Each month, the housestaff and faculty in the Department of Pathology and Laboratory Medicine highlight a challenging diagnostic case from all subspecialty areas.  Written in a multiple choice format with a discussion to follow, these educational cases represent diagnostic dilemmas due to interesting or unusual clinical presentations, microscopic or gross or other testing characteristics, or  demonstrate rare diseases or conditions.  We hope you’ll enjoy these cases.

Disclaimer: Review of the Case of the Month is intended for educational purposes ONLY, NOT for research.

2019

June 2019

A 72-year-old female had history of a thyroid mass discovered by her PCP on routine exam. Thyroid ultrasound performed at outside hospital showed bilateral thyroid nodules: a right lobe heterogeneous predominantly hypoechoic solid 3.2 x 2.3 x 2.0 cm nodule (considered suspicious), and a left lobe upper pole 2.5 x 1.9 x 1.6 cm nodule (considered mildly suspicious).

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May 2019

The patient is a 32-year-old woman with a nine-month history of constitutional symptoms of ‘just not feeling good.’ She describes symptoms of abdominal malaise, epigastric discomfort that abruptly began without any triggers. She denies any vomiting, diarrhea, or melena. Her past medical history is significant for obesity. She does not drink, smoke, or use any illicit substances.

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April 2019

The patient is an 80-year old woman who presented with sudden onset of sharp, constant pain in her epigastrium that radiates to her chest. An abdominal ultrasound performed a few months prior was notable for multiple calculi, diffuse wall thickening, and a 0.5 cm polyp in the gallbladder.

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March 2019

A 43-year-old female presented to the emergency department with a seizure.  She has history of alcoholism and seizures attributed to alcohol withdrawal. She reported that she had been binge drinking for the past two days.

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February 2019

A 29-year-old G5P2022 presented for repeat cesarean section at 38 weeks gestation. The pregnancy was a twin gestation complicated by intrauterine fetal demise of one twin at 11 weeks gestation. Subsequent chorionic villous sampling of both twins showed a normal 46 XX karyotype in the living twin and a 69 XXX genotype in the demised twin.

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January 2019

A 72-year-old man presented to the emergency department with a chief complaint of abdominal pain, vomiting, poor appetite and weight loss. CT demonstrated thickening of the duodenum and a right adrenal mass. He underwent endoscopy with biopsy showing duodenal adenocarcinoma. For his adrenal mass, he was noted to have mildly elevated urine catecholamines and metanephrines.

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2018

December 2018

A 66-year-old male presented at our institution for the evaluation of his right neck mass. After one month of the mass appearance, he started developing symptoms that included difficulty swallowing solids and change in voice. Ultrasound of his neck revealed an 18 mm slightly irregular hypoechoic mass in the submandibular gland.

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November 2018

A 34-year-old woman presented to our institution with a history of acute abdominal pain, nausea, and non-bilious, non-bloody vomiting. She had a history of lupus nephritis for which she was treated with peritoneal dialysis as an outpatient.

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October 2018

Patient is a 37-year-old G5P2032 with no significant past medical history who presents with severe abdominal pain. CT abdominal and pelvis reveal bilateral ovarian masses with central necrosis in addition to moderate ascites and nodularity suspicious for ovarian malignancy.

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September 2018

A previously healthy adolescent male presents with one week of jaundice and abdominal pain. Liver enzymes are elevated, and a CBC is normal. Radiology imaging reveals an obstructing mass at the pancreatic head.

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August 2018

A 24 year old homeless man presented to the UCD Medical Center with five months of progressive diarrhea which worsened in the past 2 months. According to the patient there was no inciting agent which has precipitated his diarrhea.

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July 2018

A 17-year-old female presented with right femur fracture and underwent intermedullary nailing and open reduction internal fixation. She complained right hip pain again 9 months after the surgery. X-ray revealed hardwire failure and non-union of the fracture.

