Wednesday, April 29, 2009

Politically Incorrect

You are doing a surgical wound debridement in the OR on an abscess infected with methicillin resistant Staphylococcus aureus. You ask the anesthesiologist to give the drug shown above. About 15 minutes into the case, the anesthesiologist mentions the patient is getting flushed. You look over and you see erythema on the upper chest, neck, and face. The patient is slightly hypotensive. If he were awake, you might complain of pruritis, pain, and muscle spasms.

Challenge: What is the drug and what is this reaction called?

Image shown under GNU Free Documentation License.

Monday, April 27, 2009


Alas, this week is pharmacology week.
An older Caucasian patient with a cardiac arrhythmia treated with the medication shown above presents with fever, myalgias, arthralgias, and pleuritis. Laboratory testing shows that the patient has antihistone antibodies and is ANA positive.

Challenge: What's the drug, and what's the disease?

Image is in the public domain.

Friday, April 24, 2009

And All the King's Men

This is part two of a two part case; the first part is the last post.

After making the timely diagnosis on your three year old patient, you admit him to the hospital and begin treatment. That night, you are called because the child has a seizure. The nurse reports some nausea and vomiting followed by anorexia, lethargy, and muscle cramps. You draw some labs and find an elevated serum uric acid, elevated serum potassium, and low serum calcium.

Challenge: What's going on?

Wednesday, April 22, 2009

All the King's Horses

This is part one of a two part case.

A three year old male with Down Syndrome presents with a limp and refusal to bear weight. He says his legs hurt. An examination shows petechiae and purpura on legs. You decide to draw some labs and find that he is anemic and thrombocytopenic with normal WBCs. A Wright's stain of the bone marrow aspirate looks like this:

Challenge: What's the most likely diagnosis?

Image shown under GNU Free Documentation License.

Monday, April 20, 2009

Differential Diagnosis

On rounds, my team looked at an MRI of a patient with a brain metastasis. My resident pimped me with the following question:

Challenge: What primary cancers have brain mets that are likely to bleed?

Image shown under fair use.

Friday, April 17, 2009


This child with a history of mental retardation presents to your emergency room with a witnessed seizure. Her past medical history is significant for many prior seizures, a cardiac rhabdomyoma detected on prenatal ultrasound, and multiple renal cysts. On exam, you note several lesions looking like the image shown below.

Challenge: What is the strange diagnosis here?

Related Questions:
1. What is shown in the first image?
2. What is shown in the second image?

Both images are in the public domain.

Wednesday, April 15, 2009


A 22 year old college student comes in with gradual onset headache, malaise, sore throat, low-grade fever, and chills. He also has an intractable nonproductive cough. He says other people around him have had a similar illness. Physical exam is unremarkable. You present the case to the attending, sure it is a benign upper respiratory tract infection.

Challenge: Your attending who has a particular interest in infectious disease says: if this patient tested positive for cold agglutinins, what organism would you suspect?

Monday, April 13, 2009

The Itch

A 25 year old G1P0 woman at 30 weeks gestational age presents with intolerable itching, worse at night, mostly on the palms and soles of her feet. Exam only shows excoriations from scratching. The only laboratory abnormalities are elevated serum bile acid and alkaline phosphatase. GGT (gamma glutamyl transpeptidase) is normal. She has no history of liver disease and on ultrasound, biliary ducts and hepatic parenchyma appear normal.

Challenge: What's the diagnosis?

Friday, April 10, 2009

By Any Other Name

A 40 year old rose gardener presents with the thumb shown above. He says there's been no purulent drainage and no odor. You note a red streak up his arm. His pain isn't too bad, and he is otherwise asymptomatic.

Image shown under fair use.

Wednesday, April 8, 2009


A 5 year old child with a travel history to Asia presents with abdominal discomfort, diarrhea, an irritating nonproductive cough, and wheezing. A complete blood count with differential shows eosinophilia at 10%.

Challenge: The organism is shown above. What is it?

Image is in the public domain.

Monday, April 6, 2009


This week is non-bacterial, non-viral infection week!

A 25 year old incarcerated man presents to the prison nurse complaining of severe itch, worst at night. He notes a new rash, shown above, involving the sides and webs of the fingers, the flexor aspects of the wrist, the extensor aspects of the elbows and knees, the axillary folds, the periumbilical area, the groin, the butt and thighs, and the lateral and posterior aspects of the feet. The back and head are spared. Many of these areas show excoriation and blood-tipped crusts.

Challenge: What's your diagnosis?

Image is in the public domain.

Friday, April 3, 2009

Sudo III

A 30 year old woman presents with vague abdominal discomfort. Several weeks ago, she started having episodic right upper quadrant pain that was worst after eating, especially ice cream. This pain lasted for several hours. However, a few days later, she got acute onset unrelenting steady mid-epigastric pain. It was band-like and went to her back. She had a lot of nausea, vomiting, and anxiety; the only thing that made it better was leaning forward. She was admitted to the hospital for several days but does not remember what the diagnosis was.

Now, weeks after that initial disease, she has abdominal discomfort, so you get a CT:

Challenge: What is it?

Image shown under fair use.

Wednesday, April 1, 2009

Sudo II

Happy April Fool's Day! Today's case is absolutely ridiculous.

You meet a child with round facies, short stature, short fourth metacarpal bones, obesity, subcutaneous calcifications, and developmental delay. You consult a geneticist who says that he would expect hypocalcemia, but when you test the patient's blood, you find normal calcium, phosphate, and parathyroid hormone levels.

Challenge: At 30 letters, this inherited disease is a contender for one of the longest words in the English language; what is it?