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?

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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?

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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?

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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?

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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?

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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?

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EKG

Challenge: Read the EKG.

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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?

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Wrong

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

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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?

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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?

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