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June 2018

A fully vaccinated 14-year-old girl with no significant medical history presented to our institution with a history of progressive decline. Ten days prior to admission, she experienced vague abdominal pain, followed by a sore throat. She developed chest pain, and after experiencing a fall, was found to have altered mental status with speech difficulties.

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May 2018

A 69-year-old female with a history of cecal tubular adenoma and tubulovillous adenomas and a family history of colon cancer presented for a repeat colonoscopy. A 2 cm sessile polyp at the base of the cecum was removed by hot snare and cold forceps.

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April 2018

The patient is a 69-year old woman who presented with a longstanding, recently enlarging left thyroid nodule. The patient initially elected for observation after having the nodule first evaluated in 2006. Serial ultrasounds over the years showed that the nodule had remained stable.

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March 2018

The patient is a 64-year-old woman who presented to an outside gastroenterologist for evaluation of dysphagia. During esophagogastroduodenoscopy, the patient was noted to have an submucosal mass in the duodenum, possibly representing a prominent papilla.

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February 2018

A 78-year-old man with a history of biliary colic admitted to outside hospital in for gallstone pancreatitis. He underwent laparoscopy for gallbladder removal but the procedure was aborted due intraoperative findings of a cirrhotic liver. The follow up CT scan showed a hypodense lesion in the pancreas and a follow up EUS with biopsy demonstrated a mass in the uncinate process.

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January 2018

A 77-year-old G4P4004 female presented for evaluation of post menopausal bleeding. She had complaints of daily vaginal spotting for the past one month.

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2017

December 2017

A 33-year-old woman presented with heavy vaginal bleeding with large clots lasting for more than two weeks. Her signs and symptoms are also significant for abdominal pain and with the presence of a large 6 cm ecchymosis over the center of her abdomen without any known trauma.

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November 2017

The patient is a 68 years old female, presented with shortness of breath and lower extremity swelling. She reports a significant abdominal distension, early satiety and small caliber bowel movements for the past 2 weeks. She also reports significant pain diffusely throughout the abdomen.

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October 2017

The patient is a 76-year-old male with a history of diabetes mellitus and bullous pemphigoid. He presented with diffused erythema, edema and slight fissuring in both palms without active blisters.

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September 2017

A 5-week-old female presented with blood in her diaper. On examination, she was unremarkable without any evidence of pain, fever, or rash. However, placing a Foley catheter revealed gross hematuria.

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August 2017

The patient is a newborn baby boy delivered at 37 weeks with a large 9 cm multicystic mass overlying his neck that significantly impaired his respiratory efforts. The mass was removed by ENT and at the time of surgery, frozen sections demonstrated tissue consistent with thyroid.

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July 2017

This patient is a 21-year-old female who initially presented with epistaxis, severe back pain and fatigue. She was found to be neutropenic with increased blasts and subsequently diagnosed with BALL with t(9;22)(q34;q11) BCR/ABL1.

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June 2017

Patient is 10-year-old female with profound iron deficiency anemia. Labs show hemoglobin of 3.6 g/dL, mean corpuscular volume of 54, serum iron of less than 5 ng/dL, serum ferritin of 1 ng/dL, and thrombocytosis with platelet count of 840/uL. Celiac serology was negative.

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May 2017

The patient was a 21-month-old, previously healthy girl who presented with abdominal distension, emesis, and irritability to an outside hospital. She was found to have a liver mass.

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April 2017

A 74-year-old man has a 1.5 year history of a right inferior pole renal mass seen incidentally on CT scan. He has been asymptomatic and under observation with imaging studies. Surveillance CT revealed a slight increase in mass size from 1.8 cm to 2.2 cm. PET/CT scan demonstrated a FDG avid lesion.

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March 2017

A 13-year-old female with past medical history of Sickle cell disease (Hb SS disease) had multiple transfusions, iron overload, abnormal transcranial doppler (TCD), status post hematopoietic stem cell transplant (HSCT) complicated with GVHD in skin and lungs during transplant course, HHV6 reactivation, Oral/labial HSV infection.

