Octopus

A 60 year old postmenopausal woman who recently had an unexpected death of her husband in a car accident presents with acute-onset severe crushing left sided substernal chest pain radiating to the arm and neck, diaphoresis, and nausea. EKG shows ST segment elevation and cardiac enzymes are mildly elevated. She is rushed to the cath lab. However, there, her coronary vasculature shows no critical lesions. A left ventriculogram during systole is shown below.

Challenge: This is the favorite Moffitt cardiac diagnosis. What are you looking at?

Image shown under fair use.

Symmetric

A 30 year old female presents with symmetric weakness of the proximal legs. She also complains of mild paresthesias in the hands and feet and pain in the lower back. The only other remarkable thing is a recent viral illness. On exam, you find tachycardia and absent deep tendon reflexes. LP shows elevated CSF protein with a normal WBC count.

Challenge: What's the diagnosis?

MI

A 65 year old man who had an MI a month ago presents with chest pain upon deep inspiration as well as malaise. He received a coronary artery bypass for the MI. Currently, exam shows a temperature of 39, a pericardial friction rub, and leukocytosis. The sed rate is increased. Sequential radiographs are shown above.

Question: What is he currently suffering from?

Image shown under fair use.

Not to be Confused with Systolic Blood Pressure

A patient with severe end stage liver disease, cirrhosis from EtOH and hepatitis C, presents with several days of low grade fever, diffuse continuous abdominal pain and tenderness, altered mental status, and diarrhea. On exam, you notice a fluid wave ascites and decide to tap it for paracentesis.

Challenge: What are you looking for when you analyze the fluid?

Au

You do a far-away rotation in Asia where you see a 20 year old woman presenting with shortness of breath, fatigue, and pretibial petechiae that had an insidious onset. She has no significant past medical history, medications, allergies, or family history. However, when you start asking about bad habits, you pause in surprise when she says she "injects gold." Apparently, she thinks it brings fortune and acts as an aphrodisiac. She is afebrile, and all her vital signs are stable. Exam is notable for some petechiae, pallor, and bounding pulses. While some basic labs are cooking, you look at a peripheral blood smear under the microscope:

A bone marrow biopsy is done; hematology describes it as "wet" and "fatty." Here is what they see:

Challenge: What's the diagnosis?

Images shown under fair use.

Embryology Review

An adolescent presents with the finding shown above. A reconstructed CT is shown below.

Challenge: What do you think it is?

Both images shown under fair use.

200

Having written 200 of these cases, I realize how much stuff is out there in medicine. It's really wonderful and intimidating. I love learning about new and strange diseases, thinking about physiology and pathophysiology, and finding fascinating physical diagnosis images. I'd love to hear any suggestions you may have for how to improve this blog, and I'm happy to entertain ideas for good cases. Though this is a big time sink, it is a hugely educational one for me and I hope it is the same for you too. It will continue through winter break, but I will skip Christmas Eve Wednesday 12/24.

Incidental

A healthy asymptomatic adolescent enrolls as a test subject for a research experiment. A bunch of baseline tests are taken, all of which are normal except for mild isolated proteinuria (1g/d). So you ask him to do the following test:
-Discard the first morning void.
-Obtain a 16 hour collection between 7am and 11pm with the patient performing normal activities.
-Obtain a separate 8 hour collection between 11pm and 7am.

While the daytime collection has high urine protein, the overnight collection has 30mg/8 hours.

Challenge: What's the diagnosis?

Mets

A 60 year old post-menopausal African American woman presents concerned about episodic color changes of her face lasting about 10-20 minutes. She says her face, neck, and upper chest become purple and feel like they are burning. She feels her pulse racing during some of these episodes. They are provoked by eating, drinking alcohol (she denies having "Asian flush"), having a bowel movement, and emotional events. On review of systems, she also notes explosive, watery, and nonbloody diarrhea, almost 10 times a day, accompanied by abdominal cramping.

The patient was diagnosed with acne rosacea as well as new onset asthma by her primary care doctor a few months ago. She was prescribed an albuterol inhaler, but it makes the flushing worse so she has not been using it.

