Jailbreak

This patient has had surgery for endometriosis in the past as well as a history of pelvic inflammatory disease. She presented, however, at 14 weeks gestation with abdominal and back pain as well as urinary retention, frequency, and the sensation of incomplete emptying. Symptoms started a few weeks prior, but resolved, and now have returned. She has no vaginal bleeding, discharge, or contractions. Pelvic exam shows anterior displacement of the cervix behind the symphysis pubis; the cervix cannot be visualized and the external os is not palpable. There is a large mass in the cul-de-sac and the uterus is difficult to palpate on bimanual exam. Ultrasound done at 16 weeks confirms the diagnosis and an intervention is planned.

Challenge: What's the diagnosis?

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Always Put This On Your Differential

A 40 year old woman presents with a right facial droop, initially thought to be Bell's palsy until she develops a left sided one subsequently. She presents to her primary care doctor who does a review of systems and finds polyuria as well as disturbances in thirst, sleep, appetite, and libido. Not much is done, and she is told to follow up in a few months. In the meantime, she has a partial seizure and returns to the hospital. A contrast-enhanced MRI shows nonspecific meningeal enhancement and multiple white matter lesions. A lumbar puncture shows a mononuclear cell pleocystosis and elevated total protein. Glucose is normal. A CT of the chest is obtained due to an abnormal routine chest X-ray and is shown below.

Challenge: What's your diagnosis?

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Basilisk

A 20 year old patient comes in with acute abdominal pain, anorexia, nausea, and vomiting. The pain started at the bellybutton, then migrated to the right lower quadrant. Exam shows fever and tachycardia. The point of maximal tenderness is 1.5 inches from the anterior superior iliac spine on a straight line from the ASIS to the umbilicus.

Challenge 1: What's this point called?

Palpation of the left lower quadrant causes pain in the right lower quadrant.

Challenge 2: What's this sign called?

The diagnosis is confirmed. The patient is brought to the operating room where standard monitors are placed and he is pre-oxygenated. A rapid sequence induction is performed with cricoid pressure. A total of 2mg midazolam, 150mcg fentanyl, 150mg propofol, and 100mg succinylcholine is administered. He is an easy intubation. A peripheral nerve stimulator is used to see when he regains neuromuscular function; however, no twitches come back. In fact, the whole operation is performed without any additional neuromuscular blockade. At the end of the surgery, the patient remains paralyzed and does not spontaneously ventilate. He is brought to the ICU. Six hours after induction, he begins to regain muscle function. He has an uneventful discharge two days later.

Challenge 3: You've done 3200 cases where this hasn't happened. What's the diagnosis? (ie. the prevalence of this disease is 1/3200).

25% of the World Has This

An immigrant from Southeast Asia brings his six year old child to the doctor because of loose stools with some mucus and blood, especially at night. A CBC with differential shows a mild anemia with peripheral eosinophilia (15%). Exam shows rectal prolapse. The patient is at the lower end of normal with regards to growth and cognition. This is seen in the stool:

Challenge: What's your diagnosis?

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Coffee Grounds

A 40 year old man with peptic ulcer disease, arthritis, and chronic low back pain presents with coffee ground emesis that began several hours ago. He takes only naproxen for his joint pain. He has a mild smoking and drinking history. His vital signs are: T 37.8, HR 95, BP 120/60, RR 14, SpO2 97%. His abdomen is diffusely tender.

You place a nasogastric tube and do an NG lavage but no blood or coffee grounds comes back. Instead, the patient becomes acutely agitated, tachypneic, and hypoxic. Vital signs are T 37.6, HR 110, BP 130/70, RR 20, SpO2 90%. You get a chest X-ray, shown below.

Challenge: What happened?

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pH

A 25 year old woman with diabetes and recurrent UTIs presents with dysuria. Initially, she thinks this is her usual UTI, but then she starts having vulvar pruritis, soreness, irritation, and dyspareunia. There is no discharge. She decided to go see her regular doctor (that's you!). Her medications are nitrofurantoin and an oral contraceptive. Examination shows vulvar erythema and edema. There is some thick, adherent, cottage-cheese-like discharge. The vaginal pH is 4. You make your diagnosis.

Challenge: What is it?

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Everything Has Its Place

A 25 year old man has a soccer injury and fractures the tibial diaphysis in his right leg. However, he doesn't have health insurance so he doesn't go to the emergency department immediately. Instead, he wraps his leg and hopes it will get better. Unfortunately it doesn't. In the next few hours, the pain rapidly worsens, spreading further than just the site of the initial injury. He describes this pain as deep aching associated with numbness and tingling. He finally goes to urgent care where passive range of motion causes pain. The skin has a tense woody feel. His sensation is diminished. He goes to surgery.

Challenge: What's your diagnosis?

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As

Two patients come into the emergency department.

The first patient is a volcanist (you know, a person who explores volcanoes) who just got back from a trip inside a volcano hours ago. He presents with nausea, vomiting, abdominal pain, and severe watery diarrhea. You ask him what he's been eating, but you can tell - he has garlic on his breath. His exam shows hypotension and signs of dehydration. An EKG shows a QTc of 500; the patient takes no medications. He is admitted to the hospital with an uncertain diagnosis and a week later develops pancytopenia and hepatitis. Three weeks into the hospitalization, he starts requiring higher and higher doses of gabapentin for a painful peripheral neuropathy starting with distal paresthesias and progressing to ascending sensory loss and weakness.

The second patient is a person visiting from West Bengal (or India, or Bangladesh). He presents with the skin changes shown above. He has a history of HTN and squamous cell carcinoma. He also has a symmetric sensorimotor polyneuropathy. This began years ago as numbness and tingling in the feet, progressing to the arms. The patient can't even walk because of intense burning in his soles. He often gets cramping in his calves. On exam, there is diminished vibratory sensation and decreased deep tendon reflexes.

Challenge: What's your diagnosis?

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A

A few days after a young child gets a sore throat, he develops a diffuse blanching erythema with numerous small papules starting at the head and neck, then involving the trunk and extremities, before having the appearance shown in the first image. The rash feels like sandpaper and is easiest to see along the inguinal crease, axillary fold, and antecubital fossa.

Challenge: What's your diagnosis?

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Popcorn

 Sorry, this post was a little late.

This 30 year old woman is transferred from an outside hospital with multiple focal progressive neurologic deficits and seizures. MRI shows several lesions shown here. They do not show up on conventional brain angiography. CT shows irregular hyperdense masses.

The patient goes to surgery where the surgeon comments on a "mulberry appearance to purplish clusters."

Challenge: What's your diagnosis?

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