Friday, August 29, 2008

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?

Wednesday, August 27, 2008


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.

Monday, August 25, 2008


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?

Friday, August 22, 2008

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.

Wednesday, August 20, 2008


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.

Monday, August 18, 2008


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?

Friday, August 15, 2008


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.

Wednesday, August 13, 2008


This is a 21 year old man with hypertension and glucose intolerance who notices easy bruising, proximal muscle weakness, hirsutism, and impotence.

Challenge: What's the diagnosis?

Image shown under fair use.

Monday, August 11, 2008


You are on vacation in Thailand when you meet a diabetic drinker with renal disease. He presents with fever, cough with sputum, chills, rigors, and respiratory distress. Even though you're on vacation, you get interested when you find out the organism that grew out is rarely seen in the U.S. A gram negative bacillus with characteristic bipolar staining looking like a "safety pin" is isolated.

Challenge: The causative organism is a facultative intracellular bacterium called what?

Image is in the public domain.

Friday, August 8, 2008


A patient recently diagnosed with HSV-1 encephalitis demonstrates remarkable placidity with loss of normal fear and anger, increased sexual aggression, and increased appetite.

Challenge: What syndrome is this?

Wednesday, August 6, 2008


This EEG is from a child who was referred to you because of declining school performance. The teacher says the child daydreams a lot and seems to zone out during class.

Challenge: What's the diagnosis?

Image shown under fair use.

Monday, August 4, 2008

Neuro Week

This is neuro week! An emaciated homeless man with alcohol on his breath presents to your emergency department confused and unable to walk. On examination, you find profound disorientation and lack of attention. Neuro exam shows horizontal nystagmus, bilateral cranial nerve VI palsy, and sluggish pupils. Unfortunately, he does not survive and an autopsy is done, showing this:

Challenge: What is the importance of the following molecule?
Related Question:
1. What does the pathology specimen show? Where is the lesion?
2. What is the diagnosis? What is the clinical triad here?

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

Friday, August 1, 2008


At the time of weaning, a 6 month old infant has irritability and vomiting. Studies show recurrent episodes of hypoglycemia after feeding, fructosuria, hepatomegaly, jaundice, aminoaciduria, a metabolic acidosis, and low urine ketones. The child begins to develop failure to thrive. Milk is okay. Sweets and fruits are not. This is not a glycogen- or gluconeogenesis-related problem.

Challenge: This is a recessive disorder caused by deficiency in what enzyme?