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February 2017

A 52-year-old man presented with progressive eosinophilia for two years. His initial eosinophilia was mild, with absolute eosinophils of 2,400/mm3, but the absolute eosinophil count increased to 13,300/mm3 two years later.

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January 2017

The patient was a 66-year-old woman with a past medical history of chronic hepatitis B infection (for more than 30 years – asymptomatic), hypothyroidism, hyperlipidemia, and degenerative joint disease. She also had a family history of Hodgkin lymphoma (mother). She underwent an ultrasound (due to a low GFR) that identified several hypodense lesions in both kidneys.

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2016

December 2016

A 75-year-old man presented with a 2-year history of a lesion on the left temple. A shave excision was performed on a 1.1 cm well-demarcated, ulcerated, brown pigmented plaque.

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November 2016

The patient is a 70 year old Caucasian male, who is transferred from an outside institution with complains of increasing black stools, fatigue, nausea and vomiting and vague upper abdominal pain. He states that his symptoms have been present for the past two months and he has been having fatigue, light headedness and weight loss.

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October 2016

An 18-year old female with a history of asthma presented to the clinic with the primary complaint of bilateral knee pain (4-5/10) that is mostly associated with running. She reports easy bruising and superficial hematomas in the past which resolve with difficulty.

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September 2016

The patient is a 44-year-old Asian man with a three month history of worsening cough and painful deep inspiration. The cough is occasionally productive of yellow/green sputum and, one week prior to presentation, he began noticing streaks of bright red blood in the sputum.

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August 2016

The patient is a young adult with a history of systemic lupus erythematosus (SLE) complicated by class IV-V lupus nephritis requiring prolonged immunosuppression on a multi-drug regimen. New onset headaches, confusion, and behavioral changes prompted evaluation by neurology.

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July 2016

A 46-year-old G2P2 female presented with bleeding and cramping pelvic pain that had gradually gotten worse. She complained of spotting in between her periods with clotting every six months. She had been experiencing dizziness for about a month.

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June 2016

A 62-year-old female with a remote past medical history of hairy cell leukemia (HCL) presented to an outside hospital with progressively worsening headaches accompanied by short term memory loss, expressive aphasia, and lethargy.

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May 2016

The patient is a 55-year-old woman with a history of alcoholic cirrhosis, currently being treated for breast cancer, who noticed a slowly-growing left cheek mass one year ago.

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April 2016

The patient is a 65-year-old woman with a history of hypothyroidism, colonic tubular adenomas, and new onset hematochezia. She underwent a colonoscopy two months prior to presentation as part of her hematochezia workup, which revealed a 1 cm. firm and rubbery rectal mass, in addition to other adenomatous polyps.

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March 2016

The patient is a 37-year-old man with a month-long history of gradual left testicular enlargement and painful swelling. Ultrasound revealed a 7.9 cm heterogeneously hypoechoic mass replacing the majority of the left testicle.

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February 2016

A 38-year-old man was transferred from outside facility for evaluation and management of an intra-abdominal mass. Pertinent history begins in 2008 when the patient underwent an excision of a skin lesion on his back. He states that the mass was 1 x 1.5 inches. Pathology showed melanoma (he could not specify the type) and he was told that no further treatment would be required.

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January 2016

A 69-year-old female returns for follow up regarding her lobular carcinoma in situ (LCIS). She has a long history of LCIS and has been on long-term follow up since 1997. Her annual mammogram of April 2015 was negative with a heterogeneously dense parenchyma, which may limit the sensitivity of mammography. A subsequent breast MRI revealed a linear non-mass enhancement.

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2015

December 2015

A 20-year-old man presented with a 1 year history of slowly progressive left sided proptosis. He denied any visual changes or associated pain.

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November 2015

The patient is a 6-year-old boy who presented with 4 days of vomiting and bloody diarrhea. Significant exposures included recent consumption of unpasteurized apple cider. Despite receiving IV fluids he became oliguric and developed mild edema in the face and extremities.