Prior to surgery, the anesthesiologist puts her on a drug that you don't recall for some sort of prophylaxis. At surgery, this is what you find:

Challenge: What's the diagnosis?

Related Questions:
1. In what other organ should you look?

Image is in the public domain.

Toxic

A 40 year old AIDS patient with CD4 count of 95 presents with a headache, confusion, and fever. A T1-weighted MRI with gadolinium is shown above.

Challenge: What's the diagnosis?

Image shown under fair use.

Sodium Channelopathy

A 40 year old Asian man presents for a routine adult check-up and because his father, paternal grandfather, and paternal uncle all died of sudden cardiac death in their sleep before the age of 40, an EKG is taken. A shows a normal EKG. B shows this patient's EKG. The cardiac review of systems is notable for an episode of unexplained syncope a few months ago.

Challenge: This is a rare cause of sudden cardiac arrest in a heart without a structural defect. What is it?

Image shown under GNU Free Documentation License.

White Spots

A 30 year old woman from Denmark presents with a several year history of intermittent sensory changes in her arms, legs, and face. From time to time, she will get in numbness or tingling but they usually self-resolve in time. She's also had episodes of double vision, vision loss, and problems with walking. On exam, when you flex her neck, she gets electric shock-like sensations that run down her back. T1-weighted MRI monthly scans are shown above.

Challenge: What's the diagnosis?

Related Question:
1. What's the sign elicited on exam?

Image is in the public domain.

Don't Miss It

This is an X-Ray of a 12 month old child with many soft tissue injuries who was said to have fallen after riding a tricycle.

Challenge: What's the diagnosis?

Image shown under fair use.

Platelet

A child presents with mucocutaneous bleeding but his platelet counts are normal. On a non-anticoagulated peripheral blood smear, you see single isolated platelets without platelet clumping. There is no response when you stimulate the platelets with ADP, epinephrine, or collagen. However, when you stimulate with ristocetin, you get a normal reaction.

Challenge: The child has developed antibodies against what complex? What is the disease called?

Prison

This is modeled after a case presented in resident report and one described in an American Family Physician 1998 article.

A man in his 20s is brought into your ER from prison because he was found seizing in his cell. He seized again in the ambulance and despite IV diazepam, he seized once more in the ER. Temperature is 38.0, pulse 105, blood pressure 170/80, respiratory rate 28. Neuro exam showed no focal abnormalities and the rest of the exam was unremarkable.

An ABG showed pH 7.03, PO2 298, PCO2 37, HCO3 9.3. Electrolytes were Na 144, Cl 104, K 3.5, CO2 10, glucose 150. CBC showed white count 18,000 (68% neutrophils). A serum and urine tox screen was negative, LFTs were normal, U/A was negative, EKG was normal. The CXR is shown below.

Upon seeing the CXR, your attending makes the diagnosis, administers one drug that reverses the seizures and corrects the metabolic acidosis.

Challenge: What's the diagnosis? What's the cure?

Image is in the public domain.

A Chicken Ain't Nothing But a Bird

Happy Thanksgiving! I was again hard-pressed to come up with a somewhat Thanksgiving related case. This one comes from a Warren Levinson lecture one year ago and I have to give thanks to him for the idea.

A medical student with known egg allergy presents with the following after receiving a vaccine.

Challenge: What vaccine was the culprit and why?

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

Image shown under fair use.

Sudden Cardiac Death

An 18 year old baseball player is hit in the chest by a regulation baseball at around 40 miles per hour and suffered cardiac arrest. He had no underlying heart disease and there was no structural damage to the chest wall, thoracic cavity, or heart itself.

Challenge: What happened?

Shades of Violet

A 45 year old female presents to your clinic complaining of weakness. She has trouble getting out of a chair or reaching for books on high shelves. She cannot identify when it started, but the weakness has been getting worse over the last few months. The weakness is symmetric and associated with mild muscle tenderness. On exam, you do not find any signs of muscle atrophy. Instead, you note the following:

Challenge: What's your diagnosis?

First two images are in the public domain; last two images shown under fair use.

The Spy Who Loved Me

This gentleman is a remarkable 7 feet, 2 inches tall. Note his facial features.

