All In

A 66 year old African American male presents with pain in his back and chest. The pain gets worse with movement and does not occur at night except when he changes position in bed. The patient also said that he used to be 6 feet, but now he's only 5'10". He also complains of weakness, tiredness, and some weight loss. You are unsure what is going on so you order some basic lab tests, including a peripheral blood smear (shown above). The abnormality is indicated by the arrow. Luckily, you remember seeing this in your hematology block.

Challenge: What's the clinical diagnosis?

Related Questions:
1. What's the finding on the peripheral blood smear called?

Image shown under fair use.

Mouth

A 50 year old homeless man presents to the ER with slurred speech, nystagmus, and unsteady gait. There is no history of head trauma. His blood smear is above with the abnormal cell marked by the arrow. This is not a hereditary or genetic condition.

Challenge: What is the cause of this finding?

Related Questions:
1. What is the blood smear finding called?

Image shown under fair use.

Gunner

Here's an easy one. As a gunner, you begin studying for Step 1 of the Boards in the fifth grade. A 65 year old male has a BNP of 500 pg/mL and a CXR that looks like this:

Challenge: What are some treatments for this?

Related Questions:
1. What does BNP measure?
2. What do you see on the CXR?
3. What is your diagnosis?

Image shown under fair use.

Happy Thanksgiving

A 30 year old man returns from a trip to Turkey where he visited some relatives on a farm. He presented to his local hospital a few days ago with a pneumonia: fever, cough, shortness of breath, headache, myalgia, and sore throat. The respiratory distress got worse and was soon accompanied by diarrhea. The referring hospital could not identify the etiology of the pneumonia; all the usual suspects were tested and negative. Radiographic findings show diffuse bilateral ground-glass infiltrates, which signifies very poor prognosis.

Infections by this bug have also been documented in Thailand, Vietnam, Indonesia, Cambodia, China, Azerbaijan, Laos, Djibouti, Egypt, Nigeria, and Iraq.

Challenge: This is an unfortunately nonspecific presentation, but give a guess for the causative organism.

Cat's Cradle

You are a third year rushing through the hospital to get coffee for your intern (and thus hopefully an "honors"). As you pass the pediatric ward, you hear a cat meow. "That's weird," you think, "why would someone bring a pet cat into the hospital?"

Suddenly, you hear the voice of your intern. "Yes, the chart indicates she was five pounds when she was born, and she hasn't been growing normally since. We'll have to monitor her cognitive, speech, motor, and behavioral progress as they may be delayed. Let me measure her head. Hmm, it's a little small."

The mother asks, "But what is wrong with her?"

The intern says, "I believe she has a syndrome called..." At that moment, he glances out the room and sees you. "Oh, this is the medical student on the team." You awkwardly introduce yourself. Well, you didn't get coffee and you were caught eavesdropping; you better impress your intern by knowing the diagnosis.

Challenge: What chromosome in this baby would be abnormal?

Related Questions:
1. What would a small head be called?
2. What is this syndrome called?

Note: The answer to this case might be posted a little later than usual. But it's a hard one - good luck.

Cool

This is the rare non-case post. We had our cancer midterm today, and one of the problems mirrored exactly one of the cases here. How exciting! Also, there will be a new case tomorrow, but I'm not sure if there will be a case Friday owing to the Thanksgiving holiday. (Perhaps I will desperately try to find a turkey-related disease).

Pathognomonic

Challenge: What is the causative organism?

Related Questions:
1. What is seen on the CXR?

Image is in the public domain.

Pandora's Box

The finding in this barium enema is seen in a young female. She also has the finding seen in the image below:
These characteristic spots are flat and brown. "I've always had freckles," she says, but you notice these spots are on her lips, around her mouth, and on the buccal mucosa. She also has some on her hands and feet.

If you were to do a colonoscopy, you'd find many polyps with variable size and features. Unfortunately, this is an inherited condition and it predisposes the patient to many different cancers of the GI tract, pancreas, liver, lungs, breast, and ovaries.

Challenge: What's this syndrome called?

Related Questions:
1. What is seen on the barium enema film?

Both images shown under fair use.

Anatomy Basics

This patient has trouble raising her arms above her head. She is currently pushing her arms against the wall. Note the appearance of the scapula.

Challenge: The most common cause is weakness in which muscle group? What is the innervation of that muscle group?

Related Questions
1. What is this presentation called?
2. Which muscles stabilize the scapula to the torso?

This case idea contributed by Kate Dinh.
Image shown under fair use.

PedsHemOnc

In your pediatric preceptorship, you meet a 7 year old boy who presents with fatigue and pallor. When you plot his growth on a chart, you find that he is short for his age, but he has always been this way. When you take a thorough history, you find that he has seen a doctor in the past for recurrent bacterial infections and an episode of hemorrhage. Both his parents are healthy and have no major medical conditions. However, the father said some of his relatives had been diagnosed with acute myelocytic leukemia. The mother said that some of her relatives had been diagnosed with squamous cell carcinoma of the head and neck. On exam, you notice several cafe au lait spots, "funny thumbs," and hypogonadism. Blood smear shows macrocytosis.

Challenge: What is your diagnosis?

Related Questions:
1. A deficiency in which blood cell type would lead to fatigue and pallor?
2. A deficiency in which blood cell type would lead to recurrent bacterial infections?
3. A deficiency in which blood cell type would lead to hemorrhage?
4. What is the combination of the above three findings called?

Shocking

It's a balmy June afternoon when a young man is rushed into the ER with superficial but not deep burns. You see this on his back. This feathering skin injury is pathognomonic for this case, but will fade within hours. You immediately stick EKG leads on this patient as he is at risk for cardiac arrhythmias. He mumbles that he was "just playing football when it happened."

Challenge: When what happened?

Related Questions:
1. What's the finding in the image?

(I have to say I'm particularly proud of discovering this one. I think it's really cool.)

Image shown under fair use.

Heart of the Matter

Challenge: Diagnosis?

Related Questions:
1. The red box in the second image marks an interval. What interval is it and how long is it?
2. What does the blue box represent?
3. The blue box plus the green box represents something. What interval is it and how long is it?

Both images are shown under GNU Free Documentation License.

Dancing

This case idea was taken from a talk by Dr. Yvonne Wu for the pediatrics subspecialties elective.

You see a 20 month old toddler, brought in because of stumbling. The child was able to walk fine several days ago, but now looks uncoordinated with rhythmic jerking of the limbs. When you examine the child, you notice his eyes have rapid, dancing movements. They are spontaneous, arrhythmic conjugate saccades in all directions.

Challenge: Unfortunately, this is a paraneoplastic syndrome associated with a tumor. What tumor are you worried about?

I Spy

Despite being an avid follower of Case of the Day, you get miffed at the silly cases so far. "Craig, what's up with all your cases? Sure, some of us might consider dermatology or radiology, but you know like 50% of us are heading for ophtho. You need to have an ophtho challenge!"

Well, never fear.


You appreciate this on ophthalmic exam. There are several things that can cause this appearance, but one of them is particularly likely in this patient of Ashkenazi Jewish descent.

Challenge: This person has an accumulation of something in his cells. What is it?

Related Questions:
1. What is the finding here called?
2. There could be a vascular cause of this finding. Which artery would be involved then?

Image is in the public domain.