Monday, November 30, 2009

Baby Got Back

On a single clinic afternoon, you get four patients with low back pain.

Challenge 1: A 45 year old has sharp or burning pain radiating down the lateral or posterior aspect of the leg to the ankle. There's a little bit of numbness and tingling. What's the diagnosis?

Challenge 2: A 70 year old man presents with urinary retention with overflow incontinence, bilateral shooting pain down the back of his legs, and leg weakness. You note perianal anesthesia. What's the diagnosis?

Challenge 3: A 16 year old IV drug user presents with low back pain after a day of heavy lifting. He has no other symptoms and no other medical problems. Do you image his back?

Challenge 4: A 30 year old woman who is a smoker presents with low back pain after sleeping funny for a week. She has no other symptoms and no other medical problems. Do you image her back?

Friday, November 27, 2009


A 35 year old woman with rheumatoid arthritis, asthma, bipolar disease, gastroesophageal reflux disease, cholelithiasis, and polycystic ovarian syndrome presents with tremors and twitching. She says that she might have mixed up her meds last week at which time she started having an irregular coarse tremor, motor agitation, weakness, ataxia, and sluggishness. She doesn't remember what meds she's normally on. Review of systems is notable for nausea, vomiting, and diarrhea. Exam shows sinus bradycardia and hypotension. Labs show a leukocytosis.

Challenge: What happened here?

Image is in the public domain.

Wednesday, November 25, 2009

Inborn Error of Metabolism

Ah yes, everyone's favorite lecture, the inborn errors of metabolism. You meet a 5 year old with mental retardation who was just diagnosed with ectopia lentis (dislocated lens), which occurs in 90% of these patients; 60% have a inferior or nasal subluxation. There is a family history of this disease which seems to skip generations. The patient is at risk for osteoporosis and thromboembolism. Physical exam shows tall stature.

Challenge: What's the diagnosis?

Image is in the public domain.

Monday, November 23, 2009

Light at the End

A 45 year old secretary presents with pain and tingling of the thumb, index, middle, and ring fingers. She's noted difficulty writing, pinching, and holding small utensils. She's been under a lot of stress lately at the law firm. Physical exam shows mild flattening of the thenar eminence. The two following tests recreate symptoms:

Challenge: What's the diagnosis and what are the tests shown above?

Both images shown under Fair Use.

Friday, November 20, 2009


A 30 year old G4P1 woman is concerned that her periods have changed in quality. They used to be regular at 29 days, heavy, lasting 5 days, but since the last few months, she's had minimal to no periods. She doesn't have any vaginal pain or discharge. Her gynecologic history is as follows: at age 18, she had an elective first trimester medical abortion; at age 22, she had a daughter at full term without complications; at age 26, she had a spontaneous first trimester abortion; and several months ago, she had to surgically terminate a second trimester pregnancy due to fetal demise. She has no significant past medical history and takes no medications. She is married but has multiple sexual partners; she does not use protection. She denies domestic violence. She smokes a pack per day. Family history is noncontributory.

A urine pregnancy test is negative. A hysterosalpingogram is shown below.

Challenge: What's the diagnosis?

Image is shown under GNU Free Documentation License.

Wednesday, November 18, 2009

Three Muskateers

Challenge: Click on the image to enlarge. This EKG has voltage criteria for LVH, non-specific inferior and lateral ST-T changes, and one peculiar finding on the intervals that identifies this as a 3-name syndrome...what is it?

Image shown under fair use.

Monday, November 16, 2009


A 25 year old woman is brought in by her roommate because she's "acting weirdly." But the patient denies this. "I feel better than ever," she says. "I'm invincible, I'm awesome, I only need four hours of sleep each night, and that's not even counting the sex, and even though I'm not getting to my job on time, I have all these projects I'm working on, and I have to go shopping, and sure, my friends can't stand me, but they couldn't before anyway when I was all moody and mopey and dopey and down, but that's okay, now I'm happy just going to the gym and working out for 3 hours a day, and besides, this has happened to me once before, a couple years ago, when all of a sudden I decided to quit school and go on a road trip and see the world, and all my friends thought I was tripping, ha, isn't that a good pun? but really I've never taken any drugs or seen a doctor, I'm healthy like that, and ooh, that's shiny." She points at a plaque you won for diagnostic acumen.

Challenge: Making the right diagnosis is important because the rate of suicide attempts is 25-50% (15% die of suicide) in this condition...what is it?

Friday, November 13, 2009

Dinner 3

Despite the last two cases, you're still eating fish for dinner. This time, on a trip to Japan, you try a local delicacy. Within minutes of eating the dish above, you note weakness, dizziness, paresthesias of the face and extremities, and nausea. Since you always carry around a trusty reflex hammer, you test your reflexes and find they're absent. The fear with this disease is paralysis and hypotension. The toxin is shown below. Cool ring structure!
Challenge: What's your diagnosis?

First image shown under Creative Commons Attribution License. Second image is in the public domain.

Wednesday, November 11, 2009

Dinner 2

You visit the Polynesian islands, enjoying the tropics and subtropics. You catch the fish above and cook it for dinner. Three to six hours after eating the fish, you start having vomiting, diarrhea, and abdominal cramps. Three to 72 hours later, you feel paresthesias, painful teeth, painful urination, blurred vision, nerve palsies, and hot/cold temperature reversal. You take your pulse, 50, and your blood pressure, 105/60. The neurologic symptoms last for days to weeks. Your vacation, unfortunately, is ruined. The toxin is shown below:
Challenge: What's your diagnosis?

Both images are in the public domain.

Monday, November 9, 2009

Dinner 1

How well do you know your toxins? This week involves toxins of a specific kind.

An hour after eating the dinner shown above, you feel flushing, warmth, and palpitations. You note an erythematous rash on the upper torso and face. You take your pulse and it is 115. Within 12 hours, the symptoms have resolved. The culprit is shown below:
Challenge: What is your diagnosis?

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

Friday, November 6, 2009

Into the Fire

Please see the last two posts for the first two parts of the case. The patient has respiratory distress and needs to be intubated. Here is your routine CXR after intubation.

(Obviously this is a different patient, but the pathology should be obvious.)

Challenge: Despite FiO2 of 100%, the patient's oxygen saturation hovers just below 90%. Why?

Image shown under fair use.

Tuesday, November 3, 2009

Out of the Frying Pan

The is the second part of a three part CXR case. Please see the previous case for the first radiograph. You initiate treatment for the patient and get a follow-up X-ray. Here's what you see.

Challenge: Explain.

Image shown under fair use.

Monday, November 2, 2009


This is the first part of a three part case for CXR week.

Challenge: In the wording of the USMLE Step 2 exam, what is your first step in management?

Image is shown under Creative Commons Attribution ShareAlike 2.5 License.