Challenge: What is the cause of this gentleman's condition?

Related Questions:
1. Who is this man and what is he known for?

Image shown under GNU Free Documentation License.

Hard to Pronounce

A five year old child presents with the finding shown above as well as several days complaint of colicky abdominal as well as hip and knee pain. You notice edema in the lower extremities, periarticular swelling and tenderness of the joints without effusion, erythema, or warmth. The stool is guaiac positive; there is also isolated microscopic hematuria.

Challenge: What's the diagnosis?

Image is in the public domain.

Identity, Supremacy, Ultimatum

You're a big fan of Matt Damon and buy the super deluxe froo-froo special collector's DVD version of The Bourne Identity. The opening scene cuts to a stormy night on an Italian fishing boat where one of the crew members pulls a body out of the water. In a scene omitted from the movie version, the medic puts on some EKG leads. With your ultra high definition Blu-Ray-Blue-Tooth TV, you can make this out:

Challenge: What's the abnormality, and what does it mean?

Image shown under fair use.

Localize the Lesion

Challenge: Where's the infarct?

Image shown under fair use.

Bananas

This is EKG week!
A hospitalized patient with known renal failure develops progressive lower extremity muscle weakness. The EKG is shown above.

Challenge: What is the abnormality seen and what is its significance?

Image shown under fair use.

The Sport of Kings

This patient presents with persistent rhinorrhea, oral ulcers, polyarthralgias, myalgias, and cough. A urinalysis shows microscopic hematuria.

Challenge: What's the diagnosis here?

Related Questions:
1. What's the finding shown here?
2. What's the sport of kings?

Image shown under fair use.

Ahhh

Challenge: This man recently completed a course of antibiotics. What's the diagnosis?

Image is in the public domain.

Vegetable

This week focuses on the head, ears, eyes, nose, and mouth exam.

Challenge: What's the diagnosis?

Image shown GNU Free Documentation License.

Happy Halloween

This woman presented asking for medication for anxiety. She just can't stop shaking. She keeps staring at you.

Challenge: What Halloween related word describes this disease?

Image shown under fair use.

Touch of God

I scrubbed into a surgery involving a lesion that looked pretty much like the one shown above. This appeared in a 40 year old female secretary after she applied lotion to her wrists and felt a pop. The lump was initially soft and painless, but over the last few months, it has grown in size, become harder, and caused a little discomfort. The mass transilluminates.

Challenge: What is the most likely diagnosis?

Image shown under GNU Free Documentation License.

Violin Strings

A 20 year old woman presents with sudden onset severe right upper quadrant abdominal pain radiating to the shoulder and pleuritic chest pain. She also complains of lower abdominal discomfort for the last few days that is worse with sexual activity and jarring movement. She just finished her last menstrual period. She does not use barrier contraception and has multiple sexual partners.

On exam, you note marked RUQ tenderness as well as diffuse lower quadrant tenderness with decreased bowel sounds and rebound tenderness. Unfortunately, she refuses a pelvic examination.

She was diagnosed with cholecystitis. On laparoscopic approach, you see the following image at the liver:

Challenge: I guess it's not cholecystitis. What's the diagnosis?

Image shown under fair use.

Honey

You see a 4 month old child brought in by the mother because of constipation, poor feeding, and weak cry. When you examine the child, you notice hypotonia, weakness, and loss of deep tendon reflexes. There is a decreased gag and suck, diminished range of eye movement, pupillary paralysis, and ptosis. You note decreased salivation and tearing and flushed skin. Prior to this illness, the child had been developing well; he had been able to lift his head, he had a social smile, and he was beginning to eat honey. He was never breastfed.

Challenge: What's the diagnosis?

Lines

You are napping on your radiology elective when your alarm rings. 4:55pm - almost time to go home! You quickly check if there are any new films and you see the one shown above. You're too lazy to read the clinical correlation; there are only 5 minutes before your shift is over.

Challenge: Quick! What's the pathology here?

Image shown under fair use.

Izzi

A patient comes in with acute right upper quadrant pain and a bit of nausea and vomiting. On exam, you note fever and jaundice. Labs show an elevated alkaline phosphatase and bilirubin. An ERCP cholangiogram is shown above. Luckily, the gastroenterologist labeled it for you.

