Friday, September 23, 2016

What'd I Miss?

Challenge: What kind of highly unstable fracture is shown above?

P.S. Taking a break on cases this weekend, back on Monday.

Images shown under Fair Use.

Thursday, September 22, 2016


I can't believe I've written 9 years of cases, almost a thousand of them, and didn't get to this one. This is the the kind of medical trivia I like.

You pump this blood pressure cuff on the arm of a patient to 200mmHg. The phone rings and you go and answer it. The BP cuff is left inflated for three minutes, and the patient begins having adduction of the thumb, flexion of the MCP joints, extension of the IP joints, and flexion of the wrist.

In addition, when you tap the patient just anterior of the ear, she gets contraction of the ipsilateral facial muscles.

Challenge: What's going on? What two signs are described above?

Image is in the public domain.

Wednesday, September 21, 2016

Sign Here

Challenge: What does the arrow indicate?

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Tuesday, September 20, 2016

My Fair Lady

My goal for the last handful of cases on this blog is to actually post a case a day; it always bothered me a little to have a blog titled "Case of the Day" that was only running twice or thrice weekly posts. This may not actually happen, but I'm trying to go out with a bang.

These CT images are from an older Caucasian woman infected with a nontuberculous mycobacterium. She has a chronic cough but no known chronic lung disease. She tries to hide her cough.

Challenge: What syndrome is this?

Image shown under Fair Use.

Monday, September 19, 2016


This disease is common in rural Africans, but can also be seen with travelers returning from Africa or the east Caribbean. It presents as a mild illness with headache, fever, and myalgias. Solitary or multiple eschars as shown above are common, along with regional lymphadenopathy. There may be a scant generalized rash, and uncommonly, subacute neuropathy or myocarditis.

Challenge: What is your diagnosis?

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Thursday, September 15, 2016


An obese (BMI 40) man with diabetes, peripheral artery disease, and tobacco abuse undergoes a CABG. He actually had a prior cardiac surgery to repair an aortic valve five years ago. Over the last year, he developed increasing shortness of breath. Workup revealed coronary disease so he underwent a redo sternotomy and bypass graft with an internal mammary artery.

Postoperatively, he has fever, tachycardia, and persistent chest pain. There is crepitus and edema of the chest wall as well as a crunching sound synchronous with the heart beat and heard by auscultation. White count is elevated.

Challenge: That weird crunching sound has a name - what is it? Also, what's the diagnosis?

Monday, September 12, 2016


This vessel starts at the junction of the left subclavian and left internal jugular veins, passes lateral to the aortic arch, and drains into the right atrium via the coronary sinus.

Challenge: What is this rare anomalous vessel?

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Thursday, September 8, 2016


A 70 year old patient comes in with septic shock. She is febrile, tachycardic, hypotensive, tachypneic, and hypoxemic. Her labs show a leukocytosis, elevated lactate, and elevated procalcitonin. Chest X-ray shows a right lower lung focal opacity. She is fluid resuscitated with 5 liters of crystalloid but still has refractory hypotension. The emergency medicine intern puts in a right internal jugular central venous catheter to start norepinephrine. Later, a KUB is taken which is shown above.

Challenge: What complication happened here?

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Thursday, September 1, 2016


A rapid response alert is called in labor and delivery. You rush in to find a woman who has just delivered who appears in acute respiratory distress. The obstetrician says, "she had postpartum bleeding from uterine atony, but I don't think she's lost more than a liter of blood." You can't get a history because the patient can barely speak. On exam, her breath sounds are very tight; she's not moving much air, and you hear expiratory wheezes. Her blood pressure and heart rate are fine. She's maintaining a sat of 90% with oxygen by face mask. Fluids are wide open along with oxytocin.

Challenge: She received one other medication which is causing her clinical presentation. What is it?

Image is in the public domain.

Monday, August 29, 2016

No Biopsy Needed

This patient also has bilateral parotid gland enlargement and facial nerve palsies. His review of systems is notable for fever and arthritis. He was seen by an ENT recently who ruled out parotid tumor. Apparently pathology showed granulomas.

Challenge: What's your diagnosis?

Image shown under Fair Use.