Wednesday, September 30, 2009


This older gentleman was working out when he noted a "pop" and pain in his shoulder. He's been having moderate anterior shoulder pain with radiation over the anterior upper arm. He noted bruising and swelling after the incident. The pain is worse with lifting, pulling, and doing overhead arm motions.

Challenge: Assessment?

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Monday, September 28, 2009

Cath Lab?

You're taking home call as the cardiology fellow when your sleep is interrupted by beeping of your fax machine. You get the EKG shown above; darn the quality of those faxed copies! The resident calls with the story: a fifty year old gentleman with hypertension, diabetes, dyslipidemia, and gout presents with several minutes of substernal crushing chest pain radiating to the jaw and left arm. This pain is accompanied by dyspnea, nausea, and diaphoresis. Troponins are negative. The EKG is shown above. Apparently, this man had a perfectly normal EKG one year ago.

Challenge: Do you drive into the hospital to cath this guy? If no, why not? If yes, where is the lesion?

Image is shown under Creative Commons Attribution-ShareAlike 3.0 License.

Friday, September 25, 2009


The newborn shown above is being treated for a rare genetic disorder. He was the product of a normal spontaneous vaginal delivery at 38 weeks to a 30 year old G1P1 mother with no medical problems. He presented at 2 days of life with jaundice. Blood tests showed a total bilirubin of 25mg/dL (direct bilirubin of 0.1). Liver function tests were all within normal limits. Coombs test is negative. Stool color is normal. In social/family history, you learn that there's consanguinity in the parents.

Challenge: Prior to the treatment shown above, nearly all infants with this disease died of kernicterus. What is the disease?

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Wednesday, September 23, 2009


A G1P0 woman at 10 weeks gestation presents with right lower quadrant abdominal pain. She also has some nausea and vomiting, worse than her normal "morning sickness." She's lost her appetite, complains of general malaise, and has fevers and chills. On exam, palpation of the left lower quadrant causes pain in the right lower quadrant. Her WBC count is 15,000. You order an MR, and a T2 weighted image is shown below. The pathology is noted by the arrow. GS refers to the gestational sac.

Challenge: What's your diagnosis?

Image shown under fair use.

Monday, September 21, 2009


A 40 year old dentist presents with the skin lesion shown above, pain, and low grade fever. To make the diagnosis, you remove the blister roof with a no. 15 blade, blot excess fluid, then scrape the base with a scalpel blade. You spread the material on a slide, add 95% methanol for 5 seconds, air dry for 1-2 minutes, then add a nuclear stain for 30-60 seconds. Finally, you wash with distilled water and restain with methanol. Here is what you see:

Challenge: What's the diagnosis?

Related Questions:
1. What stain was that?

Both images shown under fair use.

Friday, September 18, 2009

Full Moon on the Quad

A week after "Full Moon on the Quad" a Stanford freshman develops malaise, headache, low grade fever, sore throat, and "swollen glands." He then takes "an antibiotic" that his roommate has and breaks out with this rash:

Challenge: What's the initial disease? What antibiotic did he take?

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Wednesday, September 16, 2009

Follower of Artemis

This is a T2 weighted MR image of a patient with bilateral loss of pain and temperature sensation in his hands and fingers. His upper arms have preserved pain and temperature sensation. He has no deficits in light touch, vibration, or proprioception. Good thing you tested all the sensory modalities!

Challenge: What's your diagnosis?

Image is in the public domain.

Monday, September 14, 2009


This is an incidental finding in a patient with a ball-cage prosthetic valve for a remote history of refractory endocarditis.

Challenge: Why this finding?

Related Questions:
1. What do you see on the smear?

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Friday, September 11, 2009


A 25 year old man presents to your clinic with low back pain that improves with exercise but not rest. It had an insidious onset and occurs at night. He also has buttock, hip, shoulder, TMJ, and posterior thigh pain. He had an episode of anterior uveitis a month ago. Review of systems is notable for fatigue.

Physical exam is remarkable in that the patient is stooped; you note loss of normal lumbar lordosis, increased flexion of the neck, and increased thoracic kyphosis.

Challenge: What's your diagnosis?

Image is in the public domain.

Wednesday, September 9, 2009


A 20 year old man is brought in by police with agitation and combativeness. On exam, he is tachycardic, hypertensive, and hyperthermic. In general, he is a diaphoretic, flushed man. Neuro exam shows vertical nystagmus even while the patient is awake as well as hyperreflexia. HEENT exam shows miosis and hypersalivation. Psych exam reveals he has acute new-onset schizophrenia, psychosis, audio-visual hallucinations, and paranoid delusions.

Challenge: You avoid the complication of rhabdomyolysis because you recognize this diagnosis as...what?

Image is shown under GNU Free Documentation License.

Monday, September 7, 2009

Happy Labor Day

This case is based on a "pearl" article in UpToDate.

A 25 year old previously healthy G1P0 at 30 weeks gestational age presents with uterine contractions. She was admitted to the hospital and started on terbutaline, a beta-2 agonist, for premature labor. The contractions stopped for 12 hours, but resumed 12 hours later, and she had a normal spontaneous vaginal delivery. The following day, the patient develops cough, dyspnea, and pink frothy sputum. She is transfered to the intensive care unit for mechanical ventilation. Her exam showed tachypnea, sinus tachycardia, no JVD, no murmurs, rubs, or gallops, and diffuse crackles. ABG is 7.50/ 30/60 on 40% FiO2. CXR is shown below.

Challenge: What is the diagnosis and the cause?

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Friday, September 4, 2009

No Evidence But We Do It Anyway

30 year old G1P0 at 38+2 weeks gestation, contractions began 5 hours ago, ROM 1 hour ago.

Challenge: Tell me about this strip.

Image shown under fair use.

Wednesday, September 2, 2009

To Lift Up

A 60 year old gentleman presents to your clinic complaining of angina, dizziness, and dyspnea on exertion. He notes decreased exercise tolerance compared to several years ago. On physical exam, you note a slow rate of rise in the carotid pulse, a mid to late peaking systolic murmur at the right second intercostal space, and reduced intensity of the second heart sound. The cardiac impulse is sustained.

Ah, yes, the ever important arrow and circle sign. This might help orient you: the blue line on the lateral view is drawn from the carina to the junction of the diaphragm with the anterior chest wall.

Challenge: The Greek word for "to lift up" would tell you the anatomical location of the pathology. What's going on?

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