Happy New Year's

You pull the short straw and get stuck with the New Year's Eve shift. A van pulls up to the curb of your ER and rolls a body out onto the doorstep before driving away. The patient looks like he's in his early 20s. He stumbles around looking pretty unsteady. You can't really elicit a history from him; his speech is slurred and he seems to have some memory impairment. His eyes look like this (click on image to make it move!):

With a big sigh, you run tests and rule out head trauma, hypoxia, hypothermia, hepatic encephalopathy, and other metabolic disarrangements. There is an elevated osmolal gap.

Challenge 1: What's the diagnosis? What's seen on the image?

Two days later, a different patient is brought into your ER by the police; he was seen on the streets shouting about the ninjas attacking him and vomiting. He looks to be in his mid-30s and he is very disoriented. He can only tell you about the pink elephant in the room, and any attempt to calm him just riles him up more. On exam, you find tachycardia, tachypnea, hypertension, a low grade fever, and marked diaphoresis. One of the bystanders comments that he's "seen this man before - he's always drinking and panhandling for more booze."

Challenge 2: What's the diagnosis?

Image shown under GNU Free Documentation License.

X Marks the Spot

On your last day of pediatric preceptorship, you see a 13 year old boy complaining of "weird spots" on his lower abdomen and butt. He also says that since a few years ago, he often has burning pain in his hands and feet, especially when he has a fever. This pain radiates proximally and is sometimes relieved with rest. On exam, you notice the following two findings (the second is seen by the slit-lamp):

When you ask the patient about his family history, he tells you that his uncle on his mother's side recently received a kidney transplant. This uncle also has skin lesions and extremity pain.

Challenge: What is your diagnosis?

Related Questions:
1. What is the skin finding?
2. What is the eye finding?

This case written by Kate Dinh.
Both images shown under fair use.

It's Not...

This woman storms into your office, absolutely outraged (or, by the blush on her cheeks, embarrassed?). She shouts, "The other doctor accused me of having syphilis! He said a lab test even confirmed it. I can't possibly have syphilis. I haven't slept with anyone in years."

Challenge: Explain.

Case idea contributed by Alex Penn.
Image is in the public domain.

Merry Christmas

A 14 year old boy presents to your clinic with a swollen and painful left knee. He said it was preceded by stiffness and followed by a warm sensation, then acute pain. There is no history of trauma; the boy just played a basketball game. You send off labs and get a normal platelet count and PT, and a prolonged aPTT. A mixing test corrects the abnormality. You send off a specific factor VIII assay; it's normal.

Challenge: What's the next most likely diagnosis? This disease has another name; who was it named after? What is its transmission?

Related Questions:
1. What's the differential for a normal PT and a prolonged aPTT?
2. (Review) A normal aPTT and a prolonged PT?
3. (Review) A prolonged PT and aPTT?

The Answer is Stroke

A forty year old woman presents with a stroke, but doesn't have the traditional risk factors (smoking, hypertension, or hypercholesterolemia). Instead, she presents with a swollen tender right calf after an 18 hour plane ride. She is currently on oral contraceptives. When you look at her hands, you notice cyanosis and the following finding:

Challenge: What's the cause of the stroke? What's the status of her lungs? What's the physiology of her heart?

Related Questions:
1. What is shown on the image?

This case idea contributed by Alex Penn.
Image is in the public domain.

Trompe-l'oeil

An 18 year old girl comes into your primary care clinic for an annual physical for her to play water polo. At first glance, she appears to be normal and healthy. However, on exam, you find a pulse of 50, BP 95/55, and QT elongation on EKG. She stopped menstruating over a year ago, but she says that it's probably due to her sports; she is unconcerned. When you ask her about school, she says her grades are all A's, but she doesn't seem to have much self confidence. As she talks, you notice chapped lips. On exam, you find this on her arms.

Challenge: This constellation of symptoms and signs worries you that she may have or be at risk for what disorder?

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

Image shown under fair use.

Scar

An ambulance brings an unconscious woman into your ER, but no one is able to tell you what happened to her. A quick exam shows heart rate 110 bpm, respiratory rate 24, blood pressure 100/60, and temperature 102 F. She appears to be in her thirties and looks very sick. There is a well-healed abdominal scar on the left upper quadrant.