Challenge: This syndrome is pretty nifty and was named after an Argentinean physician in 1948. What is it?

Image shown under fair use.

Hands

A woman in her 50s with the longstanding finding shown above presents to your clinic because she feels a mass in her belly. She's also has recurrent respiratory tract and skin infections. The finding in her hands began in her 40s and there is a positive family history of that disease. Palpation of the belly shows an enlarged mass in the left upper quadrant. Routine lab tests show absolute neutrophil count of <2000/mm3 (low).

Challenge: What is this syndrome called?

Related Questions:
1. What HLA is she likely to have?

Image shown under fair use.

EKG

Challenge: Read the EKG.

Image is shown under Creative Commons Attribution ShareAlike 2.5 License.

I Never Learned This Nerve in Anatomy

An obese patient with a large panniculus presents with burning pain, numbness, and tingling over the upper outer thigh. It is worse when he bears down. He can demarcate the area affected; it is about 10x6 inches, oval-shaped, anterolateral thigh. Pinprick and light touch are affected. Straight leg test is negative. Deep tendon reflexes are all normal. Distal motor strength is normal. You don't notice any abnormalities in the hip, back, or sacroiliac joints.

Challenge: What nerve is involved? What is this called?

Oma

A 50 year old male presents with the strange skin finding shown above. It began as erythematous plaques on the face, perineum, and extremities, but over the last week or two, the lesions have become larger and confluent. There's some central clearing, leaving bronze indurated central areas with blistering, crusting, and scaling at the borders. The lesion is pruritic and painful.

The patient also complains of weight loss, sore lips, and abdominal pain. The chart notes a recent diagnoses of venous thrombosis, diabetes mellitus, and neuropsychiatric changes. HbA1C is 9.8. The patient has a normochromic, normocytic anemia.

Challenge: Assuming all the findings here are due to one cause, what does the patient have?

Image shown under fair use.

Wrong

Challenge: You should never see this. What is wrong with this X-Ray?

Image shown under fair use.

Hypothetical

Now if you look at this gentleman (apologies to those who don't want to), you'll notice his face isn't quite symmetric. In 2000, he had an operation to remove a malignant melanoma from the left side of his face. Now, suppose (hypothetically) that when this gentleman eats, his left cheek becomes wet. There's no open wound or fistula. When given a lemon to bite down on, his left ear and parotic regions become flushed and sweaty.

Challenge: What's the diagnosis?

Related Questions:

1. Who is this person?

Image is in the public domain, from Wikipedia.org.

The Acute Abdomen

An 18 year old girl presents with severe generalized abdominal pain and vomiting. She is hysterical, appearing to hear voices, agitated, and almost delirious. The patient also notes nausea, constipation, urinary retention, dysuria, and proximal leg weakness. For the last few days, she has not eaten very much due to social stressors. Past medical history is significant for long-standing anxiety and hypertension. She has had one previous episode of a similar attack lasting for days and it was associated with a seizure. There seems to be some family history of this disease, though the patient cannot recall what it's called. On exam, she is hypertensive and tachycardic. Her skin looks normal. You make the diagnosis by urine testing.

Challenge: What is the diagnosis?

Wing

A sheep farmer in Australia presents with the eye shown above. The patient complains it is irritating, red, and disfiguring.

Challenge: What is it?

Image shown under fair use.

Dendrite

A patient comes in with acute onset ocular pain, visual blurring, and discharge. You notice chemosis (conjunctival edema) as conjunctivitis. After using a particular stain, you notice the characteristic feature seen above.

Challenge: What's the diagnosis?

Related Questions:
1. What kind of stain is this?

Image is shown under fair use.

Japanese

A Japanese patient presents with bilateral loss of vision and the red eye shown above. Fluid accumulating behind the retina leads to retinal elevation and predisposes him to a retinal detachment. You also notice the whitening of his eyelashes, white patches on the skin, a history of sterile meningitis, loss of hair, and an 8th nerve palsy. This disease is also seen in the Hispanic population.

Challenge: This is a hard one. What is it?

