Friday, October 30, 2009

Unfaithful Mortals

A newborn with Hirschsprung's disease in the neonatal intensive care unit presents with respiratory failure. ABGs show a mildly elevated PaCO2 during wakefulness and markedly elevated PaCO2 during non-REM sleep. He seems to forget to breathe when sleeping. You test him with inhalation of CO2 and he has no respiratory discomfort.

Challenge: What's your diagnosis?

Image is in the public domain.

Wednesday, October 28, 2009


This oyster-catcher with alcoholic cirrhosis in the Chesapeake Bay presents during the summer with the wound infections shown above. The wounds look pretty bad, so you keep him in the ED for a few hours. Over that time period, he becomes hypotensive, tachycardic, and obtunded; you admit him to the ICU for sepsis. Blood cultures grow out the bacteria shown in panel C.

Challenge: What's the bug?

Image is in the public domain.

Monday, October 26, 2009

Elaine Benes

You do an away rotation in obstetrics in Turkey and saw several cases of the disease shown above, which is rarely seen in the United States. 60-75% of these newborns are deaf, 10-20% have cardiac malformations, and 10-25% have CNS defects.

Challenge: What is it and why does it not exist in the United States?

Both images are in the public domain.

Friday, October 23, 2009


I have a tendency to hunt down rare and fun and bizarre diseases, but we shouldn't neglect common solid family medicine diagnoses as well.

Challenges: According to JNC-7 guidelines,
1. What would you use to treat the otherwise-healthy African American gentleman with the BP reading above?
2. If instead, the same patient has chronic kidney disease and a BP reading of 165/102, what would you use?
3. You recommend dietary sodium restriction (100mEq/L). What kind of BP response can you tell the patient to expect? Choices: No effect on SBP, 5mmHg reduction, 10mmHg reduction, 15mmHg reduction, 20mmHg reduction.

Image shown under Creative Commons Attribution 3.0.

Wednesday, October 21, 2009

To Quench

You are on an away rotation in India. A father brings his child, shown above, to clinic. The child has been severely constipated. On exam, his height and weight are severely diminished, he is bradycardic, hypotensive, and hypothermic. He has thin, dry skin with redundant skin folds and hair loss. When you treat this condition, the child becomes ravenously hungry.

Challenge: Specifically, what is the disease called?

Image is in the public domain.

Monday, October 19, 2009


This blood smear is from a 20 year old man complaining about acute onset severe chest pain with nausea and vomiting. He is febrile, tachypneic, and hypertensive.

Challenge: Here's a multi-step classic boards question for you - if this man had instead presented with osteomyelitis, what organism would you suspect?

Image is shown under fair use.

Friday, October 16, 2009

Oncology Consult

This gadolinium CT of a 30 year old patient shows a well-circumscribed capillary-rich benign neoplasm. Unfortunately, he is at risk for developing multiple such tumors, usually infratentorial. His past medical history is notable for retinal detachment due to "bleeding from a tumor" several years ago. He is also being seen by ENT doctors for some sort of problem with his temporal bone which has caused hearing loss and tinnitus. Family history is notable for father dying of clear cell renal cell carcinoma at age 60. The grandfather also had the same cancer as well as pancreatic cysts.

When you present this patient to the attending, he asks you whether the patient has episodic headache, sweating, tachycardia, and hypertension.

Challenge: What's going on here?

Image shown under Fair Use.

Wednesday, October 14, 2009

Hematology Consult

As a hematologist, you are asked to see a 25 year old female with easy bruising and heavy periods. She says she's always been an easy bleeder with nosebleeds lasting 30 minutes and severe bleeding after wisdom tooth extraction. After she delivered her last child, she had heavy bleeding during the peripartum period and then 7 days after delivery. Her ob/gyn referred her to you. She denies any soft tissue or joint swelling. She denies using any NSAIDs or aspirin. Physical examination is normal. The pattern of inheritance is shown above. Her CBC including platelets is normal.

Challenge: What's the diagnosis?

Image is in the public domain.

Monday, October 12, 2009

Genetics Consult

This week's theme is "von." Whatever that means.
You are on the genetics consult service (you're at a tertiary care hospital) and are asked to see a 6 month old infant with seizure. Physical exam shows a protruding abdomen and hepatomegaly. Laboratory tests show hypoglycemia, hyperlipidemia, and a lactic acidosis. The infant was born to a healthy G1P0 30 year old mother but since birth has had poor growth. The pattern of inheritance is shown above.

Challenge: Given that this is "von" week, what's the diagnosis?

Image is shown under GNU Free Documentation License.

Friday, October 9, 2009


A 70 year old Caucasian man presents for a routine yearly physical. He's been doing well, without problems, happy that he lost 15 lbs. without even trying over the last few months. Sure, he has a bit of fever and night sweats, but who doesn't? "At least it's not as bad as menopause," he says. He has a little fatigue, but it's just part of getting older, he thinks.

Exam shows cervical lymphadenopathy; you feel firm, round, discrete, mobile nodes. You might feel a spleen and a liver edge too. Routine CBC shows a leukocytosis, mild anemia, and mild thrombocytopenia. Here's the blood smear:

Challenge: What's your diagnosis?

First image shown under GNU Free Documentation License; second image shown under fair use.

Wednesday, October 7, 2009


A 30 year old African American woman presents complaining of vaginal discharge. It is unpleasant but not painful. It is fishy-smelling and occurs after sex. She has multiple sex partners, but denies being at risk for STDs or HIV. She is a smoker. On exam, you note thin off-white homogenous discharge. Vaginal pH is 5. The wet mount is shown below.

Challenge: What do you prescribe?

Image shown under Fair Use.

Monday, October 5, 2009

Named by a Flemish Anatomist

This case was requested by my friend Kate. I hadn't heard of the diagnosis until she mentioned it; about 1000 cases have been reported in the medical literature.
This patient noticed a swelling in the mid-lower abdomen. Although it was painful, he could "push it in" when he's lying on his back. Within the last day, though, it's become much more painful; he's vomited and hasn't had a bowel movement. On exam you note that the mass is covered by an intact external oblique aponeurosis. It is lateral and inferior to its defect in the space posterior to the external oblique muscle.

Challenge: Specifically, what's your diagnosis?

Image shown under Fair Use.

Friday, October 2, 2009


An 18 year old woman presents with a very weird chief complaint: drooling. She's also has inappropriate uncontrollable grinning and slurring of speech. She is brought in by her college roommate who is very concerned. "Even though she's smiling, I think she's depressed," the roommate says. "She never wants to do anything, seems to have no motivation, and sometimes, thinks people are after her. Is she paranoid? Her personality's changed. And I think her grades are a lot worse." On exam, you note a tremor, rigidity, and a clumsy gait.

Challenge: What's your diagnosis?

Image shown under Creative Commons Attribution 2.0 License.