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October 2015

The patient is a 2.5 year old male, who presented with a slow growing papule on the right anterior thigh; first noticed around one year of age. The papule had occasional bleeding but no ulcer noticed at the time of examination.

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September 2015

A 20-year-old female with history of Systemic Lupus Erythematosus (SLE) and lupus nephritis causing renal failure for which she is on hemodialysis. She was on chronic immunosuppression and subsequently developed a left thigh nodule and numerous lung nodules. Incisional biopsy of the left anterior thigh mass showed suppurative granulomatous dermatitis containing fungi consistent with chromomycosis and the patient was started on Itraconazole.

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August 2015

A 74-year-old woman underwent living donor kidney transplantation for chronic kidney disease on 5/15/2012. The patient developed fatigue, fever, cough, diarrhea and small bowel obstruction 30 months after the transplantation and was found to have bilateral pleural effusion.

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July 2015

The patient is a 64-year-old female with an unremarkable past medical history who presented for evaluation of a slow growing swelling on the floor of her mouth. Physical examination revealed a firm mass (2.7 x 1.1 cm) that appeared confined to the right side with normal overlying mucosa.

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June 2015

An 82-year-old man who presented with fever, diaphoresis, fatigue, and dysphagia. On exam, he was noted to have prominent lymphadenopathy including enlarged tonsils as well as splenomegaly.

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May 2015

A 17-year-old female with past medical history of Anomalous Pulmonary Venus Connection (Left to right shunt) and Biphasic thoracolumbar Scoliosis with Restrictive Lung Disease. She present with proximal muscle weakness since last year.

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April 2015

A 66-year-old female with a past medical history of peptic ulcer disease presents to the Emergency Department with 5 weeks of vague epigastric abdominal pain with non-bloody non-bilious emesis. She does not report any weight loss, fever, chills or lymphadenopathy.

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March 2015

A 53-year-old male with history of neurofibromatosis type 1 (NF-1) presented to the ED with a 3-week history of abdominal pain. On physical examination, multiple plexiform neurofibromas and cafe-au-lait spots were noted.

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February 2015

A 30-year-old male with a history of Hodgkin lymphoma which was diagnosed 5 years ago. He received chemotherapy followed by an allogenic stem cell transplant in 2013. He subsequently developed poikiloderma, keratoconjunctivitis sicca, chronic diarrhea and lost 20% of his weight over a period of 4 months.

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January 2015

The patient is a 43-year-old woman and navy veteran who was brought to the attention of the Mather Veterans Affairs otolaryngology service after a CT scan conducted as part of a routine trauma survey following a motor vehicle accident revealed a nodular thyroid.

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2014

October 2014

The decedent is a 55-year-old Caucasian male with a past medical history of diffusely metastatic carcinoma, severe chronic obstructive pulmonary disease (on 4 L home oxygen therapy), extensive smoking history, and asbestos exposure history. He had symptomatic lesions and pathologic fractures at the lumbosacral spine, the left pelvis, the left femur and the left upper extremity. He was not a candidate for systemic treatment or surgery but was considering possible radiation therapy.

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September 2014

The patient is a 24-year-old O RhD positive G2P1 female at full term in her pregnancy. Her history includes HbSC disease and she has had sickle cell pain crises episodically requiring transfusions. Fetal monitoring has been stable.

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August 2014

The patient is a 57-year-old male with a history of atrial fibrillation on coumadin, chronic obstructive pulmonary disease, hypertension, gout, and alcohol abuse who presented with a three day history of melena. His INR was 7.

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July 2014

The patient is a 35-year-old female with a medical history significant for hypothyroidism, depression, and asthma. She presented to her primary care physician in January 2014 with four days of fever and cough after having returned from a trip to Egypt and Israel for which she was placed on antibiotics.

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May 2014

An 83-year-old female G2P2 with a past medical history of hypertension, hyperlipidemia, hypothyroidism and enterococcus endocarditis in 2013 presented in February 2014 with mid-abdominal pains. She was primarily diagnosed with gallstones. In March 2014, she returned to the hospital with abdominal pains. A CT scan showed a large cystic pelvic mass.

