cases for the weekend

21 y/o morbidly obese female presents to ED with bruising to upper extremities and lower back. Patient looks well though is anxious, PE unremarkable except for eccymosis on upper arms, right wrist and lower back.
Pmhx: suppurativa adenitis. Seen in ED 3 months ago for r/o Meningitis and ED course was pain meds and an LP which was unsuccessful due to body habitus. Labs drawn in previous visit platelet count 75, today her platelet count is 7. What's your ddx? What do you want to do?

67 y/o black female present to ED Friday night (while everyone is in the trauma room working on a GSW to the abd of a 17 y/o who we later determined was DOA) and is c/o itching all over and the feeling that her throat is closing. Seasoned RN gives 50 benedryl and 40 of solumedrol before being able to grab a clinician.
Patient states she had fish for dinner at 7pm and felt fine when around 11pm she gradually started to itch everywhere, took some benedryl with no relief and came to the ED. She states she had hives everywhere, though there is currently no evidence of rash/hives and she states she feels much better. Patient denies any travel, new pets, soaps, foods, etc.
Patient received pepcid, IVF and is observed for anaphylaxis for 5 hours. No changes, patient is d/c home with epipen and follow-up with Immunology on Mon. Patient returns to ED Saturday night, states she itches again and it's worse. Patient states she took some benedryl at home without relief also took the epipen and came in (though she reports never having the sensation of SOB, throat, lips or tongue swelling and obviously wasn't listening when I explained WHEN to use the epipen). Patient has diffuse uritcarial hives all over body surfaces best visualized on her back where she can't reach to scratch. She also has blanchable purpuric rash on her palms and feet. There appears to be no mucosal involvement and she is breathing well without wheezing. Tonight she reports she was recently visiting relatives in North Carolina. Patient is admitted to medicine. WTF? What is your ddx? What do you do?

36 y/o female presents to ED with worst HA of her life. She complains of subjective fever, some associated neck pain, and mild nausea. Initial POC work-up indicates she is pregnant and she elects to keep the pregnancy though not planned. How do you work this patient up? How do address her pain?

weird shit

There is a lot of weird shit in this world. It's lurking in the neurons and reflexes of our bodies and making many of us scratch our heads. Medicine, the great abyss, teaches and taunts us with these anomalies - or shall we just call them our limitations. Honestly, I think it's amazing we have figured out all we have so far.

My top 3 head scratchers to date are occurring in people i know and love.

Active female in early 30's with onset of ascending leg numbness, difficulty walking and extremity pain, specifically in the limbs that are having sensory deficits. She said it started with a weird constellation of symptoms that included right leg numbness, the sense that she could feel her leg hair growing which proceeded to be leg pain with shaving the hair on her legs and later difficulty climbing stairs (uncoordinated gait and muscle weakness) and some urinary incontinence due to saddle numbness. 

Another active female in early 30's with a persistent cough and tickle in her throat lasting > 3 years. She was initially evaluated by her PMD and later several ENT doc's who said she has silent GERD (gastroesophageal reflux disease) - to which end she ceased eating and drinking many offending items that would exacerbate this condition as well as using a PPI. No improvement. She went back to ENT and had an upper endoscopy and they confirmed silent GERD and put her on aciphex which has NOT improved the symptoms but caused her to have terrible bloating and bad headaches. Switched her to Zegerid which also caused terrible bloating and a 5 lb weight gain in 5 days. She was told she should have an esophageal monometry performed but that it would be very unpleasant and she's loath to spend another $50 co-pay for a very unpleasant procedure that she now doubts will yield any new information. Enter family member who had the same symptoms and went through much of the same work-up and treatment and eventually had a smart MD do an upper endoscopy with a dye that highlighted a small patch of gastric mucosa cells lining her throat. What the hell is that? Hard to find any literature on it and my friend is beside herself with who to go to since her family member said she went to a GI guy who was venerated and hadn't thought to do it. Hit or miss, eh?

Lastly, healthy female in her early 40's presents with sudden onset of binocular visual defect: a white spot that is seen in the center of both visual fields and when she closes her eyes. Said white spot is slightly shimmery and gets larger and larger with the center disappearing to have normal vision there now with a O of white-out that eventually ended in a C-shape on the periphery of her vision. This first episode lasted 2 hours and was accompanied by mild nausea and followed by a mild headache that subsided without intervention. The second episode was10 days following the first with the visual changes only lasting 30 minutes and a third episode less than a week later with even shorter duration. Migraines? Occular Migraines? Amorosis Fugax? WTF? Neuro consult? Ophtho consult? Head CT? MRI? 

Inquisitive minds continue to ponder and advise.