Prowess

The picture shows a man from Burundi who perhaps lived in crowded, cold, unhygienic conditions. He probably presented with abrupt onset fever, severe headache, tachypnea, chills, malaise, myalgias, arthralgias, abdominal tenderness, confusion, and drowsniess. The rash shown above began several days after onset of symptoms and is a red maculopapular eruption on the trunk that later spreads to the extremities. He probably had jaundice, elevated serum aminotransferases, and thrombocytopenia. All cultures are negative.

Even years after this initial episode, the patient may experience recrudescence with abrupt chills, fever, headache, malaise, and rash.

This is an interesting historical disease; periodic epidemics from the middle ages to the early 20th century killed millions of people; it has been estimated that this disease has caused more deaths than all the wars in history.

Challenge: What's the cause of this disease? What is the recrudescence called?

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Hills and Valleys

This was taken from a 62 year old man with hypertension and coronary artery disease on medications.

Challenge: What's your interpretation?

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Hera

A 20 year old woman presents to student health complaining of several days of fatigue, nausea, and vomiting. The nausea is the worst after waking and has led to several episodes of bilious non-bloody emesis. She also complains of tingling and soreness of her breasts, urinary frequency, nocturia, lightheadedness, mild dyspnea, and nasal congestion.

Challenge: What is your next question?

Change in Labeling

I've been meaning to do this for a while. Posts are now going to be "labeled" by the rotation in which you would most likely encounter the presentation (internal medicine, surgery, pediatrics, obstetrics and gynecology, family medicine, neurology and psychiatry, and emergency medicine).

ESRD

A Caucasian gentleman with end stage renal disease on hemodialysis presents with the wounds shown above. He recently had minor trauma to this area but the skin breakdown and lack of healing is out of proportion to the trauma. Note the ischemic necrosis of dermis and subcutaneous fat. Radiologic studies show something odd - his vessels have become radio-opaque on X-ray and CT.

Challenge: What's the diagnosis?

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Fish

A 25 year old Caucasian presents with the rash shown above. The lesions are symmetric, found on the scalp, extensor elbows, knees, and back. The patient is a smoker, obese, and drinks alcohol.

Challenge: This is a classic presentation of what disease?

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Yankee

A 70 year old man presents with asymmetric limb weakness. He complains that he often drops things with his right hand and cannot write, type, button, use zippers, or pick up small objects anymore. He also has a new onset foot drop which has caused him to trip and fall. On exam, you find increased reflexes and a spastic rigidity. You also notice some atrophy and fasciculations of the muscles.

Challenge: What's the diagnosis?

Serpin

A 40 year old Caucasian man presents with dyspnea, productive cough, and wheeze. He has no known history of pulmonary diseases. He does not take any medications, has no allergies, and does not smoke, drink, or do any drugs.

He is adopted so he does not know his family history. He gets tearful when he says this, and you find out that his parents abandoned him in the hospital when he was diagnosed with neonatal hepatitis with cholestasis. He was once told as an adult he has cirrhosis. On review of systems, he notes a new hot painful red nodule on his thigh.

CXR shows predominantly basilar hyperlucency so a CT is done showing the following:

Challenge: What are you worried about?

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Repealed

This unfortunate child has mental retardation and poor growth.

Challenge: What's the diagnosis?

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Scythe

A 20 year old African American male presents with severe acute onset chest pain without an identifiable trigger. It is accompanied by fever, swelling of his joints, nausea, and one episode of vomiting. He's had similar episodes in the past which did not prompt him to see health care; they lasted several days. His past medical history is significant for this as a child:
On exam, he is tachypneic and hypertensive. Laboratory results show a hematocrit of 22 with MCV 95, an unconjugated hyperbilirubinemia, elevated serum LDH, and low serum haptoglobin. An EKG is normal sinus rhythm.

Challenge: What do you expect on peripheral blood smear?

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Two in One

A 70 year old man presents with difficulty moving. When you ask further, he says he noticed a slow progressive onset of weakness. He has trouble getting up from a chair or climbing stairs. He gets muscle fatigue, cramping, stiffness, and aching. On review of systems, he notes dry mouth, blurred vision, constipation, and erectile dysfunction.

On exam, you note a bit of ptosis but sustained upgaze leads to excessive eyelid elevation. Neuro exam shows symmetric muscle weakness in the proximal but not distal muscles. There is no muscle atrophy. You get no deep tendon reflexes. A routine CXR shows a lung nodule so a follow-up CT was taken.

Challenge: Here, you can suggest two associated diagnoses. What are they?

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Valley Girl

A Filipino woman presents to your Fresno clinic during the summer with these red-violet indurated painful nodules on her shins. Her sed rate is increased.

Challenge: What's the diagnosis?

Related Questions:
1. What's the skin finding called?

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Bleeder

A 20 year old man without a significant medical history presents to the emergency room with hematemesis. The emergency department stabilizes him hemodynamically and GI is consulted to scope him. He reports no alcohol abuse, no smoking, no NSAID use. In the endoscopy, this lesion is seen:

The gastroenterologist says, "Aha! This is not peptic ulcer disease, esophageal varices, or an arteriovenous malformation."

Challenge: Well, in that case, what is it?

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