Octopus

A 60 year old postmenopausal woman who recently had an unexpected death of her husband in a car accident presents with acute-onset severe crushing left sided substernal chest pain radiating to the arm and neck, diaphoresis, and nausea. EKG shows ST segment elevation and cardiac enzymes are mildly elevated. She is rushed to the cath lab. However, there, her coronary vasculature shows no critical lesions. A left ventriculogram during systole is shown below.

Challenge: This is the favorite Moffitt cardiac diagnosis. What are you looking at?

Image shown under fair use.

Symmetric

A 30 year old female presents with symmetric weakness of the proximal legs. She also complains of mild paresthesias in the hands and feet and pain in the lower back. The only other remarkable thing is a recent viral illness. On exam, you find tachycardia and absent deep tendon reflexes. LP shows elevated CSF protein with a normal WBC count.

Challenge: What's the diagnosis?

MI

A 65 year old man who had an MI a month ago presents with chest pain upon deep inspiration as well as malaise. He received a coronary artery bypass for the MI. Currently, exam shows a temperature of 39, a pericardial friction rub, and leukocytosis. The sed rate is increased. Sequential radiographs are shown above.

Question: What is he currently suffering from?

Image shown under fair use.

Not to be Confused with Systolic Blood Pressure

A patient with severe end stage liver disease, cirrhosis from EtOH and hepatitis C, presents with several days of low grade fever, diffuse continuous abdominal pain and tenderness, altered mental status, and diarrhea. On exam, you notice a fluid wave ascites and decide to tap it for paracentesis.

Challenge: What are you looking for when you analyze the fluid?

Au

You do a far-away rotation in Asia where you see a 20 year old woman presenting with shortness of breath, fatigue, and pretibial petechiae that had an insidious onset. She has no significant past medical history, medications, allergies, or family history. However, when you start asking about bad habits, you pause in surprise when she says she "injects gold." Apparently, she thinks it brings fortune and acts as an aphrodisiac. She is afebrile, and all her vital signs are stable. Exam is notable for some petechiae, pallor, and bounding pulses. While some basic labs are cooking, you look at a peripheral blood smear under the microscope:

A bone marrow biopsy is done; hematology describes it as "wet" and "fatty." Here is what they see:

Challenge: What's the diagnosis?

Images shown under fair use.

Embryology Review

An adolescent presents with the finding shown above. A reconstructed CT is shown below.

Challenge: What do you think it is?

Both images shown under fair use.

200

Having written 200 of these cases, I realize how much stuff is out there in medicine. It's really wonderful and intimidating. I love learning about new and strange diseases, thinking about physiology and pathophysiology, and finding fascinating physical diagnosis images. I'd love to hear any suggestions you may have for how to improve this blog, and I'm happy to entertain ideas for good cases. Though this is a big time sink, it is a hugely educational one for me and I hope it is the same for you too. It will continue through winter break, but I will skip Christmas Eve Wednesday 12/24.

Incidental

A healthy asymptomatic adolescent enrolls as a test subject for a research experiment. A bunch of baseline tests are taken, all of which are normal except for mild isolated proteinuria (1g/d). So you ask him to do the following test:
-Discard the first morning void.
-Obtain a 16 hour collection between 7am and 11pm with the patient performing normal activities.
-Obtain a separate 8 hour collection between 11pm and 7am.

While the daytime collection has high urine protein, the overnight collection has 30mg/8 hours.

Challenge: What's the diagnosis?

Mets

A 60 year old post-menopausal African American woman presents concerned about episodic color changes of her face lasting about 10-20 minutes. She says her face, neck, and upper chest become purple and feel like they are burning. She feels her pulse racing during some of these episodes. They are provoked by eating, drinking alcohol (she denies having "Asian flush"), having a bowel movement, and emotional events. On review of systems, she also notes explosive, watery, and nonbloody diarrhea, almost 10 times a day, accompanied by abdominal cramping.

The patient was diagnosed with acne rosacea as well as new onset asthma by her primary care doctor a few months ago. She was prescribed an albuterol inhaler, but it makes the flushing worse so she has not been using it.

Prior to surgery, the anesthesiologist puts her on a drug that you don't recall for some sort of prophylaxis. At surgery, this is what you find:

Challenge: What's the diagnosis?

Related Questions:
1. In what other organ should you look?

Image is in the public domain.

Toxic

A 40 year old AIDS patient with CD4 count of 95 presents with a headache, confusion, and fever. A T1-weighted MRI with gadolinium is shown above.

Challenge: What's the diagnosis?

Image shown under fair use.

Sodium Channelopathy

A 40 year old Asian man presents for a routine adult check-up and because his father, paternal grandfather, and paternal uncle all died of sudden cardiac death in their sleep before the age of 40, an EKG is taken. A shows a normal EKG. B shows this patient's EKG. The cardiac review of systems is notable for an episode of unexplained syncope a few months ago.

Challenge: This is a rare cause of sudden cardiac arrest in a heart without a structural defect. What is it?

Image shown under GNU Free Documentation License.

White Spots

A 30 year old woman from Denmark presents with a several year history of intermittent sensory changes in her arms, legs, and face. From time to time, she will get in numbness or tingling but they usually self-resolve in time. She's also had episodes of double vision, vision loss, and problems with walking. On exam, when you flex her neck, she gets electric shock-like sensations that run down her back. T1-weighted MRI monthly scans are shown above.

Challenge: What's the diagnosis?

Related Question:
1. What's the sign elicited on exam?

Image is in the public domain.

Don't Miss It

This is an X-Ray of a 12 month old child with many soft tissue injuries who was said to have fallen after riding a tricycle.

Challenge: What's the diagnosis?

Image shown under fair use.

Platelet

A child presents with mucocutaneous bleeding but his platelet counts are normal. On a non-anticoagulated peripheral blood smear, you see single isolated platelets without platelet clumping. There is no response when you stimulate the platelets with ADP, epinephrine, or collagen. However, when you stimulate with ristocetin, you get a normal reaction.

Challenge: The child has developed antibodies against what complex? What is the disease called?