Dark Fleeting

A 60 year old man comes to urgent care clinic. He says that an hour ago, he experienced vision loss in one eye; he covered each eye separately to test vision. The vision loss was painless and lasted several minutes. The fundoscopic exam is shown above. Currently, his vision is normal and neurologic exam is unremarkable.

Challenge: This is a tough case, but what's the most likely etiology?

Related Questions:
1. What is the symptom described here called?
2. What is the finding in the fundoscopic exam?

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Tumorlike

Challenge: This happened after an ear piercing. What is it?

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Hailstone

This week's theme is outpatient complaints with Greek disease names.

This lesion first presented with eyelid swelling and erythema but now it is a painless, rubbery nodule. The patient's past medical history is significant for rosacea.

Challenge: What is it?

Image is in the public domain.

Two Organ Systems

A 60 year old gentleman presents with shortness of breath. Interestingly, his dyspnea is worse while upright and relieved while lying down. He has been out of care for a long time and does not know his past medical history. He takes no medications, has no known allergies, and does not know his family history. His social history is significant for being homeless, having a 40 year heavy drinking history, smoking 50 pack-years, and trying pretty much "any recreational drug invented."

Physical exam shows an O2 sat of 85%. This worsens while he is sitting and improves while he is lying down. You also notice these findings on his skin:An arterial blood gas on room air shows a PaO2 of 60mmHg. Your attending, after evaluating the patient, says, "I bet at rest, he has an elevated cardiac output, perhaps even up to 7L/min.

Challenge: What is this syndrome called?

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Post-Op

A 45 year old man who had a right pneumonectomy for a bronchogenic carcinoma about 1 year ago presents with progressive dyspnea. His surgery was uncomplicated. Immediately post-operatively, he had atrial fibrillation that was treated with amiodarone. Since then, he has been improving in function until about 2 months ago when he started getting recurrent pneumonias. He has also noticed increasing shortness of breath and a cough. On physical exam, you note inspiratory stridor. A CT is shown above.

Challenge: What's going on?

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Shining Forth

A woman in her third trimester is brought into the emergency department for a "scary fall." Unfortunately, no one knows her and she has not been receiving prenatal care. She is an African American teenager who is clearly in the third trimester of pregnancy, but dating is unknown. Bystanders witnessed her falling with brief flexion of her arms, upward deviated eyes, extension of the back, arms, and legs, and crying out. This was followed by brief, violent muscle contractions, cyanosis, foamy salivation at the mouth, and loss of bladder control. All of this resolved by itself within one minute. Currently, she is confused, complaining about sore muscles and a headache. She is hypertensive. A urinalysis shows proteinuria.

Challenge: What's the diagnosis?

Velvet

Challenge: What is shown here, and what does it signify?

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Overdose

A patient is brought in by his roommate who says the patient overdosed on the pills shown above. The patient has slurred speech, ataxia, and depressed mental status. There is mild respiratory depression, but his vital signs are normal and he is arousable. The roommate says there was no co-ingestant.

Challenge: Even though there's an antidote, this patient will be fine without it. What's the antidote?

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Top

This one-day old newborn was born by vacuum-assisted vaginal delivery at 41 weeks to a 30 year old G2P2 woman after a prolonged labor. A soft, spongy mass is felt over the right scalp which crosses suture lines.

Challenge: What is the treatment?

Image is in the public domain.

Swapped Meds

A 45 year old man presents with left foot pain, mostly at the metatarsophalangeal joint shown above. He noticed disabling pain, redness, swelling, and inability to move the toe about 16 hours ago and it's becoming progressively worse. He can't really walk anymore. Past medical history is significant for obesity and hypertension. Social history is significant for drinking several drinks a night.

When you ask about medications, he says, "Here's the problem, doc. I think I swapped my wife's and my medications. When I took my pills yesterday, I got severe flushing. There was also some itchiness, tingling, and nausea." He can't recall what diseases his wife has, but he says, "she has all the common stuff, but nothing weird."


Challenge: The offending drug is shown above; you make sure to check LFTs because another common side effect is hepatotoxicity. What drug is it?

Related Questions:
1. What's the clinical diagnosis?

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Freshwater

The image shows a cyst, trophozoite, and flagellate. This organism is found in warm bodies of water like hot springs and man-made lakes and ponds; it is not seen in seawater. The typical presentation is a previously healthy child or adult with freshwater exposure in the last 2 weeks who presents with acute onset of headache, fever, neck stiffness, nausea, and vomiting. Uniquely, sense of smell and taste are affected. Antibiotics do not help, and patients then develop seizures, ataxia, cranial nerve palsies, confusion, and coma. This disease is fatal in 95% of cases within 4-6 days due to brain herniation.

Challenge: What's the pathogen?

Image is in the public domain.

Olive

A G1P1 mother brings in her 1 month old newborn male because he is "always hungry." When you ask further, it turns out he has been having projectile nonbilious vomiting immediately after he eats, and then after the vomiting, appears to be hungry again. Right before he vomits, the mother notes quivering waves on his belly. The mother has been breastfeeding him frequently.

On exam, you note a dehydrated infant. On the abdominal exam, right upper quadrant, you appear to feel one of these at the lateral edge of the rectus abdominus muscle:
Here's a barium study:
"Oh my God," the mother says. "Is it cancer?"

Challenge: The diagnosis is easy, but what electrolyte findings do you expect in this condition?

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EtOH 3

Happy New Year's! This EKG is from a previously healthy man who presented with the chief complaint "my heart feels funny." He came in on New Year's Day because of a resolution to "be more healthy." "No more binge drinking," he says. Otherwise, he has no other medical problems, has had no surgeries, and takes no medications.

Challenge: What's the cause of the EKG finding?

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