Blue Baby

A newborn presents with profound cyanosis, agitation, and increased respiratory rate. You listen to the heart and only hear a single second heart sound (no split) along with a faint crescendo-decrescendo murmur. Here is the CXR:

Challenge: What's the diagnosis?

Related Questions:
1. With a larger obstruction, do you get a louder or fainter murmur?
2. What's seen on the CXR?

Image is shown under fair use.

Atlas

An old timer challenges you: "You and your new fangled fancy frumpy fMRI and other imaging machines. Back in my day, we did everything by physical examination alone." He pulls out an Atlas of Physical Diagnosis and flips to a random page.


Challenge: What's the likely title of the page? What does each image show?

All images shown under fair use.

An Arm and a Leg

You examine a 2-week old male. Oddly, the blood pressure in the right arm is higher than the blood pressures in the legs. You can barely feel a femoral pulse, and when you palpate both the femoral and right brachial pulses, the femoral one is delayed.

Challenge 1: What is your diagnosis?

You examine a female neonate who was delivered 8 hours ago. Her respiratory rate is elevated and she is cyanotic. You put on some pulse oximeters and oddly enough, the oxygen saturation in her right arm is higher than that in her legs.

Challenge 2: How can this be the case?

Double Take

It's the next day in the ER and you see the same case as the last one. This time, a 70 year old woman presents with dullness to percussion on her right lung fields, diminished breath sounds, decreased fremitus, and egophony. An upright chest X-ray shows blunted costophrenic angles and the lateral decubitus film looks the same as the one for the previous case.

This time though, the problem is compounded by abdominal distention. You appreciate a "fluid wave" - when you tap on one side of the belly, you generate a wave-like effect that transmits to the other side. The patient denies alcohol consumption. She reports a family history of ovarian cancer.

The treatment for this condition is surgery. Unfortunately, the patient does not survive surgery. An autopsy is done.

The pathology report has a big coffee stain on it. You can make out "bilateral...arose from ovarian stroma..."

Challenge: This syndrome is characterized by a triad of the lung finding, the abdominal finding, and the pathology finding. What is the syndrome called?

Related Questions:
1. What is the abdominal finding?
2. What is the pathology finding?

Image shown under fair use.

Double Trouble

A 70 year old man with a 40 pack-year history of smoking and a previous occupation as a shipyard worker presents to the ER with chest pain, shortness of breath, and cough. On exam, you find diminished breath sounds on the right and decreased fremitus. While listening to the patient with a stethoscope, whenever he says "E" you hear "A." A lateral decubitus chest X-ray is shown above. Your attending makes the marks "A" and "B." After further evaluation, you do a biopsy of the pleura of the lungs.

Here's the biopsy:


The left is lower magnification while the right is a higher magnification image.

Challenge: What is the pathology shown in the biopsy?

Related Questions:
1. What is the "E to A" change called?
2. What is shown on the CXR?

First image is in the public domain. Second image shown under fair use.

The Name is a Misnomer

It is early summer. A 40 year old Caucasian male in North Carolina presents with the rash seen above. He said for the past two days, he's had fever, severe headache, malaise, myalgias, arthralgias, and nausea. The rash started on his ankles and wrists and has proceeded to affect his other limbs and move centrally. He went fishing at a wooded lake a couple days ago. This is a life-threatening condition.

Challenge: What is the most likely diagnosis? What is the causative agent?

Image shown under fair use.

Complementary and Alternative Medicine

A 50 year old man presents to your emergency room in an agitated delirium. He appears anxious, restless, and disoriented. His chief complaint is vomiting and diarrhea. On examination, he is visibly sweating, his pulse is 100, his blood pressure is 140/90, and he has a fever. You notice he has a tremor in his extremities. He has rigidity of the lower extremities. On the neurologic exam, he has hyperreflexia and a bilateral Babinski sign.

You find out that he was at the hospital recently when he was diagnosed with and treated for depression. You ask him about this, and he says, "Oh yes, I read online that St. John's wort is really good for depression."

Challenge: What's the diagnosis?

Private Practice

A 30 year old woman presents to your clinic because she's lost her appetite recently. She feels really tired all the time; the fatigue gets better when she rests, but it's like she has no energy. She has general weakness and has had some weight loss. You assess for depression, but it seems to be more than that. She has nausea and occasional vomiting, abdominal pain, diarrhea, and constipation. She's felt dizzy on occasion. She says she enjoys laying out in the sun cause she tans really easily. On exam, you find orthostatic hypotension and notice this:

Challenge: What's the diagnosis?

Related Question:
1. What's seen on the image?

Image shown under fair use.

One Liner

When you see a 10-hour-old Caucasian newborn with severe vomiting and abdominal distention who has not yet passed any stool, you confirm your diagnosis by licking the baby.

Challenge: What is the diagnosis?

Related Questions:
1. What is the vomiting, abdominal distension, and absence of stool called?
2. What did you find when you licked the baby?

Note: I decided not to take a suggestion to name this case "Lollipop."

Need to Know

You are examining a 60 year old obese female patient two days after a hip replacement. She is a 50 pack-year smoker currently being treated for breast cancer. As you are examining her, she suddenly becomes short of breath. Her respiratory rate increases to 24 and heart rate increases to 110. In between breaths and coughs, she says, "it hurts when I breathe in." You hand her a tissue and when she coughs again, you see there is blood on the tissue.

She gets an immediate CT angiogram. The abnormalities are shown by the arrows.

Challenge: What is your diagnosis?

Related Questions:
1. What is the significance of the hip surgery?
2. What is the significance of the lung cancer and obesity?

Image shown under fair use.

Van Beethoven

A 30 year old man presents to your emergency department complaining of severe pain in his mouth and an inability to swallow. He leans forward as he talks. He complains of a stiff neck and drooling. You note a fever and stridor on pulmonary exam. As you look into the oral cavity, you see that the tooth shown below has partially come out of the gums in the lower right jaw. There is swelling and stiffness of the jaw and sublingual space.

Challenge: What's the diagnosis?

Related Questions:
1. What kind of tooth is that?
2. What's stridor?

First image in the public domain.

Med Student Consult

You are just beginning your second year of med school when your cousin calls you. "You're a doctor, right?" Before waiting to hear your fervent denial, she continues, "I'm a little worried, and I'm wondering if you can help me. My fingers and toes really hurt, they feel so cold. I haven't been doing anything unusual though, so I don't know why. They were really white the other day, and now they're bluish. I'm really worried! They occur in both my hands and both my feet. I don't know what to do."

You tell her to calm down. Your cousin is about 21 and just broke up with her boyfriend. She goes to school in Wisconsin. She is a smoker and has pretty bad migraines.

Challenge: What is your diagnosis?

Image in public domain.

Eggs in One Basket

A 30 year old woman presents to your fertility clinic because she is having difficulty getting pregnant. As you take a focused history, you find that she began having periods at age 14 but her cycles have always been irregular, infrequent, and unpredictable. She had severe acne when she was young and has had an abnormal amount of hair on the upper lip, chin, around the nipples, and along the linea alba of the lower abdomen. When you take an ultrasound of her ovaries, you see this:

Challenge: What is your diagnosis?

Related Questions:
1. What is the hair finding called?
2. What is seen on the image?

Image shown under Fair Use.