Image is in the public domain.

Give Me Five

Challenge: This finding in conjunction with a protruding tongue, an atrioventricular septal defect, duodenal atresia, and astigmatism suggest what disease?

Image shown under fair use.

Multisystem Disorder

This man with a positive family history of this disease presents with leg pain, exacerbated by deep palpation of the muscles. He also complains of colicky abdominal pain, constipation, diarrhea, and dysphagia. Recently, his cardiologist told him he had atrial flutter, his primary care doctor noted primary hypogonadism and testicular atrophy, and his ophthalmologist found cataracts. Review of systems picks up excessive daytime sleepiness. When he first comes in to shake your hand, you notice he has trouble letting go; when he leaves, he also has difficulty letting go of the doorknob. You note weakness in the facial muscles, intrinsic hand muscles, and bilateral foot drop.

Challenge: What's the diagnosis?

Image shown under fair use.

Obstruction 3

A 3 year old boy living in Asia presents with intermittent colicky abdominal pain, vomiting, and constipation. On exam, you feel an abdominal mass near the ileocecal valve area. In the past, he has had longstanding abdominal discomfort, anorexia, nausea, and diarrhea. About a month ago, he had an irritating nonproductive cough, pleuritic chest pain, rales, and wheezing. Laboratory tests at the time showed eosinophilia. Luckily, you recognize the cause:

Challenge: What is the disease?

Image is in the public domain.

Obstruction 2

A 70 year old man with multiple medical conditions including a recent pneumonia, a recent MI, and Parkinson's disease presents with nausea, vomiting, constipation, and diarrhea. On exam, his abdomen is so distended that it causes labored breathing. The abdomen is tympanic and bowel sounds are present. Labs show hypokalemia, hypocalcemia, and hypomagnesemia. Further workup excludes toxic megacolon and mechanical obstruction. The treatment is neostigmine.

Challenge: What is this eponymous disease?

Image shown under fair use.

Obstruction

This week is obstruction week! Here's the first case:

A 70 year old woman presents with intermittent abdominal pain and vomiting over the last few days. Past medical history is significant for coronary artery disease, COPD, and diabetes mellitus. There is no history of abdominal surgery. On exam, the patient is febrile, appears dehydrated, has increased bowel sounds, and has abdominal distension. Here's a CT with contrast:

The red and blue arrows note air, the yellow arrow notes the pathological finding, and the green arrow notes dilated and fluid-filled small bowel.

Challenge: This is small bowel obstruction but what specifically is the etiology?

Image shown under fair use.

First Described in 1849

A 35 year old African American woman who gave birth to twins 2 months ago presents with marked dyspnea and cough, sometimes bringing up blood. She says that she requires several pillows to sleep and will wake up short of breath several times in the night. Although she had pre-eclampsia in pregnancy, her cardiac function before that was normal. There was postpartum hypertension.

You do a cardiac work-up and find LV ejection fraction of 35%; EKG with sinus tachycardia, nonspecific ST wave abnormalities, and voltage abnormalities; echo showing global reduction in contractility and LV enlargement; and CXR confirming enlargement of the cardiac silhouette with pulmonary venous congestion. You rule out PE, amniotic fluid embolus, anxiety, infection, and asthma.

Challenge: What's the diagnosis here?

The Nose Knows

A 15 year old male presents with severe epistaxis from the back of his nose. There is nasal obstruction, nasal drainage, serous otitis media, and diminished hearing on exam. A gadolinium enhanced T1 weighted fat saturated MRI is shown above. Although locally aggressive, histology shows this mass to be benign.

Challenge: What is it?

Image shown under fair use.

Very Important

A 40 year old woman presents with months of diarrhea. Even when fasting, the stool volume is >700 mL/day; it averages 3 L/day. You hate to ask, but you learn the stool is tea-colored and odorless. There is no abdominal pain, but she gets some flushing, lethargy, nausea, vomiting, muscle weakness, and muscle cramps. Labs show a low potassium. A stool analysis shows an osmotic gap of 30 mOsm/kg (normal 50-125).

Challenge: What's the diagnosis?

