Wednesday, July 30, 2008

Multiple Choice

This is not an artifact.

Challenge: Of the following, which organ system should you investigate - heart, lungs, kidney, or spleen?

Related Question:
1. What is shown in the image?

Image shown under fair use.

Monday, July 28, 2008

Occupational History

A 50 year old male who works in the fluorescent lamp industry presents with nonspecific symptoms of dry cough, shortness of breath, night sweats, fatigue, and weight loss. Examination reveals bibasilar rales and clubbing. Labs show hypercalcemia. CXR is normal. PPD is negative. A methacholine stimulation test is negative. Transbronchial biopsy shows noncaseating granulomas and mononuclear cell infiltrates.

Challenge: Given the occupational history, one diagnosis is a little more likely than sarcoidosis (I know you were thinking it). What is it?

Friday, July 25, 2008


Routine blood cultures are drawn on an otherwise healthy 20 year old man enrolled in a research study. Cultures are drawn from 2 sites on different arms. The culture from the left arm is negative. The culture from the right arm shows the above image after 72 hours. The study subject does not have fever, hypotension, leukocytosis, or any other detectable laboratory abnormalities.

Challenge: What antibiotic (or class of antibiotic) would you prescribe?

Related Questions:
1. What is the organism shown above?

Image shown under fair use.

Wednesday, July 23, 2008


A patient comes in complaining of feeling "terrible," restless, muscle and joint pain, nausea, vomiting, abdominal cramping, and diarrhea. You also notice watery eyes, a watery nose, and constant yawning. On exam, you find mydriasis and piloerection.

Challenge: What is the plant shown above?

Image is in the public domain.

Monday, July 21, 2008


This is the hand from a 40 year old male smoker (40 pack years). He also notes the same findings in the other extremities. The patient is not diabetic and negative for ANA, RF, anticentromere antibody, Scl-70, antiphospholipid antibodies. Complement is normal and there are no genetic causes for clot-formation. Transthoracic echocardiography shows a normal heart.

Challenge: What's the diagnosis?

Image shown under fair use.

Friday, July 18, 2008


A 20 year old woman presents to your office complaining of "bugs crawling under her skin." She points all over her body and says she can feel mites crawling from one part of her body to the other. This has been going on for a while but the onset has been insidious, maybe over months to years. She has a history of dermatologic complaints like rashes, pruritis, and sensations of stinging or biting. She has gone to multiple physicians without relief. Today, she's brought in a specimen which she has picked from her skin; it just looks like flaky dry scales. When you confront her, she is offended, saying that she knows all about this bug's life cycle: when it's most active, when it reproduces, how it enters and leaves the body.

She has no medical or psychiatric problems other than polysubstance abuse and no history of head injuries. There is no objective evidence for any infection.

Challenge: What is the diagnosis and most likely etiology?

Wednesday, July 16, 2008

Newborn Exam

You are doing a newborn exam on a baby delivered by forceps and notice a finding that you have trouble describing. On the head, you notice a "bump." On palpation, it appears to be contained within a "compartment" though you're not sure what that really means. It is a fluctuant mass. Here's an X-ray.

The mass (white arrow) does not cross the point indicated by the black arrow.

Challenge: What's the diagnosis?

Image shown under fair use.

Monday, July 14, 2008


A 20 year old is hit in the eye by a baseball. On exam, you find enophthalmos (the eye is receded into the orbit). The eye on the affected side is lower in the horizontal plane than the other side. When you have the patient look up and left, you see this:

You get a coronal CT, shown below:

Challenge: What happened?

Images shown under fair use.

Friday, July 11, 2008

Something Different

A 30 year old female comes to your primary care practice for the first time. As you look at her history, you notice she's shopped around for many different doctors. When you ask her about it, she says she has an intense fear of abandonment and that doctors hate her.

Taking her social history, you notice many short term boyfriends; she admits that her relationships are unstable and intense. "Sometimes I think we'll get married after going out for a month and then the next day I think he's betraying me." She doesn't seem to have a strong sense of identity. She says, "I just don't know who I am. Sometimes, I feel like killing myself. I just feel so empty."

On exam, you find lesions consistent with genital herpes. "Oh yeah, I'm kind of impulsive with sex. And gambling. And drinking," she says. But when you inquire further, you get a sense that this is all the time, not episodic. "You idiot," she says, "What do you think I am? Bipolar? Stupid, all the doctors think that."

Challenge: What personality disorder does this best characterize?

Wednesday, July 9, 2008


= ?

First image is shown under GNU Free Documentation License; second image is in the public domain.

Monday, July 7, 2008


This is a kidney biopsy from an African American patient with acute onset peripheral edema, low albumin, severe proteinuria, hypertension, and microscopic hematuria. The cause is idiopathic. On the biopsy, some other glomeruli look completely normal.

Challenge: What's the diagnosis?

Image shown under fair use.

Friday, July 4, 2008


You meet a 40 year old man who had bariatric surgery about 10 weeks ago. He had a BMI of 41 and had failed non-surgical weight loss. He underwent a Roux-en-Y gastric bypass procedure without complications. Today he presents to you complaining of nausea, shaking, sweating, and diarrhea shortly after eating cookies and candies. He's developed an aversion to those foods.

Challenge: This describes a common syndrome after Roux-en-Y gastric bypass. What is it?

Wednesday, July 2, 2008

Path (Part 2)

*Note: This is the same patient as the one in the previous case (Histo).

The patient's disease is a very aggressive non-Hodgkin's lymphoma, but with chemotherapy, you induce a remission. Unfortunately, a decade later, the patient dies. He had dyspnea on exertion, impaired exercise capacity, orthopnea, paroxysmal nocturnal dyspnea, and peripheral edema. Autopsy shows the following:

You attribute this unfortunate death to this:
Challenge: What is that chemical?

First image shown under fair use, second image shown under GNU Free Documentation License.