Here's what a blood smear might show (arrow indicates abnormal finding):

Challenge: You suspect an infection. What type of organisms are most likely?

Related Questions:
1. What does the blood smear show?
2. What is the relevance of the scar?

Image shown under fair use.

Terrible T's

A 45 year old woman presents complaining of weakness that comes and goes. It's worse in the evening and after she plays tennis. She also complains that her tennis game is being affected because sometimes things "look funny." You suspect she's seeing double. On exam, you notice ptosis.

CXRs are shown above. You recognize the abnormality and remember the differential with the "T mnemonic."

Challenge: What's your diagnosis?

Related Questions:
1. What's the finding on the CXRs?
2. What's the T mnemonic? (or what is the differential for the abnormality?)
3. How does that relate to the patient's presentation?

Image shown under fair use.

Nerd Sniping

Someone compared this experiment to this comic from xkcd:
I was amused. Anyway, I'm happy with the way these cases are right now. I have a ton of ideas, but researching them, finding images, and writing up the cases and solutions takes time. Before the end of the year, I'll try to run some more really fun ones. Starting next year, I'll focus on more bread-and-butter USMLE 1 cases. I don't know how much longer things will last, but I'm having fun and hope you are too.

Image from xkcd.com, licensed under Creative Commons.

All That and a Bag of Chips

A 60 year old smoker presents with right shoulder pain that radiates up his neck and down the ipsilateral arm. He complains of dyspnea, non-productive cough, and facial swelling (worse when he bends forward or lies down). Here's another picture:

Here is a CXR of a similar patient (not the same because the finding is on a opposite side).

Challenge: This case has so many random syndromes, it seems almost artificial; it'd be such a good teaching case, you think. What's the final diagnosis? (Be specific - it's named after a Quaker who was, according to Wikipedia, the first professor of radiology).

Related Questions:
1. What's seen on the first image?
2. What's seen on the second image?
3. What's seen on the CXR?
4. Why the shoulder pain?

Images are all shown under fair use.

Also the Name of a Motorcycle

An Asian family brings their 2 year old boy into the emergency department complaining of irritability and a week long fever. They say he doesn't like to play outside anymore. On exam, you note a conjunctivitis in both eyes without exudate. His lips are chapped and erythematous. There are no ulcers or vesicles. You notice a rash on his perineum, trunk, and extremities.

Challenge: This child is at risk for serious complications. What imaging modality do you need to send him for?

Related Questions:
1. What's seen on the image?
2. This is a classic presentation of what disease?

Image shown under fair use.

History Lesson

It is 1985. An 18 year old woman presents to your office with a diagnosis of adenocarcinoma of the vagina. There is no family history of any cancers.

Challenge: Tell me about her mother.

Vera

A 60 year old man presents with an unusual chief complaint: he gets really itchy after he takes a bath. As you inquire further, you find other nonspecific complaints such as headache, weakness, dizziness, and excessive sweating. He also gets a weird sensation of burning pain in his hands and feet that's accompanied by erythema or cyanosis but he says that he feels a pulse when it happens. Past medical history is positive for peptic ulcer disease. On exam, you palpate a spleen and liver. You get back a CBC and well, all the numbers seem high. Here's a bone marrow biopsy stained for iron, 400x:


Challenge: What's the diagnosis?

Related Questions:
1. What's the symptom of itchiness called?
2. What's the symptom of burning pain called?
3. What's seen on the histology image?

Image shown under fair use.

It's Raining...

A 35 year old male presents with diarrhea and abdominal pain. This is seen on endoscopy. The patient does not take NSAIDs and is negative for H. pylori. When you take a further history, you find that the patient had a parathyroid tumor at age 30 which was successfully treated. His mother had some "pituitary thing."

Challenge: What's the cause of the finding seen on endoscopy? The patient also has an familial endocrine disease; what is it?

Related Questions:
1. What's the endoscopy finding?
2. The second part of the challenge involves "3P's." What are they?

Image shown under GNU Free Documentation License.