Monday, August 31, 2009

Hip Hop

A healthy six month old infant comes for a well child check. She had a breech presentation at birth but was delivered vaginally without complication. Otherwise, she is up to date on her vaccinations and sees you regularly. The infant is calm, not crying, and supine on the examining table with hips flexed to 90 degrees in neutral rotation. You grasp her right thigh and gently adduct the hip with posteriorly directed pressure. You note posterior sliding and a palpable "clunk." You then abduct the hip and lift anteriorly and feel another clunk. Here's an X-ray:

Challenge: What's your diagnosis?

Image is in the public domain.

Friday, August 28, 2009


A 25 year old gang member presents to the emergency department with a 1cm laceration over the third and fourth metacarpophalangeal joint of his right hand. He is right handed. When you ask him how he got this injury, he says "Uh, well, um, I was working on my house, and uh, I got cut while painting. Yeah, painting." The exam shows tenderness, erythema, swelling, purulent drainage, lymphangitis, and low grade fever. Four separate isolates are cultured out of the wound, both aerobic and anaerobic bacteria.

Challenge: How did he get this wound?

Wednesday, August 26, 2009


Easy one today since they're so much faster to write. A kid gets hit on the side of the head with a baseball bat. He loses consciousness for a few minutes but then gets better and insists he wants to keep playing. Over the next hour, his mental status deteriorates and he's rushed into the emergency department.

Challenge: Diagnosis?

Image shown under fair use.

Monday, August 24, 2009

Bad Air

This week is emergency medicine week! All these cases could be seen the ED (at least at San Francisco General Hospital).

This blood smear is from a Peace Corps volunteer in sub-Saharan Africa who returned two weeks ago and began to feel fevers, chills, night sweats, headaches, myalgias, fatigue, nausea, abdominal pain, vomiting, diarrhea, and cough.

Challenge: Organism?

Image is in the public domain.

Friday, August 21, 2009

Three Blind Mice

Isn't this the most wicked picture ever? The patient has a subconjunctival hemorrhage and weirdly disconjugate eyes but the pathognomonic finding is in the right eye conjunctiva, upper palpebral border.

This guy traveled in the tropics. Or Hawaii, which sees the highest number of cases in the U.S. Despite the title of this case, he's not blind, but he did run into rats. Lots of them.

Clinically, he presented with abrupt onset fever, rigors, myalgias, headache, nausea, vomiting, diarrhea. The eyes are the only abnormal physical exam finding. Laboratory values show WBC 8,000 with left shift, U/A with pyuria, proteinuria, and granular casts, elevated CK, and hyponatremia.

The organism is shown 200x dark-field microscope below. It can be grown in culture, but only on special media.

Challenge: What's your diagnosis?

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

Wednesday, August 19, 2009

Kid with Rash

Ah, yes, that common chief complaint. This rash is pruritic and has a bit of scale. The borders are slightly raised.

Challenge: What's the most likely diagnosis?

Image is shown under fair use.

Monday, August 17, 2009

No Easy Way To Say This

A 35 year old G0P0 with autoimmune adrenal and thyroid disease presents with pain with sexual intercourse. She has vaginal dryness, decreased libido, poor sleep, and night sweats. She was previously on oral contraceptives for 10 years but stopped about 2 years ago. Since then, her periods have not been regular. Karyotype is normal. FSH is elevated. Pregnancy test is negative.

Challenge: What's your diagnosis?

Friday, August 14, 2009


You are a third year medical student doing a standard H&P on a healthy 50 year old man in family practice. He's here for an annual check-up. He has no complaints. His past medical history is significant for hypertension, GERD, an appendectomy at age 22, peptic ulcer disease s/p treatment with amoxicillin, clarithromycin, and omeprazole, and syphilis treated with PCN 10 years ago. His current medications are metoprolol and a multivitamin. He's allergic to penicillin; he said when he got it 10 years ago, he had fever, headache, myalgia, rash about 1-2 hours after taking it, peaking at 8 hours, and resolving within 2 days. His family history is significant for depression, hypertension, and mother with breast cancer at age 60. He drinks occasionally, smoke 1/2 ppd x30 years, and denies IVDU. He works as a mechanic, lives with his wife and two kids. His review of systems is negative.

Challenge: When you present this history to your preceptor, he says, "I bet he doesn't really have a penicillin allergy." Interesting! Why does he say that?

Wednesday, August 12, 2009


On a growth curve, this infant is >90% percentile. Note the tongue and the ears. 4% of infants with this syndrome are at increased risk of malignancy, including Wilms tumor, neuroblastoma, hepatoblastoma, and gonadoblastoma. 80% have abdominal wall defects. 59% have renal abnormalities.

Challenge: What's the syndrome?

Image shown under fair use.

Monday, August 10, 2009


After a thyroidectomy for thyroid cancer, a patient develops hoarseness. Her voice is breathy and weak. She does not have any difficulty breathing.

Challenge: Explain.

Friday, August 7, 2009


A 25 year old presents with tunnel vision and gait instability. She's had neurologic problems all her life; at age 5, she was diagnosed with a sensory motor neuropathy - hypesthesia, hypalgesia, loss of proprioception, and absent tendon reflexes. Since then she's had generalized muscle weakness with distal muscle atrophy. As a result, she has ataxia. A peripheral nerve biopsy revealed loss of large myelinated fibers. She says a grandmother of hers had retinitis pigmentosa. Review of systems is positive for steatorrhea. A blood smear is shown above.

Challenge: This is a tough one, but the smear suggests what disease?

Image is in the public domain.

Wednesday, August 5, 2009

Darth Vater

(Even though the case is titled Darth Vater, it does not have to do with the ampulla itself, I just liked the title).

A 50 year old man with known untreated choledochal cysts presents with subjective fever, weight loss, and pruritis. The onset is unclear; it has been gradual over the last few months. He also has a dull ache in the right upper quadrant of the abdomen. You notice he is clearly jaundiced and when you ask, you find out he has clay-colored stools and dark urine. The rest of your physical exam is notable for hepatomegaly and a palpable gallbladder.

Laboratory results show an elevated total and direct bilirubin, alkaline phosphatase, 5'-nucleosidase, and gamma-glutamyltransferase. AST, ALT, and coags are normal. Here's a CT:

This is the finding on ERCP, showing common bile duct stricture and dilation of the proximal common bile duct:

Challenge: What's your diagnosis?

Related Questions:
1. What "sign" is the palpable gallbladder?

First image shown under GNU Free Documentation License, second image is in the public domain.

Monday, August 3, 2009

Falling Out of Place

A 70 year old G4P4 (all vaginal deliveries) presents with a sensation of pelvic heaviness. "It's like I'm sitting on an egg," she says. She also has some low back pain. Her symptoms worsen during the day and with long periods of physical exertion; lying down makes them better. She's noticed some urinary stress incontinence as well. She has obesity, COPD, and chronic cough. Review of systems is positive for constipation.

Challenge: What's your most likely diagnosis?

Image is in the public domain.