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April 2014

A 2-year-old female with no significant past medical history presented to her primary care physician six months prior with complaint of dysuria, she was placed on empiric antibiotics, urine cultures were found to be negative and she was sent home with resolution. She had two more distinct episodes of dysuria with negative urine cultures which resolved after one week. She presented again five months later with similar complaints in addition to a rash and a fever.

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March 2014

The patient is a 47-year-old male with no significant past medical history who presented with a palpable mass of several years in the anterior and lateral aspects of the left lower leg. The mass was first attributed to a musculoskeletal injury and no further evaluation was obtained. However, the lesion continued to progress in size with severe pain.

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February 2014

The patient, a 91 year old female, presented with a 6 month history of vaginal bleeding and mild abdominal discomfort.

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January 2014

The decedent is a 57-year-old female with a history of papillary serous ovarian cancer (stage IIIc) who underwent a radical hysterectomy and debulking of her primary tumor followed by six cycles of intraperitoneal chemotherapy.

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2013

December 2013

A 50-year-old female with a past medical history of fibromyalgia, chronic pain, and 25 pack year smoking history, who presented to the ED at an outside hospital one year ago with severe left upper quadrant pain without fever, chills, anorexia, nausea, vomiting, diarrhea, constipation, or back pain. She additionally had a 40 lb weight loss (unintentional) over the prior 8 months.

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November 2013

A 70-year-old woman with malaise, hot flashes, and 5-10 pound weight loss was found to have an elevated hematocrit of 46. She was referred to UC Davis Urology for further evaluation.

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October 2013

A 28-year-old woman with no significant past medical history presented with a palpable left neck mass which had been slowly increasing in size for approximately one year and was not associated with pain or other symptoms.

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September 2013

The patient is a healthy 80-year-old male with a large, right, painless scrotal swelling that has progressed in size slowly for many years.

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August 2013

A 22-year-old G1P0 female with an uncomplicated pregnancy history was at 31 weeks 6/7 days gestational age by last menstrual cycle when she presented to her OB clinic for routine screening. There was imaging concern for congenital anomalies, so she was transferred to our institution for management.

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July 2013

A 3-year-old boy presented with an enlarging mass in front of his ear. There was no bleeding or bruising, change in visual acuity, fever, pain, or drainage from the ear.

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June 2013

The patient is a 55 year old male with a past medical history significant for hypertension and osteoarthritis who presented with a 3 to 4 month history of alternating diarrhea with steatorrhea and constipation. He also noted fevers and an unintentional 40 lbs weight loss.

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April 2013

The decedent was a 33 year old male with a prior history of illicit drug use who complained of vague abdominal pain 1 week prior to death.

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March 2013

75 year old male who presented with dysphagia and epigastric discomfort.

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February 2013

A newborn female infant born at 37 weeks gestation with a left –sided multicystic lung mass discovered at 25 weeks on ultrasound.

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January 2013

63-year-old female with a past medical history of gastrointestinal bleeding from a gastric ulcer and H. pylori infection presented with new complaints of melena, progressive weakness, fatigue and shortness of breath.

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2012

December 2012

55-year-old para 1 female who presented with abdominal pain and a palpable mass.

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November 2012

27 year-old male with a recent history of recurrent pneumonia (5 times over the past two years).

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September 2012

37 year-old nulligravida female with a history of abnormal menstruation and more recently, episodes of severe lower abdominal cramping and copious vaginal bleeding.

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August 2012

44 year-old pravida 2, para 2 woman with a seven-year history of a pedunculated vulvar mass.

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July 2012

11-year-old girl with no significant past medical history who presented with a headache located behind the right eye, with radiation to bilateral temples.

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June 2012

64 year-old female with a past medical history of cervical cancer s/p vaginal hysterectomy, hemorrhagic cyst s/p right oopherectomy, hypertension, and recurrent pulmonary emboli. She presented with abdominal pain for two weeks. Computed tomography (CT) showed a multi-cystic pelvic mass.

