Friday, May 30, 2008

Weird Cancer

A 56 year old African American male presents with severely pruritic skin rashes. For the last few years, he's had nonspecific scaling skin lesions and biopsies were unremarkable. A primary care doctor gave him the diagnosis of "nonspecific dermatitis." But now he comes to your dermatology clinic with scaly patches and plaques >5cm in diameter. They are confined to the trunk. He also has generalized erythroderma and lymphadenopathy.

A skin biopsy shows this:

The red arrow indicates a specific type of microabscess. The blue arrow shows mononuclear cells in the epidermis. A blood smear shows this:

Challenge: This is one of the weirder cancers you've seen. What is it?

Both images shown under fair use.

Wednesday, May 28, 2008


An otherwise healthy 20 year old presents with palpations on exercise. He was put on cardiac monitoring and this pattern was seen; it was short-lived and terminated spontaneously. On a further history, you find that a few of his family members have had sudden cardiac death. They follow an autosomal dominant inheritance. All other organ systems are negative. The patient is not taking any medications.

Challenge: What does the EKG show? What is the most likely cause?

Image is in the public domain.

Monday, May 26, 2008


These adrenal glands came from a patient who presented with severe hypotension, abdominal pain, high fever, nausea and vomiting, and confusion. The clinical course was unfortunate, with falling hematocrit, progressive hyperkalemia and hyponatremia. Autopsy was done. The microbiology sent shows this:

Challenge: What is this syndrome called?

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

Friday, May 23, 2008


One of your friends, a 25 year old woman, calls you up in the middle of the night panicked because she "peed blood." With a sigh, you go over to her apartment to calm her down. When you examine her urine, you find that it's not blood, just red urine. Weird. You can't quite put your finger on the diagnosis yet, but as you haven't seen her for a while, you two sit around the dining table catching up about the good old college years. As you're talking, you notice that she keeps going to the freezer to get ice cubes to chew on. When she opens her fridge, you see these.

Challenge: That's all I needed to make the diagnosis. What about you?
(I'm kidding, this is a tough Encyclopedia Brown case)

Image shown under GNU Free Documentation License.

Wednesday, May 21, 2008


A 30 year old woman presents with difficulty swallowing. On exam you see the tongue shown above. She also remarks that her tongue really hurts and she has dry mouth.

Challenge: What's the diagnosis?

Image shown under Fair Use.

Monday, May 19, 2008

When All You Have is a Hammer, Everything Looks Like

A 40 year old woman recently diagnosed with celiac disease presents with fatigue. She says that she can only walk a few blocks or flights of stairs before she gets tired. She can't recall a specific incident that brought this on; now that she thinks about it, it's been going on for a while. Past medical history is remarkable only for the celiac disease. There is no pertinent family history. She has had three kids. On exam, everything seems within normal limits except for the finding shown below.

Challenge: What's the diagnosis?

Image is in the public domain.

Friday, May 16, 2008

Count the Ribs

You are doing a newborn exam and find a baby with narrow, sloping, "weird" shoulders. The baby seems unusually flexible; you can bring his shoulders almost together in the midline in front. You identify the abnormality on the CXR above. You remember that this diagnosis often involves delayed closing of the fontanelles (which may remain open to adulthood), defective bone formation, short stature, supernumerary teeth, and abnormal tooth eruption.

Challenge: The defective gene is a transcription factor called what?

Hint: The number of ribs you count isn't important, but you may notice something interesting while counting the ribs.

Image shown under fair use.

Wednesday, May 14, 2008

Skin Lesions

A young Latin American woman comes into your office for a routine check-up. On physical exam, you find these marks.

Challenge: What's the etiology?

Image shown under GNU Free Documentation License.

Monday, May 12, 2008


A 30 year old G1P1 who gave birth to a healthy baby boy two days ago presents with lethargy, anorexia, weight loss, and inability to lactate. The course of pregnancy was prolonged, and multiple units of blood were given. If the tissue in question were to be examined histologically, this would be seen:

Challenge: What's the diagnosis?

Image shown under fair use.

Friday, May 9, 2008

Tricks are for Kids

You are visiting Arkansas (it's unclear why) and decide to see the famous show, The Cat Wrestler. Unfortunately, the show is canceled at the last minute. You go to investigate why and find that the cat wrestler, star of The Cat Wrestler, presented to the local hospital with this finding:

He had an abrupt onset of fever, chills, headache, and malaise a few days after noticing this lesion. Exam showed regional tender lymphadenopathy. Routine lab tests were nonspecific. Routine cultures of blood, skin lesions, and lymph nodes did not show any organisms. But, you ask the lab to supplement the growth conditions with cysteine and CO2. The result is a pale-staining, small, aerobic, Gram negative coccobacillus.

Challenge: What is the organism? What's the clinical diagnosis?

Image is in the public domain.

Wednesday, May 7, 2008

Kneed a Diagnosis

A young male alpine skier who felt a pop in his knee with subsequent swelling and instability presents with this radiograph.

Challenge: Diagnosis?

Image shown under fair use.

Monday, May 5, 2008


A 20 year old basketball player reports hearing a "pop" at the back of his heel after landing. There was an intense pain; the patient says he thought someone had hit him with a bat. With the patient prone and foot hanging off the table, squeezing the gastrocnemius does not cause plantarflexion (it does on the unaffected side).

Challenge: This classic history with this special test point to the diagnosis what?

Friday, May 2, 2008


A 25 year old female with a positive PPD who has never been treated for TB presents to your emergency department with chest pain and trouble breathing. When you're taking her blood pressure, something odd happens. You notice the first Korotkoff sound at 110 only during expiration; you don't hear the first Korotkoff sound throughout the respiratory cycle until 95. You notice an elevated jugular venous pressure that does not change with inspiration as well as venous distension of the forehead and scalp. You can barely hear her heart sounds. EKG shows sinus tachycardia with low voltage. You get a CXR and CT.

On the CT, the red arrow points at the myocardium.

Challenge: What's the diagnosis?

Related Questions:
1. What's the blood pressure finding called?
2. What's the absence of JVP change on inspiration called?
3. This represents a triad. What is it?
4. What does the white arrow point to on the CT?

I created the first image (paradox!).
Second image shown under fair use.