular cancer with lung metastasis. Serum tumor markers (AFP, beta-hCG, and LDH) can aid in the diagnosis, staging, treatment, and surveillance of patients with testicular germ cell tumors. Highly elevated beta-hCG (often greater than 1000 IU/L) and normal AFP levels are typically seen in patients with choriocarcinoma. Management for choriocarcinoma includes orchiectomy and chemotherapy.

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A 60-year-old man presents to the emergency department with worsening shortness of breath and a non-productive cough. He has congestive heart failure and was treated three weeks earlier at a neighboring hospital. On examination, he has normal vital signs and marked bilateral pitting lower limb edema. A chest X-ray demonstrates the opacity seen here. A consultant recommends administering diuretics and repeating the chest X-ray in the morning.

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Answer: Disappearance

This patient’s findings are suggestive of a phantom (or vanishing) tumor of the lung. These pseudotumors are caused when fluid accumulates within an interlobar fissure secondary to congestive heart failure. The opacity will resolve with management of the underlying heart condition, and no other direct treatment is required. Recognition of this uncommon occurrence can help avoid unnecessary lung biopsies or antibiotic therapy.

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A majority of physicians struggle with language barriers, often with the 45 million Spanish-speakers in the United States. The risks of miscommunication are too high to ignore.

What can you do?

Patient-centered care requires meaningful communication. Practice your medical Spanish terminology with this short quiz, courtesy of Canopy Learn, and see how ready you are to provide the best care to your future patients, regardless of their primary language.

Are you ready to answer the following questions? Let’s go!

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A 20-year-old mechanic is brought to the emergency room after his co-workers found him exiting the garage inebriated and confused hours earlier. On examination, he is disoriented, ataxic, and complains of nausea. A urine toxicology screen is negative and urinalysis reveals the rhomboid calcium oxalate crystals seen here.

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Answer: Fomepizole

This patient has ethylene glycol (antifreeze) poisoning, demonstrated by the envelope-shaped calcium oxalate crystals seen here. Fomepizole — which inhibits the formation of toxic metabolites — is the preferred treatment for ethylene glycol poisoning. Severely poisoned patients presenting with acidosis may also require hemodialysis.

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