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May 2012

86 year old male with a past medical history significant for diabetes mellitus and hypertension who was incidentally found to have a left lung mass discovered on chest radiographs (during work-up for dull chest pain).

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April 2012

40-year-old Asian female status post right ovarian cystectomy and left salpingo-oophorectomy for seromucinous cystadenoma of the right ovary and mixed endometrioid and mucinous tumor of low malignant potential of the left ovary.

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March 2012

63-year-old female presents with worsening abdominal pain, distention, nausea and progressively fewer and smaller bowel movements.

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February 2012

16-year-old girl with no significant past medical history presented with a tender right breast lump.

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January 2012

53-year-old Caucasian male with a past medical history significant for hypertension.

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2011

December 2011

64-year-old female, with a past medical history significant for chronic obstructive pulmonary disease, diabetes mellitus, and hypertension, who was found to have a right adrenal mass on chest CT (during work-up for pneumonia).

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November 2011

62-year-old male, with no significant past medical history, who presented with a chief complaint of a lump in his right testicle causing mild discomfort.

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October 2011

65-year-old female who presented with increasing abdominal distention and pain.

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September 2011

2-year-old boy with a soft tissue mass in the thenar eminence of the hand. MRI showed an amorphous area of enhancing soft tissue in the thenar eminence and a suggestion of increased soft tissue between the radial metacarpals.

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August 2011

39 year-old female with a 5-month history of persistent abdominal pain and cramping. A colonoscopy was performed and found no abnormalities.

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July 2011

54 year-old woman with a history of melanoma of the right leg and a left adnexal mass that was found on CT when the patient presented to the ED with abdominal pain.

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June 2011

38 year-old male, with a past medical history significant only for gastroesophageal reflux disease, who presented with burning epigastric pain.

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April 2011

38 year-old male with a history of a left testicular varicocele and a chief complaint of infertility for four years.

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March 2011

30 year-old female from Sudan with no significant past medical history who presents with an incidental finding of persistent mildly elevated liver function tests and microcytic anemia.

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February 2011

66 year-old female with a past medical history of hypertension, atrial fibrillation and congestive heart failure who underwent a computed tomography (CT) scan of the abdomen to evaluate for an existing abdominal aneurysm.

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January 2011

22 year-old woman with a 10 year history of menorrhagia.

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2010

December 2010

15-month-old female with a 1-week history of fever, fatigue, and maculopapular rash which had recently resolved.

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October 2010

9-year-old boy with no past medical history who had a right flank mass which had been growing over several months.

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September 2010

31-year-old female with a prior history of a myelomeningocele who was noted to have a new cystic structure within the pelvis/sacrum region at the time of a C-section.

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August 2010

68 year-old man who initially presented with pancreatitis and was incidentally found to have hypercalcemia due to hyperparathyroidism.

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July 2010

34-year-old male with no significant past medical history who presented with right painful lump, behind right ear for 2.5 months.

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June 2010

56-year-old female with no significant past medical history who presented to her PMD with on going non-specific microscopic hematuria.

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May 2010

33-year-old Caucasian female with no significant past medical history who presented with a chief complaint of progressive shortness of breath over a course of 3 months.

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April 2010

79-year-old man with a history of Barrett’s esophagus.

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March 2010

37-year-old female with a two to three month history of abdominal pain, burning on urination, occasional fevers, weight loss of 10 lbs. and amenorrhea for a period of 6 months.

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February 2010

The patient is a nulligravida 47-year-old female with Turner’s Syndrome who presented with a 10 month history of irregular vaginal bleeding.

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January 2010

80 year-old woman who presented with a three month history of multiple urinary tract infections and one day of gross hematuria.

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2009

October 2009

51-year-old female with a right upper eyelid swelling present for at least nine months.

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September 2009

57-year-old male who noted a “pop” in his right thigh while doing heavy labor activities.

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August 2009

63-year-old male who presented to the emergency room because of sharp chest pain radiating to the scapula.

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