Thief

A middle age man with known atherosclerotic disease presents with left arm claudication, fatigue, coolness, and tingling. He gets dizzy when he exercises the arm. On examination, you note the left arm has a 15mmHg lower systolic pressure than the right arm. Palpation of both radial pulses shows a decreased amplitude and delayed arrival on the left side.

Challenge: If blood is flowing in the wrong direction, what syndrome is this?

Out of Crime

This smear is seen from a woman who had an uncomplicated UTI treated with an oral agent 100 mg twice daily for 7 days. This agent is only used for E coli UTI.

Challenge: What caused the finding shown in the blood smear?

Image shown under fair use.

Emergency Ultrasound

*Note: I originally put up a different case for today but decided to change it to a pregnancy-related case since, of course, it's labor day.

A 33 year old woman is BIBA (brought in by ambulance) for hypovolemic shock. You note a significant ascites, hyponatremia, hyperkalemia, and pleural effusion. She says, "I've been trying to get pregnant." You get an ultrasound:

It might look like PCOS (polycystic ovarian syndrome) but your attending suggests it is something more serious.

Challenge: What does your attending think?

Related Question:
1. How does wanting to get pregnant fit into this picture?

Image shown under fair use.

He Named It, Then Died of It

A 60 year old man presents to your emergency department with epigastric pain that radiates to the back. He says that the pain is alleviated by sitting up or leaning forward. It is worse 15-30 minutes after eating. Sometimes, he also gets nausea and vomiting. He is a heavy drinker and smoker. As you ask him about other symptoms, he mentions loose, greasy, foul smelling stools. He went to a free diabetes clinic last year and was told he had diabetes. He had several episodes of hypoglycemia in which he came to this ER but after being treated, left AMA (against medical advice).

In 1865, a physician documented an odd pattern of traveling thrombosis. He described a patient who had recurrent migratory thrombosis of the superficial veins in odd sites like the arms and chest. You notice that in this patient. He looks pretty ill, and when you ask him further, he says he's lost a significant amount of weight.

Challenge: Imaging studies are necessary to confirm, but what's your top diagnosis?

Related Questions:
1. The first and second paragraphs, though related, suggest distinct diseases (ie. the first is a risk factor for the second). What are they?
2. What's the pattern of traveling thrombosis called?

Help

A pregnant woman at 32 weeks gestation presents with abdominal pain, nausea, vomiting, and malaise. She has mid-epigastric and right upper quadrant tenderness. Exam shows blood pressure 150/90 and proteinuria. Labs show platelets at 80,000, serum LDH 800, total bilirubin 2.0, and serum AST 120.

Challenge: What is your diagnosis?

Image shown under fair use.

Sympathy

In an unfortunate industrial accident, a patient's right eye is lacerated with a sharp instrument. He loses function of that eye, but it is not removed. Several years later, the other eye is diagnosed with uveitis. Weird.

Challenge: What's the diagnosis?

No Longer Seen

A young child presents with non-specific symptoms of nausea, vomiting, headache, excitability, delirium, and combativeness. It slowly progresses to coma. The only other remarkable finding was a recent chickenpox infection that the parents treated with this:
Challenge: What is your diagnosis?

Image is in the public domain.

Derivative

A 6 year old child presents with a puffy face and puffy legs. His albumin is 2.8 g/dL (low).

Challenge: What's the most likely diagnosis?

Image shown under fair use.

Ictal

A patient presents to your clinic with moderate weakness of the left hand. It had a sudden onset and the patient is afraid he had a stroke. The history of present illness is significant for an episode earlier today of loss of consciousness. He says that his wife noted involuntary left hand movements at that time.

Within a few hours, the patient's weakness resolves.

Challenge: This condition was first described by a British physician in 1849. What is it?

Brobdingnagian

A 72 year old man complains of pain and stiffness in his neck, shoulders, and hips. He also gets some pain in his jaw when eating. Speaking of pain, he's noticed a recent new headache. Here's a biopsy:

Challenge: What should this gentleman get before he leaves your office today?

Related Questions:
1. What is the pain in the neck, shoulders, and hips called?
2. What is the feared complication of this disease?
3. What lab test would you like to get?

Images shown under fair use.